Influence of ultrasound determination of fetal head position on mode of delivery: a pragmatic randomized trial.

PubMed

Popowski, T; Porcher, R; Fort, J; Javoise, S; Rozenberg, P

2015-11-01

To evaluate the influence of ultrasound determination of fetal head position on mode of delivery. This was a pragmatic open-label randomized controlled trial that included women with a singleton pregnancy in the vertex presentation at ≥ 37 weeks' gestation, cervical dilation ≥ 8 cm and who received epidural anesthesia. Women were assigned randomly to undergo either digital vaginal examination (VE group) or both digital vaginal and ultrasound examinations (VE+US group) to determine fetal head position. When the ultrasound and digital vaginal findings were inconsistent in the VE+US group, the ultrasound result was used for clinical management. The primary outcome assessed was operative delivery (Cesarean or instrumental vaginal delivery), and maternal and fetal morbidity were also assessed. The VE and VE+US groups included 959 and 944 women, respectively. The overall rate of operative delivery was significantly higher in the VE+US group than in the VE group: 33.7% vs 27.1%, respectively (relative risk (RR), 1.24 (95% CI, 1.08-1.43)), as was the rate of Cesarean delivery: 7.8% vs 4.9%, respectively (RR, 1.60 (95% CI, 1.12-2.28)). The rate of instrumental vaginal delivery was also higher, albeit not significantly: 25.8% in the VE+US group vs 22.2% in the VE group (RR, 1.16 (95% CI, 0.99-1.37)). Neonatal outcomes did not differ between the two groups. When analysis was restricted to instrumental vaginal deliveries only, maternal and neonatal morbidity outcomes were similar in both groups. Correction of fetal occiput position, determined initially by digital vaginal examination, using systematic ultrasound examination did not improve management of labor and increased the rate of operative delivery without decreasing maternal and neonatal morbidity. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Outcomes of Spontaneous Labor in Women Undergoing Trial of Labor after Cesarean as Compared with Nulliparous Women: A Retrospective Cohort Study.

PubMed

Lassey, Sarah C; Robinson, Julian N; Kaimal, Anjali J; Little, Sarah E

2018-01-24

 The objective of this study was to compare spontaneous labor outcomes in women undergoing trial of labor after cesarean (TOLAC) and nulliparas to better counsel women.  A 4-year retrospective cohort. We included women at term in spontaneous labor with vertex singletons and no more than one prior cesarean delivery. In planned secondary analysis, we focused on a subset of women with a prior cesarean and a predicted likelihood of a successful vaginal delivery of 70% or more based on the Maternal-Fetal Medicine Units-vaginal birth after cesarean (VBAC) calculator.  Our cohort included 606 TOLACS and 606 nulliparas. Women undergoing TOLAC were more likely to undergo cesarean delivery (25.7 vs. 14.7%; p  < 0.001). Severe maternal hemorrhage (1.5 vs. 0.2%; p  = 0.02) and uterine rupture (1.9 vs. 0.0%; p  < 0.01) were more likely in the TOLAC group. For the subset of women with a predicted likelihood of VBAC of 70% or more, there were no differences in cesarean delivery (16.7 vs. 14.7%; p  = 0.51), maternal, or immediate neonatal complications.  Women undergoing TOLAC were more likely to have a cesarean delivery, hemorrhage, or uterine rupture. Those with more than 70% predicted likelihood of VBAC were no more likely to experience these outcomes. These findings help contextualize the risks of TOLAC for women considering this option. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Preterm Induction of Labor: Predictors of Vaginal Delivery and Labor Curves

PubMed Central

Feghali, Maisa; Timofeev, Julia; Huang, Chun-Chih; Driggers, Rita; Miodovnik, Menachem; Landy, Helain J.; Umans, Jason G.

2014-01-01

Objective To evaluate the labor curves of patients undergoing preterm induction of labor (IOL) and assess possible predictors of vaginal delivery (VD). Study Design Data from the NICHD Consortium on Safe Labor were analyzed. A total of 6,555 women undergoing medically-indicated IOL before 37 weeks gestational age (GA) were included in this analysis. Patients were divided into four groups based on gestational age: A: 24-27+6, B: 28-30+6, C: 31-33+6, and D: 34-36+6 weeks. Pregnant women with a contraindication to VD, IOL at or after 37 weeks and those without data from cervical exam on admission were excluded. ANOVA was used to assess differences between GA groups. Multiple logistic regression was used to assess predictors of VD. A repeated measures analysis was used to determine average labor curves. Results Rates of vaginal live births increased with GA, from 35% (Group A) to 76% (Group D). Parous women [odds ratio (OR)=6.78, 95% confidence interval (CI) 6.38-7.21] and those with a favorable cervix at the start of IOL (OR=2.35, 95% CI 2.23-2.48) were more likely to deliver vaginally. Analysis of labor curves in nulliparous women showed shorter duration of labor with increasing GA; the active phase of labor was, however, similar across all GA. Conclusion The majority of women undergoing medically-indicated preterm IOL between 24 and 36+6 weeks’ GA deliver vaginally. The strongest predictor of VD was parity. Preterm IOL had a limited influence on estimated labor curves across gestational age. PMID:25068566

Long-term outcomes of the Stop Traumatic OASI Morbidity Project (STOMP).

PubMed

Basu, Maya; Smith, Dot

2018-06-09

To evaluate long-term sustainability of the Stop Traumatic OASI Morbidity Project (STOMP) in reducing the incidence of obstetric anal sphincter injury (OASI). A prospective observational study of women undergoing vaginal delivery at a UK district general hospital between September 1, 2014, and February 28, 2017. The principles of STOMP involve encouraging upright positioning, verbal coaching to avoid expulsive pushing and to slow down delivery, and tactile support to the vertex to judge speed and slow down delivery. After a training period, STOMP was implemented for all vaginal deliveries. Clinical and demographic data on women affected by OASI were collected across a 30-month period. The primary outcome measure was the incidence of OASI. There were 8782 vaginal deliveries during the 30-month period after implementation of STOMP. There was a significant decrease in the mean incidence of OASI relative to the 9 months before implementation (P<0.001). There was a significant decrease in the incidence of OASI for both spontaneous vaginal and instrumental deliveries (both P<0.05). There was no change in the frequency of episiotomy. Implementation of STOMP led to a significant decrease in OASI, confirming the sustainability of this approach to improve outcomes. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Vaginal Cleansing Before Cesarean Delivery: A Systematic Review and Meta-analysis.

PubMed

Caissutti, Claudia; Saccone, Gabriele; Zullo, Fabrizio; Quist-Nelson, Johanna; Felder, Laura; Ciardulli, Andrea; Berghella, Vincenzo

2017-09-01

To assess the efficacy of vaginal cleansing before cesarean delivery in reducing postoperative endometritis. MEDLINE, Ovid, EMBASE, Scopus, Clinicaltrials.gov, and Cochrane Library were searched from their inception to January 2017. Selection criteria included all randomized controlled trials comparing vaginal cleansing (ie, intervention group) with a control group (ie, either placebo or no intervention) in women undergoing cesarean delivery. Any method of vaginal cleansing with any type of antiseptic solution was included. The primary outcome was the incidence of endometritis. Meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of relative risk (RR) with 95% CI. Sixteen trials (4,837 women) on vaginal cleansing immediately before cesarean delivery were identified as relevant and included in the review. In most of the included studies, 10% povidone-iodine was used as an intervention. The most common way to perform the vaginal cleansing was the use of a sponge stick for approximately 30 seconds. Women who received vaginal cleansing before cesarean delivery had a significantly lower incidence of endometritis (4.5% compared with 8.8%; RR 0.52, 95% CI 0.37-0.72; 15 studies, 4,726 participants) and of postoperative fever (9.4% compared with 14.9%; RR 0.65, 95% CI 0.50-0.86; 11 studies, 4,098 participants) compared with the control group. In the planned subgroup analyses, the reduction in the incidence of endometritis with vaginal cleansing was limited to women in labor before cesarean delivery (8.1% compared with 13.8%; RR 0.52, 95% CI 0.28-0.97; four studies, 440 participants) or those with ruptured membranes (4.3% compared with 20.1%; RR 0.23, 95% CI 0.10-0.52; three studies, 272 participants). Vaginal cleansing immediately before cesarean delivery in women in labor and in women with ruptured membranes reduces the risk of postoperative endometritis. Because it is generally inexpensive and a simple intervention, we recommend preoperative vaginal preparation before cesarean delivery in these women with sponge stick preparation of povidone-iodine 10% for at least 30 seconds. More data are needed to assess whether this intervention may be also useful for cesarean deliveries performed in women not in labor and for those without ruptured membranes. PROSPERO International prospective register of systematic reviews, https://www.crd.york.ac.uk/PROSPERO/, CRD42017054843.

Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.

PubMed

Haas, David M; Morgan, Sarah; Contreras, Karenrose

2014-12-21

Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries. To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 December 2014). We included randomized and quasi-randomized trials assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post-cesarean infectious morbidity. We independently assessed eligibility and quality of the studies. Seven trials randomizing 2816 women (2635 analyzed) evaluated the effects of vaginal cleansing (all with povidone-iodine) on post-cesarean infectious morbidity. The risk of bias was generally low, with the quality of most of the studies being high. Vaginal preparation immediately before cesarean delivery significantly reduced the incidence of post-cesarean endometritis from 8.3% in control groups to 4.3% in vaginal cleansing groups (average risk ratio (RR) 0.45, 95% confidence interval (CI) 0.25 to 0.81, seven trials, 2635 women). The risk reduction was particularly strong for women who were already in labor at the time of the cesarean delivery (7.4% in the vaginal cleansing group versus 13.0% in the control group; RR 0.56, 95% CI 0.34 to 0.95, three trials, 523 women) and for women with ruptured membranes (4.3% in the vaginal cleansing group versus 17.9% in the control group; RR 0.24, 95% CI 0.10 to 0.55, three trials, 272 women). No other outcomes realized statistically significant differences between the vaginal cleansing and control groups. No adverse effects were reported with the povidone-iodine vaginal cleansing.The quality of the evidence using GRADE was low for post-cesarean endometritis, moderate for postoperative fever, and low for wound infection. Vaginal preparation with povidone-iodine solution immediately before cesarean delivery reduces the risk of postoperative endometritis. This benefit is particularly realized for women undergoing cesarean delivery, who are already in labor or who have ruptured membranes. As a simple, generally inexpensive intervention, providers should consider implementing preoperative vaginal cleansing with povidone-iodine before performing cesarean deliveries.

The impact of mode of delivery on outcomes in patients with perianal Crohn's disease

PubMed Central

Cheng, Alice G; Oxford, Emily C; Sauk, Jenny; Nguyen, Deanna D; Yajnik, Vijay; Friedman, Sonia; Ananthakrishnan, Ashwin N

2014-01-01

Introduction Crohn's disease (CD) often affects women during the reproductive years. While several studies have examined the impact of pregnancy on luminal disease, limited literature exists in those with perianal CD. Decision regarding mode of delivery is a unique challenge in such patients due to concerns regarding the effect of pelvic floor trauma during delivery on pre-existing perianal involvement. Methods We performed a retrospective chart review of CD patients with established perianal disease undergoing either vaginal delivery or Caesarean section (C-section) at our institutions. We examined the occurrence of symptomatic perianal disease flares within 5 years after delivery in such women compared to non-pregnant CD controls. We also compared the occurrence of such flares between the two modes of delivery in women with established perianal CD. Results We identified 61 pregnant CD patients with established perianal disease (11 vaginal delivery, 50 via C-section) and 61 non-pregnant CD controls with perianal disease. One-third of the C-sections were primarily for obstetric indications. Six of the vaginal deliveries were complicated. Approximately 36% of cases had a symptomatic perianal flare within 1 year after delivery. This was similar across both modes of delivery (p=0.53), and similar to non-pregnant CD patients. There was no difference in the rates of perianal surgical intervention or luminal disease flares in our population based on mode of delivery, or between pregnant CD patients and non-pregnant CD controls. Conclusion We observed no difference in risk of symptomatic perianal flares in patients with established perianal CD delivering vaginally or via C-section. PMID:24918322

Neurological outcomes by mode of delivery for fetuses with open neural tube defects: A systematic review and meta-analysis.

PubMed

Tolcher, Mary C; Shazly, Sherif A; Shamshirsaz, Alireza A; Whitehead, William E; Espinoza, Jimmy; Vidaeff, Alex C; Belfort, Michael A; Nassr, Ahmed A

2018-06-20

Controversy exists regarding the optimal mode of delivery for fetuses with open neural tube defects. To compare neurological outcomes among infants with open neural tube defects who underwent vaginal compared to caesarean delivery. Electronic databases MEDLINE, EMBASE, Scopus, and Clinicaltrials. gov were searched from inception to November 2017. Eligible studies included observational or randomised studies comparing vaginal and caesarean delivery in pregnancies with fetal open neural tube defects who did not undergo prenatal repair. Two reviewers independently reviewed abstracts and full text articles. Outcomes were compared between vaginal and caesarean delivery and prelabour caesarean versus labour. The primary outcome was motor-anatomic level difference. Secondary outcomes included shunt requirement, sac disruption, meningitis, and ambulation at 2 years. Meta-analysis was performed and mean difference or odds ratios with 95% confidence interval calculated. Of 201 abstracts identified in the primary search, 9 studies (672 women) met eligibility criteria. Comparing vaginal and caesarean delivery, there was no significant difference in motor-anatomic level difference (mean difference -0.10, 95% CI -0.58-0.38; I 2 =57%). The vaginal delivery group was less likely to require a shunt or have sac disruption (OR 0.37, 95% CI 0.14-0.95 and OR 0.46, 95% CI 0.23-0.90, respectively). Comparisons by prelabour caesarean versus labour showed no significant difference in motor-anatomic level difference (OR 1.29, 95% CI -0.63-3.21) or ambulation at 2 years (OR 2.13, 95% CI 0.35-13.12). Caesarean delivery was not associated with improved neurological outcomes among fetuses with open neural tube defects. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Evaluation of third-degree and fourth-degree laceration rates as quality indicators.

PubMed

Friedman, Alexander M; Ananth, Cande V; Prendergast, Eri; D'Alton, Mary E; Wright, Jason D

2015-04-01

To examine the patterns and predictors of third-degree and fourth-degree laceration in women undergoing vaginal delivery. We identified a population-based cohort of women in the United States who underwent a vaginal delivery between 1998 and 2010 using the Nationwide Inpatient Sample. Multivariable log-linear regression models were developed to account for patient, obstetric, and hospital factors related to lacerations. Between-hospital variability of laceration rates was calculated using generalized log-linear mixed models. Among 7,096,056 women who underwent vaginal delivery in 3,070 hospitals, 3.3% (n=232,762) had a third-degree laceration and 1.1% (n=76,347) had a fourth-degree laceration. In an adjusted model for fourth-degree lacerations, important risk factors included shoulder dystocia and forceps and vacuum deliveries with and without episiotomy. Other demographic, obstetric, medical, and hospital variables, although statistically significant, were not major determinants of lacerations. Risk factors in a multivariable model for third-degree lacerations were similar to those in the fourth-degree model. Regression analysis of hospital rates (n=3,070) of lacerations demonstrated limited between-hospital variation. Risk of third-degree and fourth-degree laceration was most strongly related to operative delivery and shoulder dystocia. Between-hospital variation was limited. Given these findings and that the most modifiable practice related to lacerations would be reduction in operative vaginal deliveries (and a possible increase in cesarean delivery), third-degree and fourth-degree laceration rates may be a quality metric of limited utility.

Vaginal biological and sexual health--the unmet needs.

PubMed

Graziottin, A

2015-01-01

The vagina is a most neglected organ. It is usually clinically considered with a minimalistic view, as a 'connecting tube' for a number of physiologic functions: passage of menstrual blood, intercourse, natural conception and delivery. Unmet needs include, but are not limited to, respect of vaginal physiologic biofilms; diagnosis and care of the optimal tone of the levator ani, which surrounds and partly support it; care of its anatomic integrity at and after delivery and at pelvic/vaginal surgery; care of long-term consequences of pelvic radiotherapy; long-term care of the atrophic changes it will undergo after the menopause, unless appropriate, at least local, estrogen therapy is used; appreciation and respect of its erotic meaning, as a loving, receptive, 'bonding' organ for the couple. The vaginal erotic value is key as a non-visible powerful center of femininity and sexuality, deeply and secretly attractive in terms of taste, scent (together with the vulva), touch and proprioception. The most welcoming when lubrication, softness and vaginal orgasm award the woman and the partner with the best of pleasures. Prevention of sexual/vaginal abuse is a very neglected unmet need, as well. Who cares?

Preterm induction of labor: predictors of vaginal delivery and labor curves.

PubMed

Feghali, Maisa; Timofeev, Julia; Huang, Chun-Chih; Driggers, Rita; Miodovnik, Menachem; Landy, Helain J; Umans, Jason G

2015-01-01

The purpose of this study was to evaluate the labor curves of patients who undergo preterm induction of labor (IOL) and to assess possible predictors of vaginal delivery (VD). Data from the National Institute of Child Health and Human Development Consortium on Safe Labor were analyzed. A total of 6555 women who underwent medically indicated IOL at <37 weeks of gestation were included in this analysis. Patients were divided into 4 groups based on gestational age (GA): group A, 24-27+6 weeks; B, 28-30+6 weeks; C, 31-33+6 weeks; and D, 34-36+6 weeks. Pregnant women with a contraindication to VD, IOL ≥37 weeks of gestation, and without data from cervical examination on admission were excluded. Analysis of variance was used to assess differences between GA groups. Multiple logistic regression was used to assess predictors of VD. A repeated measures analysis was used to determine average labor curves. Rates of vaginal live births increased with GA, from 35% (group A) to 76% (group D). Parous women (odds ratio, 6.78; 95% confidence interval, 6.38-7.21) and those with a favorable cervix at the start of IOL (odds ratio, 2.35; 95% confidence interval, 2.23-2.48) were more likely to deliver vaginally. Analysis of labor curves in nulliparous women showed shorter duration of labor with increasing GA; the active phase of labor was, however, similar across all GAs. Most women who undergo medically indicated preterm IOL between 24 and 36+6 weeks of gestation deliver vaginally. The strongest predictor of VD was parity. Preterm IOL had a limited influence on estimated labor curves across GAs. Copyright © 2015 Elsevier Inc. All rights reserved.

Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study

PubMed Central

Carroli, Guillermo; Zavaleta, Nelly; Donner, Allan; Wojdyla, Daniel; Faundes, Anibal; Velazco, Alejandro; Bataglia, Vicente; Langer, Ana; Narváez, Alberto; Valladares, Eliette; Shah, Archana; Campodónico, Liana; Romero, Mariana; Reynoso, Sofia; de Pádua, Karla Simônia; Giordano, Daniel; Kublickas, Marius; Acosta, Arnaldo

2007-01-01

Objective To assess the risks and benefits associated with caesarean delivery compared with vaginal delivery. Design Prospective cohort study within the 2005 WHO global survey on maternal and perinatal health. Setting 410 health facilities in 24 areas in eight randomly selected Latin American countries; 123 were randomly selected and 120 participated and provided data Participants 106 546 deliveries reported during the three month study period, with data available for 97 095 (91% coverage). Main outcome measures Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics. Results Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6), respectively), which remained higher even after exclusion of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective. Conclusions Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations. PMID:17977819

Impact of Bacterial Vaginosis on Perineal Tears during Delivery: A Prospective Cohort Study

PubMed Central

Letouzey, Vincent; Bastide, Sophie; Ulrich, Daniela; Beccera, Laurie; Lomma, Mariella; de Tayrac, Renaud; Lavigne, Jean Philippe

2015-01-01

Objective Long term effects of perineal tears pose a major worldwide health issue for women during delivery. Since bacterial vaginosis is related to major obstacles in obstetrics the aim of this study was to determine the relationship between bacterial vaginosis and the occurrence of perineal tears during vaginal delivery. Methods Between June 2013 and December 2013 pregnant women delivering after 37 weeks were recruited at one University hospital / tertiary care referral center in the course of this single-center, prospective cohort study. Bacterial vaginosis was assessed according to Nugent score method. Logistic-regression model was used to estimate odds ratios, adjusted for other risk factors to test the relationship between bacterial vaginosis and the occurrence of 1st to 4th degree perineal tears in women undergoing vaginal delivery. Results A total of 728 woman were included, 662 analyzed with a complete Nugent Score of the vaginal swab. The prevalence of 1st to 4th degree perineal tears was 35.8% (95% Confidence Interval (95%CI) = [32.2; 39.6]). The presence of BV was not significantly associated to the incidence of perineal tears neither in the univariate analysis (crude Odds Ratio = 1.43; 95%CI = [0.79; 2.60]; p = 0.235) nor in the multivariate analysis (adjusted Odds Ratio = 1.65; 95%CI = [0.81; 3.36]; p = 0.167). Instrumental delivery was the most important risk factor for perineal lacerations. Conclusions There is no evidence that vaginosis is a risk factor for vaginal tears. Trial Registration ClinicalTrials.gov N° NCT01822782 PMID:26544959

Duration of second stage of labor and instrumental delivery as risk factors for severe perineal lacerations: population-based study.

PubMed

Simic, Marija; Cnattingius, Sven; Petersson, Gunnar; Sandström, Anna; Stephansson, Olof

2017-02-21

We sought to investigate the impact of the duration of second stage of labor on risk of severe perineal lacerations (third and fourth degree). This population based cohort study was conducted in the Stockholm/Gotland region, Sweden, 2008-2014. Study population included 52 211 primiparous women undergoing vaginal delivery with cephalic presentation at term. Unconditional logistic regression analysis was used to calculate crude and adjusted odds ratios (OR), using 95% confidence intervals (CI). Main exposure was duration of second stage of labor, and main outcome was risks of severe perineal lacerations (third and fourth degree). Risk of severe perineal lacerations increased with duration of second stage of labor. Compared with a second stage of labor of 1 h or less, women with a second stage of more than 2 h had an increased risk (aOR 1.42; 95% CI 1.28-1.58). Compared with non-instrumental vaginal deliveries, the risk was elevated among instrumental vaginal deliveries (aOR 2.24; 95% CI 2.07-2.42). The risk of perineal laceration increased with duration of second stage of labor until less than 3 h in both instrumental and non-instrumental vaginal deliveries, but after 3 h, the ORs did not further increase. After adjustments for potential confounders, macrosomia (birth weight > 4 500 g) and occiput posterior fetal position were risk factors of severe perineal lacerations. The risk of severe perineal laceration increases with duration until the third hour of second stage of labor. Instrumental delivery is the most significant risk factor for severe lacerations, followed by duration of second stage of labor, fetal size and occiput posterior fetal position.

Women's perceptions, expectations and satisfaction with induced labour--a questionnaire-based study.

PubMed

Shetty, Ashalatha; Burt, Rhona; Rice, Pat; Templeton, Allan

2005-11-01

To evaluate the understanding and expectations of women undergoing labour induction, to assess their actual experience of the process and to compare their satisfaction with labour to those labouring spontaneously. Four hundred and fifty women at term undergoing induction of labour and cervical ripening with prostaglandinE2 vaginal tablets and 450 women labouring spontaneously were recruited into the study. The induction group were requested to complete a questionnaire prior to the start of their induction process and another questionnaire post-delivery. The post-delivery questionnaire contained two sections, one pertaining to issues to do with the induction and the second with the actual labour process. The spontaneously labouring group was requested to complete a questionnaire post-delivery, which only contained the section pertaining to the actual labour process. The main outcome measures were satisfaction with labour, perception of pain and length of labour between the induced and spontaneous labour groups, and issues that the women might wish changed about their induction. In the induction group, 34.7% were not satisfied with the information they received about the induction prior to the procedure and 27.2% expected to deliver within 12h of the administration of the inducing agent. Post-induction, 40% of the women felt the most important aspect they would like to change about their induction were they to have another one, would be the speed of the induction, 13.6% felt they might wish to take the inducing agent orally, 7% to have fewer vaginal examinations and 9% to have fewer complications. Among the women who returned questionnaires, 26.3% had a caesarean delivery in the induction group and 21.4% in the spontaneous labour group. Significantly more women were satisfied with their labour in the spontaneous labour group 79.5% versus 70.4%, RR 0.89, 95% CI 0.8-0.96, P=0.006). Labour that is artificially induced does result in lower satisfaction rates as compared to that following spontaneous onset. The longer time delay between the start of the induction and the delivery plays a significant part in this, with the mode of administration of the inducing agent, more vaginal examinations and the increase in caesarean deliveries being perceived as secondary issues. There is a need to improve the information provided to women undergoing labour induction, to counter unrealistic expectations and thereby improve satisfaction.

Finite element model focused on stress distribution in the levator ani muscle during vaginal delivery.

PubMed

Krofta, Ladislav; Havelková, Linda; Urbánková, Iva; Krčmář, Michal; Hynčík, Luděk; Feyereisl, Jaroslav

2017-02-01

During vaginal delivery, the levator ani muscle (LAM) undergoes severe deformation. This stress can lead to stretch-related LAM injuries. The objective of this study was to develop a sophisticated MRI-based model to simulate changes in the LAM during vaginal delivery. A 3D finite element model of the female pelvic floor and fetal head was developed. The model geometry was based on MRI data from a nulliparous woman and 1-day-old neonate. Material parameters were estimated using uniaxial test data from the literature and by least-square minimization method. The boundary conditions reflected all anatomical constraints and supports. A simulation of vaginal delivery with regard to the cardinal movements of labor was then performed. The mean stress values in the iliococcygeus portion of the LAM during fetal head extension were 4.91-7.93 MPa. The highest stress values were induced in the pubovisceral and puborectal LAM portions (mean 27.46 MPa) at the outset of fetal head extension. The last LAM subdivision engaged in the changes in stress was the posteromedial section of the puborectal muscle. The mean stress values were 16.89 MPa at the end of fetal head extension. The LAM was elongated by nearly 2.5 times from its initial resting position. The cardinal movements of labor significantly affect the subsequent heterogeneous stress distribution in the LAM. The absolute stress values were highest in portions of the muscle that arise from the pubic bone. These areas are at the highest risk for muscle injuries with long-term complications.

Risk factors for cesarean section and instrumental vaginal delivery after successful external cephalic version.

PubMed

de Hundt, Marcella; Vlemmix, Floortje; Bais, Joke M J; de Groot, Christianne J; Mol, Ben Willem; Kok, Marjolein

2016-01-01

Aim of this article is to examine if we could identify factors that predict cesarean section and instrumental vaginal delivery in women who had a successful external cephalic version. We used data from a previous randomized trial among 25 hospitals and their referring midwife practices in the Netherlands. With the data of this trial, we performed a cohort study among women attempting vaginal delivery after successful ECV. We evaluated whether maternal age, gestational age, parity, time interval between ECV and delivery, birth weight, neonatal gender, and induction of labor were predictive for a vaginal delivery on one hand or a CS or instrumental vaginal delivery on the other hand. Unadjusted and adjusted odds ratios were calculated with univariate and multivariate logistic regression analysis. Among 301 women who attempted vaginal delivery after a successful external cephalic version attempt, the cesarean section rate was 13% and the instrumental vaginal delivery rate 6%, resulting in a combined instrumental delivery rate of 19%. Nulliparity increased the risk of cesarean section (OR 2.7 (95% CI 1.2-6.1)) and instrumental delivery (OR 4.2 (95% CI 2.1-8.6)). Maternal age, gestational age at delivery, time interval between external cephalic version and delivery, birth weight and neonatal gender did not contribute to the prediction of failed spontaneous vaginal delivery. In our cohort of 301 women with a successful external cephalic version, nulliparity was the only one of seven factors that predicted the risk for cesarean section and instrumental vaginal delivery.

Variation in vaginal breech delivery rates by hospital type.

PubMed

Gregory, K D; Korst, L M; Krychman, M; Cane, P; Platt, L D

2001-03-01

To relate vaginal breech delivery rates to the following hospital types: public, health maintenance organization, private teaching, or private nonteaching. In a retrospective study using administrative discharge data from Los Angeles County, California, we calculated the vaginal breech delivery rates of singleton breech deliveries during calendar years 1988 and 1991. Ten thousand four hundred breech deliveries were identified, 8988 (86.4%) term and 1412 (13.6%) preterm. Twelve percent (1252 of 10,400) were vaginal deliveries (10.1% term and 24.5% preterm). Term vaginal breech deliveries varied by hospital type and were more frequent in public hospitals (28.4%, 95% confidence interval [CI] 26.1%, 30.7%) and less frequent in private nonteaching hospitals (5.4%, 95% CI 4.8%, 5.9%). Term vaginal deliveries were 2.4 to 11.3 times more likely among black women and 1.3 to 6.3 times more likely for Hispanic women across all hospital types, compared with white women in private nonteaching hospitals. There was no difference in the proportion of preterm vaginal breech deliveries by hospital type (mean 24.5%). However, with the exception of public hospitals, the proportion of vaginal breech deliveries for both term and preterm deliveries varied significantly by ethnicity. The use of vaginal breech delivery varied by hospital type and patient ethnicity. Within private teaching and nonteaching hospitals, vaginal breech delivery was more likely for black women than for women of other ethnic groups. Further study is needed to understand the hospital policies or organizational factors, as well as the patient-related sociocultural and clinical factors, that contribute to those differences.

Undiagnosed vertebral hemangioma causing a lumbar compression fracture and epidural hematoma in a parturient undergoing vaginal delivery under epidural analgesia: a case report.

PubMed

Staikou, Chryssoula; Stamelos, Matthaios; Boutas, Ioannis; Koutoulidis, Vassileios

2015-08-01

Vertebral hemangiomas are benign vascular tumours of the bony spine which are usually asymptomatic. Pregnancy-related anatomical and hormonal changes may lead to expansion of hemangiomas and development of neurological symptoms. We present an unusual case of vertebral fracture due to an undiagnosed hemangioma presenting as postpartum back pain following epidural analgesia. A multiparous female with an unremarkable history developed intense lumbar pain after vaginal delivery under epidural analgesia. The pain was attributed to tissue trauma associated with the epidural technique. The patient had no clinical improvement with analgesics, and her symptoms deteriorated over the following days. A magnetic resonance imaging scan revealed an acute fracture of the second lumbar vertebra (L2) with epidural extension and mild compression of the dural sac, suggesting hemangioma as the underlying cause. The patient underwent successful spinal surgery with pedicle screw fixation to stabilize the fracture. Vertebral fractures secondary to acute expansion of a vertebral hemangioma rarely occur during vaginal delivery. In such cases, the labour epidural technique and analgesia may challenge the physician in making the diagnosis. Postpartum severe back pain should be thoroughly investigated even in the absence of neurological deficits, and osseous spinal pathology should be considered in the differential diagnosis.

Clinical Factors Associated With Presentation Change of the Second Twin After Vaginal Delivery of the First Twin.

PubMed

Panelli, Danielle M; Easter, Sarah Rae; Bibbo, Carolina; Robinson, Julian N; Carusi, Daniela A

2017-11-01

To identify clinical factors associated with a change from vertex to nonvertex presentation in the second twin after vaginal birth of the first. We assembled a retrospective cohort of women with viable vertex-vertex twin pregnancies who delivered the presenting twin vaginally. Women whose second twin changed from vertex to nonvertex after vaginal birth of the first were classified as experiencing an intrapartum change in presentation. Characteristics associated with intrapartum presentation change in a univariate analysis with a P value ≤.10 were then evaluated in a multivariate logistic regression model. Four-hundred fifty women met inclusion criteria, of whom 55 (12%) had intrapartum presentation change of the second twin. Women experiencing intrapartum presentation change were more likely to be multiparous (69% compared with 47%, P<.01) and to have had a change in the presentation of the second twin between the most recent antepartum ultrasonogram and the ultrasonogram done on admission to labor and delivery (11% compared with 4%, P=.04). In an adjusted analysis, multiparity and gestational age less than 34 weeks were significantly associated with presentation change (adjusted odds ratio [OR] 2.9, 95% CI 1.5-5.6 and adjusted OR 2.6, 95% CI 1.1-5.9, respectively). Women with intrapartum presentation change were more likely to undergo cesarean delivery for their second twin (44% compared with 7%, P<.01) with an adjusted OR of 10.50 (95% CI 5.20-21.20) compared with those with stable intrapartum presentation. Twenty of the 24 (83%) cesarean deliveries performed in the intrapartum presentation change group were done for issues related to malpresentation. Multiparity and gestational age less than 34 weeks are associated with intrapartum presentation change of the second twin.

Lactate in Amniotic Fluid: Predictor of Labor Outcome in Oxytocin-Augmented Primiparas’ Deliveries

PubMed Central

Pembe, Andrea B.; Järnbert-Pettersson, Hans; Norman, Margareta; Wihlbäck, Anna-Carin; Hoesli, Irene; Todesco Bernasconi, Monya; Azria, Elie; Åkerud, Helena; Darj, Elisabet

2016-01-01

Background One of the major complications related to delivery is labor dystocia, or an arrested labor progress. Many dystocic deliveries end vaginally after administration of oxytocin, but a large numbers of women with labor dystocia will undergo a long and unsafe parturition. As a result of the exertion required in labor, the uterus produces lactate. The uterine production of lactate is mirrored by the level of lactate in amniotic fluid (AFL). Objectives To evaluate whether the level of AFL, analysed in a sample of amniotic fluid collected vaginally at arrested labor when oxytocin was needed, could predict labor outcome in nulliparous deliveries. Methods A prospective multicentre study including 3000 healthy primiparous women all with a singleton pregnancy, gestational age 37 to 42 weeks and no maternal /fetal chronic and/or pregnancy-related conditions. A spontaneous onset of labor, regular contractions and cervical dilation ≥ 3 cm were required before the women were invited to take part in the study. Results AFL, analysed within 30 minutes before augmentation, provides information about delivery outcome. Sensitivity for an acute cesarean section according to high (≥10.1mmol/l) or low (< 10.1mmol/l) AFL values was 39.0% (95% CI; 27–50), specificity 90.3% (95% CI; 87–93) PPV 37.3% (95% CI; 27–48) and NPV was 91.0% (95% CI; 88–93). The overall percentage of correct predictions of delivery outcome when the AFL level was used was 83.7%. Deliveries with a high AFL-level correlated with delivery time >12h (p = 0.04), post-partum fever (>38°C, p = 0.01) and post-partum haemorrhage >1.5L (p = 0.04). Conclusion The AFL is a good predictor of delivery outcome in arrested nulliparous deliveries. Low levels of AFL may support the decision to continue a prolonged vaginal labor by augmentation with oxytocin. A high level of AFL correlates with operative interventions and post-partum complications. PMID:27783611

Comparison of outcomes between operative vaginal deliveries and spontaneous vaginal deliveries in southeast Nigeria.

PubMed

Lawani, Lucky O; Anozie, Okechukwu B; Ezeonu, Paul O; Iyoke, Chukwuemeka A

2014-06-01

To evaluate the incidence of, indications for, and outcome of operative vaginal deliveries compared with spontaneous vaginal deliveries in southeast Nigeria. A retrospective cohort study was conducted involving cases of operative vaginal delivery performed at Ebonyi State University Teaching Hospital over a 10-year period. Data on the procedures were abstracted from the operation notes of the medical records of parturients. An incidence of 4.7% (n = 461) was recorded. The most common indications for vacuum and forceps delivery were prolonged second stage of labor (44.9%) and poor maternal effort (27.8%). The only indication for destructive operation was intrauterine fetal death (3.7%). The risk ratio (RR) for hemorrhage/vulvar hematoma was 1.14 (95% confidence interval [CI], 0.53-2.48) for vacuum-assisted delivery and 5.49 (95% CI, 0.82-36.64) for forceps delivery. The RR for genital laceration was 1.21 (95% CI, 0.44-3.30) for vacuum-assisted delivery and 9.41 (95% CI, 1.33-66.65) for forceps delivery. The risk of fetal scalp bruises and caput succedaneum was higher for operative vaginal delivery than for spontaneous vaginal delivery, with no significant difference in maternal morbidity. The perinatal mortality rate was 0.9 per 1000 live births. Operative vaginal delivery by experienced healthcare providers is associated with good obstetric outcomes with minimal risk. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Labor patterns in women attempting vaginal birth after cesarean with normal neonatal outcomes.

PubMed

Grantz, Katherine L; Gonzalez-Quintero, Victor; Troendle, James; Reddy, Uma M; Hinkle, Stefanie N; Kominiarek, Michelle A; Lu, Zhaohui; Zhang, Jun

2015-08-01

We sought to describe labor patterns in women with a trial of labor after cesarean (TOLAC) with normal neonatal outcomes. In a retrospective observational study at 12 US centers (2002 through 2008), we examined time interval for each centimeter of cervical dilation and compared labor progression stratified by spontaneous or induced labor in 2892 multiparous women with TOLAC (second delivery) and 56,301 nulliparous women at 37 0/7 to 41 6/7 weeks of gestation. Analyses were performed including women with intrapartum cesarean delivery, and also limiting only to women who delivered vaginally. Labor was induced in 23.4% of TOLAC and 44.1% of nulliparous women (P < .001). Cesarean delivery rates were 57.7% in TOLAC vs 19.0% in nulliparous women (P < .001). Oxytocin was used in 52.4% of TOLAC vs 64.3% of nulliparous women with spontaneous labor (P < .001) and 89.8% of TOLAC vs 91.6% of nulliparous women with induced labor (P = .099); however, TOLAC had lower maximum doses of oxytocin compared to nulliparous women: median (90th percentile): 6 (18) mU/min vs 12 (28) mU/min, respectively (P < .001). Median (95th percentile) labor duration for TOLAC vs nulliparous women with spontaneous labor from 4-10 cm was 0.9 (2.2) hours longer (P = .007). For women who entered labor spontaneously and achieved vaginal delivery, labor patterns for TOLAC were similar to nulliparous women. For induced labor, labor duration for TOLAC vs nulliparous women from 4-10 cm was 1.5 (4.6) hours longer (P < .001). For women who achieved vaginal delivery, labor patterns were slower for induced TOLAC compared to nulliparous women. Labor duration for TOLAC was slower compared to nulliparous labor, particularly for induced labor. By improved understanding of the rates of progress at different points in labor, this new information on labor curves in women undergoing TOLAC, particularly for induction, should help physicians when managing labor. Published by Elsevier Inc.

An Audit of Singleton Breech Deliveries in a Hospital with a High Rate of Vaginal Delivery

PubMed Central

Nordin, Noraihan Mohd.

2007-01-01

The term breech trial (TBT) has brought about radical changes but it is debatable whether it provides unequivocal evidence regarding the practice of breech deliveries. There is a need to publish the data of a study that was performed before the era of the TBT in a hospital where there was a high rate of breech vaginal delivery. The objectives were to ascertain the incidence, mode of delivery and fetal outcome in singleton breech deliveries. The study design was a retrospective cohort study where 165 consecutive breech and 165 controls (cephalic) were included. Statistical analysis, used were Chi squared and Fischer’s exact test. P<0.05 is taken as the level of significance. The incidence of breech deliveries was found to be 3% and has remained fairly constant but the rate of breech vaginal delivery has fallen and the CS rates have increased. Even though more breech compared to controls were significantly sectioned, majority of the breeches {n=137 (83%)} were planned for vaginal delivery and in these patients two-thirds attained vaginal delivery. There was 1 fetal death in the CS group compared to 12 deaths in the vaginally delivered breech. However, most death in the breech delivered vaginally are unavoidable. In conclusion, there is a high rate of breech vaginal delivery in this series of patients and most perinatal deaths were not related to the mode of delivery. PMID:22593649

Delays in the delivery room of a primary maternity unit: a retrospective analysis of obstetric outcomes.

PubMed

Giannella, Luca; Mfuta, Kabala; Pedroni, Deborah; Delrio, Elisabetta; Venuta, Agnese; Bergamini, Ezio; Cerami, Lillo B

2013-04-01

To compare obstetric outcomes in women undergoing vaginal delivery with or without delay in the 2nd and 3rd stage of labour (SOL). This is an observational retrospective study including 10,416 full-term vaginal deliveries occurred at a primary obstetric unit. Our sample was divided according to the length of 2nd and 3rd SOL: >2 h vs. ≤2 h; and >1 h vs. ≤1 h, respectively. Obstetric outcomes were compared using univariate and multivariate analysis. A prolonged 2nd SOL was associated with severe perineal tears (odds ratio (OR) = 3.53), episiotomy (OR = 3.25), major post-partum hemorrhage (PPH) (OR = 2.35), operative delivery (OR = 3.54), and Asian ethnicity (OR = 12.12). Likewise, a prolonged 3rd SOL was associated with operative deliveries (OR = 10.49), labor induction (OR = 3.24), non-use of oxytocin after delivery (OR = 12.39), major PPH (OR = 46.95), retained placenta (OR = 3.57) and female fetal gender (OR = 4.07). even at a primary care setting, where there are mostly low-risk pregnancies, a prolonged 2nd and 3rd SOL may occur and lead to poor obstetric outcomes. Our findings raise a very controversial issue about the meaning of "low obstetrics risk", given the unpredictability of any labor, and the management of complications in the delivery room of primary maternity units.

Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery.

PubMed

Lutgendorf, Monica A; Schindler, Lynnett L; Hill, James B; Magann, Everett F; O'Boyle, John D

2011-06-01

Retained sponges (gossypiboma) following vaginal delivery are an uncommon occurrence. Although significant morbidity from such an event is unlikely, there are many reported adverse effects, including symptoms of malodorous discharge, loss of confidence in providers and the medical system, and legal claims. To report a protocol intended to reduce the occurrence of retained sponges following vaginal delivery. After identification of limitations with existing delivery room protocols, we developed a sponge count protocol to reduce occurrence of retained vaginal sponges. We report our experience at Naval Medical Center Portsmouth, a large tertiary care military treatment facility with our efforts to implement a sponge count protocol to reduce retained sponges following vaginal delivery. With appropriate pre-implementation training, protocols which incorporate post-delivery vaginal sweep and sponge counts are well accepted by the health care team and can be incorporated into the delivery room routine.

Assisted Vaginal Delivery

MedlinePlus

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Vaginal breech delivery: results of a prospective registration study

PubMed Central

2013-01-01

Background Most countries recommend planned cesarean section in breech deliveries, which is considered safer than vaginal delivery. As one of few countries in the western world Norway has continued to practice planned vaginal delivery in selected women. The aim of this study is to evaluate prospectively registered neonatal and maternal outcomes in term singleton breech deliveries in a Norwegian hospital during a ten years period. We aim to compare maternal and neonatal outcomes in term breech pregnancies subjected either to planned vaginal or elective cesarean section. Methods A prospective registration study including 568 women with term breech deliveries (>37 weeks) consecutively registered at Sorlandet Hospital Kristiansand between 2001 and 2011. Fetal and maternal outcomes were compared according to delivery method; planned vaginal delivery versus planned cesarean section. Results Of 568 women, elective cesarean section was planned in 279 (49%) cases and vaginal delivery was planned in 289 (51%) cases. Acute cesarean section was performed in 104 of the planned vaginal deliveries (36.3%). There were no neonatal deaths. Two cases of serious neonatal morbidity were reported in the planned vaginal group. One infant had seizures, brachial plexus injury, and cephalhematoma. The other infant had 5-minutes Apgar < 4. Twenty-nine in the planned vaginal group (10.0%) and eight in the planned cesarean section group (2.9%) (p < 0.001) were transferred to the neonatal intensive care unit. However, only one infant was admitted for ≥4 days. According to follow-up data (median six years) none of these infants had long-term sequelae. Regarding maternal morbidity, blood loss was the only variable that was significantly higher in the planned cesarean section group versus in the vaginal delivery group (p < 0.001). Conclusions Strict guidelines were followed in all cases. There were no neonatal deaths. Two infants had serious neonatal morbidity in the planned vaginal group without long-term sequelae. PMID:23883361

The immediate effect of vaginal and caesarean delivery on anal sphincter measurements.

PubMed

Karcaaltincaba, Deniz; Erkaya, Salim; Isik, Hatice; Haberal, Ali

2016-08-01

This study evaluated the effects of vaginal and caesarean delivery on internal and external anal sphincter muscle thickness using translabial ultrasonography (TL-US). This prospective cohort study enrolled nulliparous women who either had vaginal or caesarean deliveries. The thickness of the hypoechoic internal anal sphincter (IAS) and hyperechoic external anal sphincter (EAS) at the 12, 3, 6, and 9 o'clock positions at the distal level were measured before delivery and within 24-48 h after delivery. A total 105 consecutive women were enrolled in the study: 60 in the vaginal delivery group and 45 in the caesarean delivery group. The IAS muscle thickness at the 12 o'clock position in the vaginal delivery group was significantly thicker before compared with after delivery (mean ± SD: 2.31 ± 0.74 mm versus 1.81 ± 0.64 mm, respectively). The EAS muscle thickness at the 12 o'clock position in the vaginal delivery group was significantly thicker before compared with after delivery (mean ± SD: 2.42 ± 0.64 mm versus 1.97 ± 0.85, respectively). There was significant muscle thinning of both the IAS and EAS at the 12 o'clock position after vaginal delivery, but not after caesarean delivery. © The Author(s) 2016.

Postpartum urinary tract infection by mode of delivery: a Danish nationwide cohort study.

PubMed

Gundersen, Tina Djernis; Krebs, Lone; Loekkegaard, Ellen Christine Leth; Rasmussen, Steen Christian; Glavind, Julie; Clausen, Tine Dalsgaard

2018-03-14

To examine the association between postpartum urinary tract infection and intended mode of delivery as well as actual mode of delivery. Retrospective cohort study. All live births in Denmark between 2004 and 2010 (n=450 856). Births were classified by intended caesarean delivery (n=45 053) or intended vaginal delivery (n=405 803), and by actual mode of delivery: spontaneous vaginal delivery, operative vaginal delivery, emergency or planned caesarean delivery in labour or prelabour. The primary outcome measure was postpartum urinary tract infection (n=16 295) within 30 days post partum, defined as either a diagnosis of urinary tract infection in the National Patient Registry or redemption of urinary tract infection-specific antibiotics recorded in the Register of Medicinal Product Statistics. We found that 4.6% of women with intended caesarean delivery and 3.5% of women with intended vaginal delivery were treated for postpartum urinary tract infection.Women with intended caesarean delivery had a significantly increased risk of postpartum urinary tract infection compared with women with intended vaginal delivery (OR 1.33, 95% CI 1.27 to 1.40), after adjustment for age at delivery, smoking, body mass index, educational level, gestational diabetes mellitus, infection during pregnancy, birth weight, preterm delivery, preterm prelabour rupture of membranes, pre-eclampsia, parity and previous caesarean delivery (adjusted OR 1.24, 95% CI 1.17 to 1.46).Using actual mode of delivery as exposure, all types of operative delivery had an equally increased risk of postpartum urinary tract infection compared with spontaneous vaginal delivery. Compared with intended vaginal delivery, intended caesarean delivery was significantly associated with a higher risk of postpartum urinary tract infection. Future studies should focus on reducing routine catheterisation prior to operative vaginal delivery as well as improving procedures related to catheterisation. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Postpartum urinary tract infection by mode of delivery: a Danish nationwide cohort study

PubMed Central

Krebs, Lone; Loekkegaard, Ellen Christine Leth; Rasmussen, Steen Christian; Glavind, Julie; Clausen, Tine Dalsgaard

2018-01-01

Objectives To examine the association between postpartum urinary tract infection and intended mode of delivery as well as actual mode of delivery. Design Retrospective cohort study. Setting and participants All live births in Denmark between 2004 and 2010 (n=450 856). Births were classified by intended caesarean delivery (n=45 053) or intended vaginal delivery (n=405 803), and by actual mode of delivery: spontaneous vaginal delivery, operative vaginal delivery, emergency or planned caesarean delivery in labour or prelabour. Primary and secondary outcome measures The primary outcome measure was postpartum urinary tract infection (n=16 295) within 30 days post partum, defined as either a diagnosis of urinary tract infection in the National Patient Registry or redemption of urinary tract infection-specific antibiotics recorded in the Register of Medicinal Product Statistics. Results We found that 4.6% of women with intended caesarean delivery and 3.5% of women with intended vaginal delivery were treated for postpartum urinary tract infection. Women with intended caesarean delivery had a significantly increased risk of postpartum urinary tract infection compared with women with intended vaginal delivery (OR 1.33, 95% CI 1.27 to 1.40), after adjustment for age at delivery, smoking, body mass index, educational level, gestational diabetes mellitus, infection during pregnancy, birth weight, preterm delivery, preterm prelabour rupture of membranes, pre-eclampsia, parity and previous caesarean delivery (adjusted OR 1.24, 95% CI 1.17 to 1.46). Using actual mode of delivery as exposure, all types of operative delivery had an equally increased risk of postpartum urinary tract infection compared with spontaneous vaginal delivery. Conclusions Compared with intended vaginal delivery, intended caesarean delivery was significantly associated with a higher risk of postpartum urinary tract infection. Future studies should focus on reducing routine catheterisation prior to operative vaginal delivery as well as improving procedures related to catheterisation. PMID:29540408

Obstetrician call schedule and obstetric outcomes among women eligible for a trial of labor after cesarean.

PubMed

Yee, Lynn M; Liu, Lilly Y; Grobman, William A

2017-01-01

Reducing cesarean deliveries is a major public health goal. The low rate of vaginal birth after cesarean has been attributed largely to a decrease in the likelihood of choosing a trial of labor after cesarean, despite evidence suggesting a majority of women with 1 prior low transverse cesarean are trial of labor after cesarean candidates. Although a number of reasons for this decrease have been explored, it remains unclear how systems issues such as physician call schedules influence delivery approach and mode in this context. The objective of the study was to investigate the relationship between obstetricians' call schedule and obstetric outcomes among women eligible for a trial of labor after cesarean. This is a retrospective cohort study of the likelihood of attempting a trial of labor after cesarean and achieving vaginal birth after cesarean among women with 1 prior low transverse cesarean delivery and a term, cephalic singleton gestation based on the delivering provider's call schedule. Attending obstetrician call schedules were classified as traditional or night float call. Night float call was defined as a schedule in which the provider had clinical responsibilities only for a day or night shift, without other clinical responsibilities before or after the period of responsibility for laboring patients. Call schedules are determined by individual provider groups. Bivariable analyses and random-effects logistic regression were used to examine the relationship between obstetricians' call schedule and the frequency of trial of labor after cesarean. Secondary outcomes including frequency of vaginal birth after cesarean and maternal and neonatal outcomes also were assessed. Of 1502 eligible patients, 556 (37%) were delivered by physicians in a night float call system. A total of 22.6% underwent a trial of labor after cesarean and 12.8% achieved vaginal birth after cesarean; the vaginal birth after cesarean rate for women attempting a trial of labor after cesarean was 56.5%. Women were more likely to undergo a trial of labor after cesarean (33.1% vs 16.5%, P < .001) and achieve vaginal birth after cesarean (18.7% vs 9.3%, P < .001) when cared for by physicians with a night float call schedule. Regression analyses demonstrated physicians with a night float call schedule remained significantly more likely to have patients undergo trial of labor after cesarean (adjusted odds ratio, 2.64, 95% confidence interval, 1.65-4.25) and experience vaginal birth after cesarean (adjusted odds ratio, 2.17, 95% confidence interval, 1.36-3.45) after adjusting for potential confounders. However, the likelihood of achieving vaginal birth after cesarean if a trial of labor after cesarean was attempted was not different based on provider call type (adjusted odds ratio, 0.96, 95% confidence interval, 0.57-1.62). Although women delivered by providers with a night float schedule were more likely to experience uterine rupture (1.8% vs 0.6%, P = .03), chorioamnionitis (4.3% vs 1.7%, P = .002), postpartum hemorrhage (7.6% vs 4.8%, P = .03), and neonates admitted to the neonatal intensive care unit (6.8% vs 3.9%, P = .01), these associations did not persist when the population was limited to women attempting trial of labor after cesarean. Although physicians working on a night float call system were significantly more likely to have patients with a prior cesarean undergo trial of labor after cesarean and achieve vaginal birth after cesarean, their patients also were more likely to experience maternal and neonatal morbidity. However, these differences did not persist when limiting analyses to women attempting a trial of labor after cesarean. Using a night float call schedule may be an effective measure to promote a trial of labor after cesarean and vaginal birth after cesarean. Copyright © 2016 Elsevier Inc. All rights reserved.

Influence of age, mode of delivery and parity on the prevalence of posterior pelvic floor dysfunctions.

PubMed

Murad-Regadas, Sthela Maria; Regadas, Francisco Sergio P; Rodrigues, Lusmar Veras; Furtado, Débora Couto; Gondim, Ana Cecília; Dealcanfreitas, Iris Daiana

2011-01-01

The correlation between vaginal delivery, age and pelvic floor dysfunctions involving obstructed defecation is still a matter of controversy. To determine the influence of age, mode of delivery and parity on the prevalence of posterior pelvic floor dysfunctions in women with obstructed defecation syndrome. Four hundred sixty-nine females with obstructed defecation syndrome were retrospectively evaluated using dynamic 3D ultrasonography to quantify posterior pelvic floor dysfunctions (rectocele grade II or III, rectal intussusception, paradoxical contraction/non-relaxation of the puborectalis and entero/ sigmoidocele grade III). In addition, sphincter damage was evaluated. Patients were grouped according to age (≤50y x >50y) and stratified by mode of delivery and parity: group I (≤50y): 218 patients, 75 nulliparous, 64 vaginal delivery and 79 only cesarean section and group II (>50y): 251 patients, 60 nulliparous, 148 vaginal delivery and 43 only caesarean section. Additionally, patients were stratified by number of vaginal deliveries: 0 - nulliparous (n = 135), 1 - vaginal (n = 46), >1 - vaginal (n = 166). Rectocele grade II or III, intussusception, rectocele + intussusception and sphincter damage were more prevalent in Group II (P = 0.0432; P = 0.0028; P = 0.0178; P = 0.0001). The stratified groups (nulliparous, vaginal delivery and cesarean) did not differ significantly with regard to rectocele, intussusception or anismus in each age group. Entero/sigmoidocele was more prevalent in the vaginal group <50y and in the nulliparous and vaginal groups >50y. No correlation was found between rectocele and the number of vaginal deliveries. Higher age (>50 years) was shown to influence the prevalence of significant rectocele, intussusception and sphincter damage in women. However, delivery mode and parity were not correlated with the prevalence of rectocele, intussusception and anismus in women with obstructed defecation.

Successful vaginal delivery at term after vaginal reconstruction with labium minus flaps in a patient with vaginal atresia: A rare case report.

PubMed

Liu, Yu; Wang, Yi-Feng

2017-07-01

We report a case of successful vaginal delivery after vaginal reconstruction with labium minus flaps in a 23-year-old patient with congenital vaginal atresia. The patient primarily presented with amenorrhea and cyclic abdominal pain; transabdominal ultrasonography revealed an enlarged uterus due to hematometra and absence of the lower segment of the vagina. Eight years ago, she had undergone an unsuccessful attempt at canalization at a local hospital. Upon referral to our hospital, she underwent vaginal reconstruction with labium minus flaps. Four months after this procedure, she became pregnant and, subsequently, successfully and safely vaginally delivered a healthy female baby weighing 3250 g at 38 +1 weeks' gestation. The delivery did not involve perineal laceration by lateral episiotomy. To the best of our knowledge, this is the first reported case of successful vaginal delivery at term after vaginal reconstruction with labium minus flaps in a patient with vaginal atresia. © 2017 Japan Society of Obstetrics and Gynecology.

Epidemiological profile and postoperative complications of women undergoing gynecological surgery in a reference center in the northern Brazilian legal Amazon.

PubMed

Coelho, Sônia Maria; Perez, Elizabeth de La Trinidad Castro; Lins, Cynthia Dantas de Macedo; Gomes, Mariano Tamura Vieira; Bella, Zsuzsanna Illona Katalin de Jármy Di; Andres, Marina de Paula; Podgaec, Sergio

2015-01-01

To evaluate the epidemiological profile and the operative complications of patients undergoing gynecological operations for benign diseases in a tertiary public hospital in the state of Roraima, Brazil. We conducted a retrospective survey through the analysis of 518 records of patients submitted to gynecological operations between January and June 2012. We included the three major operations during this period (n = 175): hysterectomy, colpoperineoplasty and suburethral sling placement. We excluded 236 cases of tubal ligation and 25 cases where it was not possible to access to medical records. The mean age was 47.6 years; the education level of most patients was completed junior high (36.6%); 77% were from the State capital, 47.4% were in stable relationships and 26.3% were housewives. The majority of patients had given birth three or more times (86.6%), with previous vaginal delivery in 50.2%, and cesarean delivery, 21%. The main diagnostic indications for surgical treatment were uterine myoma (46.3%), urinary incontinence (27.4%) and genital dystopias (17.7%). We found three cases (1.7%) of high-grade intraepithelial lesions on Pap smear. The most common procedure was total hysterectomy (19.8%), 15.5% vaginally. The most common complication was wound infection (2.2%). Women undergoing gynecological operations due to benign disease had a mean age of 47 years, most had levels of basic education, came from the capital, were in stable relationships, predominantly housewives, multiparous and showed low operative complication rates.

Childbirth after pelvic floor surgery: analysis of Hospital Episode Statistics in England, 2002-2008.

PubMed

Pradhan, A; Tincello, D G; Kearney, R

2013-01-01

To report the numbers of patients having childbirth after pelvic floor surgery in England. Retrospective analysis of Hospital Episode Statistics data. Hospital Episode Statistics database. Women, aged 20-44 years, undergoing childbirth after pelvic floor surgery between the years 2002 and 2008. Analysis of the Hospital Episode Statistics database using Office of Population, Censuses and Surveys: Classification of Interventions and Procedures, 4th Revision (OPCS-4) code at the four-character level for pelvic floor surgery and delivery, in women aged 20-44 years, between the years 2002 and 2008. Numbers of women having delivery episodes after previous pelvic floor surgery, and numbers having further pelvic floor surgery after delivery. Six hundred and three women had a delivery episode after previous pelvic floor surgery in the time period 2002-2008. In this group of 603 women, 42 had a further pelvic floor surgery episode following delivery in the same time period. The incidence of repeat surgery episode following delivery was higher in the group delivered vaginally than in those delivered by caesarean (13.6 versus 4.4%; odds ratio, 3.38; 95% confidence interval, 1.87-6.10). There were 603 women having childbirth after pelvic floor surgery in the time period 2002-2008. The incidence of further pelvic floor surgery after childbirth was lower after caesarean delivery than after vaginal delivery, and this may indicate a protective effect of abdominal delivery. © 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.

Perinatal outcomes of singleton term breech deliveries in Basra.

PubMed

Alshaheen, H; Abd Al-Karim, A

2010-01-01

This study aimed to assess the perinatal morbidity and mortality in breech deliveries, to study the correlation of parity and birth weight with perinatal mortality by mode of delivery. Of 210 women in labour in Basra maternity and child hospital, 97 underwent vaginal breech deliveries and 113 delivered by caesarean section. Birth trauma was restricted to vaginal deliveries. The perinatal mortality was significantly higher in vaginal deliveries (8.2%) compared with caesarean deliveries (0.9%). A higher perinatal mortality was recorded among infants > 3500-4000 g birth weight in vaginal deliveries. Caesarean section reduced the perinatal mortality in both nulliparous and parous women in term breech infants.

Safety of vaginal delivery among dichorionic diamniotic twins over 10 years in a UK teaching hospital.

PubMed

Rzyska, Ewelina; Ajay, Bini; Chandraharan, Edwin

2017-01-01

To determine whether vaginal delivery among dichorionic diamniotic twins remains a safe option following full implementation of the European Working Time Directive in the UK. A retrospective study was conducted using data for women with dichorionic diamniotic twin pregnancies who attended a teaching hospital in London, UK, for delivery between January 4, 2000, and December 23, 2010. Among 892 women, 474 (53.1%) attempted vaginal delivery, 220 (46.4%) of whom achieved spontaneous vaginal delivery of both twins. Instrumental vaginal delivery was performed among 89 women (18.8%), and 165 (34.8%) women underwent emergency cesarean delivery. Delivery of the second twin by emergency cesarean (n=31) was predominantly for fetal distress (13 [41.9%]) or abnormal lie (10 [32.3%]). A 5-minute Apgar score of 9 or 10 was recorded for 384 (83.7%) of 459 first twins and 369 (82.9%) of 445 second twins, irrespective of the mode of delivery. Vaginal delivery among dichorionic diamniotic twins had a good success rate and a low intrapartum emergency cesarean delivery rate. Training in cardiotocography and intrapartum procedures might further reduce the need for emergency cesarean delivery. © 2016 International Federation of Gynecology and Obstetrics.

[Progress in research of relationship between vaginal Lactobacillus and preterm delivery].

PubMed

He, Y N; Xiong, H Y; Zheng, Y J

2017-03-10

The vaginal flora in most healthy women is dominated by Lactobacillus species. The absence of Lactobacillus species in vaginal flora might lead to a series of symptoms, especially in pregnant women causing adverse pregnancy outcomes, such as preterm delivery. This review focuses on the progress in the research of the relationship between vaginal Lactobacillus and preterm delivery, providing reference for the reduction of the incidence of preterm delivery.

Vaginal delivery among women who underwent labor induction with vaginal dinoprostone (PGE2) insert: a retrospective study of 1656 women in China.

PubMed

Zhao, Lei; Lin, Ying; Jiang, Ting-Ting; Wang, Ling; Li, Min; Wang, Ying; Sun, Guo-Qiang; Xiao, Mei

2017-12-21

This study aimed to qualify relevant factors for vaginal delivery among women who underwent labor induction with vaginal dinoprostone (PGE2) insert in a Chinese tertiary maternity hospital. A retrospective study was conducted in Hubei Maternal and Child Health Hospital. A total of 1656 pregnancies that underwent labor induction with vaginal dinoprostone insert between January and August 2016 were finally included in this study. Data were analyzed using univariate and multivariable regression modeling. Of 1656 women with PGE2-induced labor at term, 396 (23.91%) gave birth by cesarean section, 1260 (76.09%) had a vaginal delivery among which 921 (55.61%) delivered vaginally within 24 h. Multivariable regression analysis showed that maternal age (p < .001, OR = 0.89, 95%CI 0.85-0.93), parity (multiparous versus nulliparous, p < .001, OR = 8.74, 95%CI 4.36-17.50), baseline fetal heart rate (p = .009, OR = 0.98, 95%CI 0.96-0.99), and birth weight (p < .001, OR = 0.37, 95%CI 0.28-0.51) were significantly correlated with vaginal delivery. Moreover, body mass index (p < .001, OR = 1.11, 95%CI 1.05-1.19), parity (multiparous versus nulliparous, p < .001, OR = 6.57, 95%CI 2.37-18.23), baseline fetal heart rate (p = .004, OR = 0.96, 95%CI 0.94-0.99), and birth weight (p < .001, OR = 0.34, 95%CI 0.21-0.54) were independent predictors of vaginal delivery within 24-h. Our findings suggested a vaginal delivery rate of 76.09% when dinoprostone vaginal insert was used for labor induction, which was markedly higher than the overall annual vaginal delivery rate of 65.1% in China during 2014. Maternal age, parity, baseline fetal heart rate, and birth weight were significant factors for vaginal delivery. This study enables us to better understand the efficiency of dinoprostone and the potential predictors of vaginal delivery in dinoprostone-induced labor, which may be helpful to guide the clinical use of dinoprostone and therefore provide better service clinically.

Mode of delivery preferences in a diverse population of pregnant women.

PubMed

Yee, Lynn M; Kaimal, Anjali J; Houston, Kathryn A; Wu, Erica; Thiet, Mari-Paule; Nakagawa, Sanae; Caughey, Aaron B; Firouzian, Atoosa; Kuppermann, Miriam

2015-03-01

The objective of the study was to assess women's preferences for vaginal vs cesarean delivery in 4 contexts: prior cesarean delivery, twins, breech presentation, and absent indication for cesarean. This was a cross-sectional study of pregnant women at 24-40 weeks' gestation. After assessing stated preferences for vaginal or cesarean delivery, we used the standard gamble metric to measure the strength of these preferences and the time tradeoff metric to determine how women value the potential processes and outcomes associated with these 2 delivery approaches. Among the 240 participants, 90.8% had a stated preference for vaginal delivery. Across the 4 contexts, these women indicated that, on average, they would accept a 59-75% chance of an attempted vaginal birth ending in a cesarean delivery before choosing a planned cesarean delivery, indicating strong preferences for spontaneous, uncomplicated vaginal delivery. Variations in preferences for labor processes emerged. Although uncomplicated labor ending in vaginal birth was assigned mean utilities of 0.993 or higher (on a 0-1 scale, with higher scores indicating more preferred outcomes), the need for oxytocin, antibiotics, or operative vaginal delivery resulted in lower mean scores, comparable with those assigned to uncomplicated cesarean delivery. Substantially lower scores (ranging from 0.432 to 0.598) were obtained for scenarios ending in severe maternal or neonatal morbidity. Although most women expressed strong preferences for vaginal delivery, their preferences regarding interventions frequently used to achieve that goal varied. These data underscore the importance of educating patients about the process of labor and delivery to facilitate incorporation of informed patient preferences in shared decision making regarding delivery approach. Copyright © 2015 Elsevier Inc. All rights reserved.

Impact of delivery mode on the colostrum microbiota composition.

PubMed

Toscano, Marco; De Grandi, Roberta; Peroni, Diego Giampietro; Grossi, Enzo; Facchin, Valentina; Comberiati, Pasquale; Drago, Lorenzo

2017-09-25

Breast milk is a rich nutrient with a temporally dynamic nature. In particular, numerous alterations in the nutritional, immunological and microbiological content occur during the transition from colostrum to mature milk. The objective of our study was to evaluate the potential impact of delivery mode on the microbiota of colostrum, at both the quantitative and qualitative levels (bacterial abundance and microbiota network). Twenty-nine Italian mothers (15 vaginal deliveries vs 14 Cesarean sections) were enrolled in the study. The microbiota of colostrum samples was analyzed by next generation sequencing (Ion Torrent Personal Genome Machine). The colostrum microbiota network associated with Cesarean section and vaginal delivery was evaluated by means of the Auto Contractive Map (AutoCM), a mathematical methodology based on Artificial Neural Network (ANN) architecture. Numerous differences between Cesarean section and vaginal delivery colostrum were observed. Vaginal delivery colostrum had a significant lower abundance of Pseudomonas spp., Staphylococcus spp. and Prevotella spp. when compared to Cesarean section colostrum samples. Furthermore, the mode of delivery had a strong influence on the microbiota network, as Cesarean section colostrum showed a higher number of bacterial hubs if compared to vaginal delivery, sharing only 5 hubs. Interestingly, the colostrum of mothers who had a Cesarean section was richer in environmental bacteria than mothers who underwent vaginal delivery. Finally, both Cesarean section and vaginal delivery colostrum contained a greater number of anaerobic bacteria genera. The mode of delivery had a large impact on the microbiota composition of colostrum. Further studies are needed to better define the meaning of the differences we observed between Cesarean section and vaginal delivery colostrum microbiota.

Induction of labor in elderly nulliparous women.

PubMed

Hadar, Eran; Hiersch, Liran; Ashwal, Eran; Chen, Rony; Wiznitzer, Arnon; Gabbay-Benziv, Rinat

2017-09-01

Maternal age is an important consideration for antenatal care, labor and delivery. We aimed to evaluate the induction of labor (IoL) failure rates among elderly nulliparous women. We conducted a retrospective analysis of all nulliparous women at 34 + 0 to 41 + 6 weeks, undergoing cervical ripening by prostaglandin E2 (PGE2) vaginal insert. Study group included elderly (≥35 years) nulliparous and control group included non-elderly (<35 years) nulliparous women. Primary outcome was IoL failure rate and secondary outcome was cesarean delivery rate. Outcomes were compared between the groups by univariate analysis followed by regression analysis to adjust results to potential confounders. Of 537 women undergoing IoL, 69 (12.8%) were elderly. The univariate analysis demonstrated no difference in IoL failure rate (26.5% versus 34.8%, p = 0.502) between groups. However, elderly nulliparous women had higher rates of cesarean delivery (36.2% versus 21.4%, p = 0.009). This difference was no longer significant after adjustment for maternal body mass index, indication for delivery, birth weight and gestational age at delivery. Among nulliparous women, older maternal age is not associated with higher rates of IoL failure or cesarean deliveries.

On the Biomechanics of Vaginal Birth and Common Sequelae

PubMed Central

Ashton-Miller, James A.; DeLancey, John O.L.

2010-01-01

Approximately 11% of U.S. women undergo surgery for pelvic floor dysfunction, including genital organ prolapse and urinary and fecal incontinence. The major risk factor for developing these conditions is giving vaginal birth. Vaginal birth is a remarkable event about which little is known from a biomechanical perspective. We first review the functional anatomy of the female pelvic floor, the normal loads acting on the pelvic floor in activities of daily living, and the functional capacity of the pelvic floor muscles. Computer models show that the stretch ratio in the pelvic floor muscles can reach an extraordinary 3.26 by the end of the second stage of labor. Magnetic resonance images provide evidence that show that the pelvic floor regions experiencing the most stretch are at the greatest risk for injury, especially in forceps deliveries. A conceptual model suggests how these injuries may lead to the most common form of pelvic organ prolapse, a cystocele. PMID:19591614

Pelvic Floor Disorders in Female Veterans: What a Difference an X Makes

DTIC Science & Technology

2011-07-22

vaginal support has weakened  Known risk factors:  Vaginal deliveries  Multiple deliveries  High birth weight deliveries  Chronic cough – increase...2010 Backup slides: UTI, Lowe Study Symptoms of vaginitis and urinary tract infections are miserable, distracting, and significantly affect women’s...had been deployed, vaginal infections were experienced by 30.1% and urinary tract infections by 18.4% of them during deployment. Vaginal symptoms were

Demographic variations and clinical associations of episiotomy and severe perineal lacerations in vaginal delivery.

PubMed

Ogunyemi, Dotun; Manigat, Brandy; Marquis, Jesse; Bazargan, Mohsen

2006-11-01

Primiparity, birthweight, operative delivery and obstetrical complications contribute to episiotomy and severe perineal lacerations. Episiotomy correlates with Hispanics, while African Americans correlate with severe perineal lacerations. The purpose of this study was to identify risk factors for both episiotomy and severe perineal lacerations in a large population from a single institution. This was a review of 66,224 vaginal deliveries of African Americans or Hispanics delivering between 25-44 gestational weeks between 1981-2001. Univariate and multiple regression analysis were done as indicated. Independent predictors of episiotomy were: primiparity eight-fold, forceps delivery seven-fold, vacuum delivery five-fold, shoulder dystocia 3.6-fold, macrosomia 1.8-fold, epidural analgesia 1.6-fold, postdates 1.5-fold, Hispanics 1.4-fold. Independent predictors of severe perineal lacerations were; macrosomia seven-fold, episiotomy 4.5-fold, primiparity 4.4-fold, shoulder dystocia 3.6-fold, average birthweight 3.5-fold, forceps delivery 2.6-fold, vacuum delivery two-fold, epidural analgesia two-fold, African-American 1.5-fold. Nonreassuring fetal heart rate patterns, meconium and cord accidents appeared protective. Primiparous women with larger babies undergoing operative delivery with epidural analgesia are at risk for both episiotomy incisions and severe perineal lacerations. Though Hispanics are more likely to have an episiotomy, they are at significantly less risk for severe perineal lacerations compared to African Americans. Even though episiotomy is independently associated with severe perineal laceration, other factors such as macrosomia and primiparity are as important.

A randomized trial of planned cesarean or vaginal delivery for twin pregnancy.

PubMed

Barrett, Jon F R; Hannah, Mary E; Hutton, Eileen K; Willan, Andrew R; Allen, Alexander C; Armson, B Anthony; Gafni, Amiram; Joseph, K S; Mason, Dalah; Ohlsson, Arne; Ross, Susan; Sanchez, J Johanna; Asztalos, Elizabeth V

2013-10-03

Twin birth is associated with a higher risk of adverse perinatal outcomes than singleton birth. It is unclear whether planned cesarean section results in a lower risk of adverse outcomes than planned vaginal delivery in twin pregnancy. We randomly assigned women between 32 weeks 0 days and 38 weeks 6 days of gestation with twin pregnancy and with the first twin in the cephalic presentation to planned cesarean section or planned vaginal delivery with cesarean only if indicated. Elective delivery was planned between 37 weeks 5 days and 38 weeks 6 days of gestation. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity, with the fetus or infant as the unit of analysis for the statistical comparison. A total of 1398 women (2795 fetuses) were randomly assigned to planned cesarean delivery and 1406 women (2812 fetuses) to planned vaginal delivery. The rate of cesarean delivery was 90.7% in the planned-cesarean-delivery group and 43.8% in the planned-vaginal-delivery group. Women in the planned-cesarean-delivery group delivered earlier than did those in the planned-vaginal-delivery group (mean number of days from randomization to delivery, 12.4 vs. 13.3; P=0.04). There was no significant difference in the composite primary outcome between the planned-cesarean-delivery group and the planned-vaginal-delivery group (2.2% and 1.9%, respectively; odds ratio with planned cesarean delivery, 1.16; 95% confidence interval, 0.77 to 1.74; P=0.49). In twin pregnancy between 32 weeks 0 days and 38 weeks 6 days of gestation, with the first twin in the cephalic presentation, planned cesarean delivery did not significantly decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery. (Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00187369; Current Controlled Trials number, ISRCTN74420086.).

Prophylactic antibiotics for manual removal of retained placenta during vaginal birth: a systematic review of observational studies and meta-analysis.

PubMed

Chibueze, Ezinne C; Parsons, Alexander J Q; Ota, Erika; Swa, Toshiyuki; Oladapo, Olufemi T; Mori, Rintaro

2015-11-26

Manual removal of the placenta is an invasive obstetric procedure commonly used for the management of retained placenta. However, it is unclear whether antibiotic prophylaxis is beneficial in preventing infectious morbidity. We conducted a systematic review to determine the efficacy and safety of routine use of antibiotics for preventing adverse maternal outcomes related to manual placenta removal following vaginal birth. A detailed search of MEDLINE, EMBASE, Cochrane library and the CINAHL databases was conducted for non-randomized studies involving women undergoing manual placenta delivery after vaginal births and where antibiotic prophylaxis use was compared with no treatment or placebo to prevent maternal infection. Search terms including 'delivery, obstetric', 'placenta, retained', 'anti-infective agents', and 'chemoprevention' were used. Of the 407 citations that resulted after elimination of duplicates, 81 full texts were potentially eligible after independent assessment of the title and abstracts. Independent review of the full texts identified three eligible cohort studies which were retrospective in design. These studies contained data on two of the pre-specified outcomes, endometritis and puerperal fever. Other secondary outcomes such as perineal infection and/or any infection, hospital stay duration, sepsis, hemorrhage >1000 ml or hospital readmissions were not reported on excluding puerperal fever. A meta-analysis showed no significant reduction in the incidence of endometritis (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.38 to 1.85, three studies, 567 women) and puerperal fever (OR 0.99, 95% CI 0.38 to 2.27, one study, 302 women). There is currently no evidence to suggest beneficial effects for routine antibiotic use in women undergoing manual placental removal following vaginal birth. In appropriate settings, further research is required to determine whether a policy of routine antibiotic prophylaxis for the procedure should be maintained or discouraged.

A Comparison of Vaginal Pressures and Abdominal Muscle Thickness According to Childbirth Delivery Method during the Valsalva Maneuver

PubMed Central

Kim, Haroo; Kak, Hwang-Bo; Kim, Boin

2014-01-01

[Purpose] The purpose of this study was to compare the effect of childbirth delivery method on vaginal pressure and abdominal thickness during the Valsalva maneuver (VAL). [Subjects] Thirty healthy female volunteers (26–39 years of age) were selected for this research. Their delivery histories were: nulliparous 10, vaginal delivery 10, and Cesarean delivery 10. None of the participants had a history of incontinence. [Methods] In the crook-lying position, a perineometer probe was inserted into the vagina and the transducer was placed transversely on the right side of the body during the Valsalva maneuver. [Results] There were significant differences in the thickness of the transverses abdominis (TrA) between in all the groups rest and the Valsalva maneuver, and there were significant differences in the internus oblique (IO) in the nulliparous group. During the Valsalva maneuver, there were significant differences in the TrA between the nulliparous group and the vaginal delivery group, and there were significant differences in the IO between the nulliparous delivery group and the vaginal delivery group, and between the nulliparous group and the Cesarean section group. Delivery history changed vaginal pressure, and there were significant differences between the nulliparous group and the vaginal delivery group, and between the nulliparous group and the Cesarean delivery group. [Conclusion] Pregnancy and delivery method may affect pelvic floor and abdominal muscles during the Valsalva maneuver. PMID:24707104

Evaluation and Management of Vaginitis

PubMed Central

Carr, Phyllis L; Felsenstein, Donna; Friedman, Robert H

1998-01-01

OBJECTIVE To evaluate recent advances in our understanding of the clinical relevance, diagnosis, and treatment of vaginal infections, and to determine an efficient and effective method of evaluating this clinical problem in the outpatient setting. DATA SOURCES Relevant papers on vaginitis limited to the English language obtained through a MEDLINE search for the years 1985 to 1997 were reviewed. DATA SYNTHESIS Techniques that enable the identification of the various strains of candida have helped lead to a better understanding of the mechanisms of recurrent candida infection. From this information a rationale for the treatment of recurrent disease can be developed. Bacterial vaginosis has been associated with complications, including upper genital tract infection, preterm delivery, and wound infection. Women undergoing pelvic surgery, procedures in pregnancy, or pregnant women at risk of preterm delivery should be evaluated for bacterial vaginosis to decrease the rate of complications associated with this condition. New, more standardized criteria for the diagnosis of bacterial vaginosis may improve diagnostic consistency among clinicians and comparability of study results. Use of topical therapies in the treatment of bacterial vaginosis are effective and associated with fewer side effects than systemic medication. Trichomonas vaginalis, although decreasing in incidence, has been associated with upper genital tract infection. Therapy of T. vaginalis infection has been complicated by an increasing incidence of resistance to metronidazole. CONCLUSIONS Vaginitis is a common medical problem in women that is associated with significant morbidity and previously unrecognized complications. Research in recent years has improved diagnostic tools as well as treatment modalities for all forms of vaginitis. PMID:9613891

Mucoadhesive and thermogelling systems for vaginal drug delivery.

PubMed

Caramella, Carla M; Rossi, Silvia; Ferrari, Franca; Bonferoni, Maria Cristina; Sandri, Giuseppina

2015-09-15

This review focuses on two formulation approaches, mucoadhesion and thermogelling, intended for prolonging residence time on vaginal mucosa of medical devices or drug delivery systems, thus improving their efficacy. The review, after a brief description of the vaginal environment and, in particular, of the vaginal secretions that strongly affect in vivo performance of vaginal formulations, deals with the above delivery systems. As for mucoadhesive systems, conventional formulations (gels, tablets, suppositories and emulsions) and novel drug delivery systems (micro-, nano-particles) intended for vaginal administration to achieve either local or systemic effect are reviewed. As for thermogelling systems, poly(ethylene oxide-propylene oxide-ethylene oxide) copolymer-based and chitosan-based formulations are discussed as thermogelling systems. The methods employed for functional characterization of both mucoadhesive and thermogelling drug delivery systems are also briefly described. Copyright © 2015 Elsevier B.V. All rights reserved.

Risk of episiotomy and perineal lacerations recurring after first delivery.

PubMed

Manzanares, Sebastian; Cobo, Davinia; Moreno-Martínez, Maria Dolores; Sánchez-Gila, Mar; Pineda, Alicia

2013-12-01

To assess whether the presence of an episiotomy or spontaneous perineal trauma at the first delivery increases the risk of perineal trauma at the following one. We studied 2,695 women who gave birth twice at Virgen de las Nieves University Hospital of Granada, Spain. All second deliveries were from 2004 to 2011 and prenatal database records were used to obtain information about the first deliveries. All births, first and second, were single, vaginal, unassisted, and in a cephalic presentation. Two groups were made as follows: Intact perineum (no perineal trauma or first-degree spontaneous tear at the first delivery) and perineal trauma (episiotomy or second-degree or higher spontaneous tear at the first delivery). Both groups were compared according to the degree of perineal trauma at the second delivery. Women included in the perineal trauma group were significantly older and a higher proportion was attended by a midwife with an obstetrician present in the delivery room. No differences were observed according to gestational age, epidural analgesia or fetal birth weight. Adjusting for these possible compounding factors and the year of birth, the risk of undergoing a second-degree or higher spontaneous tear at their next delivery was fivefold (adjusted OR 5.15, 95% CI 3.11-8.54), and the risk of undergoing an episiotomy in the second delivery was threefold (adjusted OR 3.20, 95% CI 2.19-4.69) for the perineal trauma group. The risk of undergoing a spontaneous perineal tear or an episiotomy in the second delivery is increased by the practice of episiotomy in the first one. © 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc.

The Costs and Their Determinant of Cesarean Section and Vaginal Delivery: An Exploratory Study in Chongqing Municipality, China

PubMed Central

He, Zhifei; Cheng, Zhaohui; Wu, Tailai; Zhou, Yan; Chen, Junguo; Fu, Qian

2016-01-01

Objectives. This study aims to analyze the cesarean section (CS) rates and vaginal delivery rates in tertiary hospitals of China, explore the costs of two different deliveries, and examine the relative influencing factors of the costs in both CS and vaginal deliveries. Methods. 30,168 anonymized obstetric medical cases were selected from three sample tertiary hospitals in Chongqing Municipality from 2011 to 2013. Chi-square test was used to compare the distributions of CS and vaginal deliveries under different indicators. Mann–Whitney test and Kruskal-Wallis test were adopted to analyze the differences under different items. Multiple linear regression was used to determine the influencing factors of the costs of different delivery modes. Results. (1) The rates of CS were 69%, 65.5%, and 59.2% in the three sample tertiary hospitals in Chongqing from 2011 to 2013. (2) The costs and the length of stay of CS were greater than those of vaginal delivery, which had significant differences (P < 0.005). (3) The areas, length of stay, age, medical insurance, and modes of delivery were the influencing factors of both CS and vaginal delivery costs. Discussion. The high CS rates in China must be paid significant attention. The indicators of two modes of delivery should be regulated strictly. CS rate reduction and saving medical resources will be the benefits if vaginal delivery is chosen by pregnant women. PMID:27995142

Prenatal attitudes toward vaginal delivery and actual delivery mode: Variation by race/ethnicity and socioeconomic status.

PubMed

Attanasio, Laura B; Hardeman, Rachel R; Kozhimannil, Katy B; Kjerulff, Kristen H

2017-12-01

Researchers documenting persistent racial/ethnic and socioeconomic status disparities in chances of cesarean delivery have speculated that women's birth attitudes and preferences may partially explain these differences, but no studies have directly tested this hypothesis. We examined whether women's prenatal attitudes toward vaginal delivery differed by race/ethnicity or socioeconomic status, and whether attitudes were differently related to delivery mode depending on race/ethnicity or socioeconomic status. Data were from the First Baby Study, a cohort of 3006 women who gave birth to a first baby in Pennsylvania between 2009 and 2011. We used regression models to examine (1) predictors of prenatal attitudes toward vaginal delivery, and (2) the association between prenatal attitudes and actual delivery mode. To assess moderation, we estimated models adding interaction terms. Prenatal attitudes toward vaginal delivery were not associated with race/ethnicity or socioeconomic status. Positive attitudes toward vaginal delivery were associated with lower odds of cesarean delivery (AOR=0.60, P < .001). However, vaginal delivery attitudes were only related to delivery mode among women who were white, highly educated, and privately insured. There are racial/ethnic differences in chances of cesarean delivery, and these differences are not explained by birth attitudes. Furthermore, our findings suggest that white and high-socioeconomic status women may be more able to realize their preferences in childbirth. © 2017 Wiley Periodicals, Inc.

The importance of the vaginal delivery route for antiretrovirals in HIV prevention

PubMed Central

Ferguson, Lindsay M; Rohan, Lisa Cencia

2012-01-01

The HIV/AIDS pandemic continues to be a global health priority, with high rates of new HIV-1 infections persisting in young women. One HIV prevention strategy is topical pre-exposure prophylactics or microbicides, which are applied vaginally or rectally to protect the user from HIV and possibly other sexually transmitted infections. Vaginal microbicide delivery will be the focus of this review. Multiple nonspecific and specific antiretroviral microbicide products have been clinically evaluated, and many are in preclinical development. The events of HIV mucosal transmission and dynamics of the cervicovaginal environment should be considered for successful vaginal microbicide delivery. Beyond conventional vaginal formulations, intravaginal rings, tablets and films are employed as platforms in the hope to increase the likelihood of microbicide use. Furthermore, combining multiple antiretrovirals within a given formulation, combining a microbicide product with a vaginal device and integrating novel drug-delivery strategies within a microbicide product are approaches to successful vaginal-microbicide delivery. PMID:22468220

Enhanced vaginal drug delivery through the use of hypotonic formulations that induce fluid uptake

PubMed Central

Ensign, Laura M.; Hoen, Timothy; Maisel, Katharina; Cone, Richard; Hanes, Justin

2013-01-01

Mucosal epithelia use osmotic gradients for fluid absorption and secretion. We hypothesized that administration of hypotonic solutions would induce fluid uptake that could be advantageous for rapidly delivering drugs through mucus to the vaginal epithelium. We found that hypotonic formulations markedly increased the rate at which small molecule drugs and muco-inert nanoparticles (mucus-penetrating particles, or MPP), but not conventional mucoadhesive nanparticles (CP), reached the vaginal epithelial surface in vivo in mice. Additionally, hypotonic formulations greatly enhanced drug and MPP delivery to the entire epithelial surface, including deep into the vaginal folds (rugae) that drugs or MPP in isotonic formulations failed to reach efficiently. However, hypotonic formulations caused unencapsulated “free” drugs to be drawn through the epithelium, reducing vaginal retention. In contrast, hypotonic formulations caused MPP to accumulate rapidly and uniformly on vaginal surfaces, ideally positioned for localized sustained drug delivery. Using a mouse model of vaginal genital herpes (HSV-2) infection, we found that hypotonic delivery of free drug led to improved immediate protection, but diminished longer-term protection. In contrast, as we previously demonstrated, hypotonic delivery of drug via MPP led to better long-term retention and protection in the vagina. Importantly, we demonstrate that slightly hypotonic formulations provided rapid and uniform delivery of MPP to the entire vaginal surface, thus enabling formulations with minimal risk of epithelial toxicity. Hypotonic formulations for vaginal drug delivery via MPP may significantly improve prevention and treatment of reproductive tract diseases and disorders. PMID:23769419

Preferred Physical Characteristics of Vaginal Film Microbicides for HIV Prevention in Pittsburgh Women

PubMed Central

Fan, Maria D.; Kramzer, Lindsay F.; Hillier, Sharon L.; Chang, Judy C.; Meyn, Leslie A.; Rohan, Lisa C.

2016-01-01

Unprotected heterosexual intercourse is the leading cause of HIV acquisition in women. Due to the complex nature of correct and consistent condom use by both men and women, developing alternative female-controlled HIV prevention options is a global health priority. Vaginal films containing antiretroviral drugs are a potential delivery system for the prevention of HIV acquisition through sexual contact. In this study, we explored women’s preferences regarding physical characteristics of microbicide vaginal films through questionnaires and focus groups. Eighty-four sexually active, ethnically diverse women 18 to 30 years of age from Pittsburgh, Pennsylvania, participated in the study. Women visually and manually examined a variety of vaginal films, as well as three other vaginal products undergoing evaluation for HIV prevention: tablet, ring, and gel. Means and standard deviations or frequencies and 95% confidence intervals were calculated for questionnaire data. Focus groups were audio-recorded, transcribed verbatim, and coded for content analysis. Women most frequently preferred vaginal films to be smooth and thin (63%), translucent (48%), and 2"×2" square size (36%). Driving these preferences were five major themes: ease and accuracy of use, desire for efficacy, discretion, intravaginal comfort and minimal impact, and minimizing disruption of sexual mood/activities. Women’s preferences for various microbicide vaginal film physical attributes represented a balance of multiple values. In general, women desired a comfortable, efficacious, easy-to-use, and minimally intrusive product. PMID:27571742

Effect of systematic local infiltration analgesia on postoperative pain in vaginal hysterectomy: a randomized, placebo-controlled trial.

PubMed

Hristovska, Ana-Marija; Kristensen, Billy B; Rasmussen, Marianne A; Rasmussen, Yvonne H; Elving, Lisbeth B; Nielsen, Christian V; Kehlet, Henrik

2014-03-01

To assess the effect of systematic local infiltration analgesia on postoperative pain in vaginal hysterectomy, and describe the technique in detail. A randomized, double-blind, placebo-controlled study following the CONSORT criteria. A university hospital. Thirty-seven patients undergoing vaginal hysterectomy. Patients received high-volume (50 mL) ropivacaine 0.50% (n = 20) or saline (n = 17) infiltration using a systematic technique ensuring uniform delivery to all tissues incised, handled or instrumented during the procedure. Pain, nausea, vomiting and opioid requirements were assessed for 32 h as well as time spent in the post-anesthesia care unit and time to first mobilization. Pain at rest was significantly reduced after one, four and eight hours in the ropivacaine group (p ≤ 0.001-0.01). Pain during coughing was significantly reduced after one and four hours (p ≤ 0.001 and p ≤ 0.003), and pain during movement was significantly reduced after four hours (p ≤ 0.02). Opioid requirements and time spent in the post-anesthesia care unit were significantly reduced in the ropivacaine group (p < 0.001 and p < 0.001, respectively), as well as the time to first mobilization (p < 0.001). Intra-operative systematic local infiltration analgesia reduces postoperative pain in patients undergoing vaginal hysterectomy, facilities mobilization and improves early recovery. © 2013 Nordic Federation of Societies of Obstetrics and Gynecology.

Spray-dried powders enhance vaginal siRNA delivery by potentially modulating the mucus molecular sieve structure.

PubMed

Wu, Na; Zhang, Xinxin; Li, Feifei; Zhang, Tao; Gan, Yong; Li, Juan

2015-01-01

Vaginal small interfering RNA (siRNA) delivery provides a promising strategy for the prevention and treatment of vaginal diseases. However, the densely cross-linked mucus layer on the vaginal wall severely restricts nanoparticle-mediated siRNA delivery to the vaginal epithelium. In order to overcome this barrier and enhance vaginal mucus penetration, we prepared spray-dried powders containing siRNA-loaded nanoparticles. Powders with Pluronic F127 (F127), hydroxypropyl methyl cellulose (HPMC), and mannitol as carriers were obtained using an ultrasound-assisted spray-drying technique. Highly dispersed dry powders with diameters of 5-15 μm were produced. These powders showed effective siRNA protection and sustained release. The mucus-penetrating properties of the powders differed depending on their compositions. They exhibited different potential of opening mesh size of molecular sieve in simulated vaginal mucus system. A powder formulation with 0.6% F127 and 0.1% HPMC produced the maximum increase in the pore size of the model gel used to simulate vaginal mucus by rapidly extracting water from the gel and interacting with the gel; the resulting modulation of the molecular sieve effect achieved a 17.8-fold improvement of siRNA delivery in vaginal tract and effective siRNA delivery to the epithelium. This study suggests that powder formulations with optimized compositions have the potential to alter the steric barrier posed by mucus and hold promise for effective vaginal siRNA delivery.

Mucus-penetrating nanoparticles for vaginal and gastrointestinal drug delivery

NASA Astrophysics Data System (ADS)

Ensign-Hodges, Laura

A method that could provide more uniform and longer-lasting drug delivery to mucosal surfaces holds the potential to greatly improve the effectiveness of prophylactic and therapeutic approaches for numerous diseases and conditions, including sexually transmitted infections and inflammatory bowel disease. However, the body's natural defenses, including adhesive, rapidly cleared mucus linings coating nearly all entry points to the body not covered by skin, has limited the effectiveness of drug and gene delivery by nanoscale delivery systems. Here, we investigate the use of muco-inert mucus-penetrating nanoparticles (MPP) for improving vaginal and gastrointestinal drug delivery. Conventional hydrophobic nanoparticles strongly adhere to mucus, facilitating rapid clearance from the body. Here, we demonstrate that mucoadhesive polystyrene nanoparticles (conventional nanoparticles, CP) become mucus-penetrating in human cervicovaginal mucus (CVM) after pretreatment with sufficient concentrations of Pluronic F127. Importantly, the diffusion rate of large MPP did not change in F127 pretreated CVM, implying there is no affect on the native pore structure of CVM. Additionally, there was no increase in inflammatory cytokine release in the vaginal tract of mice after daily application of 1% F127 for one week. Importantly, HSV virus remains adherent in F127-pretreated CVM. Mucosal epithelia use osmotic gradients for fluid absorption and secretion. We hypothesized that hypotonically-induced fluid uptake could be advantageous for rapidly delivering drugs through mucus to the vaginal epithelium. We evaluated hypotonic formulations for delivering water-soluble drugs and for drug delivery with MPP. Hypotonic formulations markedly increased the rate at which drugs and MPP reached the epithelial surface. Additionally, hypotonic formulations greatly enhanced drug and MPP delivery to the entire epithelial surface, including deep into the vaginal folds (rugae) that isotonic formulations failed to reach. However, hypotonic formulations caused free drugs to be drawn through the epithelium, reducing vaginal retention. In contrast, hypotonic formulations caused MPP to accumulate rapidly and uniformly on vaginal surfaces, ideally positioned for sustained drug delivery. Using a mouse model of vaginal genital herpes (HSV-2) infection, we found that hypotonic delivery of free drug led to improved immediate protection, but diminished longer-term protection. Minimally hypotonic formulations provided rapid and uniform delivery of MPP to the entire vaginal surface, thus enabling formulations with minimal risk of epithelial toxicity. We then describe an ex vivo method for characterizing particle transport on freshly excised mucosal tissues. By directly observing MPP transport on vaginal, gastrointestinal, and respiratory tissue, we were able to determine an innate difference in mucus mesh size at different anatomical locations. In addition, we were able to optimize particle size for gastrointestinal delivery in mice. As described here, there are numerous barriers to effective drug delivery in the gastrointestinal tract, including the mucus barrier. We go on to demonstrate that MPP can improve delivery in the gastrointestinal tract, both by rectal and oral administration. Finally, we describe the use of MPP for improving vaginal drug delivery. Incomplete drug coverage and short duration of action limit the effectiveness of vaginally administered drugs, including microbicides for preventing sexually transmitted infections. We show that MPP provide uniform distribution over the vaginal epithelium, whereas CP are aggregated by mouse vaginal mucus, leading to poor distribution. By penetrating into the deepest mucus layers in the rugae, more MPP were retained in the vaginal tract compared to CP. After 24 h, when delivered in a conventional vaginal gel, patches of a model drug remained on the vaginal epithelium, whereas the epithelium was coated with drug delivered by MPP. We then demonstrate that when administered 30 min prior to inoculum, anti-HSV-2 MPP protected 53% of mice compared to only 16% protected by soluble drug. Overall, MPP improved vaginal drug distribution and retention, provided more effective protection against vaginal viral challenge than soluble drug, and were non-toxic when administered daily for one week.

Comparison of induction of labor methods for unfavorable cervices in trial of labor after cesarean delivery.

PubMed

Shah, Utsavi; Bellows, Patricia; Drexler, Kathleen; Hawley, Lauren; Davidson, Christina; Sangi-Haghpeykar, Haleh; Gandhi, Manisha

2017-05-01

To compare induction of labor methods in patients attempting a trial of labor after cesarean (TOLAC) with an unfavorable cervix. This is a retrospective cohort study from patients attempting TOLAC from 2009 to 2013. Patients with a simplified Bishop score of three or less where labor was initiated with either a Cook balloon or oxytocin were included. Our primary outcome was mode of delivery. Our secondary outcomes included duration of labor and multiple maternal and neonatal morbidities. Two-hundred and fourteen women met inclusion criteria: 150 received oxytocin and 64 had the Cook balloon placed. The vaginal birth after cesarean delivery rate was significantly higher in the oxytocin group at 70.7% versus 50.0% in the Cook balloon group (p = 0.004). In the multivariable analysis, odds for cesarean delivery were two times higher with the Cook balloon than with oxytocin (Adjusted OR = 2.09, 95% CI = 1.05-4.18, p = 0.036). The duration of labor was longer with the Cook balloon versus oxytocin (21.9 versus 16.3 hours, p = 0.0002). There were no significant differences in maternal and neonatal health outcomes. Oxytocin induction of labor was associated with a higher rate of vaginal delivery and a shorter duration of labor compared to the Cook balloon in women undergoing TOLAC with an unfavorable cervix.

Pelvic muscles' mechanical response to strains in the absence and presence of pregnancy-induced adaptations in a rat model.

PubMed

Catanzarite, Tatiana; Bremner, Shannon; Barlow, Caitlin L; Bou-Malham, Laura; O'Connor, Shawn; Alperin, Marianna

2018-05-01

Maternal birth trauma to the pelvic floor muscles is thought to be consequent to mechanical demands placed on these muscles during fetal delivery that exceed muscle physiological limits. The above is consistent with studies of striated limb muscles that identify hyperelongation of sarcomeres, the functional muscle units, as the primary cause of mechanical muscle injury and resultant muscle dysfunction. However, pelvic floor muscles' mechanical response to strains have not been examined at a tissue level. Furthermore, we have previously demonstrated that during pregnancy, rat pelvic floor muscles acquire structural and functional adaptations in preparation for delivery, which likely protect against mechanical muscle injury by attenuating the strain effect. We sought to determine the mechanical impact of parturition-related strains on pelvic floor muscles' microstructure, and test the hypothesis that pregnancy-induced adaptations modulate muscle response to strains associated with vaginal delivery. Three-month-old Sprague-Dawley late-pregnant (N = 20) and nonpregnant (N = 22) rats underwent vaginal distention, replicating fetal crowning, with variable distention volumes. Age-matched uninjured pregnant and nonpregnant rats served as respective controls. After sacrifice, pelvic floor muscles, which include coccygeus, iliocaudalis, and pubocaudalis, were fixed in situ and harvested for fiber and sarcomere length measurements. To ascertain the extent of physiological strains during spontaneous vaginal delivery, analogous measurements were obtained in intrapartum rats (N = 4) sacrificed during fetal delivery. Data were compared with repeated measures and 2-way analysis of variance, followed by pairwise comparisons, with significance set at P < .05. Gross anatomic changes were observed in the pelvic floor muscles following vaginal distention, particularly in the entheseal region of pubocaudalis, which appeared translucent. The above appearance resulted from dramatic stretch of the myofibers, as indicated by significantly longer fiber length compared to controls. Stretch ratios, calculated as fiber length after vaginal distention divided by baseline fiber length, increased gradually with increasing distention volume. Paralleling these macroscopic changes, vaginal distention resulted in acute and progressive increase in sarcomere length with rising distention volume. The magnitude of strain effect varied by muscle, with the greatest sarcomere elongation observed in coccygeus, followed by pubocaudalis, and a smaller increase in iliocaudalis, observed only at higher distention volumes. The average fetal rat volume approximated 3 mL. Pelvic floor muscle sarcomere lengths in pregnant animals undergoing vaginal distention with 3 mL were similar to intrapartum sarcomere lengths in all muscles (P > .4), supporting the validity of our experimental approach. Vaginal distention resulted in dramatically longer sarcomere lengths in nonpregnant compared to pregnant animals, especially in coccygeus and pubocaudalis (P < .0001), indicating significant attenuation of sarcomere elongation in the presence of pregnancy-induced adaptations in pelvic floor muscles. Delivery-related strains lead to acute sarcomere elongation, a well-established cause of mechanical injury in skeletal muscles. Sarcomere hyperelongation resultant from mechanical strains is attenuated by pregnancy-induced adaptations acquired by the pelvic floor muscles prior to parturition. Copyright © 2018 Elsevier Inc. All rights reserved.

Effect of cryotherapy on relief of perineal pain after vaginal childbirth with episiotomy: a randomized and controlled clinical trial.

PubMed

Beleza, Ana Carolina Sartorato; Ferreira, Cristine Homsi Jorge; Driusso, Patricia; Dos Santos, Claudia Benedita; Nakano, Ana Márcia Spanó

2017-12-01

Verify the effectiveness of cryotherapy in relieving perineal pain in women after vaginal delivery with episiotomy. Randomized controlled clinical trial. Reference Center of Women's Health of Ribeirão Preto (MATER), in the state of São Paulo. The study included 50 women who reported pain in the postpartum period following vaginal delivery with episiotomy. The women in the experimental group applied a bag of crushed ice to the perineal region for 20minutes. Both groups were assessed before, immediately after removal of the ice bag, and one hour after cryotherapy treatment. Complaint of pain was evaluated using a numerical pain assessment scale (0 to 10). Perineal temperature was also measured using an infrared thermometer, and the satisfaction of women undergoing the treatment was assessed using a questionnaire. Pain relief was verified for the experimental group compared to the control group in the second (immediately after use of cryotherapy) and third evaluations (one hour after cryotherapy). The temperature of the perineal region was found to be related to the intensity of pain, e.g. the lower the temperature provided by cryotherapy, the lower the woman's complaint of pain. 88% of women reported being satisfied with the treatment. After 20minutes of application, cryotherapy was effective in relieving perineal pain in women in the immediate postpartum period after vaginal birth with episiotomy. ACTRN12613000052730. Copyright © 2016. Published by Elsevier Ltd.

Simulation training and resident performance of singleton vaginal breech delivery.

PubMed

Deering, Shad; Brown, Jill; Hodor, Jonathon; Satin, Andrew J

2006-01-01

To determine whether simulation training improves resident competency in the management of a simulated vaginal breech delivery. Without advance notice or training, residents from 2 obstetrics and gynecology residency programs participated in a standardized simulation scenario of management of an imminent term vaginal breech delivery. The scenario used an obstetric birth simulator and human actors, with the encounters digitally recorded. Residents then received a training session with the simulator on the proper techniques for vaginal breech delivery. Two weeks later they were retested using a similar simulation scenario. A physician, blinded to training status, graded the residents' performance using a standardized evaluation sheet. Statistical analysis included the Wilcoxon signed rank test, McNemar chi2, regression analysis, and paired t test as appropriate with a P value of less than .05 considered significant. Twenty residents from 2 institutions completed all parts of the study protocol. Trained residents had significantly higher scores in 8 of 12 critical delivery components (P < .05). Overall performance of the delivery and safety in performing the delivery also improved significantly (P = .001 for both). Simulation training improved resident performance in the management of a simulated vaginal breech delivery. Performance of a term breech vaginal delivery is well suited for simulation training, because it is uncommon and inevitable, and improper technique may result in significant injury. II-2.

A randomized trial of misoprostol versus extra-amniotic sodium chloride infusion with oxytocin for induction of labor.

PubMed

Buccellato, C A; Stika, C S; Frederiksen, M C

2000-05-01

Our purpose was to compare the efficacy and safety of misoprostol and extra-amniotic sodium chloride infusion with oxytocin for induction of labor. This randomized trial compared two methods of labor induction in women requiring cervical ripening. One hundred twenty-three women undergoing labor induction with a Bishop score < or =5 were randomly selected to receive either misoprostol, 50 microg intravaginally every 4 hours, or extra-amniotic sodium chloride infusion. The primary outcome variable was the time interval from induction to vaginal delivery. Sixty-one women received extra-amniotic sodium chloride infusion and 62 women received misoprostol. The mean time interval from the start of induction to vaginal delivery was 15.0 +/- 5.0 hours and 16.5 +/- 7.2 hours for the extra-amniotic infusion and misoprostol groups, respectively (P, not significant). The cesarean delivery rate was not significantly different between the 2 groups (32.8% for the extra-amniotic infusion group; 19.4% for the misoprostol group). Maternal and neonatal outcomes were similar between the 2 groups. Both methods of induction are equally efficacious and result in similar maternal and neonatal outcomes.

Characterisation of the vaginal Lactobacillus microbiota associated with preterm delivery.

PubMed

Petricevic, Ljubomir; Domig, Konrad J; Nierscher, Franz Josef; Sandhofer, Michael J; Fidesser, Maria; Krondorfer, Iris; Husslein, Peter; Kneifel, Wolfgang; Kiss, Herbert

2014-05-30

The presence of an abnormal vaginal microflora in early pregnancy is a risk factor for preterm delivery. There is no investigation on vaginal flora dominated by lactic acid bacteria and possible association with preterm delivery. We assessed the dominant vaginal Lactobacillus species in healthy pregnant women in early pregnancy in relation to pregnancy outcome. We observed 111 low risk pregnant women with a normal vaginal microflora 11 + 0 to 14 + 0 weeks of pregnancy without subjective complaints. Vaginal smears were taken for the identification of lactobacilli using denaturing gradient gel electrophoresis (DGGE). Pregnancy outcome was recorded as term or preterm delivery (limit 36 + 6 weeks of gestation). The diversity of Lactobacillus species in term vs. preterm was the main outcome measure. L. iners alone was detected in 11 from 13 (85%) women who delivered preterm. By contrast, L. iners alone was detected in only 16 from 98 (16%) women who delivered at term (p < 0.001). Fifty six percent women that delivered at term and 8% women that delivered preterm had two or more vaginal Lactobacillus spp. at the same time. This study suggests that dominating L. iners alone detected in vaginal smears of healthy women in early pregnancy might be associated with preterm delivery.

Labor Patterns in Women Attempting Vaginal Birth After Cesarean With Normal Neonatal Outcomes

PubMed Central

GRANTZ, Katherine L.; GONZALEZ-QUINTERO, Victor; TROENDLE, James; REDDY, Uma M.; HINKLE, Stefanie N.; KOMINIAREK, Michelle A.; LU, Zhaohui; ZHANG, Jun

2015-01-01

Objective To describe labor patterns in women with a trial of labor after cesarean (TOLAC) with normal neonatal outcomes. Study Design In a retrospective observational study at 12 U.S. centers (2002–2008), we examined time interval for each centimeter of cervical dilation and compared labor progression stratified by spontaneous or induced labor in 2,892 multiparous women with TOLAC (second delivery) and 56,301 nulliparous women at 37 0/7 to 41 6/7 weeks of gestation. Analyses were performed including women with intrapartum cesarean delivery, and then repeated limiting only to women who delivered vaginally. Results Labor was induced in 23.4% of TOLAC and 44.1% of nulliparous women (P<.001). Cesarean delivery rates were 57.7% in TOLAC versus 19.0% in nulliparous women (P<.001). Oxytocin was used in 52.4% of TOLAC versus 64.3% of nulliparous women with spontaneous labor (P<.001) and 89.8% of TOLAC versus 91.6% of nulliparous women with induced labor (P=.099); however, TOLAC had lower maximum doses of oxytocin compared to nulliparous women: median (90th percentile): 6 (18) mU/min versus 12 (28) mU/min, respectively (P<.001). Median (95th percentile) labor duration for TOLAC versus nulliparous women with spontaneous labor from 4–10cm was 0.9 (2.2) hours longer (P=.007). For women who entered labor spontaneously and achieved vaginal delivery, labor patterns for TOLAC were similar to nulliparous women. For induced labor, labor duration for TOLAC versus nulliparous women from 4–10cm was 1.5 (4.6) hours longer (P<.001). For women who achieved vaginal delivery, labor patterns were slower for induced TOLAC compared to nulliparous women. Conclusions Labor duration for TOLAC was slower compared to nulliparous labor, particularly for induced labor. By improved understanding of the rates of progress at different points in labor, this new information on labor curves in women undergoing TOLAC, particularly for induction, should help physicians when managing labor. PMID:25935774

Demographic variations and clinical associations of episiotomy and severe perineal lacerations in vaginal delivery.

PubMed Central

Ogunyemi, Dotun; Manigat, Brandy; Marquis, Jesse; Bazargan, Mohsen

2006-01-01

Primiparity, birthweight, operative delivery and obstetrical complications contribute to episiotomy and severe perineal lacerations. Episiotomy correlates with Hispanics, while African Americans correlate with severe perineal lacerations. OBJECTIVE: The purpose of this study was to identify risk factors for both episiotomy and severe perineal lacerations in a large population from a single institution. STUDY DESIGN: This was a review of 66,224 vaginal deliveries of African Americans or Hispanics delivering between 25-44 gestational weeks between 1981-2001. Univariate and multiple regression analysis were done as indicated. RESULTS: Independent predictors of episiotomy were: primiparity eight-fold, forceps delivery seven-fold, vacuum delivery five-fold, shoulder dystocia 3.6-fold, macrosomia 1.8-fold, epidural analgesia 1.6-fold, postdates 1.5-fold, Hispanics 1.4-fold. Independent predictors of severe perineal lacerations were; macrosomia seven-fold, episiotomy 4.5-fold, primiparity 4.4-fold, shoulder dystocia 3.6-fold, average birthweight 3.5-fold, forceps delivery 2.6-fold, vacuum delivery two-fold, epidural analgesia two-fold, African-American 1.5-fold. Nonreassuring fetal heart rate patterns, meconium and cord accidents appeared protective. CONCLUSION: Primiparous women with larger babies undergoing operative delivery with epidural analgesia are at risk for both episiotomy incisions and severe perineal lacerations. Though Hispanics are more likely to have an episiotomy, they are at significantly less risk for severe perineal lacerations compared to African Americans. Even though episiotomy is independently associated with severe perineal laceration, other factors such as macrosomia and primiparity are as important. PMID:17128701

Delivery mode and neonatal outcome after a trial of external cephalic version (ECV): a prospective trial of vaginal breech versus cephalic delivery.

PubMed

Reinhard, Joscha; Sänger, Nicole; Hanker, Lars; Reichenbach, Lena; Yuan, Juping; Herrmann, Eva; Louwen, Frank

2013-04-01

To examine the delivery mode and neonatal outcome after a trial of external cephalic version (ECV) procedures. This is an interim analysis of an ongoing larger prospective off-centre randomised trial, which compares a clinical hypnosis intervention against neuro-linguistic programming (NLP) of women with a singleton breech foetus at or after 37(0/7) (259 days) weeks of gestation and normal amniotic fluid index. Main outcome measures were delivery mode and neonatal outcome. On the same day after the ECV procedure two patients (2 %), who had unsuccessful ECVs, had Caesarean sections (one due to vaginal bleeding and one due to pathological CTG). After the ECV procedure 40.4 % of women had cephalic presentation (n = 38) and 58.5 % (n = 55) remained breech presentation. One patient remained transverse presentation (n = 1; 1.1 %). Vaginal delivery was observed by 73.7 % of cephalic presentation (n = 28), whereas 26.3 % (n = 10) had in-labour Caesarean sections. Of those, who selected a trial of vaginal breech delivery, 42.4 % (n = 14) delivered vaginally and 57.6 % (n = 19) delivered via Caesarean section. There is a statistically significant difference between the rate of vaginal birth between cephalic presentation and trial of vaginal breech delivery (p = 0.009), however, no difference in neonatal outcome was observed. ECV is a safe procedure and can reduce not only the rate of elective Caesarean sections due to breech presentation but also the rate of in-labour Caesarean sections even if a trial of vaginal breech delivery is attempted.

Prevalence of vaginal microorganisms among pregnant women according to trimester and association with preterm birth

PubMed Central

Son, Kyung-A; Kim, Minji; Kim, Yoo Min; Kim, Soo Hyun; Choi, Suk-Joo; Roh, Cheong-Rae; Kim, Jong-Hwa

2018-01-01

Objective The aim of this study was to investigate the prevalence of abnormal vaginal microorganisms in pregnant women according to trimester, and to determine whether the presence of abnormal vaginal colonization is associated with higher risk of miscarriage or preterm delivery. Furthermore, we analyzed delivery outcomes according to individual microorganism species. Methods We included pregnant women who underwent vaginal culture during routine prenatal check-up between January 2011 and June 2016. We compared delivery outcomes according to the presence or absence of abnormal vaginal flora grouped by trimester. Results This study included 593 singleton pregnancies. We classified participants into 3 groups, according to the trimester in which vaginal culture was performed; 1st trimester (n=221), 2nd trimester (n=138), and 3rd trimester (n=234). Abnormal vaginal colonization rate significantly decreased with advancing trimester of pregnancy (21.7% for 1st, 21.0% for 2nd, 14.5% for 3rd; P=0.048). Abnormal vaginal colonization detected in the 2nd trimester but not in 1st trimester was associated with a significant increase in preterm delivery before 28 weeks of gestation (6.9% vs. 0%; P=0.006). Among abnormal vaginal flora isolated in the 2nd trimester, the presence of Klebsiella pneumonia was identified as significant microorganism associated with preterm delivery before 28 weeks of gestation (50% vs. 0.7% for K. pneumonia; P=0.029). Conclusion There is an association between abnormal vaginal colonization detected in the 2nd trimester and preterm delivery before 28 weeks. K. pneumonia has been identified as the likely causative microorganisms. PMID:29372148

Efficacy and Safety of Prophylactic Uterine Artery Embolization in Pregnancy Termination with Placenta Previa

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pei, Renguang, E-mail: mediprg@bjmu.edu.cn; Wang, Guoxiang; Wang, Heping

PurposeTo appraise the efficacy and safety of prophylactic uterine artery embolization in pregnancy termination with placenta previa.MethodsA cohort of 54 consecutive patients with placenta previa underwent prophylactic uterine artery embolization before vaginal delivery from February 2012 to March 2015. Vaginal delivery was attempted in all patients. Cesarean section or hysterectomy was introduced when vaginal delivery failed.ResultsVaginal delivery succeeded in 50 patients (93.6%) and failed in 4 patients (6.4%), thereupon converted to cesarean delivery. No patients resorted to hysterectomy. Six patients (11.1%) underwent blood transfusion. None of clinical characteristics, including maternal age, gestational age, history of abortion, history of cesarean delivery,more » and volume of vaginal bleeding, was significantly associated with complete placenta previa (P > 0.05). However, patients with complete placenta previa had a significantly lower successful rate of vaginal delivery than did patients without complete placenta previa (81 vs 100%, P = 0.038). The rate of complications was 3.7%. No major complications were observed.ConclusionUterine artery embolization is an effective and safe technique to assist pregnancy termination with placenta previa, which may lower the risk of cesarean section, hysterectomy, and blood transfusion.« less

Efficacy and Safety of Prophylactic Uterine Artery Embolization in Pregnancy Termination with Placenta Previa.

PubMed

Pei, Renguang; Wang, Guoxiang; Wang, Heping; Huang, Xinyu; Yan, Xiaoxing; Yang, Xiaohua

2017-03-01

To appraise the efficacy and safety of prophylactic uterine artery embolization in pregnancy termination with placenta previa. A cohort of 54 consecutive patients with placenta previa underwent prophylactic uterine artery embolization before vaginal delivery from February 2012 to March 2015. Vaginal delivery was attempted in all patients. Cesarean section or hysterectomy was introduced when vaginal delivery failed. Vaginal delivery succeeded in 50 patients (93.6%) and failed in 4 patients (6.4%), thereupon converted to cesarean delivery. No patients resorted to hysterectomy. Six patients (11.1%) underwent blood transfusion. None of clinical characteristics, including maternal age, gestational age, history of abortion, history of cesarean delivery, and volume of vaginal bleeding, was significantly associated with complete placenta previa (P > 0.05). However, patients with complete placenta previa had a significantly lower successful rate of vaginal delivery than did patients without complete placenta previa (81 vs 100%, P = 0.038). The rate of complications was 3.7%. No major complications were observed. Uterine artery embolization is an effective and safe technique to assist pregnancy termination with placenta previa, which may lower the risk of cesarean section, hysterectomy, and blood transfusion.

Maternal and fetal outcomes after uterine fundal pressure in spontaneous and assisted vaginal deliveries.

PubMed

Furrer, Romana; Schäffer, Leonhard; Kimmich, Nina; Zimmermann, Roland; Haslinger, Christian

2016-10-01

This study aimed to evaluate maternal and fetal outcomes after uterine fundal pressure (UFP) in spontaneous and assisted vaginal deliveries. In a retrospective cohort study, 9743 singleton term deliveries with cephalic presentation were analyzed from 2004 to 2013. Spontaneous and assisted vaginal deliveries were analyzed separately with and without the application of UFP. Odds ratios were adjusted in a multivariate logistic regression analysis. Prevalence of UFP was 8.9% in spontaneous and 12.1% in assisted vaginal deliveries. UFP was associated with a higher incidence of shoulder dystocia in both spontaneous (adjusted odds ratio [adj. OR] 2.44, confidence interval [CI] 95% 1.23-4.84) and assisted vaginal deliveries (adj. OR 6.88 CI 95% 3.50-13.53). Fetal acidosis (arterial umbilical pH<7.2) was seen more often after the application of UFP in spontaneous vaginal deliveries (adj. OR 3.18, CI 95% 2.64-3.82) and assisted vaginal deliveries (adj. OR 1.59 CI 95% 1.17-2.16). The incidence of 5'-Apgar<7 (adj. OR 2.19 CI 95% 1.04-4.6) and 10'-Apgar<7 (adj. OR 3.04 CI 95% 1.17-7.88) was also increased after the application of UFP in spontaneous deliveries. A higher incidence of anal sphincter tears (AST) (adj. OR 46.25 CI 95% 11.78-181.6) in the UFP group of spontaneous deliveries was observed. UFP is associated with increased occurrence of shoulder dystocia and fetal acidosis. In spontaneous deliveries, the risk for lower Apgar scores after 5 and 10 min is increased, as well as the risk for AST.

Administration of oral and vaginal prebiotic lactoferrin for a woman with a refractory vaginitis recurring preterm delivery: appearance of lactobacillus in vaginal flora followed by term delivery.

PubMed

Otsuki, Katsufumi; Tokunaka, Mayumi; Oba, Tomohiro; Nakamura, Masamitsu; Shirato, Nahoko; Okai, Takashi

2014-02-01

Lactoferrin (LF) is one of the prebiotics present in the human body. A 38-year-old multiparous woman with poor obstetrical histories, three consecutive preterm premature rupture of membrane at the 19th, 23rd and 25th week of pregnancy, was referred to our hospital. She was diagnosed as having refractory vaginitis. Although estriol vaginal tablets were used for 4 months, the vaginitis was not cured. We administrated vaginal tablets and oral agents of prebiotic LF, resulting in a Lactobacillus predominant vaginal flora. When she was pregnant, she continued to use the LF, and the Lactobacillus in the vaginal flora was continuously observed during pregnancy. An elective cesarean section was performed at the 38th week of pregnancy. When the administration of LF was discontinued after the delivery, Lactobacillus in the vaginal flora was disappeared. © 2013 The Authors. Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology.

Reducing high-order perineal laceration during operative vaginal delivery.

PubMed

Hirsch, Emmet; Haney, Elaine I; Gordon, Trent E J; Silver, Richard K

2008-06-01

This study was undertaken to assess the impact of a focused intervention on reducing high-order (third and fourth degree) perineal lacerations during operative vaginal delivery. The following recommendations for clinical management were promulgated by departmental lectures, distribution of pertinent articles and manuals, training of physicians, and prominent display of an instructional poster: (1) increased utilization of vacuum extraction over forceps delivery; (2) conversion of occiput posterior to anterior positions before delivery; (3) performance of mediolateral episiotomy if episiotomy was deemed necessary; (4) flexion of the fetal head and maintenance of axis traction; (5) early disarticulation of forceps; and (6) reduced maternal effort at expulsion. Peer comparison was encouraged by provision of individual and departmental statistics. Clinical data were extracted from the labor and delivery database and the medical record. One hundred fifteen operative vaginal deliveries occurred in the 3 quarters preceding the intervention, compared with 100 afterward (P = .36). High-order laceration with operative vaginal delivery declined from 41% to 26% (P = .02), coincident with increased use of vacuum (16% vs 29% of operative vaginal deliveries, P = .02); fewer high-order lacerations after episiotomy (63% vs 22%, P = .003); a nonsignificant reduction in performance of episiotomy (30% vs 23%, P = .22); and a nonsignificant increase in mediolateral episiotomy (14% vs 30% of episiotomies, P = .19). Introduction of formal practice recommendations and performance review was associated with diminished high-order perineal injury with operative vaginal delivery.

Propylene glycol-embodying deformable liposomes as a novel drug delivery carrier for vaginal fibrauretine delivery applications.

PubMed

Li, Wei-Ze; Hao, Xu-Liang; Zhao, Ning; Han, Wen-Xia; Zhai, Xi-Feng; Zhao, Qian; Wang, Yu-E; Zhou, Yong-Qiang; Cheng, Yu-Chuan; Yue, Yong-Hua; Fu, Li-Na; Zhou, Ji-Lei; Wu, Hong-Yu; Dong, Chun-Jing

2016-03-28

The purpose of this work was to develop and characterize the fibrauretine (FN) loaded propylene glycol-embodying deformable liposomes (FDL), and evaluate the pharmacokinetic behavior and safety of FDL for vaginal drug delivery applications. FDL was characterized for structure, particle size, zeta potential, deformability and encapsulation efficiency; the ability of FDL to deliver FN across vagina tissue in vitro and the distribution behavior of FN in rat by vaginal drug delivery were investigated, the safety of FDL to the vagina of rabbits and rats as well as human vaginal epithelial cells (VK2/E6E7) were also evaluated. Results revealed that: (i) the FDL have a closed spherical shape and lamellar structure with a homogeneous size of 185±19nm, and exhibited a negative charge of -53±2.7mV, FDL also have a good flexibility with a deformability of 92±5.6 (%phospholipids/min); (ii) the dissolving capacity of inner water phase and hydrophilicity of phospholipid bilayers of deformable liposomes were increased by the presence of propylene glycol, this may be elucidated by the fluorescent probes both lipophilic Nile red and hydrophilic calcein that were filled up the entire volume of the FDL uniformly, so the FDL with a high entrapment capacity (were calculated as percentages of total drug) for FN was 78±2.14%; (iii) the permeability of FN through vaginal mucosa was obviously improved by propylene glycol-embodying deformable liposomes, no matter whether the FN loaded in liposomes or not, although FN loaded in liposomes caused the highest permeability and drug reservoir in vagina; (iv) the FN mainly aggregated in the vagina and uterus, then the blood, spleen, liver, kidney, heart and lungs for vaginal drug delivery, this indicating vaginal delivery of FDL have a better 'vaginal local targeting effect'; and (v) the results of safety evaluation illustrate that the FDL is non-irritant and well tolerated in vivo, thereby establishing its vaginal drug delivery potential. These results indicate that the propylene glycol-embodying deformable liposomes may be a promising drug delivery carrier for vaginal delivery of fibrauretine. Copyright © 2016 Elsevier B.V. All rights reserved.

The maternal childbirth experience more than a decade after delivery.

PubMed

Bossano, Carla M; Townsend, Kelly M; Walton, Alexandra C; Blomquist, Joan L; Handa, Victoria L

2017-09-01

Maternal satisfaction with the birth experience is multidimensional and influenced by many factors, including mode of delivery. To date, few studies have investigated maternal satisfaction outside of the immediate postpartum period. This study investigated whether differences in satisfaction based on mode of delivery are observed more than a decade after delivery. This was a planned, supplementary analysis of data collected for the Mothers' Outcomes after Delivery study, a longitudinal cohort study of pelvic floor disorders in parous women and their association with mode of delivery. Obstetric and demographic data were obtained through patient surveys and obstetrical chart review. Maternal satisfaction with childbirth experience was assessed via the Salmon questionnaire, administered to Mothers' Outcomes after Delivery study participants >10 years from their first delivery. This validated questionnaire yields 3 scores: fulfillment, distress, and difficulty. These 3 scores were compared by mode of delivery (cesarean prior to labor, cesarean during labor, spontaneous vaginal delivery, and operative vaginal delivery). In addition, the impact of race, age, education level, parity, episiotomy, labor induction, and duration of second stage of labor on maternal satisfaction were examined. Among 576 women, 10.1-17.5 years from delivery, significant differences in satisfaction scores were noted by delivery mode. Salmon scale scores differed between women delivering by cesarean and those delivering vaginally: women delivering vaginally reported greater fulfillment (0.40 [-0.37 to 0.92] vs 0.15 [-0.88 to 0.66], P < .001) and less distress (-0.34 [-0.88 to 0.38] vs 0.20 [-0.70 to 0.93], P < .001) than those who delivered by cesarean. Women who delivered by cesarean prior to labor reported the greatest median fulfillment scores and the lowest median difficulty scores. Median distress scores were lowest among those who delivered by spontaneous vaginal birth. Among women who underwent cesarean delivery, labor induction and prolonged second stage were associated with higher difficulty scores. These factors did not affect satisfaction scores among women who delivered vaginally. Among women who delivered vaginally, operative vaginal delivery was associated with less favorable scores across all 3 scores. Maternal satisfaction with childbirth is influenced by mode of delivery. The birth experience leaves an impression on women more than a decade after delivery. Copyright © 2017 Elsevier Inc. All rights reserved.

[The possibility of antepartal prevention of episiotomy and perineal tears during delivery].

PubMed

Bohatá, P; Dostálek, L

To determine the effect of antepartal methods on the prevention of birth injuries in primiparous women. Retrospective study. Nemocnice Český Krumlov, a.s. Between February 2014 and November 2015 were 315 primiparous women questioned after a vaginal delivery on the use of methods of birth injury prevention (vaginal dilatators EPI-NO and Aniball, perineal massage, natural methods - raspberry-leaf tea or linseed). Consecutively, the rates of intact perineum, perineal tears and episiotomies among respective methods were compared with the control group using no preventive method. The effects of the methods were tested on the occurrence of spontaneous or vaginal operative delivery. There was a significantly higher number of women with intact perineum after the use of vaginal dilatators (43.1% vs.14.1% in control group (p < 0.001). We also found a significant reduction of episiotomies in this group (29.3% vs. 57.7%, p < 0.001). There was no significant effect of perineal massage, raspberry-leaf tea or linseed on perineum injury prevention. A lower occurrence of vaginal operative delivery was also confirmed in the group of women using vaginal dilatators (p = 0.02). Significant benefit of the use of the antepartal vaginal dilatators in the reduction of birth injuries was shown as well as of the occurrence of vaginal operative delivery.

Reoccurrence of retained placenta at vaginal delivery: an observational study.

PubMed

Nikolajsen, Sys; Løkkegaard, Ellen Christine Leth; Bergholt, Thomas

2013-04-01

To estimate the prevalence and validate the diagnosis of retained placenta in nulliparous women and the risk of reoccurrence at subsequent vaginal delivery. Nested cohort study. Department of Gynecology and Obstetrics, university-affiliated teaching hospital. 10 334 nulliparous singleton pregnancies who delivered vaginally at the hospital during 2000-2009. Data from a computerized database information system were used to identify 287 women who had an ICD-10 diagnosis of retained placenta and 572 randomly selected controls matched by the date of first delivery. At chart review the diagnosis was confirmed by: (1) excessive bleeding <30 minutes after delivery without placental separation, (2) placenta not separated 30 minutes after delivery or (3) confirmation of retained placental tissue >2 hours postpartum. Confirmation of the diagnosis and prevalence of retained placenta. Risk of reoccurrence in a subsequent vaginal delivery. The prevalence of retained placenta increased from 2.8 to 7.0% after confirmation according to the set criteria. Of the selected women, 48.4% had a subsequent vaginal delivery. Of these women, 25.3% (23/91) with a previous retained placenta and 5.3% (11/206) without previously retained placenta, experienced retained placenta in subsequent delivery. This corresponds to an adjusted odds ratio of 5.5 (95% confidence interval 2.6-12.7) in the multivariate analysis for recurrence of retained placenta in a subsequent vaginal delivery. The use of the ICD-10 diagnosis of retained placenta underestimated the prevalence. The risk of reoccurrence of retained placenta is significantly increased in a subsequent vaginal delivery. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2012 Nordic Federation of Societies of Obstetrics and Gynecology.

Thromboprophylaxis after vaginal delivery: a district general hospital experience.

PubMed

Potdar, N; Jabbar, B; Burrell, S J

2006-01-01

The Confidential Enquiries into Maternal Deaths (RCOG 2001) recommends risk assessment and appropriate thromboprophylaxis after vaginal delivery. This study examines the risk group and the need for thromboprophylaxis after vaginal delivery in our local population and the cost implications for the same. It is a retrospective study of women who delivered in the month of November 2003. There were 307 deliveries, of these 251 (81.7%) were vaginal deliveries. Confidential Enquiries into Maternal Deaths (CEMD) risk classification was possible for 243 women. A total of 170 women were low risk, 66 (27.16%) moderate risk and 7 (2.88%) high risk. The costs of thromboprophylaxis for the year in our unit were calculated as pound7,339.71 for unfractionated heparin (UFH) 5,000 IU twice daily and pound7,098.27 for 40 mg enoxaparin once daily. A total of 30% of our District General Hospital population were classified as moderate or high risk for thromboprophylaxis after vaginal delivery. It is less expensive to use enoxaparin compared with unfractionated heparin for thromboprophylaxis.

Preferred Physical Characteristics of Vaginal Film Microbicides for HIV Prevention in Pittsburgh Women.

PubMed

Fan, Maria D; Kramzer, Lindsay F; Hillier, Sharon L; Chang, Judy C; Meyn, Leslie A; Rohan, Lisa C

2017-05-01

Unprotected heterosexual intercourse is the leading cause of HIV acquisition in women. Due to the complex nature of correct and consistent condom use by both men and women, developing alternative female-controlled HIV prevention options is a global health priority. Vaginal films containing antiretroviral drugs are a potential delivery system for the prevention of HIV acquisition through sexual contact. In this study, we explored women's preferences regarding physical characteristics of microbicide vaginal films through questionnaires and focus groups. Eighty-four sexually active, ethnically diverse women 18-30 years of age from Pittsburgh, Pennsylvania, participated in the study. Women visually and manually examined a variety of vaginal films, as well as three other vaginal products undergoing evaluation for HIV prevention: tablet, ring, and gel. Means and standard deviations or frequencies and 95 % confidence intervals were calculated for questionnaire data. Focus groups were audio-recorded, transcribed verbatim, and coded for content analysis. Women most frequently preferred vaginal films to be smooth and thin (63 %), translucent (48 %), and 2″ × 2″ square size (36 %). Driving these preferences were five major themes: ease and accuracy of use, desire for efficacy, discretion, intravaginal comfort and minimal impact, and minimizing disruption of sexual mood/activities. Women's preferences for various microbicide vaginal film physical attributes represented a balance of multiple values. In general, women desired a comfortable, efficacious, easy to use, and minimally intrusive product.

Is prophylaxis required for delivery in women with factor VII deficiency?

PubMed Central

Baumann Kreuziger, Lisa M.; Morton, Colleen T.; Reding, Mark T.

2013-01-01

Introduction Factor VII (fVII) deficiency is a rare congenital bleeding disorder in which fVII activity level and bleeding tendency do not completely correlate. Pregnancy and delivery present a significant hemostatic challenge to women with fVII deficiency. Treatment with recombinant factor VIIa (rfVIIa) carries a thrombotic risk and the literature is unclear whether prophylaxis is necessary prior to delivery. Aim To define management, hemorrhagic and thrombotic complications of pregnant women with fVII deficiency through a systematic review. Methods Medical databases (PubMed, MEDLINE, CINAHL, Academic Search Premier, Cochrane Library, Web of Science and Scopus) were searched using “factor VII deficiency” and “pregnancy” or “surgery.” Overall 34 articles, 4 abstracts, and 3 institutional cases were reviewed. Results Literature from 1953–2011 reported 94 live births from 62 women with fVII deficiency. The median fVII activity was 5.5%. Hemostatic prophylaxis was used in 32% of deliveries. Without prophylaxis, 40 vaginal deliveries and 16 cesarean sections were completed. The odds of receiving prophylaxis were 2.9 times higher in women undergoing cesarean section compared to vaginal delivery. Post-partum hemorrhage occurred in 10% of deliveries with prophylaxis and 13% of deliveries without prophylaxis. The fVII level did not significantly differ between women who did and did not receive prophylaxis. Conclusion We present the only systematic review of the management of pregnancy in fVII deficient women. No difference in post-partum hemorrhage was seen in deliveries with and without prophylaxis. Therefore we recommend that rfVIIa be available in the case of hemorrhage or surgical intervention, but not as mandatory prophylaxis. PMID:23607277

Is prophylaxis required for delivery in women with factor VII deficiency?

PubMed

Baumann Kreuziger, L M; Morton, Colleen T; Reding, Mark T

2013-11-01

Factor VII (fVII) deficiency is a rare congenital bleeding disorder in which fVII activity level and bleeding tendency do not completely correlate. Pregnancy and delivery present a significant haemostatic challenge to women with fVII deficiency. Treatment with recombinant factor VIIa (rfVIIa) carries a thrombotic risk and the literature is not clear whether prophylaxis is necessary prior to delivery. The aim of this study was to define management, haemorrhagic and thrombotic complications of pregnant women with fVII deficiency through a systematic review. Medical databases (PubMed, MEDLINE, CINAHL, Academic Search Premier, Cochrane Library, Web of Science and Scopus) were searched using "factor VII deficiency" and "pregnancy" or "surgery." Overall 34 articles, four abstracts, and three institutional cases were reviewed. Literature from 1953 to 2011 reported 94 live births from 62 women with fVII deficiency. The median fVII activity was 5.5%. Haemostatic prophylaxis was used in 32% of deliveries. Without prophylaxis, 40 vaginal deliveries and 16 caesarean sections were completed. The odds of receiving prophylaxis were 2.9 times higher in women undergoing caesarean section compared to vaginal delivery. Post-partum haemorrhage occurred in 10% of deliveries with prophylaxis and 13% of deliveries without prophylaxis. The fVII level did not significantly differ between women who did and did not receive prophylaxis. We present the only systematic review of the management of pregnancy in fVII deficient women. No difference in post-partum haemorrhage was seen in deliveries with and without prophylaxis. Therefore, we recommend that rfVIIa be available in the case of haemorrhage or surgical intervention, but not as mandatory prophylaxis. © 2013 John Wiley & Sons Ltd.

Evaluation of delivery options for second stage events

PubMed Central

Bailit, Jennifer L.; Grobman, William A.; Rice, Madeline Murguia; Wapner, Ronald J.; Reddy, Uma M.; Varner, Michael W.; Thorp, John M.; Caritis, Steve N.; Iams, Jay D.; Saade, George; Rouse, Dwight J.; Tolosa, Jorge E.

2015-01-01

Background Cesarean delivery in the second stage of labor is common, whereas the frequency of operative vaginal delivery has been declining. However, data comparing outcomes for attempted operative vaginal delivery in the second stage versus cesarean in the second stage are scant. Previous studies that examine operative vaginal delivery have compared it to a baseline risk of complications from a spontaneous vaginal delivery and cesarean delivery. However, when a woman has a need for intervention in the second stage, spontaneous vaginal delivery is not an option she or the provider can choose. Thus, the appropriate clinical comparison is cesarean versus operative vaginal delivery. Objective Our objective was to compare outcomes by the first attempted operative delivery (vacuum, forceps versus cesarean delivery) in patients needing second stage assistance at a fetal station of +2 or below. Study Design Secondary analysis of an observational obstetric cohort in 25 academically-affiliated U.S. hospitals over a three-year period. A subset of ≥37 weeks, non-anomalous, vertex, singletons, with no prior vaginal delivery who reached a station of +2 or below and underwent an attempt at an operative delivery were included. Indications included for operative delivery were: failure to descend, non-reassuring fetal status, labor dystocia or maternal exhaustion. The primary outcomes included a composite neonatal outcome (death, fracture, length of stay ≥3 days beyond mother’s, low Apgar, subgaleal hemorrhage, ventilator support, hypoxic encephalopathy, brachial plexus injury, facial nerve palsy) and individual maternal outcomes (postpartum hemorrhage, third and fourth degree tears [severe lacerations], and postpartum infection). Outcomes were examined by the three attempted modes of delivery. Odds ratios were calculated for primary outcomes adjusting for confounders. Final mode of delivery was quantified. Results 2531 women met inclusion criteria. Vacuum attempt was associated with the lowest frequency of the neonatal composite (4.2% vs. 6.1% vaginal forceps vs. 6.9% cesarean) and maternal complications (Postpartum infection 0.2% vs. 0.9% forceps vs. 5.3% cesarean, Postpartum hemmorhage 1.4% vs. 2.8% forceps vs. 3.8% cesarean), except for severe lacerations (19.1% vs. 33.8% forceps vs. 0% cesarean). When confounders were taken into account, both forceps (odds ratio 0.16, 95%CI 0.05-0.49) and vacuum (odds ratio 0.04, 95%CI 0.01-0.17) were associated with a significantly lower odds of Post partuminfection. The neonatal composite and Postpartum hemmorhage were not significantly different between modes of attempted delivery. Cesarean occurred in 6.4% and 4.4% of attempted vacuum and forceps groups (P=.04). Conclusion In patients needing second stage delivery assistance with a station of +2 or below, attempted operative vaginal delivery was associated with a lower frequency of Postpartum infection, but higher frequency of severe lacerations. PMID:26596236

Risk factors for the breakdown of perineal laceration repair after vaginal delivery.

PubMed

Williams, Meredith K; Chames, Mark C

2006-09-01

The purpose of this study was to identify risk factors that are associated with the breakdown of perineal laceration repair in the postpartum period. We conducted a retrospective, case-control study to review perineal laceration repair breakdown in patients who were delivered between September 1995 and February 2005 at the University of Michigan. Bivariate analysis with chi-square test and t-test and stepwise logistic regression analysis were performed. Fifty-nine cases and 118 control deliveries were identified from a total of 14,124 vaginal deliveries. Risk factors were longer second stage of labor (142 vs 87 minutes; P = .001), operative vaginal delivery (odds ratio, 3.6; 95% CI, 1.8-7.3), mediolateral episiotomy (odds ratio, 6.9; 95% CI, 2.6-18.7), third- or fourth-degree laceration (odds ratio, 3.1; 95% CI, 1.5-6.4), and meconium-stained amniotic fluid (odds ratio, 3.0; 95% CI, 1.1-7.9). Previous vaginal delivery was protective (odds ratio, 0.38; 95% CI, 0.18-0.84). Logistic regression showed the most significant factor to be an interaction between operative vaginal delivery and mediolateral episiotomy (odd ratio, 6.36; 95% CI, 2.18-18.57). The most significant events were mediolateral episiotomy, especially in conjunction with operative vaginal delivery, third- and fourth-degree lacerations, and meconium.

Comparison of Reproductive Outcomes following Retained Products of Conception after Vaginal Delivery versus First-Trimester Abortion.

PubMed

Melcer, Yaakov; Smorgick, Noam; Schneider, David; Pansky, Moty; Halperin, Reuvit; Ben-Ami, Ido

2015-01-01

To compare the reproductive outcomes of women with pathologically confirmed retained products of conception (RPOC) following spontaneous vaginal delivery versus first-trimester pregnancy termination. We retrospectively reviewed all cases of women who underwent uterine re-evacuation due to pathologically confirmed RPOC between January 1, 2000 and December 31, 2010. Reproductive outcomes were compared between women with RPOC following spontaneous vaginal delivery and those who underwent dilatation and curettage (D&C) due to first-trimester abortion. The study group consisted of 176 patients with pathologically confirmed RPOC. Of those, 83 (47.1%) were admitted after spontaneous vaginal delivery and 93 (52.9%) following D&C due to first-trimester abortion. There were no significant differences in the conception rate, the mean time to conception and the rate of a new infertility problem between women with RPOC after vaginal delivery compared to those following pregnancy termination (p > 0.05). Furthermore, there were no significant differences between the groups in pregnancy outcomes following RPOC. Pathologically confirmed RPOC harbors the same reproductive outcomes following spontaneous vaginal delivery and first-trimester pregnancy termination. © 2015 S. Karger AG, Basel.

Induction of labor versus expectant management for women with a prior cesarean delivery.

PubMed

Palatnik, Anna; Grobman, William A

2015-03-01

Previous studies of induction of labor in the setting of trial of labor after cesarean have compared women undergoing trial of labor after cesarean to those undergoing spontaneous labor. However, the clinically relevant comparison is to those undergoing expectant management. The objective of this study was to compare obstetric outcomes between women undergoing induction of labor and those undergoing expectant management ≥39 weeks of gestation. This was a secondary analysis of data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network Cesarean Registry that included women with singleton gestations at a gestational age of ≥39 weeks and a history of 1 low transverse cesarean delivery. Outcomes of induction at 39, 40, and 41 weeks were compared to expectant management beyond each gestational age period using univariable and multivariable analyses. Women with scheduled repeat cesarean deliveries done for the indication of prior cesarean delivery were excluded from the analysis. In all, 12,676 women were eligible for analysis. The rate of vaginal birth after cesarean (VBAC) was higher among women undergoing induction of labor at 39 weeks compared to expectant management (73.8% vs 61.3%, P < .001). The risk of uterine rupture also was higher among women undergoing induction of labor at 39 weeks compared to expectant management (1.4% vs 0.5%, P = .006, respectively). In multivariable analysis, induction of labor at 39 weeks remained associated with a significantly higher chance of VBAC and uterine rupture (odds ratio, 1.31; 95% confidence interval, 1.03-1.67; and odds ratio, 2.73; 95% confidence interval, 1.22-6.12, respectively). Induction of labor at 39 weeks, when compared to expectant management, was associated with a higher chance of VBAC but also of uterine rupture. Copyright © 2015 Elsevier Inc. All rights reserved.

Can a prediction model for vaginal birth after cesarean also predict the probability of morbidity related to a trial of labor?

PubMed

Grobman, William A; Lai, Yinglei; Landon, Mark B; Spong, Catherine Y; Leveno, Kenneth J; Rouse, Dwight J; Varner, Michael W; Moawad, Atef H; Caritis, Steve N; Harper, Margaret; Wapner, Ronald J; Sorokin, Yoram; Miodovnik, Menachem; Carpenter, Marshall; O'Sullivan, Mary J; Sibai, Baha M; Langer, Oded; Thorp, John M; Ramin, Susan M; Mercer, Brian M

2009-01-01

The objective of the study was to determine whether a model for predicting vaginal birth after cesarean (VBAC) can also predict the probabilty of morbidity associated with a trial of labor (TOL). Using a previously published prediction model, we categorized women with 1 prior cesarean by chance of VBAC. Prevalence of maternal and neonatal morbidity was stratfied by probability of VBAC success and delivery approach. Morbidity became less frequent as the predicted chance of VBAC increased among women who underwent TOL (P < .001) but not elective repeat cesarean section (ERCS) (P > .05). When the predicted chance of VBAC was less than 70%, women undergoing a TOL were more likely to have maternal morbidity (relative risk [RR], 2.2; 95% confidence interval [CI], 1.5-3.1) than those who underwent an ERCS; when the predicted chance of VBAC was at least 70%, total maternal morbidity was not different between the 2 groups (RR, 0.8; 95% CI, 0.5-1.2). The results were similar for neonatal morbidity. A prediction model for VBAC provides information regarding the chance of TOL-related morbidity and suggests that maternal morbidity is not greater for those women who undergo TOL than those who undergo ERCS if the chance of VBAC is at least 70%.

Mode of Delivery and Long-Term Health-Related Quality-of-Life Outcomes: A Prospective Population-Based Study.

PubMed

Petrou, Stavros; Kim, Sung Wook; McParland, Penny; Boyle, Elaine M

2017-06-01

Relatively little is known about the effects of mode of delivery on long-term health-related quality-of-life outcomes. Furthermore, no previous study has expressed these outcomes in preference-based (utility) metrics. The study population comprised 2,161 mothers recruited from a prospective population-based study in the East Midlands of England encompassing live births and stillbirths between 32 +0 and 36 +6 weeks' gestation and a sample of term-born controls. Perinatal data were extracted from the mothers' maternity records. Health-related quality-of-life outcomes were assessed at 12 months postpartum, using the EuroQol Five Dimensions (EQ-5D) measure with responses to the EQ-5D descriptive system converted into health utility scores. Descriptive statistics and multivariable analyses were used to estimate the relationship between the mode of delivery and health-related quality-of-life outcomes. The overall health-related quality-of-life profile of the women in the study cohort mirrored that of the English adult population as revealed by national health surveys. A significantly higher proportion of women delivering by cesarean delivery reported some, moderate, severe, or extreme pain or discomfort at 12 months postpartum than women undergoing spontaneous vaginal delivery. Multivariable analyses, using the Ordinary Least Squares estimator revealed that, after controlling for maternal sociodemographic characteristics, cesarean delivery without maternal or fetal compromise was associated with a significant EQ-5D utility decrement in comparison to spontaneous vaginal delivery among all women (-0.026; p = 0.038) and among mothers of term-born infants (-0.062; p < 0.001). Among mothers of term-born infants, this result was replicated in models that controlled for all maternal and infant characteristics (utility decrement of -0.061; p < 0.001). The results were confirmed by sensitivity analyses that varied the categorization of the main exposure variable (mode of delivery) and the econometric strategy. Among mothers of term-born infants, cesarean delivery without maternal or fetal compromise is associated with poorer long-term health-related quality of life in comparison to spontaneous vaginal delivery. Further longitudinal studies are needed to understand the magnitude, trajectory, and underpinning mechanisms of health-related quality-of-life outcomes following different modes of delivery. © 2016 Wiley Periodicals, Inc.

Conjoined twins and legal authorization for abortion.

PubMed

Nomura, Roseli Mieko Yamamoto; Brizot, Maria de Lourdes; Liao, Adolfo Wenjaw; Hernandez, Wagner Rodrigues; Zugaib, Marcelo

2011-01-01

To describe pregnancies with conjoined twins according to the request for legal termination of pregnancy. Retrospective review of pregnancies with conjoined twins, with no possibility of extrauterine survival or postnatal surgical separation, observed at a tertiary teaching hospital, between 1998 and 2010. Amongst 30 cases seen during the study period, six (20.0%) couples decided to continue with the pregnancy, termination of pregnancy was not requested due to advanced gestational age (> 25 weeks) in 5 cases (16.7%). Legal authorization to terminate the pregnancy was requested in 19 (63.3%) cases: permission was granted in 12 (63.2%), denied in five (26.3%) and information was missing in two (10.5%) cases. A successful vaginal delivery was performed in 83.3% of the cases undergoing termination of pregnancy and a cesarean section was performed in all the remaining cases (p < 0.01). In pregnancies with conjoined twins and without fetal prognosis, legal termination of the pregnancy is an alternative. Moreover, a successful vaginal delivery can be performed in most cases before the third trimester, further reducing maternal risks and parental suffering.

[Pregnancy and delivery in patients with a personal history of cesarean section in Dakar: epidemiological, clinical, therapeutic and prognostic aspects].

PubMed

Koulimaya-Gombet, Cyr Espérance; Diouf, Abdoul Aziz; Diallo, Moussa; Dia, Anna; Sène, Codou; Moreau, Jean Charles; Diouf, Alassane

2017-01-01

The aim of our study was to determine hospitalization rate for vaginal birth after cesarean section in Pikine, to evaluate the quality of the management of pregnant women with previous cesarean section and to determine prognostic factors of the outcome of a trial of scar. We conducted a retrospective study based on medical records and operational protocols of patients who underwent vaginal birth after cesarean section over the period 1 January 2010 - 31 December 2011. We analyzed socio-demographic data, pregnancy follow-up, therapeutic modalities and prognosis. Data were collected and analyzed using Microsoft Office Excel 2007 software and SPSS software 17.0. The frequency of vaginal births after cesarean section was 9.6%. The average age of our patients was 29.4 years. Primiparous women accounted for 54%. Short spacing interval between births was found in 52.6% of cases. Based on the number of cesarean sections, the breakdown was as follows: patients with a history of one previous cesarean section (79.8%), patients with a history of two previous caesarean sections (17.9%) and patients with a history of three previous caesarean sections (2.3%). The number of antenatal consultations performed was greater than or equal to 3 in 79.8% of cases. Patients undergoing evacuation accounted for 54.2% and they were already in labor at the time of admission in 81.7% of cases. Trial of scar was authorized in 177 patients (34.3%) and, at the end of this test, 147 patients (83%) had vaginal birth, of whom 21.7% by vacuum extraction. Cesarean section was performed in 71.4% of cases with 245 emergency cesarean sections and 93 scheduled cesarean sections. A history of vaginal birth was a determining factor in normal delivery (p = 0.0001). There was also a significant relationship between mode of admission and decision to perform a cesarean section (p = 0.0001). Maternal mortality was 0.4%. Perinatal mortality rate was 28.2‰ of live births. We are witnessing a dramatic increase of deliveries after cesarean section in our SONUC Health Centre. The quality of management should be enhanced through a better strategy in preparation for delivery. Trial of scar is a procedure to encourage in order to reduce the rate of iterative cesarean sections.

Spontaneous Caecal Perforation Associated with Ogilvie's Syndrome Following Vaginal Delivery - A Case Report.

PubMed

E, Harish; Vk, Sundeep; Kola, Sivasai Krishnaprasad; Kg, Dharma Kumar

2014-06-01

Acute pseudo-obstruction of the large bowel, Ogilvie's syndrome, can occur in the postpartum period following caesarean section which can result in caecal dilatation and may progress to perforation. This is quiet rare following normal vaginal delivery. Only two previous reports have been found in the English literature. We report a case of Ogilvie's syndrome with caecal perforation following normal vaginal delivery.

Complication rates on weekends and weekdays in US hospitals.

PubMed

Bendavid, Eran; Kaganova, Yevgenia; Needleman, Jack; Gruenberg, Leonard; Weissman, Joel S

2007-05-01

Recent studies and anecdotal evidence suggest that patient safety may be compromised on weekends. Our objective was to determine whether rates of complications in hospitals are higher on weekends than on weekdays. We examined records from 4,967,114 admissions to acute care hospitals in 3 states and analyzed complication rates using the Patient Safety Indicators. We selected 8 indicators that could be assigned to a single day: complications of anesthesia, retained foreign bodies, postoperative hemorrhage, accidental cuts and lacerations during procedures, birth trauma, obstetric trauma during vaginal deliveries with and without instrumentation, and obstetric trauma during cesarean delivery. Odds ratios (ORs) comparing weekends versus weekdays were adjusted for demographics, type of admission, and admission route. In a subgroup analysis of surgical complications, we restricted the population to patients who underwent cardiac or vascular procedures. Four of the 8 complications occurred more frequently on weekends: postoperative hemorrhage (OR 1.07, 95% confidence interval [CI], 1.01-1.14), newborn trauma (OR 1.06, 95% CI, 1.03-1.10), vaginal deliveries without instrumentation (OR 1.03, 95% CI, 1.02-1.04), and obstetric trauma during cesarean sections (OR 1.36, 95% CI, 1.29-1.44). Complications related to anesthesia occurred less frequently on weekends (OR 0.86). Among patients undergoing vascular procedures, surgical complications occurred more frequently on weekends (OR 1.46, 95% CI, 1.16-1.85). Rates of complications are marginally higher on weekends than on weekdays for some surgical and newborn complications, but more significantly for obstetric trauma and for surgical complications involving patients undergoing vascular procedures. Hospitals should work toward increasing the robustness of safeguards on weekends.

Intrapartum ultrasound: A useful method for evaluating labor progress and predicting operative vaginal delivery

PubMed Central

Ahn, Ki Hoon

2014-01-01

The last step of a successful pregnancy is the safe delivery of the fetus. An important question is if the delivery should vaginal or operative. In addition to the use of conventional antenatal ultrasound, the use of intrapartum ultrasound to evaluate fetal head station, position, cervical ripening, and placental separation is promising. This review evaluates and summarizes the usefulness of intrapartum ultrasound for the evaluation of labor progress and predicting successful operative vaginal delivery. PMID:25469329

The frequent shift to intermediate flora in preterm delivery cases after abnormal vaginal flora screening

PubMed Central

Honda, Hiroshi; Yokoyama, Takanori; Akimoto, Yumiko; Tanimoto, Hirotoshi; Teramoto, Mitsue; Teramoto, Hideki

2014-01-01

The effect of screening and treatment for abnormal vaginal flora on the reduction of preterm deliveries remains controversial. We evaluated whether this screening and treatment reduces the preterm delivery rate for general-population pregnant women. Pregnant women of the Intervention group (n = 574) underwent the screening test and the treatment of vaginal metronidazole during the early second trimester, and those of the Control group (n = 1,161) did not. We compared the preterm delivery rate between these two groups. We also compared the profiles of vaginal flora of the preterm delivery cases with those of the pregnant women with a normal course. There was no significant difference in the preterm delivery rate between these two groups. However, in the preterm delivery cases, a frequent shift to intermediate flora was observed not before but after the screening in the Intervention group. This shift may explain why most of the previous studies failed in regard to the prevention of preterm deliveries. PMID:24762852

Antibiotic prescribing in women during and after delivery in a non-teaching, tertiary care hospital in Ujjain, India: a prospective cross-sectional study.

PubMed

Sharma, Megha; Sanneving, Linda; Mahadik, Kalpana; Santacatterina, Michele; Dhaneria, Suryaprakash; Stålsby Lundborg, Cecilia

2013-01-01

Antibacterial drugs (hereafter referred to as antibiotics) are crucial to treat infections during delivery and postpartum period to reduce maternal mortality. Institutional deliveries have the potential to save lives of many women but extensive use of antibiotics, add to the development and spread of antibiotic resistance. The aim of this study was to present antibiotic prescribing among inpatients during and after delivery in a non-teaching, tertiary care hospital in the city of Ujjain, Madhya Pradesh, India. A prospective cross-sectional study was conducted including women having had either a vaginal delivery or a cesarean section in the hospital. Trained nursing staff collected the data on daily bases, using a specific form attached to each patient file. Statistical analysis, including bivariate and multivariable logistic regression was conducted. Of the total 1077 women, 566 (53%) had a vaginal delivery and 511 (47%) had a cesarean section. Eighty-seven percent of the women that had a vaginal delivery and 98% of the women having a cesarean section were prescribed antibiotics. The mean number of days on antibiotics in hospital for the women with a vaginal delivery was 3.1 (±1.7) and for the women with cesarean section was 6.0 (±2.5). Twenty-eight percent of both the women with vaginal deliveries and the women with cesarean sections were prescribed antibiotics at discharge. The most commonly prescribed antibiotic group in the hospital for both the women that had a vaginal delivery and the women that had a cesarean section were third-generation cephalosporins (J01DD). The total number of defined daily doses (DDD) per100 bed days for women that had a vaginal delivery was 101, and 127 for women that had a cesarean section. The high percentage of women having had a vaginal delivery that received antibiotics and the deviation from recommendation for cesarean section in the hospital is a cause of concern. Improved maternal health and rational use of antibiotics are intertwined. Specific policy and guidelines on how to prescribe antibiotics during delivery at health care facilities are needed. Additionally, monitoring system of antibiotic prescribing and resistance needs to be developed and implemented.

Cervical dilation at the time of cesarean section for dystocia -- effect on subsequent trial of labor.

PubMed

Abildgaard, Helle; Ingerslev, Marie Diness; Nickelsen, Carsten; Secher, Niels Joergen

2013-02-01

To investigate the effect of cervical dilation at the time of cesarean section due to dystocia and success in a subsequent pregnancy of attempted vaginal delivery. Retrospective study. University hospital in Copenhagen capital area. All women with a prior cesarean section due to dystocia who had undergone a subsequent pregnancy with a singleton delivery during 2006-2010. Medical records were reviewed for prior vaginal birth, cervical dilation reached before cesarean section and induction of labor, gestational age, use of oxytocin, epidural anesthesia and mode of birth was collected. A total of 889 women were included; 373 had had a trial of labor. The success rate for vaginal birth among women with prior cesarean section for dystocia at 4-8 cm dilation was 39%, but 59% for women in whom prior cesarean section had been done at a fully or almost fully dilated cervix (9-10 cm) (p < 0.001). Among the women with a previous vaginal delivery prior to their cesarean section, the success rate for vaginal birth was 76.2%, in contrast to 48.9% in the group without a previous vaginal delivery (p < 0.01). Women who had a trial of labor after a prior cesarean section for dystocia done late in labor and women with a vaginal delivery prior to their cesarean section had a greater chance of a successful vaginal birth during a subsequent delivery. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology.

Instrumental delivery: clinical practice guidelines from the French College of Gynaecologists and Obstetricians.

PubMed

Vayssière, Christophe; Beucher, Gael; Dupuis, Olivier; Feraud, Olivia; Simon-Toulza, Caroline; Sentilhes, Loïc; Meunier, Emmanuelle; Parant, Olivier; Schmitz, Thomas; Riethmuller, Didier; Baud, Olivier; Galley-Raulin, Fabienne; Diemunsch, Pierre; Pierre, Fabrice; Schaal, Jean-Patrick; Fournié, Alain; Oury, Jean François

2011-11-01

Routine use of a partograph is associated with a reduction in the use of forceps, but is not associated with a reduction in the use of vacuum extraction (Level A). Early artificial rupture of the membranes, associated with oxytocin perfusion, does not reduce the number of operative vaginal deliveries (Level A), but does increase the rate of fetal heart rate abnormalities (Level B). Early correction of lack of progress in dilatation by oxytocin perfusion can reduce the number of operative vaginal deliveries (Level B). The use of low-concentration epidural infusions of bupivacaine potentiated by morphinomimetics reduces the number of operative interventions compared with larger doses (Level A). Placement of an epidural before 3-cm dilatation does not increase the number of operative vaginal deliveries (Level A). Posterior positions of the fetus result in more operative vaginal deliveries (Level B). Manual rotation of the fetus from a posterior position to an anterior position may reduce the number of operative deliveries (Level C). Walking during labour is not associated with a reduction in the number of operative vaginal deliveries (Level A). Continuous support of the parturient by a midwife or partner/family member during labour reduces the number of operative vaginal deliveries (Level A). Under epidural analgesia, delayed pushing (2h after full dilatation) reduces the number of difficult operative vaginal deliveries (Level A). Ultrasound is recommended if there is any clinical doubt about the presentation of the fetus (Level B). The available scientific data are insufficient to contra-indicate attempted midoperative delivery (professional consensus). The duration of the operative intervention is slightly shorter with forceps than with a vacuum extractor (Level C). Nonetheless, the urgency of operative delivery is not a reason to choose one instrument over another (professional consensus). The cup-shaped vacuum extractor seems to be the instrument of choice for operative deliveries of fetuses in a cephalic transverse position, and may also be preferred for fetuses in a posterior position (professional consensus). Vacuum extraction deliveries fail more often than forceps deliveries (Level B). Overall, immediate maternal complications are more common for forceps deliveries than vacuum extraction deliveries (Level B). Compared with forceps, operative vaginal delivery using a vacuum extractor appears to reduce the number of episiotomies (Level B), first- and second-degree perineal lesions, and damage to the anal sphincter (Level B). Among the long-term complications, the rate of urinary incontinence is similar following forceps, vacuum extraction and spontaneous vaginal deliveries (Level B). Anal incontinence is more common following forceps delivery (Level B). Persistent anal incontinence has a similar prevalence regardless of the mode of delivery (caesarean or vaginal, instrumental or non-instrumental), suggesting the involvement of other factors (Level B). Rates of immediate neonatal mortality and morbidity are similar for forceps and vacuum extraction deliveries (Level B). It appears that difficult instrumental delivery may lead to psychological sequelae that may result in a decision not to have more children (Level C). The rates of neonatal convulsions, intracranial haemorrhage and jaundice do not differ between forceps and vacuum extraction deliveries (Levels B and C). Rapid sequence induction with a Sellick manoeuvre (pressure to the cricoid cartilage) and tracheal intubation with a balloon catheter is recommended for any general anaesthesia (Level B). Training must ensure that obstetricians can identify indications and contra-indications, choose the appropriate instrument, use the instruments correctly, and know the principles of quality control applied to operative vaginal delivery. Nowadays, traditional training can be accompanied by simulations. Training should be individualized and extended for some students. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Women's Psychological Adjustment Following Emergency Cesarean versus Vaginal Delivery.

ERIC Educational Resources Information Center

Padawer, Jill A.; And Others

1988-01-01

Investigated psychological adjustment and satisfaction in women who had given birth vaginally or by cesarean section. Cesarean mothers reported significantly less satisfaction with the delivery than did vaginal mothers; however no differences were found in postpartum psychological adjustment as measured by depression, anxiety, and confidence in…

Caesarean section on maternal request: risks and benefits in healthy nulliparous women and their infants.

PubMed

Dahlgren, Leanne S; von Dadelszen, Peter; Christilaw, Jan; Janssen, Patricia A; Lisonkova, Sarka; Marquette, Gerald P; Liston, Robert M

2009-09-01

To determine the risks and benefits of an elective Caesarean section (CS) at term in healthy nulliparous women. We conducted a population-based cohort study of deliveries between 1994 and 2002. Using bivariate and multivariable techniques, we compared maternal and neonatal outcomes in healthy nulliparous women who had undergone elective pre-labour CS (using breech presentation as a surrogate) with those in women who had undergone spontaneous labour with anticipated vaginal delivery (SL) at full term. There were 1046 deliveries in the pre-labour CS group and 38 021 in the SL group. Life-threatening maternal morbidity was similar in each group. Life-threatening neonatal morbidity was decreased in the CS group (RR 0.34; 99% CI 0.12 to 0.97). Subgroup analysis of the SL group by mode of delivery demonstrated the increased neonatal risk was associated with operative vaginal delivery and intrapartum CS but not spontaneous vaginal delivery. An elective pre-labour Caesarean section in a nulliparous woman at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery. However, the 63% of women with spontaneous labour who achieved a spontaneous vaginal delivery would not have benefited from delivery by Caesarean section. Further research is needed to better identify women with an increased likelihood of an operative vaginal or intrapartum Caesarean section, as this may assist maternity caregivers in decision-making about childbirth. Further research is also needed to determine if these findings can be confirmed in a prospective study.

Planned vaginal delivery versus Caesarean section for breech presentation in Ile-Ife, Nigeria.

PubMed

Orji, E O; Ajenifuja, K O

2003-11-01

The optimum mode of breech delivery remains a matter of controversy among obstetricians worldwide. To determine whether term breech babies born by planned vaginal delivery are at higher risk of neonatal mortality and morbidity than those born by planned caesarean delivery. A hospital based non-experimental comparison of outcome of breech delivery. Ife State Hospitals Complex, Ile-Ife. Two hundred and fourty four singleton breech deliveries occurring at term. They include low 5-minute Apgar score, birth trauma, maternal and perinatal morbidity and mortality. The perinatal mortality was not significantly different in both groups: OR 2.7 (95% C.I. 0.3-26.8). The low 5-minute Apgar scores were higher in the planned vaginal delivery OR 9.0 (95% C.I. 1-73.4), but the traumatic morbidity was not (OR 1.8, 95% C.I. 0.2-20.1). Maternal morbidity occurred more in the planned Caesarean delivery group OR 0.4 (95% C.I. 0.2-0.9). Given appropriate selection criteria and management protocol, the outcome from elective caesarean section might not be better than from planned vaginal delivery.

Evaluation of delivery options for second-stage events.

PubMed

Bailit, Jennifer L; Grobman, William A; Rice, Madeline Murguia; Wapner, Ronald J; Reddy, Uma M; Varner, Michael W; Thorp, John M; Caritis, Steve N; Iams, Jay D; Saade, George; Rouse, Dwight J; Tolosa, Jorge E

2016-05-01

Cesarean delivery in the second stage of labor is common, whereas the frequency of operative vaginal delivery has been declining. However, data comparing outcomes for attempted operative vaginal delivery vs cesarean in the second stage are scant. Previous studies that examine operative vaginal delivery have compared it to a baseline risk of complications from a spontaneous vaginal delivery and cesarean delivery. However, when a woman has a need for intervention in the second stage, spontaneous vaginal delivery is not an option she or the provider can choose. Thus, the appropriate clinical comparison is cesarean vs operative vaginal delivery. Our objective was to compare outcomes by the first attempted operative delivery (vacuum, forceps vs cesarean delivery) in patients needing second-stage assistance at a fetal station of +2 or below. We conducted secondary analysis of an observational obstetric cohort in 25 academically affiliated US hospitals over a 3-year period. A subset of ≥37 weeks, nonanomalous, vertex, singletons, with no prior vaginal delivery who reached a station of +2 or below and underwent an attempt at an operative delivery were included. Indications included for operative delivery were: failure to descend, nonreassuring fetal status, labor dystocia, or maternal exhaustion. The primary outcomes included a composite neonatal outcome (death, fracture, length of stay ≥3 days beyond mother's, low Apgar, subgaleal hemorrhage, ventilator support, hypoxic encephalopathy, brachial plexus injury, facial nerve palsy) and individual maternal outcomes (postpartum hemorrhage, third- and fourth-degree tears [severe lacerations], and postpartum infection). Outcomes were examined by the 3 attempted modes of delivery. Odds ratios (OR) were calculated for primary outcomes adjusting for confounders. Final mode of delivery was quantified. In all, 2531 women met inclusion criteria. No difference in the neonatal composite outcome was observed between groups. Vacuum attempt was associated with the lowest frequency of maternal complications (postpartum infection 0.2% vs 0.9% forceps vs 5.3% cesarean, postpartum hemorrhage 1.4% vs 2.8% forceps vs 3.8% cesarean), except for severe lacerations (19.1% vs 33.8% forceps vs 0% cesarean). When confounders were taken into account, both forceps (OR, 0.16; 95% confidence interval, 0.05-0.49) and vacuum (OR, 0.04; 95% confidence interval, 0.01-0.17) were associated with a significantly lower odds of postpartum infection. The neonatal composite and postpartum hemorrhage were not significantly different between modes of attempted delivery. Cesarean occurred in 6.4% and 4.4% of attempted vacuum and forceps groups (P = .04). In patients needing second-stage delivery assistance with a station of +2 or below, attempted operative vaginal delivery was associated with a lower frequency of postpartum infection, but higher frequency of severe lacerations. Copyright © 2016 Elsevier Inc. All rights reserved.

Defining an at-risk population for obstetric anal sphincter laceration.

PubMed

Minaglia, Steven M; Kimata, Chieko; Soules, Karen A; Pappas, Tamara; Oyama, Ian A

2009-11-01

The purpose of this study was to calculate the number of cesarean deliveries needed to prevent 1 case of obstetric anal sphincter laceration associated with operative vaginal delivery in an at-risk cohort. An institutional, computerized database was used to analyze women with obstructed labor who could have been managed by either operative vaginal or cesarean delivery from September 2006 to March 2008. Women with 1 or more of the following diagnoses comprised the cohort: cephalopelvic disproportion (CPD), arrest of descent, maternal exhaustion, and fetal distress. Fifty (23.9%) out of a total of 209 women managed by operative vaginal delivery experienced an anal sphincter laceration compared to none of 254 women in the cesarean delivery group (P < .0001). The ARR therefore was 23.9% (95% confidence interval, 18.1-29.7) and the NNT was 4.2 (95% confidence interval, 3.4-5.5). Five cesarean deliveries are needed to prevent 1 anal sphincter laceration associated with operative vaginal delivery in this cohort.

Spontaneous Caecal Perforation Associated with Ogilvie’s Syndrome Following Vaginal Delivery – A Case Report

PubMed Central

VK, Sundeep; Kola, Sivasai Krishnaprasad; KG, Dharma Kumar

2014-01-01

Acute pseudo-obstruction of the large bowel, Ogilvie’s syndrome, can occur in the postpartum period following caesarean section which can result in caecal dilatation and may progress to perforation. This is quiet rare following normal vaginal delivery. Only two previous reports have been found in the English literature. We report a case of Ogilvie’s syndrome with caecal perforation following normal vaginal delivery. PMID:25121027

Simulation to Improve Trainee Knowledge and Comfort About Twin Vaginal Birth.

PubMed

Easter, Sarah Rae; Gardner, Roxane; Barrett, Jon; Robinson, Julian N; Carusi, Daniela

2016-10-01

To describe a simulation-based curriculum on twin vaginal delivery and evaluate its effects on trainee knowledge and comfort about twin vaginal birth. Trainees participated in a three-part simulation consisting of a patient counseling session, a twin delivery scenario, and a breech extraction skills station. Consenting trainees completed a 21-item presimulation survey and a 22-item postsimulation survey assessing knowledge, experience, attitudes, and comfort surrounding twin vaginal birth. Presimulation and postsimulation results were compared using univariate analysis. Our primary outcomes were change in knowledge and comfort before and after the simulation. Twenty-four obstetrics and gynecology residents consented to participation with 18 postsimulation surveys available for comparison (75%). Trainees estimated their participation in 445 twin deliveries (median 19, range 0-52) with only 20.4% of these as vaginal births. Participants reported a need for more didactic or simulated training on this topic (64% and 88%, respectively). Knowledge about twin delivery improved after the simulation (33.3% compared with 58.3% questions correct, P<.01). Before training, 33.3% of participants reported they would strongly counsel a patient to attempt vaginal birth instead of elective cesarean delivery for twins compared with 50% after training (P=.52). Personal comfort with performing a breech extraction of a nonvertex second twin improved from 5.5% to 66.7% after the simulation (P<.01). Resident exposure to twin vaginal birth is infrequent and variable with a demonstrable need for more training. Our contemporary obstetric climate is prioritizing vaginal birth despite less frequent operative obstetric interventions. We describe a reproducible twin delivery simulation associated with a favorable effect on resident knowledge and comfort levels.

Predictive value for preterm birth of abnormal vaginal flora, bacterial vaginosis and aerobic vaginitis during the first trimester of pregnancy.

PubMed

Donders, G G; Van Calsteren, K; Bellen, G; Reybrouck, R; Van den Bosch, T; Riphagen, I; Van Lierde, S

2009-09-01

Abnormal vaginal flora (AVF) before 14 gestational weeks is a risk factor for preterm birth (PTB). The presence of aerobic microorganisms and an inflammatory response in the vagina may also be important risk factors. The primary aim of the study was to investigate the differential influences of AVF, full and partial bacterial vaginosis, and aerobic vaginitis in the first trimester on PTB rate. The secondary aim was to elucidate why treatment with metronidazole has not been found to be beneficial in previous studies. Unselected women with low-risk pregnancies attending the prenatal unit of the Heilig Hart General Hospital in Tienen, Belgium, were included in the study. At the first prenatal visit, 1026 women were invited to undergo sampling of the vaginal fluid for wet mount microscopy and culture, of whom 759 were fully evaluable. Abnormal vaginal flora (AVF; disappearance of lactobacilli), bacterial vaginosis (BV), aerobic vaginitis (AV), increased inflammation (more than ten leucocytes per epithelial cell) and vaginal colonisation with Candida (CV) were scored according to standardised definitions. Partial BV was defined as patchy streaks of BV flora or sporadic clue cells mixed with other flora, and full BV as a granular anaerobic-type flora or more than 20% clue cells. Vaginal fluid was cultured for aerobic bacteria, Mycoplasma hominis and Ureaplasma urealyticum. Outcome was recorded as miscarriage

Twin vaginal delivery: innovate or abdicate.

PubMed

Easter, Sarah Rae; Taouk, Laura; Schulkin, Jay; Robinson, Julian N

2017-05-01

Neonatal safety data along with national guidelines have prompted renewed interest in vaginal delivery of twins, particularly in the case of the noncephalic second twin. Yet, the rising rate of twin cesarean deliveries, coupled with the national decline in operative obstetrics, raises concerns about the availability of providers who are skilled in twin vaginal birth. Providers are key stakeholders for increasing rates of twin vaginal delivery. We surveyed a group of practicing obstetricians to explore potential barriers to the vaginal birth of twins with a focus on delivery of the noncephalic second twin. Among 107 responding providers, only 57% would deliver a noncephalic second twin by breech extraction. Providers who preferred breech extraction had a higher rate of maternal-fetal medicine subspecialty training (26.2% vs 4.3%; P<.01) and were more likely to be in an academic practice environment (36.1% vs 10.9%; P<.01) and to practice in high-volume centers that deliver >30 sets of twins annually (57.4% vs 34.8%; P=.02). Most providers (54.2%) were familiar with the findings from the recent randomized trial that demonstrated the safety of twin vaginal birth. However, knowledge of the trial was not associated statistically with a preference for breech extraction (62.3% vs 43.5%; P=.05). Providers who preferred breech extraction were more likely to agree with recent society guidelines that encourage the vaginal birth of twins (86.9% vs 63.0%; P<.01). In an adjusted analysis, the 46% of providers with a perceived need for more training were far less likely to prefer breech extraction for delivery of a noncephalic second twin (adjusted odds ratio, 0.38; 95% confidence interval, 0.16-0.95). Furthermore, 57% of providers who would not offer their patient breech extraction would be willing to consult a colleague for support with a noncephalic twin delivery. These results suggest that scientific evidence and society opinion are likely insufficient to reverse the national trends that favor cesarean delivery for twins. Instead, implementation of provider training and support programs is critical for increasing the rates of twin vaginal birth. Changing our national landscape of vaginal twin delivery may require innovation. Without novel provider-focused strategies, we may relinquish passively the requisite skills for not only our patients but also for future generations of obstetricians. Copyright © 2017 Elsevier Inc. All rights reserved.

Severe postpartum haemorrhage after vaginal delivery: a statistical process control chart to report seven years of continuous quality improvement.

PubMed

Dupont, Corinne; Occelli, Pauline; Deneux-Tharaux, Catherine; Touzet, Sandrine; Duclos, Antoine; Bouvier-Colle, Marie-Hélène; Rudigoz, René-Charles; Huissoud, Cyril

2014-07-01

Severe postpartum haemorrhage after vaginal delivery: a statistical process control chart to report seven years of continuous quality improvement To use statistical process control charts to describe trends in the prevalence of severe postpartum haemorrhage after vaginal delivery. This assessment was performed 7 years after we initiated a continuous quality improvement programme that began with regular criteria-based audits Observational descriptive study, in a French maternity unit in the Rhône-Alpes region. Quarterly clinical audit meetings to analyse all cases of severe postpartum haemorrhage after vaginal delivery and provide feedback on quality of care with statistical process control tools. The primary outcomes were the prevalence of severe PPH after vaginal delivery and its quarterly monitoring with a control chart. The secondary outcomes included the global quality of care for women with severe postpartum haemorrhage, including the performance rate of each recommended procedure. Differences in these variables between 2005 and 2012 were tested. From 2005 to 2012, the prevalence of severe postpartum haemorrhage declined significantly, from 1.2% to 0.6% of vaginal deliveries (p<0.001). Since 2010, the quarterly rate of severe PPH has not exceeded the upper control limits, that is, been out of statistical control. The proportion of cases that were managed consistently with the guidelines increased for all of their main components. Implementation of continuous quality improvement efforts began seven years ago and used, among other tools, statistical process control charts. During this period, the prevalence of severe postpartum haemorrhage after vaginal delivery has been reduced by 50%. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Neuraxial labor analgesia for vaginal delivery and its effects on childhood learning disabilities.

PubMed

Flick, Randall P; Lee, Kunmoo; Hofer, Ryan E; Beinborn, Charles W; Hambel, Ellen M; Klein, Melissa K; Gunn, Paul W; Wilder, Robert T; Katusic, Slavica K; Schroeder, Darrell R; Warner, David O; Sprung, Juraj

2011-06-01

In prior work, children born to mothers who received neuraxial anesthesia for cesarean delivery had a lower incidence of subsequent learning disabilities compared with vaginal delivery. The authors speculated that neuraxial anesthesia may reduce stress responses to delivery, which could affect subsequent neurodevelopmental outcomes. To further explore this possibility, we examined the association between the use of neuraxial labor analgesia and development of childhood learning disabilities in a population-based birth cohort of children delivered vaginally. The educational and medical records of all children born to mothers residing in the area of 5 townships of Olmsted County, Minnesota from 1976 to 1982 and remaining in the community at age 5 years were reviewed to identify those with learning disabilities. Cox proportional hazards regression was used to compare the incidence of learning disabilities between children delivered vaginally with and without neuraxial labor analgesia, including analyses adjusted for factors of either potential clinical relevance or that differed between the 2 groups in univariate analysis. Of the study cohort, 4684 mothers delivered children vaginally, with 1495 receiving neuraxial labor analgesia. The presence of childhood learning disabilities in the cohort was not associated with use of labor neuraxial analgesia (adjusted hazard ratio, 1.05; 95%confidence interval, 0.85-1.31; P = 0.63). The use of neuraxial analgesia during labor and vaginal delivery was not independently associated with learning disabilities diagnosed before age 19 years. Future studies are needed to evaluate potential mechanisms of the previous finding indicating that the incidence of learning disabilities is lower in children born to mothers via cesarean delivery under neuraxial anesthesia compared with vaginal delivery.

Filled Prescriptions for Opioids After Vaginal Delivery.

PubMed

Jarlenski, Marian; Bodnar, Lisa M; Kim, Joo Yeon; Donohue, Julie; Krans, Elizabeth E; Bogen, Debra L

2017-03-01

To estimate the prevalence of filled opioid prescriptions after vaginal delivery. We conducted a retrospective cohort study of 164,720 Medicaid-enrolled women in Pennsylvania who delivered a liveborn neonate vaginally from 2008 to 2013, excluding women who used opioids during pregnancy or who had an opioid use disorder. We assessed overall filled prescriptions as well as filled prescriptions in the presence or absence of the following pain-inducing conditions: bilateral tubal ligation, perineal laceration, or episiotomy. Outcomes included a binary measure of whether a woman had any opioid prescription fill 5 days or less after delivery and, among those women, a second opioid prescription fill 6-60 days after delivery. Among women with no coded pain-inducing conditions at delivery, we used multivariable logistic regression with standard errors clustered to account for within-hospital correlation to assess the association between patient characteristics and odds of a filled opioid prescription. Twelve percent of women (n=18,131) filled an outpatient opioid prescription 5 days or less after vaginal delivery; among those women, 14% (n=2,592, or 1.6% of the total) filled a second opioid prescription 6-60 days after delivery. Of the former, 5,110 (28.2%) had one or more pain-inducing conditions. Predictors of filled opioid prescriptions with no observed pain-inducing condition at delivery included tobacco use (adjusted odds ratio [OR] 1.3, 95% confidence interval [CI] 1.2-1.4) and a mental health condition (adjusted OR 1.3, 95% CI 1.2-1.4). Having a diagnosis of substance use disorder other than opioid use disorder was not associated with filling an opioid prescription 5 days or less after delivery, but was associated with having a second opioid prescription 6-60 days after delivery (adjusted OR 1.4, 95% CI 1.2-1.6). More than 1 in 10 Medicaid-enrolled women fill an outpatient opioid prescription after vaginal delivery. National opioid-prescribing recommendations for common obstetrics procedures such as vaginal delivery are warranted.

Use of translabial three-dimensional power Doppler ultrasound for cervical assessment before labor induction.

PubMed

Esin, Sertac; Yirci, Bulent; Yalvac, Serdar; Kandemir, Omer

2017-07-26

To compare translabial three-dimensional (3D) power Doppler ultrasound with Bishop score and transvaginal ultrasound measurements for cervical assessment before induction of labor with dinoprostone or cervical ripening balloon. Translabial cervical volume and length, vascularization indices and transvaginal cervical length were measured. Results were compared among women who had vaginal delivery at 24 h or less and more than 24 h after the insertion of the dinoprostone vaginal insert or cervical ripening balloon and among women who had vaginal delivery and cesarean delivery for failure to go into labor or failure to progress. There was no correlation between the time to delivery after a ripening agent was applied and translabial cervical volume, translabial cervical length, vascularization index (VI), flow index (FI), vascularization flow index (VFI), transvaginal cervical length and Bishop scores. The ultrasonographic measurements were no different among women who had vaginal delivery at 24 h or less and more than 24 h and among women who had vaginal delivery and cesarean delivery for failure to go into labor or failure to progress. In this study, we failed to demonstrate the superiority of translabial 3D ultrasonography over Bishop score and transvaginal ultrasonography for predicting the success of induction of labor.

Effect of Rotation on Perineal Lacerations in Forceps-Assisted Vaginal Deliveries

PubMed Central

Bradley, Megan S.; Kaminski, Robert J.; Streitman, David C.; Dunn, Shannon L.; Krans, Elizabeth E.

2013-01-01

Objective To determine the difference in the rates of severe perineal lacerations between forceps-assisted vaginal deliveries in the occiput-posterior (OP) position compared with forceps-assisted vaginal deliveries in which the fetal head was rotated to occiput anterior (OA) prior to delivery. Methods We studied a retrospective cohort of 148 women who had a forceps-assisted vaginal delivery from 2008–2011 at the University of Pittsburgh. Mild perineal lacerations were defined as first or second degree, and severe lacerations were defined as third or fourth degree. Chi-square and t tests were used for bivariate and logistic regression was used for multivariable analyses. P<.05 was considered statistically significant. Results Of 148 forceps-assisted deliveries, 81 delivered OA after either manual or forceps rotation, 10 delivered in the OP or occiput-transverse position after an unsuccessful rotation, and 57 delivered OP without attempted rotation. No significant differences were found between demographic, obstetric and neonatal characteristics of the groups. Overall, 86 (67.7%) women had mild lacerations and 41 (32.3%) had severe lacerations. A significantly greater rate of severe perineal lacerations were found in the OP nonrotated compared with the rotated group (43.4% compared with 24.3%; P=.02). In multivariable analyses, adjusted for age, race, insurance, body mass index, gestational age, parity, episiotomy and neonatal weight, forceps-assisted vaginal delivery in the OP position without rotation remained significantly more likely to be associated with severe lacerations (OR 3.67; 95% CI 1.42–9.47). Conclusion Forceps-assisted vaginal delivery after rotation of an OP position to an OA position is associated with less severe maternal perineal trauma than forceps-assisted delivery in the OP position. PMID:23743462

Effect of rotation on perineal lacerations in forceps-assisted vaginal deliveries.

PubMed

Bradley, Megan S; Kaminski, Robert J; Streitman, David C; Dunn, Shannon L; Krans, Elizabeth E

2013-07-01

To determine the difference in the rates of severe perineal lacerations between forceps-assisted vaginal deliveries in the occiput-posterior position compared with forceps-assisted vaginal deliveries in which the fetal head was rotated to occiput-anterior before delivery. We studied a retrospective cohort of 148 women who had a forceps-assisted vaginal delivery from 2008 to 2011 at the University of Pittsburgh. Mild perineal lacerations were defined as first or second degree, and severe lacerations were defined as third or fourth degree. χ and t tests were used for bivariate and logistic regression was used for multivariable analyses. P<.05 was considered statistically significant. Of 148 forceps-assisted deliveries, 81 delivered occiput-anterior after either manual or forceps rotation, 10 delivered in the occiput-posterior or occiput-transverse position after an unsuccessful rotation, and 57 delivered occiput-posterior without attempted rotation. No significant differences were found among demographic, obstetric, and neonatal characteristics of the groups. Overall, 86 (67.7%) women had mild lacerations and 41 (32.3%) had severe lacerations. A significantly greater rate of severe perineal lacerations was found in the occiput-posterior nonrotated compared with the rotated group (43.4% compared with 24.3%; P=.02). In multivariable analyses, adjusted for age, race, insurance, body mass index, gestational age, parity, episiotomy, and birth weight, forceps-assisted vaginal delivery in the occiput-posterior position without rotation remained significantly more likely to be associated with severe lacerations (odds ratio 3.67, 95% confidence interval 1.42-9.47). Forceps-assisted vaginal delivery after rotation of an occiput-posterior position to an occiput-anterior position is associated with less severe maternal perineal trauma than forceps-assisted delivery in the occiput-posterior position. II.

Perinatal and maternal morbidity and mortality after attempted operative vaginal delivery at midpelvic station

PubMed Central

Muraca, Giulia M.; Sabr, Yasser; Lisonkova, Sarka; Skoll, Amanda; Brant, Rollin; Cundiff, Geoffrey W.; Joseph, K.S.

2017-01-01

BACKGROUND: Increased use of operative vaginal delivery (i.e., forceps or vacuum application), of which 20% occurs at midpelvic station, has been advocated to reduce the rate of cesarean delivery. We aimed to quantify severe perinatal and maternal morbidity and mortality associated with attempted midpelvic operative vaginal delivery. METHODS: We studied all term singleton deliveries in Canada between 2003 and 2013, by attempted midpelvic operative vaginal or cesarean delivery with labour (with and without prolonged second stage). The primary outcomes were composite severe perinatal morbidity and mortality (e.g., convulsions, assisted ventilation, severe birth trauma and perinatal death), and composite severe maternal morbidity and mortality (e.g., severe postpartum hemorrhage, shock, sepsis, cardiac complications, acute renal failure and death). RESULTS: The study population included 187 234 deliveries. Among women with dystocia and prolonged second stage of labour, midpelvic operative vaginal delivery was associated with higher rates of severe perinatal morbidity and mortality compared with cesarean delivery (forceps, adjusted odds ratio [AOR] 1.81, 95% confidence interval [CI] 1.24 to 2.64; vacuum, AOR 1.81, 95% CI 1.17 to 2.80; sequential instruments, AOR 3.19, 95% CI 1.73 to 5.88), especially with higher rates of severe birth trauma. Rates of severe maternal morbidity and mortality were not significantly different after operative vaginal delivery, although rates of obstetric trauma were higher (forceps, AOR 4.51, 95% CI 4.04 to 5.02; vacuum, AOR 2.70, 95% CI 2.35 to 3.09; sequential instruments, AOR 4.24, 95% CI 3.46 to 5.19). Among women with fetal distress, similar associations were seen for severe birth trauma and obstetric trauma, although vacuum was associated with lower rates of severe maternal morbidity and mortality (AOR 0.52, 95% CI 0.33 to 0.80). Associations tended to be stronger among women without a prolonged second stage. INTERPRETATION: Midpelvic operative vaginal delivery is associated with higher rates of severe birth trauma and obstetric trauma, whereas overall rates of severe perinatal and maternal morbidity and mortality vary by indication and operative instrument. PMID:28584040

Women's antenatal preferences for delivery route in a setting with high cesarean section rates and a medically dominated maternity system.

PubMed

Dweik, Diána; Girasek, Edmond; Töreki, Annamária; Mészáros, Gyula; Pál, Attila

2014-04-01

To assess birth preferences in a sample of Hungarian pregnant women and identify determinants of ambivalence or clear choices for cesarean section throughout pregnancy. Follow-up two-point questionnaire survey. University Department of Obstetrics and Gynecology in Hungary. A total of 413 women with singleton pregnancies where there was no awareness of medical contradictions to vaginal delivery, attending for routine ultrasound examination in mid-pregnancy from November 2011 to March 2012. Questionnaires completed in mid- and late pregnancy (gestational weeks 18-22 and 35-37) including the Wijma Delivery Expectancy/Experience Questionnaire A. Prevalence of women preferring cesarean section or being uncertain about what delivery route to choose, in case they had the choice; their demographic characteristics, attitudes toward birth issues and their Wijma Delivery Expectancy/Experience Questionnaire A scores, compared with women consistent in their preference for vaginal delivery. Of the 413 respondents, 365 (88.4%) were consistent in their preference for vaginal delivery. In logistic regression models the important contributors to describing preferences for cesarean section or uncertain preferences were previous cesarean section and maternal belief that cesarean section is more beneficial than vaginal delivery. The majority of pregnant women preferred vaginal delivery to cesarean section. Neither a higher Wijma Delivery Expectancy/Experience Questionnaire A score nor sociodemographic differences were important determinants of a preference for cesarean section or for an uncertain preference. On the other hand, previous cesarean section and certain preconceived maternal attitudes towards delivery were characteristic for these women. © 2014 Nordic Federation of Societies of Obstetrics and Gynecology.

Coupled gel spreading and diffusive transport models describing microbicidal drug delivery

NASA Astrophysics Data System (ADS)

Funke, Claire; MacMillan, Kelsey; Ham, Anthony S.; Szeri, Andrew J.; Katz, David F.

2016-11-01

Gels are a drug delivery platform being evaluated for application of active pharmaceutical ingredients, termed microbicides, that act topically against infection by sexually transmitted HIV. Despite success in one Phase IIb trial of a vaginal gel delivering tenofovir, problems of user adherence to designed gel application regimen compromised results in two other trials. The microbicide field is responding to this issue by simultaneously analyzing behavioral determinants of adherence and pharmacological determinants of drug delivery. Central to both user adherence and mucosal drug delivery are gel properties (e.g. rheology) and applied volume. The specific problem to be solved here is to develop a model for how gel rheology and volume, interacting with loaded drug concentration, govern the transport of the microbicide drug tenofovir into the vaginal mucosa to its stromal layer. The analysis here builds upon our current understanding of vaginal gel deployment and drug delivery, incorporating key features of the gel's environment, fluid production and subsequent gel dilution, and vaginal wall elasticity. We consider the microbicide drug tenofovir as it is the most completely studied drug, in both in vitroand in vivostudies, for use in vaginal gel application. Our goal is to contribute to improved pharmacological understanding of gel functionality, providing a computational tool that can be used in future vaginal microbicide gel design.

Vaginal birth after one previous caesarean section in a tertiary institution in Nigeria.

PubMed

Aisien, A O; Oronsaye, A U

2004-11-01

Vaginal birth after one previous lower segment caesarean section represents one of the most significant and challenging issues in obstetric practice. A 5-year retrospective study was carried out at the University of Benin Teaching Hospital between January 1999 and December 2003, to determine the incidence, the maternal and fetal outcome following vaginal delivery after one previous caesarean section with a view to evaluating its safety and efficacy. There were 5234 deliveries, with 395 cases of one previous caesarean section, giving an incidence of 7.5%. The incidences of emergency caesarean section, elective caesarean section and spontaneous vaginal delivery following trial of vaginal delivery were 34.7%, 9.4% and 48.1%, respectively. During the study period there were 1317 cases of caesarean section, giving an incidence of 25.2% caesarean section rate. The incidence of one previous section among all caesarean section births was 30%. The major morbidity following vaginal delivery was uterine rupture with an incidence of 1.5% and hysterectomy of 0.8%. Three of the uterine ruptures occurred before admission because the patients laboured at home. One maternal death occurred as a result of uterine rupture and postpartum haemorrhage, giving a maternal mortality ratio of 19/100,000 and a case fatality rate of 0.3%. The corrected perinatal mortality rate was 15.2/1000, mainly from obstructed labour, abruptio placenta and fetal distress. Both maternal and fetal mortalities from vaginal birth after one previous section were significantly less than the respective overall maternal and fetal mortality from the institution. The 1-minute apgar score of babies delivered by elective section was significantly (P < 0.001) higher than the apgar score of babies delivered by emergency section and vaginally. There was only one patient with wound dehiscence at elective section without associated perinatal death. Vaginal delivery following caesarean section is relatively safe. However, women in developing countries will continue to require counselling to counter the myths of aversion to operative delivery even at the expense of losing their lives. Our hospitals should have adequate monitoring equipment for high-risk pregnancies so that patients and their babies can be assured of survival.

Meta-analysis of randomized controlled trials comparing 17α-hydroxyprogesterone caproate and vaginal progesterone for the prevention of recurrent spontaneous preterm delivery.

PubMed

Oler, Elizabeth; Eke, Ahizechukwu C; Hesson, Ashley

2017-07-01

Vaginal progesterone and 17α-hydroxyprogesterone (17α-OHP) are both used to prevent preterm delivery in women who have experienced spontaneous preterm delivery (SPTD) previously. Randomized trial data of the comparative effectiveness of these interventions have been mixed. To compare the efficacy of intramuscular 17α-OHP and vaginal progesterone in the prevention of recurrent SPTD. Cochrane Central Register of Controlled Trials, African Journals Online, Embase, Google Scholar, ISI Web of Science, LILACS, CINAHL, PubMed, and registers of ongoing trials were searched using keywords related to 17α-OHP, vaginal progesterone, and preterm delivery. Randomized controlled trials published between January 1, 1966, and November 30, 2016, comparing 17α-OHP and vaginal progesterone for the prevention of recurrent SPTD during singleton pregnancies were included. Study data were extracted and meta-analyses were performed when outcomes were comparable. The meta-analyses included data from three randomized trials. Lower rates of SPTD before 34 weeks (relative risk 0.71, 95% confidence interval 0.53-0.95) and before 32 weeks (relative risk 0.62, 95% confidence interval 0.40-0.94) of pregnancy were observed among patients treated with vaginal progesterone. Vaginal progesterone and 17α-OHP were comparable for the prevention of recurrent SPTD in singleton pregnancies; vaginal progesterone could be superior. © 2017 International Federation of Gynecology and Obstetrics.

Grouping Parturients by Parity, Previous-Cesarean, and Mode of Delivery (P-C-MoD Classification) Better Identifies Groups at Risk for Postpartum Hemorrhage.

PubMed

Reichman, Orna; Gal, Micahel; Sela, Hen Y; Khayyat, Izzat; Emanuel, Michael; Samueloff, Arnon

2016-10-01

Objective We aimed to create a clinical classification to better identify parturients at risk for postpartum hemorrhage (PPH). Method A retrospective cohort, including all women who delivered at a single tertiary care medical center, between 2006 and 2014. Parturients were grouped by parity and history of cesarean delivery (CD): primiparas, multipara, and multipara with previous CD. Each were further subgrouped by mode of delivery (spontaneous vaginal delivery [SVD], operative vaginal delivery [OVD], emergency or elective CD). In all, 12 subgroups, based on parity, previous cesarean, and mode of delivery, formed the P-C-MoD classification. PPH was defined as a decrease of ≥3 gram% hemoglobin from admission and/or transfusion of blood products. Univariate analysis followed by multivariate analysis was performed to assess risk for PPH, controlling for confounders. Results The crude rate of PPH among 126,693 parturients was 7%. The prevalence differed significantly among independent risk factors: primiparity, 14%; multiparity, 4%; OVD, 22%; and CD, 15%. The P-C-MoD classification, segregated better between parturients at risk for PPH. The prevalence of PPH was highest for primiparous undergoing OVD (27%) compared with multiparous with SVD (3%), odds ratio [OR] = 12.8 (95% confidence interval [CI],11.9-13.9). These finding were consistent in the multivariate analysis OR = 13.1 (95% CI,12.1-14.3). Conclusion Employing the P-C-MoD classification more readily identifies parturients at risk for PPH and is superior to estimations based on single risk factors. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Comparative Study of Oral and Vaginal Misoprostol for Induction of Labour, Maternal and Foetal Outcome

PubMed Central

Komala, Kambhampati; Reddy, Meherlatha; Quadri, Iqbal Jehan; B., Suneetha; V., Ramya

2013-01-01

Background: Misoprostol is a new promising agent for cervical ripening and induction of labour .The ideal dose, route and frequency of administration of misoprostol are still under investigation. Although, vaginal application of misoprostol has been validated as a reasonable mean of induction, there is a patient resistance to digital examination and there is a risk of ascending infection. For this reason, oral administration of misoprostol for cervical ripening and labour induction has been tried. Aims and Objectives: To compare 50μg of oral misoprostol versus 25μg of intravaginal misoprostol for induction of labour at term and maternal, foetal outcomes. Methods: Two hundred women who were at term, with indication for induction of labour and Bishop scores of ≤5 were randomly assigned to receive misoprostol 50μg or 25μg intravaginal, every 4-6 hours, for a maximum of 5 doses. In either group, pregnant females with inadequate uterine contractions despite being given maximum 5 doses of misoprostol, were augmented using oxytocin. The primary outcome measure was time-interval from induction to vaginal delivery and vaginal delivery rate within 24 hours. Results: The median induction to vaginal delivery time in oral group (12.92h) and vaginal group (14.04 h) was not significant. Oral misoprostol resulted in more number of vaginal deliveries as compared to vaginal misoprostol (94% as compared to 86%), which was not significant. There was a significantly higher incidence of uterine tachysystole in the vaginal group, as compared to oral group. There were no significant differences between the groups with respect to oxytocin augmentation, caesarean section rate, analgesic requirement and neonatal outcome. Conclusion: Oral misoprostol is as efficacious as vaginal misoprostol because of shorter induction delivery interval, lower caesarean section rates, and lower incidence of failed induction rates. Lower incidence of foetal distress and easy intake are observed if the drug is administered orally. PMID:24551660

Fetal presentation and successful twin vaginal delivery.

PubMed

Easter, Sarah Rae; Lieberman, Ellice; Carusi, Daniela

2016-01-01

Despite the demonstrated safety of a trial of labor for pregnancies with a vertex-presenting twin and clinical guidelines in support of this plan, the rate of planned cesarean delivery for twin pregnancies remains high. This high rate, as well as variation in cesarean rates for twin pregnancies across providers, may be influenced strongly by concern about delivery of the second twin, particularly when it is in a nonvertex presentation. There are limited data in the literature that has examined the impact of the position of the nonpresenting twin on successful vaginal delivery or maternal/neonatal morbidity. We hypothesized that nonvertex presentation of the second twin would be associated with lower rates of successful vaginal birth for those patients attempting labor. This institutional review board-approved, retrospective cohort study of women who labored with twin pregnancies in a single urban hospital from 2007-2011. We included women with vertex-presenting first twins at >32 weeks gestation without a contraindication to labor and excluded those with uterine scar or lethal fetal anomaly. Vaginal delivery rates were evaluated according to vertex or nonvertex presentation of the second twin at admission and again at delivery. Maternal and neonatal morbidities were evaluated separately. Logistic regression was used to control for multiple confounders. Seven hundred sixteen patients met the inclusion criteria; 349 patients (49%) underwent a trial of labor. This included 73% (296/406) of eligible vertex/vertex twins and 17% (53/310) eligible vertex/nonvertex twins (P < .01). When compared with laboring patients with vertex/vertex-presenting twins, those with vertex/nonvertex twins were younger (median age, 32 vs 33 years; P = .05), were more often multiparous (60% vs 43%; P = .02), and were less likely to have hypertension (13% vs 27%; P = .03). Eighty-five percent of patients with nonvertex second twins at admission delivered vaginally, compared with 70% of patients with vertex second twins (P = .02). After we controlled for confounders, the difference was not statistically significant (adjusted odds ratio, 2.10; 95% confidence interval, 0.93-4.73). In the subset of patients with nonvertex second twins at delivery, those who initiated labor had an 89% vaginal delivery rate, compared with a 56% rate for those who changed from vertex to nonvertex presentation during labor (adjusted odds ratio, 19.90; 95% confidence interval, 3.86-102.78). Labor induction and increasing provider years in practice were also significant positive predictors of vaginal birth when the second twin was nonvertex at delivery. Maternal and neonatal morbidity was low and similar between groups, although 8% of women with nonvertex second twins experienced cervical lacerations, compared with 1% with vertex second twins (P = .01). Patients with nonvertex second twins had comparable, if not higher, rates of vaginal delivery than their vertex-presenting counterparts. The higher rate of vaginal delivery with stable nonvertex lie and the association with labor induction and the physician's years in practice all suggest a role for provider selection and delivery planning. These findings and the observed 11% rate of intrapartum presentation change support vaginal delivery of the nonvertex second twin. Copyright © 2016 Elsevier Inc. All rights reserved.

Twin Birth Study: 2-year neurodevelopmental follow-up of the randomized trial of planned cesarean or planned vaginal delivery for twin pregnancy.

PubMed

Asztalos, Elizabeth V; Hannah, Mary E; Hutton, Eileen K; Willan, Andrew R; Allen, Alexander C; Armson, B Anthony; Gafni, Amiram; Joseph, K S; Ohlsson, Arne; Ross, Susan; Sanchez, J Johanna; Mangoff, Kathryn; Barrett, Jon F R

2016-03-01

The Twin Birth Study randomized women with uncomplicated pregnancies, between 32(0/7)-38(6/7) weeks' gestation where the first twin was in cephalic presentation, to a policy of either a planned cesarean or planned vaginal delivery. The primary analysis showed that planned cesarean delivery did not increase or decrease the risk of fetal/neonatal death or serious neonatal morbidity as compared with planned vaginal delivery. This study presents the secondary outcome of death or neurodevelopmental delay at 2 years of age. A total of 4603 children from the initial cohort of 5565 fetuses/infants (83%) contributed to the outcome of death or neurodevelopmental delay. Surviving children were screened using the Ages and Stages Questionnaire with abnormal scores validated by a clinical neurodevelopmental assessment. The effect of planned cesarean vs planned vaginal delivery on death or neurodevelopmental delay was quantified using a logistic model to control for stratification variables and using generalized estimating equations to account for the nonindependence of twin births. Baseline maternal, pregnancy, and infant characteristics were similar. Mean age at assessment was 26 months. There was no significant difference in the outcome of death or neurodevelopmental delay: 5.99% in the planned cesarean vs 5.83% in the planned vaginal delivery group (odds ratio, 1.04; 95% confidence interval, 0.77-1.41; P = .79). A policy of planned cesarean delivery provides no benefit to children at 2 years of age compared with a policy of planned vaginal delivery in uncomplicated twin pregnancies between 32(0/7)-38(6/7)weeks' gestation where the first twin is in cephalic presentation. Copyright © 2016 Elsevier Inc. All rights reserved.

Mucoadhesive drug delivery systems

PubMed Central

Shaikh, Rahamatullah; Raj Singh, Thakur Raghu; Garland, Martin James; Woolfson, A David; Donnelly, Ryan F.

2011-01-01

Mucoadhesion is commonly defined as the adhesion between two materials, at least one of which is a mucosal surface. Over the past few decades, mucosal drug delivery has received a great deal of attention. Mucoadhesive dosage forms may be designed to enable prolonged retention at the site of application, providing a controlled rate of drug release for improved therapeutic outcome. Application of dosage forms to mucosal surfaces may be of benefit to drug molecules not amenable to the oral route, such as those that undergo acid degradation or extensive first-pass metabolism. The mucoadhesive ability of a dosage form is dependent upon a variety of factors, including the nature of the mucosal tissue and the physicochemical properties of the polymeric formulation. This review article aims to provide an overview of the various aspects of mucoadhesion, mucoadhesive materials, factors affecting mucoadhesion, evaluating methods, and finally various mucoadhesive drug delivery systems (buccal, nasal, ocular, gastro, vaginal, and rectal). PMID:21430958

Comparison of Breast Crawl Between Infants Delivered by Vaginal Delivery and Cesarean Section.

PubMed

Heidarzadeh, Mohammad; Hakimi, Sevil; Habibelahi, Abbas; Mohammadi, Marzieh; Shahrak, Shakiba Pourasad

2016-05-12

Exclusive breastfeeding is the single most cost-effective intervention to reduce infant mortality. Breast crawl (BC) is deemed a natural way for the baby to behave immediately after delivery. BC is the method that may help initiation of breastfeeding in the most natural way. The aim of this study is to compare successful BC between neonates born through vaginal delivery and those born through cesarean section (CS) and factors associated with a positive outcome. Participants were mothers who delivered their babies during the period of October 2012 to December 2013 in Alzahra Hospital in Tabriz, through cesarean or vaginal delivery. Infants were placed prone on their mothers' abdomen after delivery. Data show that babies delivered through vaginal delivery had significantly more success in BC than babies born through the cesarean delivery (88.01% versus 11.21%). Moreover, babies in the CS group used significantly less time to achieve BC (45 versus 28 minutes). There is a remarkable difference in completion and length of time used to achieve BC between infants with regard to the delivery mode. Encouraging BC in all dyads, especially in cesarean births, may unduly delay the infant's first breastfeed.

[Assessment of vacuum-assisted vaginal delivery in a frank breech presentation].

PubMed

Bleu, G; Deruelle, P; Demetz, J; Michel, S; Dufour, P; Depret, S; Subtil, D

2015-02-01

After verification of the eligibility criteria and with an obstetrician familiar with the specific maneuvers likely to be needed, vaginal delivery of breech presentations is possible. If problems arise during the active pushing phase of labor, vacuum extraction has been described in the literature for this uncommon condition with limited series. The aim of this study is to assess retrospectively vacuum extraction in frank breech presentation in our center. This retrospective study of trials of vaginal delivery of fetuses in breech presentation at term compares cases according to whether they did or did not use a vacuum extraction. During a two-year period, 83 patients, whom had trials of vaginal delivery in breech presentations, reached the active pushing/bearing down stage after complete cervical dilatation. Vacuum assistance was applied in six of these (7.2 %). The failure rate for vaginal delivery was significantly higher in the group with compared to without vacuum extraction (33.3 % versus 6.5 %, P<0.05). Moreover, the mean pH at birth was significantly lower in the group with vacuum extraction (7.12±0.11 versus 7.20±0.08, P<0.05), and these infants more frequently had deep cutaneous injuries (66.7 % versus 26.0 %, P<0.05). In fetuses in breech presentation, when vaginal delivery failed, it seems to be safer for the fetuses to perform caesarean section rather than attempt vacuum extraction. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Conservative Management of Placenta Accreta/Increta after Vaginal Birth

PubMed Central

Peiffer, S.; Reinhard, J.; Reitter, A.; Louwen, F.

2012-01-01

Aim: Aim of the study was to show that conservative management with preservation of the uterus and of fertility is possible in patients with placenta accreta/increta after vaginal delivery. Method: A retrospective analysis of patients with placental attachment disorders after vaginal delivery was done in a perinatal centre between November 2009 and April 2011. The patient collective was identified using the ICD-10 codes for placenta accreta/increta/percreta, and patient records were analysed for risk factors, maternal morbidity, preservation of the uterus and of fertility, and neonatal outcome. Results: Three cases of placenta increta were identified in the last 1.5 years out of a total of 1457 vaginal deliveries, and all 3 cases were treated conservatively. Mean maternal age was 35.3 years; gestational age ranged from 39 to 41 weeks, and mean duration between delivery of the child and delivery of the placenta was 44.67 days (range: 14–100 days). Two patients developed symptoms of endomyometritis, including fever, leukocytosis and increased CRP levels. All 3 women were successfully managed with preservation of the uterus. Conclusion: In selected cases with placenta accreta/increta after vaginal delivery, it is possible to avoid surgical procedures, particularly hysterectomy procedures, and successfully manage these patients conservatively with preservation of the uterus. PMID:25308979

Management of patients with placenta accreta in association with fever following vaginal delivery

PubMed Central

Zhong, Liuying; Chen, Dunjin; Zhong, Mei; He, Yutian; Su, Chunhong

2017-01-01

Abstract This study aims to analyze the clinical characteristics and to manage patients with retained placenta left in situ accompanied by fever following vaginal delivery. Twenty-one patients with retained placenta in association with fever following vaginal delivery were enrolled and managed at the maternity department of our university hospital between 2012 and 2014. All patients had risk factors for development of placenta accreta: previous cesarean sections (4/21), previous curettage (15/21), or uterine malformations (7/21). Placenta accreta was diagnosed following vaginal delivery in all patients, and manual removal of the placenta was attempted in 20 of 21 patients. The placenta left in situ was partial in 19 patients and was complete in 2 patients. All patients were managed with a multidisciplinary approach. Mifepristone was administrated to 16 patients. Fourteen patients received uterine artery embolization. Eleven patients were treated with ultrasound-guided curettage within 24 hours following delivery. Seven patients needed delayed-hysterectomy due to development of complications. Intrauterine operations during labor are not recommended if placenta accreta occurs in the fundus and/or in the cornual region of the uterus. Antibiotic treatment, interventional therapy, and ultrasound-guided curettage within 24 hours following vaginal delivery are the recommended conservative management strategies. PMID:28272244

Successful Pregnancy with a Full-Term Vaginal Delivery One Year After n-Butyl Cyanoacrylate Embolization of a Uterine Arteriovenous Malformation

DOE Office of Scientific and Technical Information (OSTI.GOV)

McCormick, Colleen C.; Kim, Hyun S.

Uterine arteriovenous malformation (AVM) causes significant morbidity with vaginal bleeding. Traditional therapy is a hysterectomy with no potential for future pregnancy. We present a case of successful superselective embolization of uterine AVM using n-butyl cyanoacrylate with subsequent normal term pregnancy and uncomplicated vaginal delivery in 1 year.

The incidence and risk factors for retained placenta after vaginal delivery - a single center experience.

PubMed

Ashwal, Eran; Melamed, Nir; Hiersch, Liran; Wiznitzer, Arnon; Yogev, Yariv; Peled, Yoav

2014-12-01

We aimed to determine the incidence and risk factors for retained placenta immediately after vaginal delivery in a single, university-affiliated tertiary center. A case-control study. Women who delivered vaginally and diagnosed with suspected retained placenta were compared to control group of women with spontaneous vaginal delivery with spontaneous non-complicated placental separation between the years 2007 and 2012. Eligibility was limited to singleton fetuses in vertex presentation with no history of more than one cesarean section, stillbirth or major fetal anomaly. Overall, 33,925 women delivered vaginally, of them, 491 (1.4%) underwent revision of uterine cavity due to suspected retained placenta. Women with retained placenta were characterized by a higher rate of previous cesarean section (OR 1.71, 95% CI 1.23-2.36), previous abortions, lower parity (OR 0.79, 95% CI 0.68-0.91), lower gestational age at delivery. Hypertensive disorders, oligohydramnios and labor and delivery interventions as induction of labor (OR 1.84, 95% CI 1.30-2.59), neuro-axial analgesia (OR 1.60, 95% CI 1.27-2.00) and vacuum delivery (OR 1.89, 95% CI 1.48-2.41) were independently associated with uterine revision for retained placenta. Risk factors for manual revision due to retained placenta can be recognized. This data should be taken into consideration in the assessment of women immediately after delivery.

Prior Prelabor or Intrapartum Cesarean Delivery and Risk of Placenta Previa

PubMed Central

Downes, Katheryne L.; Hinkle, Stefanie N.; Sjaarda, Lindsey A.; Albert, Paul S.; Grantz, Katherine L.

2015-01-01

Objective To examine the association between previous cesarean delivery and subsequent placenta previa while distinguishing cesarean delivery prior to onset of labor from intrapartum cesarean delivery. Study Design Retrospective cohort study of electronic medical records from 20 Utah hospitals (2002–2010) with restriction to the first two singleton deliveries of women nulliparous at study entry (n=26,987). First pregnancy delivery mode was classified as 1) vaginal (reference); 2) cesarean delivery prior to labor onset (prelabor); or 3) cesarean delivery after labor onset (intrapartum). Risk of second delivery previa was estimated by prior delivery mode using logistic regression and adjusted for maternal age, insurance, smoking, co-morbidities, prior pregnancy loss, and history of previa. Results The majority of first deliveries were vaginal (82%, n=22,142), followed by intrapartum cesarean delivery (14.6%, n=3,931), or prelabor cesarean delivery (3.4%, n=914). Incidence of second delivery previa was 0.29% (n=78) and differed by prior delivery mode: vaginal, 0.24%; prelabor cesarean delivery, 0.98%; intrapartum cesarean delivery, 0.38% (P<0.001). Relative to vaginal delivery, prior prelabor cesarean delivery was associated with an increased risk of second delivery previa (adjusted odds ratio, 2.62 [95% confidence interval, 1.24–5.56]). There was no significant association between prior intrapartum cesarean delivery and previa [adjusted odds ratio, 1.22 (95% confidence interval, 0.68–2.19)]. Conclusion Prior prelabor cesarean delivery was associated with a more than two-fold significantly increased risk of previa in the second delivery, while the approximately 20% increased risk of previa associated with prior intrapartum cesarean delivery was not significant. Although rare, the increased risk of placenta previa after prior prelabor cesarean delivery may be important when considering non-medically indicated prelabor cesarean delivery. PMID:25576818

Previous prelabor or intrapartum cesarean delivery and risk of placenta previa.

PubMed

Downes, Katheryne L; Hinkle, Stefanie N; Sjaarda, Lindsey A; Albert, Paul S; Grantz, Katherine L

2015-05-01

The purpose of this study was to examine the association between previous cesarean delivery and subsequent placenta previa while distinguishing cesarean delivery before the onset of labor from intrapartum cesarean delivery. We conducted a retrospective cohort study of electronic medical records from 20 Utah hospitals (2002-2010) with restriction to the first 2 singleton deliveries of nulliparous women at study entry (n=26,987). First pregnancy delivery mode was classified as (1) vaginal (reference), (2) cesarean delivery before labor onset (prelabor), or (3) cesarean delivery after labor onset (intrapartum). Risk of second delivery previa was estimated by previous delivery mode with the use of logistic regression and was adjusted for maternal age, insurance, smoking, comorbidities, previous pregnancy loss, and history of previa. Most first deliveries were vaginal (82%; n=22,142), followed by intrapartum cesarean delivery (14.6%; n=3931), or prelabor cesarean delivery (3.4%; n=914). Incidence of second delivery previa was 0.29% (n=78) and differed by previous delivery mode: vaginal, 0.24%; prelabor cesarean delivery, 0.98%; intrapartum cesarean delivery, 0.38% (P<.001). Relative to vaginal delivery, previous prelabor cesarean delivery was associated with an increased risk of second delivery previa (adjusted odds ratio, 2.62; 95% confidence interval, 1.24-5.56). There was no significant association between previous intrapartum cesarean delivery and previa (adjusted odds ratio, 1.22; 95% confidence interval, 0.68-2.19). Previous prelabor cesarean delivery was associated with a >2-fold significantly increased risk of previa in the second delivery, although the approximately 20% increased risk of previa that was associated with previous intrapartum cesarean delivery was not significant. Although rare, the increased risk of placenta previa after previous prelabor cesarean delivery may be important when considering nonmedically indicated prelabor cesarean delivery. Published by Elsevier Inc.

Analysis of variation in charges and prices paid for vaginal and caesarean section births: a cross-sectional study.

PubMed

Hsia, Renee Y; Akosa Antwi, Yaa; Weber, Ellerie

2014-01-15

To examine the between-hospital variation of charges and discounted prices for uncomplicated vaginal and caesarean section deliveries, and to determine the institutional and market-level characteristics that influence adjusted charges. Using data from the California Office of Statewide Health Planning and Development (OSHPD), we conducted a cross-sectional study of all privately insured patients admitted to California hospitals in 2011 for uncomplicated vaginal delivery (diagnosis-related group (DRG) 775) or uncomplicated caesarean section (DRG 766). Hospital charges and discounted prices adjusted for each patient's clinical and demographic characteristics. We analysed 76 766 vaginal deliveries and 32 660 caesarean sections in California in 2011. After adjusting for patient demographic and clinical characteristics, we found that the average California woman could be charged as little as US$3296 or as much as US$37 227 for a vaginal delivery, and US$8312-US$70 908 for a caesarean section depending on which hospital she was admitted to. The discounted prices were, on an average, 37% of the charges. We found that hospitals in markets with middling competition had significantly lower adjusted charges for vaginal deliveries, while hospitals with higher wage indices and casemixes, as well as for-profit hospitals, had higher adjusted charges. Hospitals in markets with higher uninsurance rates charged significantly less for caesarean sections, while for-profit hospitals and hospitals with higher wage indices charged more. However, the institutional and market-level factors included in our models explained only 35-36% of the between-hospital variation in charges. These results indicate that charges and discounted prices for two common, relatively homogeneous diagnosis groups-uncomplicated vaginal delivery and caesarean section-vary widely between hospitals and are not well explained by observable patient or hospital characteristics.

Risk of Intrapartum Cervical Lacerations in Vaginal Singleton Deliveries in Women With Cerclage

PubMed Central

Suzuki, Shunji

2015-01-01

Background We examined the obstetric outcomes of singleton vaginal deliveries in women with cerclage at our institute to confirm the risk of intrapartum cervical lacerations in vaginal deliveries of women with cerclage. Methods Data on all Japanese singleton vaginal deliveries at ≥ 34 weeks’ gestation managed at the Japanese Red Cross Katsushika Maternity Hospital between 2008 and 2014 were collected. Results During the study period, cervical cerclage was performed in 95 of 9,490 (1.0%) women with singleton pregnancy at 12 - 22 weeks of singleton pregnancy who delivered at ≥ 34 weeks’ gestation. The incidence of intrapartum cervical lacerations and postpartum hemorrhage ≥ 1,000 mL in the women with cerclage were higher significantly than that in the women without cerclage (cervical lacerations: crude odds ratio (OR): 26.9, 95% confidence interval (CI): 14 - 51, P < 0.01; postpartum hemorrhage: crude OR: 2.86, 95% CI: 1.6 - 4.9, P < 0.01). Using a multivariate analysis, cerclage was independently associated with the increased incidence of intrapartum cervical lacerations (P < 0.01). Conclusions Cervical cerclage is an independent risk factor of intrapartum cervical lacerations in vaginal deliveries. PMID:26251687

Compartmental transport model of microbicide delivery by an intravaginal ring

PubMed Central

Geonnotti, Anthony R.; Katz, David F.

2010-01-01

Topical antimicrobials, or microbicides, are being developed to prevent HIV transmission through local, mucosal delivery of antiviral compounds. While hydrogel vehicles deliver the majority of current microbicide products, intravaginal rings (IVRs) are an alternative microbicide modality in preclinical development. IVRs provide a long-term dosing alternative to hydrogel use, and might provide improved user adherence. IVR efficacy requires sustained delivery of antiviral compounds to the entire vaginal compartment. A two-dimensional, compartmental vaginal drug transport model was created to evaluate the delivery of drugs from an intravaginal ring. The model utilized MRI-derived ring geometry and location, experimentally defined ring fluxes and vaginal fluid velocities, and biophysically relevant transport theory. Model outputs indicated the presence of potentially inhibitory concentrations of antiviral compounds along the entire vaginal canal within 24 hours following IVR insertion. Distributions of inhibitory concentrations of antiviral compounds were substantially influenced by vaginal fluid flow and production, while showing little change due to changes in diffusion coefficients or ring fluxes. Additionally, model results were predictive of in vivo concentrations obtained in clinical trials. Overall, this analysis initiates a mechanistic computational framework, heretofore missing, to understand and evaluate the potential of IVRs for effective delivery of antiviral compounds. PMID:20222027

Vaginal delivery - discharge

MedlinePlus

... slowly. Get plenty of rest. You can start sexual activity around 6 weeks after delivery, if the discharge or lochia has stopped. Women who breastfeed may have a lower sex drive than normal, along with vaginal dryness and pain ...

Combined effects of prenatal medication use and delivery type are associated with eczema at age 2 years.

PubMed

Wegienka, G; Havstad, S; Zoratti, E M; Kim, H; Ownby, D R; Johnson, C C

2015-03-01

Separately, prenatal antibiotics and Caesarian delivery have been found to be associated with increased risk of allergic diseases. It is not clear whether these factors may modify the effect of each other. To assess whether the associations between delivery types and eczema, sensitization and total IgE at age 2 years were modified by maternal use of prenatal medications. Prenatal charts of women enrolled in the WHEALS birth cohort were reviewed for delivery mode and medications prescribed and administered throughout their entire pregnancy, including systemic antibiotics and vaginally applied antifungal medications. The associations between the delivery mode and select medications and, eczema, sensitization (≥ 1 of 10 allergen-specific IgE ≥ 0.35 IU/mL) and total IgE at age 2 years were assessed. There was a lower risk of eczema among vaginally vs. c-section born children (relative risk adjusted for race = aRR = 0.77, 95% CI 0.56, 1.05). Although not statistically significantly different, this association was stronger among the subset of children born vaginally to a mother who did not use systemic antibiotics or vaginal antifungal medications (aRR = 0.69, 95% CI 0.44, 1.08) compared to those born vaginally to mothers who used systemic antibiotics or vaginal antifungals (aRR = 0.81, 95% CI 0.57, 1.14). A protective association between vaginal birth and sensitization (aRR = 0.86, 95% CI 0.72, 1.03) was similar for those children born vaginally to a mother who did not (aRR = 0.87, 95% CI 0.69, 1.10) and who did (RR = 0.85, 95% CI 0.70, 1.04) use systemic antibiotics or vaginal antifungal medications. There were no associations with total IgE. Children born vaginally had lower risk of eczema and sensitization compared with those born via c-section; however, the protective association with eczema may be slightly weakened when mothers took systemic antibiotics or vaginally applied medications during pregnancy. © 2014 John Wiley & Sons Ltd.

Effect of epidural anaesthesia on clinician-applied force during vaginal delivery.

PubMed

Poggi, Sarah H; Allen, Robert H; Patel, Chirag; Deering, Shad H; Pezzullo, John C; Shin, Young; Spong, Catherine Y

2004-09-01

Epidural anesthesia (EA) is used in 80% of vaginal deliveries and is linked to neonatal and maternal trauma. Our objectives were to determine (1) whether EA affected clinician-applied force on the fetus and (2) whether this force influenced perineal trauma. After informed consent, multiparas with term, cephalic, singletons were delivered by 1 physician wearing a sensor-equipped glove to record force exerted on the fetal head. Those with EA were compared with those without for delivery force parameters. Regression analysis was used to identify predictors of vaginal laceration. The force required for delivery was greater in patients with EA (n = 27) than without (n = 5) (P < .01). Clinical parameters, including birth weight (P = .31) were similar between the groups. Clinician force was similar in those with no versus first- versus second-degree laceration (P = .5). Only birth weight was predictive of laceration (P = .02). Epidural use resulted in greater clinician force required for vaginal delivery of the fetus in multiparas, but this force was not associated with perineal trauma.

Nanoparticle-based drug delivery to the vagina: a review

PubMed Central

Ensign, Laura M.; Cone, Richard; Hanes, Justin

2014-01-01

Vaginal drug administration can improve prophylaxis and treatment of many conditions affecting the female reproductive tract, including sexually transmitted diseases, fungal and bacterial infections, and cancer. However, achieving sustained local drug concentrations in the vagina can be challenging, due to the high permeability of the vaginal epithelium and expulsion of conventional soluble drug dosage forms. Nanoparticle-based drug delivery platforms have received considerable attention for vaginal drug delivery, as nanoparticles can provide sustained release, cellular targeting, and even intrinsic antimicrobial or adjuvant properties that can improve the potency and/or efficacy of prophylactic and therapeutic modalities. Here, we review the use of polymeric nanoparticles, liposomes, dendrimers, and inorganic nanoparticles for vaginal drug delivery. Although most of the work toward nanoparticle-based drug delivery in the vagina has been focused on HIV prevention, strategies for treatment and prevention of other sexually transmitted infections, treatment for reproductive tract cancer, and treatment of fungal and bacterial infections are also highlighted. PMID:24830303

Management of Labor and Delivery After Fetoscopic Repair of an Open Neural Tube Defect.

PubMed

Kohn, Jaden R; Rao, Vibha; Sellner, Allison A; Sharhan, Dina; Espinoza, Jimmy; Shamshirsaz, Alireza A; Whitehead, William E; Belfort, Michael A; Sanz Cortes, Magdalena

2018-06-01

To report labor, delivery, and neonatal outcomes in a cohort of women delivering neonates who had undergone fetoscopic neural tube defect repair. We conducted a retrospective cohort study from April 2014 to January 2018. All patients met Management of Myelomeningocele Study eligibility criteria. We included patients with completed second-trimester fetoscopic neural tube defect repair (laparotomy, uterine exteriorization, and minimally invasive access through two or three uterine ports) followed by standardized management of labor and delivery at our institution. Outcomes included rates of vaginal delivery, term delivery, and intrapartum cesarean delivery as well as obstetric and neonatal outcomes after oxytocin. Complications of interest included preterm prelabor rupture of membranes, chorioamnionitis, uterine dehiscence or rupture, 5-minute Apgar score less than 7, and neonatal acidosis (umbilical artery pH less than 7.15). Thirty-four patients had fetoscopic repair, followed by 17 vaginal deliveries (50%, 95% CI 32-68%). Median gestational age was 38 1/7 weeks at vaginal delivery (range 26 0/7-40 2/7 weeks of gestation) and 37 1/7 weeks of gestation at cesarean delivery (range 25 5/7-40 5/7 weeks of gestation); 62% of deliveries occurred at term. Eight patients had prelabor cesarean delivery: three nonurgent and five urgent (for nonreassuring fetal heart tracings). Twenty-six patients labored; six were induced and 20 labored spontaneously. Of the latter, five were augmented. Of 26 laboring patients, 17 delivered vaginally and nine underwent urgent cesarean delivery (35%, 95% CI 17-56%; seven nonreassuring fetal heart tracings and two breech). There were no cases of uterine rupture or dehiscence. Most (94%, 95% CI 80-99%) had normal 5-minute Apgar scores; one neonate (3%, 95% CI 0-15%) had acidosis but normal Apgar scores. Our data regarding trial of labor, use of low-dose oxytocin, and vaginal delivery after prenatal fetoscopic neural tube defect repair are reassuring. Importantly, fetoscopic repair may permit delivery at advanced gestational ages.

Ultrafast MR imaging of the pelvic floor.

PubMed

Unterweger, M; Marincek, B; Gottstein-Aalame, N; Debatin, J F; Seifert, B; Ochsenbein-Imhof, N; Perucchini, D; Kubik-Huch, R A

2001-04-01

The aim of this study was to compare pelvic floor anatomy and laxity at rest and on straining (Valsalva's maneuver) using dynamic ultrafast MR imaging in women who were continent versus those with stress incontinence differing in obstetric history. Thirty continent women were divided into three equal groups (nulliparous, previous cesarean delivery, previous vaginal delivery) and compared with 10 women with stress-incontinence with a history of at least one vaginal delivery. MR imaging of the pelvic floor at rest and on maximal strain was performed, using axial T2-weighted fast spin-echo images followed by sagittal ultrafast T2-weighted single-shot fast spin-echo sequences. Mean population age (age range, 22-45 years; mean +/- SD, 36 +/- 5.4 years), was similar in the four groups, as was parity in the three parous groups. Mean distances between the bladder floor and pubococcygeal line at rest did not differ between the four groups. On straining, bladder floor descent was 1.1 +/- 0.9, 1.0 +/- 1.1, and 1.9 +/- 0.9 cm in continent nulliparous, cesarean delivery, and vaginal delivery women, respectively, versus 3.2 +/- 1.0 cm in incontinent women (p = 0.0005). Cervical descent was greater in incontinent versus nulliparous women (p = 0.0019). Bladder floor descent was greater in the continent vaginal delivery group than in continent cesarean delivery control patients (p = 0.04). In patients with stress incontinence, symptoms did not correlate with amplitude of descent. The right levator muscle was thinner overall than the left, regardless of frequency direction (p = 0.001). Ultrafast MR imaging using the T2-weighted single-shot fast spin-echo sequence allows dynamic evaluation of the pelvic compartments at maximal strain with no need for contrast medium. Pelvic floor laxity and supporting fascia abnormalities were most common in patients with stress incontinence followed by continent women with a history of vaginal delivery. The results are therefore compatible with the hypothesis of vaginal delivery as a contributory factor to stress incontinence in older parous women.

Frequency of anal sphincter rupture at delivery in Sweden and Finland--result of difference in manual help to the baby's head.

PubMed

Pirhonen, J P; Grenman, S E; Haadem, K; Gudmundsson, S; Lindqvist, P; Siihola, S; Erkkola, R U; Marsal, K

1998-11-01

Anal sphincter rupture is a serious complication of vaginal delivery and almost half the affected women have persistent defecatory symptoms despite adequate primary repair. During the past decade, the incidence of anal sphincter ruptures has been increasing in Sweden and is currently estimated to occur in 2.5% of vaginal deliveries. The aim of the study was to report the frequency of anal sphincter ruptures in two university hospitals in two Scandinavian countries, Malmö in Sweden and Turku in Finland, and analyze the potential determinants. Retrospective analysis of a population of 30,933 deliveries (26,541 vaginal) during the years 1990 to 1994. The incidence of anal sphincter ruptures in Malmö, Sweden was 2.69%, and in Turku, Finland 0.36%. There were no significant population differences for the known risk factors (fetal weight, nulliparity or fetal head circumference). However, there is a difference in manual support given to the perineum and to the baby's head when crowning through the vaginal introitus between Malmö and Turku. The proportion of operative vaginal deliveries and abnormal presentations was significantly higher in Turku reflected in the lower Apgar score at 5 minutes and longer duration of second phase of labor. When high risk deliveries (operative vaginal delivery, abnormal presentation and newborns over 4,000 g) were excluded, the risk for anal sphincter ruptures was estimated to be 13 times higher in Malmö than in Turku. The difference in the incidence of anal sphincter rupture between Malmö, Sweden and Turku, Finland may be due to the difference in manual control of the baby's head when crowning.

Assessment of pelvic floor by three-dimensional-ultrasound in primiparous women according to delivery mode: initial experience from a single reference service in Brazil.

PubMed

Araujo Júnior, Edward; de Freitas, Rogério Caixeta Moraes; Di Bella, Zsuzsanna Ilona Katalin de Jármy; Alexandre, Sandra Maria; Nakamura, Mary Uchiyama; Nardozza, Luciano Marcondes Machado; Moron, Antonio Fernandes

2013-03-01

To evaluate changes to the pelvic floor of primiparous women with different delivery modes, using three-dimensional ultrasound. A prospective cross-sectional study on 35 primiparae divided into groups according to the delivery mode: elective cesarean delivery (n=10), vaginal delivery (n=16), and forceps delivery (n=9). Three-dimensional ultrasound on the pelvic floor was performed on the second postpartum day with the patient in a resting position. A convex volumetric transducer (RAB4-8L) was used, in contact with the large labia, with the patient in the gynecological position. Biometric measurements of the urogenital hiatus were taken in the axial plane on images in the rendering mode, in order to assess the area, anteroposterior and transverse diameters, average thickness, and avulsion of the levator ani muscle. Differences between groups were evaluated by determining the mean differences and their respective 95% confidence intervals. The proportions of levator ani muscle avulsion were compared between elective cesarean section and vaginal birth using Fisher's exact test. The mean areas of the urogenital hiatus in the cases of vaginal and forceps deliveries were 17.0 and 20.1 cm(2), respectively, versus 12.4 cm(2) in the Control Group (elective cesarean). Avulsion of the levator ani muscle was observed in women who underwent vaginal delivery (3/25), however there was no statistically significant difference between cesarean section and vaginal delivery groups (p=0.5). Transperineal three-dimensional ultrasound was useful for assessing the pelvic floor of primiparous women, by allowing pelvic morphological changes to be differentiated according to the delivery mode.

Successful vaginal birth after caesarean section in patient with Ehler-Danlos syndrome type 2.

PubMed

Maraj, Hemant; Mohajer, Michelle; Bhattacharjee, Deepannita

2011-12-01

We present the case of a 31-year-old woman with Ehler-Danlos syndrome (EDS) type 2. She had a previous caesarean section and went on to have an uncomplicated vaginal birth in her last pregnancy. To our knowledge, this is the first case of a successful vaginal birth after caesarean section in a patient with EDS. EDS is a multisystem disorder involving a genetic defect in collagen and connective-tissue synthesis and structure. It is a heterogeneous group of 11 different inherited disorders. Obstetric complications in these patients include miscarriages, stillbirths, premature rupture of the membranes, preterm labour, uterine prolapse, uterine rupture and severe postpartum haemorrhage. There has been much controversy over the appropriate mode of delivery. Abdominal deliveries are complicated by delayed wound healing and increased perioperative blood loss. Vaginal deliveries may be complicated by tissue friability causing extensive perineal tears, pelvic floor and bladder lesions. Our case highlights that in specific, controlled situations it is possible to have a vaginal delivery even after previous caesarean section in patients with EDS.

Successful vaginal birth after caesarean section in patient with Ehler-Danlos syndrome type 2

PubMed Central

Maraj, Hemant; Mohajer, Michelle; Bhattacharjee, Deepannita

2011-01-01

We present the case of a 31-year-old woman with Ehler-Danlos syndrome (EDS) type 2. She had a previous caesarean section and went on to have an uncomplicated vaginal birth in her last pregnancy. To our knowledge, this is the first case of a successful vaginal birth after caesarean section in a patient with EDS. EDS is a multisystem disorder involving a genetic defect in collagen and connective-tissue synthesis and structure. It is a heterogeneous group of 11 different inherited disorders. Obstetric complications in these patients include miscarriages, stillbirths, premature rupture of the membranes, preterm labour, uterine prolapse, uterine rupture and severe postpartum haemorrhage. There has been much controversy over the appropriate mode of delivery. Abdominal deliveries are complicated by delayed wound healing and increased perioperative blood loss. Vaginal deliveries may be complicated by tissue friability causing extensive perineal tears, pelvic floor and bladder lesions. Our case highlights that in specific, controlled situations it is possible to have a vaginal delivery even after previous caesarean section in patients with EDS. PMID:27579117

National Rates of Uterine Rupture are not Associated with Rates of Previous Caesarean Delivery: Results from the Nordic Obstetric Surveillance Study.

PubMed

Colmorn, Lotte B; Langhoff-Roos, Jens; Jakobsson, Maija; Tapper, Anna-Maija; Gissler, Mika; Lindqvist, Pelle G; Källen, Karin; Gottvall, Karin; Klungsøyr, Kari; Bøhrdahl, Per; Bjarnadóttir, Ragnhild I; Krebs, Lone

2017-05-01

Previous caesarean delivery and intended mode of delivery after caesarean are well-known individual risk factors for uterine rupture. We examined if different national rates of uterine rupture are associated with differences in national rates of previous caesarean delivery and intended mode of delivery after a previous caesarean delivery. This study is an ecological study based on data from a retrospective cohort in the Nordic countries. Data on uterine rupture were collected prospectively in each country as part of the Nordic obstetric surveillance study and included 91% of all Nordic deliveries. Information on the comparison population was retrieved from the national medical birth registers. Incidence rate ratios by previous caesarean delivery and intended mode of delivery after caesarean were modelled using Poisson regression. The incidence of uterine rupture was 7.8/10 000 in Finland and 4.6/10 000 in Denmark. Rates of caesarean (21.3%) and previous caesarean deliveries (11.5%) were highest in Denmark, while the rate of intended vaginal delivery after caesarean was highest in Finland (72%). National rates of uterine rupture were not associated with the population rates of previous caesarean but increased by 35% per 1% increase in the population rate of intended vaginal delivery and in the subpopulation of women with previous caesarean delivery by 4% per 1% increase in the rate of intended vaginal delivery. National rates of uterine rupture were not associated with national rates of previous caesarean, but increased with rates of intended vaginal delivery after caesarean. © 2017 John Wiley & Sons Ltd.

Selective vs routine midline episiotomy for the prevention of third- or fourth-degree lacerations in nulliparous women.

PubMed

Rodriguez, Alexander; Arenas, Edgar A; Osorio, Alba L; Mendez, Omar; Zuleta, John J

2008-03-01

The purpose of this study was to determine whether selective midline episiotomy contributes to the prevention of third- or fourth-degree perineal lacerations. A randomized controlled clinical trial was performed with 446 nulliparous women with deliveries after 28 weeks of pregnancy. Patients were randomized to undergo either routine episiotomy or selective episiotomy. In the selective episiotomy group, episiotomies were performed only in cases of imminent lacerations, fetal distress, or forceps delivery. In the group of 223 patients who underwent routine episiotomy, 32 (14.3%) had third- or fourth-degree perineal lacerations, as compared to 15 (6.8%) in the group of 222 patients undergoing selective episiotomy (relative risk, 2.12; 95% confidence interval, 1.18-3.81). Only reduction in third-degree lacerations was significant when analyzed separately. Moreover, periurethral, labia minora, and superficial vaginal lacerations were significantly more frequent in the selective episiotomy group. The policy of performing selective midline episiotomy in nulliparous patients results in a reduction in the risk of third-degree perineal lacerations.

Delivery route determines the presence of immune complexes on umbilical cord erythrocytes.

PubMed

de Lima, Andrés; Franco, Luis C; Sarmiento, Andrés; González, John M

2017-11-01

Umbilical cord blood offers a unique opportunity to study the basal level of immunoglobulin complexes. This study aims to determine the presence of immune complexes and complement deposition on erythrocytes from umbilical cord blood from normal, full-term pregnancies. In vitro pre-formed IgA, IgG, and IgM complexes were used as positive control for flow cytometry detection, and for C3d deposition. Blood samples (34) of umbilical cord blood taken from vaginal and cesarean deliveries were tested for the presence of immunoglobulin complexes. Fourteen samples from vaginal deliveries and 20 samples from cesarean deliveries were assessed. IgG and IgM complexes were detected on erythrocytes, whereas no IgA complexes or complement deposition was observed. Interestingly, the percentage of IgG complexes was higher on erythrocytes from vaginal delivery samples compared to those from cesarean deliveries. No other associations between immune complexes and other maternal or newborn variables were found. IgG and IgM complexes seem to be normally present on umbilical cord erythrocytes. Erythrocytes from vaginal deliveries have a higher percentage of IgG complexes present compared to that from cesarean deliveries. Since no C3d activity was detected, these complexes are non-pathological and should be part of the newborn's initial innate immune response.

Inadvertent intrathecal injection of labetalol in a patient undergoing post-partum tubal ligation.

PubMed

Balestrieri, P J; Hamza, M S; Ting, P H; Blank, R S; Grubb, C T

2005-10-01

After receiving a continuous spinal anesthetic for labor following an inadvertent dural puncture with a 17-gauge epidural needle, a morbidly obese parturient underwent post-partum tubal ligation 12 h after vaginal delivery. The patient received a total of 2 mL of 0.75% hyperbaric bupivacaine for the surgery. In response to moderate hypertension the patient received intravenous labetalol hydrochloride 20 mg. She subsequently was inadvertently administered approximately 15 mg of labetalol through the spinal catheter. The spinal catheter was removed immediately after the procedure. She suffered no apparent adverse neurologic effects.

Use of urea and creatinine levels in vaginal fluid for the diagnosis of preterm premature rupture of membranes and delivery interval after membrane rupture.

PubMed

Gezer, Cenk; Ekin, Atalay; Golbasi, Ceren; Kocahakimoglu, Ceysu; Bozkurt, Umit; Dogan, Askin; Solmaz, Ulaş; Golbasi, Hakan; Taner, Cuneyt Eftal

2017-04-01

To determine whether urea and creatinine measurements in vaginal fluid could be used to diagnose preterm premature rupture of membranes (PPROM) and predict delivery interval after PPROM. A prospective study conducted with 100 pregnant women with PPROM and 100 healthy pregnant women between 24 + 0 and 36 + 6 gestational weeks. All patients underwent sampling for urea and creatinine concentrations in vaginal fluid at the time of admission. Receiver operator curve analysis was used to determine the cutoff values for the presence of PPROM and delivery within 48 h after PPROM. In multivariate logistic regression analysis, vaginal fluid urea and creatinine levels were found to be significant predictors of PPROM (p < 0.001 and p < 0.001, respectively) and delivery within 48 h after PPROM (p = 0.012 and p = 0.017, respectively). The optimal cutoff values for the diagnosis of PPROM were >6.7 mg/dl for urea and >0.12 mg/dl for creatinine. The optimal cutoff values for the detection of delivery within 48 h were >19.4 mg/dl for urea and >0.23 mg/dl for creatinine. Measurement of urea and creatinine levels in vaginal fluid is a rapid and reliable test for diagnosing and also for predicting delivery interval after PPROM.

Vaginal delivery of carboplatin-loaded thermosensitive hydrogel to prevent local cervical cancer recurrence in mice.

PubMed

Wang, Xue; Wang, Jin; Wu, Wenbin; Li, Hongjun

2016-11-01

Local tumor recurrence after cervical cancer surgery remains a clinical problem. Vaginal delivery of thermosensitive hydrogel may be suited to reduce tumor relapse rate with more efficacy and safety. A pilot study was carried out to evaluate the efficacy of carboplatin-loaded poloxamer hydrogel to prevent local recurrence of cervical cancer after surgery. In vivo vaginal retention evaluation of 27% poloxamer hydrogel in mice was proven to be a suitable vaginal drug delivery formulation due to its low gelation temperature. A mimic orthotopic cervical/vaginal cancer recurrence model after surgery was established by injecting murine cervical cancer cell line U14 into the vaginal submucosa to simulate the residual tumor cells infiltrated in the surgical site, followed by drug administration 24 h later to interfere with the formation/recurrence of the tumor. By infusing fluorescein sodium-loaded hydrogel into the vagina of mice, a maximized accumulation of fluorescein sodium (Flu) in the vagina was achieved and few signals were observed in other organs. When used in the prevention of the cervical cancer formation/recurrence in mice, the carboplatin-loaded poloxamer hydrogel exhibited great efficacy and systemic safety. In conclusion, thermosensitive hydrogel presents a simple, practical approach for the local drug delivery via vagina against cervical cancer recurrence.

Do changes in anal sphincter anatomy correlate with anal function in women with a history of vaginal delivery?

PubMed

Murad-Regadas, Sthela Maria; Dealcanfreitas, Iris Daiana; Regadas, Francisco Sergio Pinheiro; Rodrigues, Lusmar Veras; Fernandes, Graziela Olivia da Silva; Pereira, Jacyara de Jesus Rosa

2014-01-01

To evaluate anal sphincter anatomy using three-dimensional ultrasonography (3-DAUS) in incontinent women with vaginal delivery, correlate anatomical findings with symptoms of fecal incontinence and determine the effect of vaginal delivery on anal canal anatomy and function. Female with fecal incontinence and vaginal delivery were assessed with Wexner's score, manometry, and 3DAUS. A control group comprising asymptomatic nulliparous was included. Anal pressure, the angle of the defect and length of the external anal sphincter (EAS), the anterior and posterior internal anal sphincter (IAS), the EAS + puborectal and the gap were measured and correlated with score. Of the 62, 49 had fecal incontinence and 13 were asymptomatic. Twenty five had EAS defects, 8 had combined EAS+IAS defects, 16 had intact sphincters and continence scores were similar. Subjects with sphincter defects had a shorter anterior EAS, IAS and longer gap than women without defects. Those with a vaginal delivery and intact sphincters had a shorter anterior EAS and longer gap than nulliparous. We found correlations between resting pressure and anterior EAS and IAS length in patients with defects. Fecal incontinence symptoms did not correlate with anal pressures and anal sphincter anatomy changes, but women with sphincter defects have shorter anterior EAS and IAS and a longer gap.

Nanoparticle-releasing nanofiber composites for enhanced in vivo vaginal retention.

PubMed

Krogstad, Emily A; Ramanathan, Renuka; Nhan, Christina; Kraft, John C; Blakney, Anna K; Cao, Shijie; Ho, Rodney J Y; Woodrow, Kim A

2017-11-01

Current approaches for topical vaginal administration of nanoparticles result in poor retention and extensive leakage. To overcome these challenges, we developed a nanoparticle-releasing nanofiber delivery platform and evaluated its ability to improve nanoparticle retention in a murine model. We individually tailored two components of this drug delivery system for optimal interaction with mucus, designing (1) mucoadhesive fibers for better retention in the vaginal tract, and (2) PEGylated nanoparticles that diffuse quickly through mucus. We hypothesized that this novel dual-functioning (mucoadhesive/mucus-penetrating) composite material would provide enhanced retention of nanoparticles in the vaginal mucosa. Equivalent doses of fluorescent nanoparticles were vaginally administered to mice in either water (aqueous suspension) or fiber composites, and fluorescent content was quantified in cervicovaginal mucus and vaginal tissue at time points from 24 h to 7d. We also fabricated composite fibers containing etravirine-loaded nanoparticles and evaluated the pharmacokinetics over 7d. We found that our composite materials provided approximately 30-fold greater retention of nanoparticles in the reproductive tract at 24 h compared to aqueous suspensions. Compared to nanoparticles in aqueous suspension, the nanoparticles in fiber composites exhibited sustained and higher etravirine concentrations after 24 h and up to 7d, demonstrating the capabilities of this new delivery platform to sustain nanoparticle release out to 3d and drug retention out to one week after a single administration. This is the first report of nanoparticle-releasing fibers for vaginal drug delivery, as well as the first study of a single delivery system that combines two components uniquely engineered for complementary interactions with mucus. Copyright © 2017 Elsevier Ltd. All rights reserved.

Biomechanics of the rat vagina during pregnancy and postpartum: a 3-dimensional ultrasound approach.

PubMed

Feola, Andrew; Endo, Masayuki; Deprest, Jan

2014-07-01

The vagina and surrounding structures have been shown to remodel during pregnancy. Our objective was to characterize the biomechanical properties of the vagina in the rodent model in vivo utilizing three-dimensional (3D) ultrasound. The vagina was visualized by ultrasound after distention by increasing pressures throughout pregnancy (15 and 18 days) and after vaginal delivery (7 and 30 days postpartum) of six longitudinally followed rodents. The pelvic floor compliance and vaginal cross-sectional area of the proximal, middle, and distal vagina were compared with those of nulliparous control animals (n = 8). The compliance of the pelvic floor increased 3.5- and 5.4-fold at days 15 and 18 of pregnancy respectively (p < 0.05). The compliance of the pelvic floor decreased 7 days postpartum, and it continued to decrease after vaginal delivery through the 30 day time point. Using 3D ultrasound, we could characterize the remodeling of the vagina throughout pregnancy and after vaginal delivery. We could reconstruct the vaginal wall cross-sectional area and found the distal vaginal wall throughout pregnancy to be distended more than the proximal and middle regions. The observed changes in vaginal area may improve our understanding of which areas are at risk of injury during delivery. Further, 3D ultrasound allowed the determination of the in vivo biomechanical properties of the vagina. This image modality is beneficial for characterizing the in vivo properties of the vagina and surrounding pelvic support longitudinally within an animal.

Analysis of variation in charges and prices paid for vaginal and caesarean section births: a cross-sectional study

PubMed Central

Hsia, Renee Y; Akosa Antwi, Yaa; Weber, Ellerie

2014-01-01

Objective To examine the between-hospital variation of charges and discounted prices for uncomplicated vaginal and caesarean section deliveries, and to determine the institutional and market-level characteristics that influence adjusted charges. Design, setting and participants Using data from the California Office of Statewide Health Planning and Development (OSHPD), we conducted a cross-sectional study of all privately insured patients admitted to California hospitals in 2011 for uncomplicated vaginal delivery (diagnosis-related group (DRG) 775) or uncomplicated caesarean section (DRG 766). Outcome measures Hospital charges and discounted prices adjusted for each patient's clinical and demographic characteristics. Results We analysed 76 766 vaginal deliveries and 32 660 caesarean sections in California in 2011. After adjusting for patient demographic and clinical characteristics, we found that the average California woman could be charged as little as US$3296 or as much as US$37 227 for a vaginal delivery, and US$8312–US$70 908 for a caesarean section depending on which hospital she was admitted to. The discounted prices were, on an average, 37% of the charges. We found that hospitals in markets with middling competition had significantly lower adjusted charges for vaginal deliveries, while hospitals with higher wage indices and casemixes, as well as for-profit hospitals, had higher adjusted charges. Hospitals in markets with higher uninsurance rates charged significantly less for caesarean sections, while for-profit hospitals and hospitals with higher wage indices charged more. However, the institutional and market-level factors included in our models explained only 35–36% of the between-hospital variation in charges. Conclusions These results indicate that charges and discounted prices for two common, relatively homogeneous diagnosis groups—uncomplicated vaginal delivery and caesarean section—vary widely between hospitals and are not well explained by observable patient or hospital characteristics. PMID:24435892

Maternal and neonatal copeptin levels at cesarean section and vaginal delivery.

PubMed

Foda, Ashraf A; Abdel Aal, Ibrahim A

2012-12-01

The objective of the study was to measure the copeptin levels in maternal serum and umbilical cord serum at cesarean section and vaginal delivery in normotensive pregnancy and pre-eclamptic women. This was a prospective study at Mansoura University Hospital, Egypt. Ninety cases were included. They were divided into six groups: (1) normal pregnancy near term, as a control group, (2) primiparas who had vaginal delivery, (3) primiparas who had vaginal delivery and mild preeclampsia, (4) elective repeat cesarean section, (5) intrapartum cesarean section for indications other than fetal distress, and (6) intrapartum cesarean section for fetal distress. Serum copeptin concentrations were quantified with an enzyme-linked immunosorbent assay (ELISA). Mean, standard deviation, and paired t-test were used to test for significant change in quantitative data. The vaginal delivery groups had higher levels of maternal serum copeptin than the elective cesarean section group (P<0.01). Higher maternal serum copeptin levels were found in cases with pre-eclampsia as compared with the normotensive cases. The maternal copeptin levels during intrapartum cesarean section were higher than that during elective repeat cesarean section. There was a significant correlation between maternal copeptin levels and the duration of the first stage. In the presence of fetal distress, umbilical cord serum copeptin levels were significantly higher than other groups. Vaginal delivery can be very painful and stressful, and is accompanied by a marked increase of maternal serum copeptin. Increased maternal levels of serum copeptin were found in cases with pre-eclampsia as compared with the normotensive cases, and it may be helpful in assessing the disease. Intrauterine fetal distress is a strong stimulus to the release of copeptin into the fetal circulation. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Long-term outcomes of twins based on the intended mode of delivery.

PubMed

Fox, Nathan S; Cohen, Natalie; Odom, Elizabeth; Gupta, Simi; Lam-Rachlin, Jennifer; Saltzman, Daniel H; Rebarber, Andrei

2018-08-01

Recent studies have shown that for twin pregnancies with a cephalic presenting first twin, planned vaginal delivery is not associated with adverse short-term neonatal outcomes, as compared to planned cesarean delivery. Our objective was to compare long-term outcomes in twins, based on planned mode of delivery. This was a prospective, observational cohort of twin pregnancies delivered by a single MFM practice. All the patients with a twin pregnancy >34 weeks delivered from 2005-2014 were surveyed regarding pediatric outcomes at or after 2 years of life. The survey was mail-based, with phone follow-up for nonresponses or for clarification of answers. Using chi-square, Student's t-tests, and regression analysis we compared outcomes between women who planned a vaginal (with active management of the second stage) versus cesarean delivery. The main outcome measures were: (1) a composite of major adverse outcomes (death, cerebral palsy, necrotizing enterocolitis, chronic renal, heart, or lung disease); (2) a composite of minor adverse outcomes (learning disability, speech therapy, occupational therapy, physical therapy). Five hundred and thirty-two women met inclusion criteria and 354 (66.5%) responded. 178 (50.3%) women planned to have a cesarean delivery (100% of whom had a cesarean delivery) and 176 (49.7%) women planned to have a vaginal delivery (83% of whom had a vaginal delivery). The average age of the children at the time of the survey was 5.9 years. There were no differences in any pediatric outcomes between the two groups. After controlling for maternal age, IVF, obesity, and preeclampsia, the planned mode of delivery was not associated with a composite of major adverse outcomes (aOR 0.673, 95% CI 0.228, 1.985), nor a composite of minor adverse outcomes (aOR 0.767, 95% CI 0.496, 1.188). Planned vaginal delivery with active management of the second stage of labor in twin pregnancies >34 weeks is not associated with adverse childhood outcomes.

Cohort study of the depression, anxiety, and anhedonia components of the Edinburgh Postnatal Depression Scale after delivery.

PubMed

Zanardo, Vincenzo; Giliberti, Lara; Volpe, Francesca; Parotto, Matteo; de Luca, Federico; Straface, Gianluca

2017-06-01

To investigate the applicability of the Edinburgh Postnatal Depression Scale (EPDS) for identifying depressive symptoms following vaginal or cesarean delivery. The present observational study included consecutive Italian-speaking women who underwent vaginal or cesarean deliveries of uncomplicated singleton pregnancies at term at Policlinico Abano Terme, Abano Terme, Italy, between February 1, 2014, and May 31, 2015, who completed the EPDS 2 days after delivery. EPDS scores and the depression, anxiety, and anhedonia subscale items were compared between delivery methods to identify factors predictive of high EPDS scores. There were 950 patients included in the analysis; 694 (73.1%) and 256 (26.9%) patients underwent vaginal and cesarean deliveries, respectively. Total EPDS scores were higher among patients who had cesarean deliveries compared with vaginal deliveries (6.95±4.80 vs 6.05±4.20; P=0.007); the depression (0.53±0.72 vs 0.37±0.65; P=0.007), anxiety (1.07±0.88 vs 1.16±0.93; P=0.021), and anhedonia (0.32±0.59 vs 0.19±0.48; P=0.009) subscale scores were all higher among patients who underwent cesarean deliveries. Women who underwent cesarean deliveries demonstrated higher EPDS scores and could be at increased risk of developing early postpartum depressive symptomatology, particularly anhedonia, anxiety, and depression. © 2017 International Federation of Gynecology and Obstetrics.

Comparison of Apgar scores in breech presentations between vaginal and cesarean delivery

PubMed Central

Fajar, Jonny Karunia; Andalas, Mohd; Harapan, Harapan

2017-01-01

Objective: The mode of delivery in breech presentation (BP) is controversial. Several studies have reported the advantages and disadvantages of delivery mode in BP. The aim of this study was to compare the Apgar scores in BPs between vaginal and cesarean delivery. Materials and Methods: A retrospective study was conducted at Dr. Zainoel Abidin General Hospital from January 2010 to December 2012. Data on the mode of delivery and Apgar scores at 1 and 5 min for infants with a BP were extracted from the medical records. Logistic regression was employed to assess the correlation between mode of delivery and Apgar scores. In addition, a meta-analysis was conducted to summarize findings from other regions. Results: A total of 205 (3.9%) BPs among 5252 deliveries between January 2010 and December 2012 were analyzed for this study. There were 26% (52 cases) vaginal and 74% (153 cases) cesarean deliveries. The mode of delivery for BP had a significant association with Apgar score at 1 min (odds ratio [OR] 95% confidence interval [CI] = 6.462 [2.476–16.870], P = 0.0001) and 5 min (OR 95% CI = 7.727 [1.416–42.175], P = 0.018). Our meta-analysis showed that the delivery mode had a significant association with Apgar score in BP (OR: 3.69; 95% CI: 2.18–6.26, P = 0.0001). Conclusions: There was a significant association between Apgar scores in BPs and mode of delivery. Our results suggest better outcomes for cesarean than vaginal delivery in BPs. PMID:28757760

Maternal and neonatal outcomes of hospital vaginal deliveries in Tibet

PubMed Central

Miller, S; Tudor, C; Nyima; Thorsten, VR; Sonam; Droyoung; Craig, S; Le, P; Wright, LL; Varner, MW

2007-01-01

Introduction To determine the outcomes of vaginal deliveries in three study hospitals in Lhasa, Tibet Autonomous Region (TAR), People's Republic of China (PRC), at high altitude (3,650 m). Methods Prospective observational study of 1,121 vaginal deliveries. Results Pre-eclampsia/gestational hypertension (PE/GH) was the most common maternal complication 18.9% (n=212), followed by postpartum hemorrhage (blood loss ≥ 500 ml) 13.4%. There were no maternal deaths. Neonatal complications included: low birth weight (10.2%), small for gestational age (13.7%), preterm delivery (4.1%) and low Apgar (3.7%). There were 11 stillbirths (9.8/1,000 live births) and 19 early neonatal deaths (17/1,000 live births). Conclusion This is the largest study of maternal and newborn outcomes in Tibet. It provides information on the outcomes of institutional vaginal births among women delivering infants at high altitude. There was a higher incidence of PE/GH and low birth weight; rates of PPH were not increased compared to those at lower altitudes. PMID:17481630

Efficiency of the modified Sims maternal position in the rotation of persistent occiput posterior position during labor: A randomized clinical trial.

PubMed

Bueno-Lopez, Vanessa; Fuentelsaz-Gallego, Carmen; Casellas-Caro, Manel; Falgueras-Serrano, Ana Maria; Crespo-Berros, Silvia; Silvano-Cocinero, Ana Maria; Alcaine-Guisado, Carolina; Zamoro Fuentes, Manuela; Carreras, Elena; Terré-Rull, Carmen

2018-03-14

Fetal occiput posterior position in labor is associated with more painful and prolonged labor, and an increase in both maternal and fetal morbidity. The aim of this study is to assess whether the modified Sims position on the side of the fetal spine increases the rotation to occiput anterior position in women with epidural analgesia and a fetus in persistent occiput posterior (POP) position. This is an open, randomized controlled, clinical trial. One hundred and twenty women in labor with fetuses in POP position were included. The diagnosis was performed through digital vaginal examination and confirmed with an ultrasound scan. Women were randomized into the free position group or the modified Sims on the side of the fetal spine. The primary outcome was rotation to occiput anterior, and secondary outcomes were type of delivery, postpartum perineal condition, perinatal results, and maternal satisfaction. In pregnant women undergoing labor in the Sims position, fetuses in POP rotated to occiput anterior in 50.8% of cases, whilst in the free position group, the rotation occurred in 21.7% (P = .001). The rate of vaginal deliveries was higher in the Sims group compared with the free position group (84.7% vs 68.3%, P = .035). The modified Sims position is a maternal posture intervention efficient in POP rotation, which decreases cesarean delivery rate. It is a simple and noninvasive intervention, reproducible, and well tolerated by pregnant women. © 2018 Wiley Periodicals, Inc.

Comparative study of titrated oral misoprostol solution and vaginal dinoprostone for labor induction at term pregnancy.

PubMed

Wang, Xiu; Yang, Aijun; Ma, Qingyong; Li, Xuelan; Qin, Li; He, Tongqiang

2016-09-01

To evaluate effectiveness and safety of titrated oral misoprostol solution (OMS) in comparison with vaginal dinoprostone for cervix ripening and labor induction in term pregnant women. A multicenter randomized controlled trial of women with term singleton pregnancy with indications for labor induction; 481 participants were allocated to receive titrated OMS with different doses by hourly administration according to the procedure or insert vaginal dinoprostone for cervix ripening and labor induction to compare maternal outcomes including indication of labor induction, mode of outcome of delivery, maternal morbidity, and neonatal outcomes between two groups for evaluating the efficacy and safety of titrated oral misoprostol induction. Proportion of delivery within 12 h of titrated oral misoprostol is significantly less than vaginal dinoprostone (p = 0.03), but no difference of total vaginal delivery rate (p = 0.93); the mean time of first treatment to vaginal delivery was longer in OMS group (21.3 ± 14.5 h) compared with the vaginal dinoprostone group (15.7 ± 9.6 h). Although the proportion of cesarean section between the two groups showed no statistically significant difference, OMS group showed significantly lower frequency of uterine hyperstimulation, hypertonus, partus precipitatus and non-reassuring fetal heart rate than dinoprostone group. Neonatal outcomes were similar evaluating from Apgar score and NICU admission. Our study also showed that labor induction of women with cervix Bishop score ≤3 needed increased dosage of misoprostol solution. Titrated OMS is as effective as vaginal dinoprostone in labor induction for term pregnant women, with safer effect for its lower rate of adverse effect for women.

Biodistribution and pharmacokinetics of dapivirine-loaded nanoparticles after vaginal delivery in mice.

PubMed

das Neves, José; Araújo, Francisca; Andrade, Fernanda; Amiji, Mansoor; Bahia, Maria Fernanda; Sarmento, Bruno

2014-07-01

To assess the potential of polymeric nanoparticles (NPs) to affect the genital distribution and local and systemic pharmacokinetics (PK) of the anti-HIV microbicide drug candidate dapivirine after vaginal delivery. Dapivirine-loaded, poly(ethylene oxide)-coated poly(epsilon-caprolactone) (PEO-PCL) NPs were prepared by a nanoprecipitation method. Genital distribution of NPs and their ability to modify the PK of dapivirine up to 24 h was assessed after vaginal instillation in a female mouse model. Also, the safety of NPs upon daily administration for 14 days was assessed by histological analysis and chemokine/cytokine content in vaginal lavages. PEO-PCL NPs (180-200 nm) were rapidly eliminated after administration but able to distribute throughout the vagina and lower uterus, and capable of tackling mucus and penetrate the epithelial lining. Nanocarriers modified the PK of dapivirine, with higher drug levels being recovered from vaginal lavages and vaginal/lower uterine tissues as compared to a drug suspension. Systemic drug exposure was reduced when NPs were used. Also, NPs were shown safe upon administration for 14 days. Dapivirine-loaded PEO-PCL NPs were able to provide likely favorable genital drug levels, thus attesting the potential value of using this vaginal drug delivery nanosystem in the context of HIV prophylaxis.

Obstetric outcomes of pre-induction of labor with a 200 μg misoprostol vaginal insert.

PubMed

Jagielska, Iwona; Kazdepka-Ziemińska, Anita; Tyloch, Małgorzata; Sopońska-Brzoszczyk, Paulina; Nowak, Karina; Dziedzic, Dawid; Dzikowska, Ewa; Grabiec, Marek

2017-01-01

Labor induction is indicated in 20% to 40% of pregnancies. Over half of pregnancies qualified for the induction of labor require stimulation of the cervix to ripen. The drug used increasingly more often in pre-induction is the PGE-1 pros-taglandin analog - misoprostol 200 μg. The study includes a total of 100 patients qualified for labor pre-induction with Misodel® (miso-prostol 200 μg vaginal insert). The study group comprises two subgroups: primigravidas and multiparas. Assessments included: indications for labor pre-induction, time from Misodel application to delivery, caesarean section rate and indica-tions, duration of first and second stage of labor, rate of vaginal deliveries, need for oxytocin or fenoterol administration side effects and newborn condition. The most common indication for labor induction was gestational diabetes and pregnancy past term. The average time to vaginal delivery was 14 h 45 min, time to the onset of active phase of labor - 11 h 45 min, time to membranes' rupture - 15 h, time to vaginal delivery - 14 h 18 min. The times of multiparas were significantly shorter. The rate of vaginal deliveries within 12 hours amounted to 42.42%, while within 24 hours it reached 83.33%. The overall caesarean section rate was 33%. The most common indication for caesarean section was the risk of intrauterine hypoxia. Tachysystole and hyperstimulation was observed in 4% of cases, while abnormalities in the cardiotocographic tracing in 43%. Misodel is an effective method for labor pre-induction, without affecting the caesarean section rate and has no adverse effect on the newborn condition.

Route of delivery following successful external cephalic version.

PubMed

Policiano, Catarina; Costa, Ana; Valentim-Lourenço, Alexandre; Clode, Nuno; Graça, Luís M

2014-09-01

To evaluate the delivery route and the indications for cesarean delivery after successful external cephalic version (ECV). A retrospective matched case-control study was conducted at a hospital in Lisbon, Portugal, between 2002 and 2012. Each woman who underwent successful ECV (n = 44) was compared with the previous and next women who presented for labor management and who had the same parity and a singleton vertex pregnancy at term (n = 88). The outcome measures were route of delivery, indications for cesarean delivery, and incidence of nonreassuring fetal status. Attempts at ECV were successful in 62 (46%) of 134 women, and 44 women whose fetuses remained in a cephalic presentation until delivery were included in the study. The rates of intrapartum cesarean delivery and operative vaginal delivery did not differ significantly between cases and controls (intrapartum cesarean delivery, 9 [20%] vs 16 [18%], P = 0.75; operative vaginal delivery, 14 [32%] vs 19 [22%], P = 0.20). The indications for cesarean delivery after successful ECV did not differ; in both groups, cesarean delivery was mainly performed for labor arrest disorders (cases, 6 [67%] vs controls, 13 [81%]; P = 0.63). Successful ECV was not associated with increased rates of intrapartum cesarean delivery or operative vaginal delivery. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Safety of a silicone elastomer vaginal ring as potential microbicide delivery method in African women: A Phase 1 randomized trial.

PubMed

Nel, Annaléne; Martins, Janine; Bekker, Linda-Gail; Ramjee, Gita; Masenga, Gileard; Rees, Helen; van Niekerk, Neliëtte

2018-01-01

Women in sub-Saharan Africa are in urgent need of female-initiated human immunodeficiency virus (HIV) preventative methods. Vaginal rings are one dosage form in development for delivery of HIV microbicides. However, African women have limited experience with vaginal rings. This Phase I, randomized, crossover trial assessed and compared the safety, acceptability and adherence of a silicone elastomer placebo vaginal ring, intended as a microbicide delivery method, inserted for a 12-week period in healthy, HIV-negative, sexually active women in South Africa and Tanzania. 170 women, aged 18 to 35 years were enrolled with 88 women randomized to Group A, using a placebo vaginal ring for 12 weeks followed by a 12-week safety observation period. 82 women were randomized to Group B and observed for safety first, followed by a placebo vaginal ring for 12 weeks. Safety was assessed by clinical laboratory assessments, pelvic/colposcopy examinations and adverse events. Possible carry-over effect was addressed by ensuring no signs or symptoms of genital irritation at crossover. No safety concerns were identified for any safety variables assessed during the trial. No serious adverse events were reported considered related to the placebo vaginal ring. Vaginal candidiasis was the most common adverse event occurring in 11% of participants during each trial period. Vaginal discharge (2%), vaginal odour (2%), and bacterial vaginitis (2%) were assessed as possibly or probably related to the vaginal ring. Thirty-four percent of participants had sexually transmitted infections (STIs) at screening, compared to 12% of participants who tested positive for STIs at crossover and the final trial visit. Three participants (2%) tested HIV positive during the trial. The silicone elastomer vaginal ring had no safety concerns, demonstrating a profile favorable for further development for topical release of antiretroviral-based microbicides.

Safety of a silicone elastomer vaginal ring as potential microbicide delivery method in African women: A Phase 1 randomized trial

PubMed Central

Nel, Annaléne; Bekker, Linda-Gail; Ramjee, Gita; Masenga, Gileard; Rees, Helen; van Niekerk, Neliëtte

2018-01-01

Background Women in sub-Saharan Africa are in urgent need of female-initiated human immunodeficiency virus (HIV) preventative methods. Vaginal rings are one dosage form in development for delivery of HIV microbicides. However, African women have limited experience with vaginal rings. Objectives This Phase I, randomized, crossover trial assessed and compared the safety, acceptability and adherence of a silicone elastomer placebo vaginal ring, intended as a microbicide delivery method, inserted for a 12-week period in healthy, HIV-negative, sexually active women in South Africa and Tanzania. Methods 170 women, aged 18 to 35 years were enrolled with 88 women randomized to Group A, using a placebo vaginal ring for 12 weeks followed by a 12-week safety observation period. 82 women were randomized to Group B and observed for safety first, followed by a placebo vaginal ring for 12 weeks. Safety was assessed by clinical laboratory assessments, pelvic/colposcopy examinations and adverse events. Possible carry-over effect was addressed by ensuring no signs or symptoms of genital irritation at crossover. Results No safety concerns were identified for any safety variables assessed during the trial. No serious adverse events were reported considered related to the placebo vaginal ring. Vaginal candidiasis was the most common adverse event occurring in 11% of participants during each trial period. Vaginal discharge (2%), vaginal odour (2%), and bacterial vaginitis (2%) were assessed as possibly or probably related to the vaginal ring. Thirty-four percent of participants had sexually transmitted infections (STIs) at screening, compared to 12% of participants who tested positive for STIs at crossover and the final trial visit. Three participants (2%) tested HIV positive during the trial. Conclusions The silicone elastomer vaginal ring had no safety concerns, demonstrating a profile favorable for further development for topical release of antiretroviral-based microbicides. PMID:29813074

High Diversity and Variability in the Vaginal Microbiome in Women following Preterm Premature Rupture of Membranes (PPROM): A Prospective Cohort Study

PubMed Central

Paramel Jayaprakash, Teenus; Wagner, Emily C.; van Schalkwyk, Julie; Albert, Arianne Y. K.; Hill, Janet E.; Money, Deborah M.

2016-01-01

Objective To characterize the vaginal microbiota of women following preterm premature rupture of membranes (PPROM), and determine if microbiome composition predicts latency duration and perinatal outcomes. Design A prospective cohort study Setting Canada Population Women with PPROM between 24+0 and 33+6 weeks gestational age (GA). Methods Microbiome profiles, based on pyrosequencing of the cpn60 universal target, were generated from vaginal samples at time of presentation with PPROM, weekly thereafter, and at delivery. Main Outcome Measures Vaginal microbiome composition, latency duration, gestational age at delivery, perinatal outcomes. Results Microbiome profiles were generated from 70 samples from 36 women. Mean GA at PPROM was 28.8 wk (mean latency 2.7 wk). Microbiome profiles were highly diverse but sequences representing Megasphaera type 1 and Prevotella spp. were detected in all vaginal samples. Only 13/70 samples were dominated by Lactobacillus spp. Microbiome profiles at the time of membrane rupture did not cluster by gestational age at PPROM, latency duration, presence of chorioamnionitis or by infant outcomes. Mycoplasma and/or Ureaplasma were detected by PCR in 81% (29/36) of women, and these women had significantly lower GA at delivery and correspondingly lower birth weight infants than Mycoplasma and/or Ureaplasma negative women. Conclusion Women with PPROM had mixed, abnormal vaginal microbiota but the microbiome profile at PPROM did not correlate with latency duration. Prevotella spp. and Megasphaera type I were ubiquitous. The presence of Mollicutes in the vaginal microbiome was associated with lower GA at delivery. The microbiome was remarkably unstable during the latency period. PMID:27861554

Maternal and cord plasma concentrations of beta-lipotrophin, beta-endorphin and gamma-lipotrophin at delivery; effect of analgesia.

PubMed

Browning, A J; Butt, W R; Lynch, S S; Shakespear, R A; Crawford, J S

1983-12-01

Maternal venous plasma concentrations of beta-LPH, beta-EP and gamma-LPH were compared in (i) patients undergoing vaginal delivery, 11 with an epidural block and 13 with pethidine and nitrous oxide or no analgesics; (ii) patients delivered by caesarean section, 7 under epidural block and 8 under general anaesthesia. Patients delivered by either method under epidural block had significantly lower levels of all three peptides than those receiving no epidural. There were significant negative correlations between umbilical vein beta-LPH, beta-EP and gamma-LPH concentrations and umbilical artery pH and positive correlations between beta-LPH and beta-EP but not gamma-LPH and cord PCO2 in 29 patients. There was no relation between cord levels of any of the three peptides and the method of analgesia or the route of delivery. Although concentrations of all three peptides were closely correlated to one another in either maternal or cord plasma, there was no relationship between maternal and fetal levels.

Further evidence of psychological factors underlying choice of elective cesarean delivery (ECD) by primigravidae.

PubMed

Matinnia, Nasrin; Haghighi, Mohammad; Jahangard, Leila; Ibrahim, Faisal B; Rahman, Hejar A; Ghaleiha, Ali; Holsboer-Trachsler, Edith; Brand, Serge

2018-01-01

Requests for elective cesarean delivery (ECD) have increased in Iran. While some sociodemographic and fear-related factors have been linked with this choice, psychological factors such as self-esteem, stress, and health beliefs are under-researched. A total of 342 primigravidae (mean age = 25 years) completed questionnaires covering psychological dimensions such as self-esteem, perceived stress, marital relationship quality, perceived social support, and relevant health-related beliefs. Of the sample, 214 (62.6%) chose to undergo ECD rather than vaginal delivery (VD). This choice was associated with lower self-esteem, greater perceived stress, belief in higher susceptibility to problematic birth and barriers to an easy birth, along with lower perceived severity of ECD, fewer perceived benefits from VD, lower self-efficacy and a lower feeling of preparedness. No differences were found for marital relationship quality or perceived social support. The pattern suggests that various psychological factors such as self-esteem, self-efficacy, and perceived stress underpin the decision by primigravidae to have an ECD.

Predicting obstetric anal sphincter injuries in a modern obstetric population.

PubMed

Meister, Melanie R L; Cahill, Alison G; Conner, Shayna N; Woolfolk, Candice L; Lowder, Jerry L

2016-09-01

Perineal lacerations are common at the time of vaginal delivery and may predispose patients to long-term pelvic floor disorders, such as urinary incontinence and pelvic organ prolapse. Obstetric anal sphincter injuries, which are the most severe form of perineal lacerations, result in disruption of the anal sphincter and, in some cases, the rectal mucosa during vaginal delivery. Long-term morbidity, including pain, pelvic floor disorders, fecal incontinence, and predisposition to recurrent injury at subsequent delivery may result. Despite several studies that have reported risk factors for obstetric anal sphincter injuries, no accurate risk prediction models have been developed. The purpose of this study was to identify risk factors and develop prediction models for perineal lacerations and obstetric anal sphincter injuries. This was a nested case control study within a retrospective cohort of consecutive term vaginal deliveries at 1 tertiary care facility from 2004-2008. Cases were patients with any perineal laceration that had been sustained during vaginal delivery; control subjects had no lacerations of any severity. Secondary analyses investigated obstetric anal sphincter injury (3rd- to 4(th)-degree laceration) vs no obstetric anal sphincter injury (0 to 2(nd)-degree laceration). Baseline characteristics were compared between groups with the use of the chi-square and Student t test. Adjusted odds ratios and 95% confidence intervals were calculated with the use of multivariable logistic regression. Prediction models were created and model performance was estimated with receiver-operator characteristic curve analysis. Receiver-operator characteristic curves were validated internally with the use of the bootstrap method to correct for bias within the model. Of the 5569 term vaginal deliveries that were recorded during the study period, complete laceration data were available in 5524 deliveries. There were 3382 perineal lacerations and 249 (4.5%) obstetric anal sphincter injuries. After adjusted analysis, significant predictors for laceration included nulliparity, non-black race, longer second stage, nonsmoking status, higher infant birthweight, and operative delivery. Private health insurance, labor induction, pushing duration, and regional anesthesia were not statistically significant in adjusted analyses. Significant risk factors for obstetric anal sphincter injury were similar to predictors for any laceration; nulliparity and operative vaginal delivery had the highest predictive value. Area under the curve for the predictive ability of the models was 0.70 for overall perineal laceration, and 0.83 for obstetric anal sphincter injury. When limited to primiparous patients, 1996 term vaginal deliveries were recorded. One hundred ninety-two women sustained an obstetric anal sphincter injury; 1796 women did not. After adjusted analysis, significant predictors for laceration included non-black race, age, obesity, and nonsmoking status. In secondary analyses, significant predictors for obstetric anal sphincter injury included non-black race, nonsmoking status, longer duration of pushing, operative vaginal delivery, and infant birthweight. Area under the curve for the predictive ability of the models was 0.60 for any laceration and 0.77 for obstetric anal sphincter injury. Significant risk factors for sustaining any laceration and obstetric anal sphincter injury during vaginal deliveries were identified. These results will help identify clinically at-risk patients and assist providers in counseling patients about modifications to decrease these risks. Copyright © 2016 Elsevier Inc. All rights reserved.

Forceps delivery is associated with increased risk of pelvic organ prolapse and muscle trauma: a cross-sectional study 16-24 years after first delivery.

PubMed

Volløyhaug, I; Mørkved, S; Salvesen, Ø; Salvesen, K Å

2015-10-01

To study possible associations between mode of delivery and pelvic organ prolapse (POP) and pelvic floor muscle trauma 16-24 years after first delivery and, in particular, to identify differences between forceps and vacuum delivery. This was a cross-sectional study including 608 women who delivered their first child in 1990-1997 and were examined with POP quantification (POP-Q) and pelvic floor ultrasound in 2013-2014. Outcome measures were POP ≥ Stage 2 or previous prolapse surgery, levator avulsion and levator hiatal area on Valsalva. Univariable and multivariable logistic regression analyses and ANCOVA were applied to identify outcome variables associated with mode of delivery. Comparing forceps to vacuum delivery, the adjusted odds ratios (aOR) were 1.72 (95% CI, 1.06-2.79; P = 0.03) for POP ≥ Stage 2 or previous prolapse surgery and 4.16 (95% CI, 2.28-7.59; P < 0.01) for levator avulsion. Hiatal area on Valsalva was larger, with adjusted mean difference (aMD) of 4.75 cm(2) (95% CI, 2.46-7.03; P < 0.01). Comparing forceps with normal vaginal delivery, the adjusted odds ratio (aOR) was 1.74 (95% CI, 1.12-2.68; P = 0.01) for POP ≥ Stage 2 or surgery and 4.35 (95% CI, 2.56-7.40; P < 0.01) for levator avulsion; hiatal area on Valsalva was larger, with an aMD of 3.84 cm(2) (95% CI, 1.78-5.90; P < 0.01). Comparing Cesarean delivery with normal vaginal delivery, aOR was 0.06 (95% CI, 0.02-0.14; P < 0.01) for POP ≥ Stage 2 or surgery and crude OR was 0.00 (95% CI, 0.00-0.30; P < 0.01) for levator avulsion; hiatal area on Valsalva was smaller, with an aMD of -8.35 cm(2) (95% CI, -10.87 to -5.84; P < 0.01). No differences were found between vacuum and normal vaginal delivery. We found that mode of delivery was associated with POP and pelvic floor muscle trauma in women from a general population, 16-24 years after their first delivery. Forceps was associated with significantly more POP, levator avulsion and larger hiatal areas than were vacuum and normal vaginal deliveries. There were no statistically significant differences between vacuum and normal vaginal deliveries. Cesarean delivery was associated with significantly less POP and pelvic floor muscle trauma than were normal or operative vaginal delivery. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Severe perineal laceration during operative vaginal delivery: the impact of occiput posterior position.

PubMed

Hirsch, E; Elue, R; Wagner, A; Nelson, K; Silver, R K; Zhou, Y; Adams, M G

2014-12-01

To identify risk factors for severe (third/fourth degree) perineal laceration with operative vaginal delivery (OVD, forceps or vacuum). Case-control study comparing singleton OVDs with or without severe laceration (n=138). In multivariable analyses, severe perineal laceration was associated with occiput posterior (OP) position at delivery, vaginal nulliparity, use of forceps, longer period pushing in the second stage and lower gestational age, but not birth weight, labor induction or episiotomy. Among 29 OP patients at full dilation, 9/13 (69%) attempted rotations to occiput anterior (OA) were successful, and 14/16 (88%) patients in whom rotation was not attempted remained OP at delivery. Successful rotation from OP to OA was associated with fewer severe lacerations than no attempt or unsuccessful rotation (22 vs 75%, P=0.01). Severe perineal laceration during OVD is associated with OP position at delivery and is reduced threefold in patients successfully rotated from OP to OA.

The effect of primary delivery of the anterior compared with the posterior shoulder on perineal trauma: a study protocol for a randomized controlled trial

PubMed Central

2014-01-01

Background Approximately 85% of vaginal deliveries are accompanied by perineal trauma. The objective of this trial is to compare the incidence and degree of perineal trauma after primary delivery of the anterior compared with the posterior shoulder during vaginal birth. The hypothesis is that primary delivery of the posterior shoulder reduces the rate and degree of perineal trauma. Methods/design This is a single-centre, randomized controlled trial, with computer-generated randomization in a 1:1 allocation ratio. Women planning their first vaginal delivery (n = 650) are randomized to primary delivery of either the anterior or posterior shoulder. The primary outcome is any perineal trauma. Additional outcomes are the perineal injury subtypes, postpartum bleeding, umbilical artery pH, Apgar score at 5 minutes and any neonatal birth trauma. Perineal trauma is assessed by a midwife or doctor blinded to the method of shoulder delivery. All midwives are trained in the two methods of shoulder delivery and in the grading of perineal tears. The trial is being undertaken at a Danish community hospital with 1,600 yearly deliveries. Data will be analyzed according to the intention-to-treat principle. Recruitment started in January 2013 and the trial is planned to proceed for 24 months. Discussion Most delivery assistance techniques are based on tradition and heritage and lack objective evidence. This trial provides an example of how vaginal delivery techniques can be evaluated in a randomized controlled trial. The results of this trial will clarify the role that delivery of the shoulders has on perineal trauma and thereby provide knowledge to recommendations on birthing technique. Trial registration ClinicalTrials.gov: NCT01937546. PMID:25047001

Women's attitudes toward mode of delivery in South Korea--a society with high cesarean section rates.

PubMed

Lee, Sang-Il; Khang, Young-Ho; Lee, Moo-Song

2004-06-01

In South Korea, cesarean section rates (i.e., the proportion of all live births delivered by cesarean section) approached 40 percent in 2000. The relative contribution of physicians and women to this high rate has been a source of debate. This study explored attitudes toward mode of delivery among South Korean women. A nationwide cross-sectional telephone survey of 505 Korean women aged 20 to 49 years was conducted using a proportionate quota and systematic random sampling method. The response rate was 57.3 percent. Data were collected using a structured questionnaire consisting of 7 questions about vaginal and cesarean delivery. Over 95 percent of women preferred vaginal delivery during pregnancy and were willing to recommend this method to others. Of the women who delivered by cesarean section, 10.6 percent stated that they had requested a cesarean birth. Attitudes toward vaginal or cesarean delivery differed significantly according to a woman's education level. Most study participants showed more favorable attitudes toward vaginal delivery than cesarean delivery. This result does not support the assumption that the upsurge of cesarean section rates in South Korea is associated with women's positive attitudes toward cesarean section. The main cause of the rapid rise of cesarean section rates in South Korea during the past two decades have its origins in health care practitioners and the health care system in which they work.

Vernix caseosa peritonitis after vaginal delivery.

PubMed

Sadath, Shameema A; Abo Diba, Fathiya I; Nayak, Surendra; Shamali, Iman Al; Diejomaoh, Michael F

2013-01-01

Vernix caseosa peritonitis (VCP) is a very unusual complication caused by inflammatory response to amniotic fluid spilled into the maternal peritoneal cavity. Twenty-seven cases have been reported, and all occurred after cesarean section. We present a case of VCP following vaginal delivery; this may be the first case reported after vaginal delivery. Mrs. A, 28 years old, gravida 3, para 2, with one previous cesarean section, was admitted at 41 weeks gestation in active labor. Vacuum extraction was performed to deliver a healthy male baby, 4.410 kg, Apgar scores 7, 8. She developed fever, acute abdominal pain, and distension about 3 hours after delivery. A diagnosis of acute abdomen was made. Laparotomy was performed and it revealed neither uterine scar rupture nor other surgical emergencies, but 500 mL of turbid fluid and some cheesy material on the serosal surface of all viscera. Biopsies were taken. She had a course of antibiotics and her recovery was complete. Histology of the peritoneal fluid and tissue biopsy resulted in a diagnosis of VCP. Clinical diagnosis of peritonitis due to vernix caseosa should be considered in patients presenting postpartum with an acute abdomen after vaginal delivery.

[Quality of birth care in maternity hospitals of Rio de Janeiro, Brazil].

PubMed

d'Orsi, Eleonora; Chor, Dóra; Giffin, Karen; Angulo-Tuesta, Antonia; Barbosa, Gisele Peixoto; Gama, Andrea de Souza; Reis, Ana Cristina; Hartz, Zulmira

2005-08-01

To evaluate the quality of birth care based on the World Health Organization guidelines. A case-control study was carried out in a public and a private maternity hospitals contracted by the Brazilian Health System in the city of Rio de Janeiro, Brazil, from October 1998 to March 1999. The sample comprised 461 women in the public maternity hospital (230 vaginal deliveries and 231 Cesarean sections) and 448 women in the private one (224 vaginal deliveries and 224 Cesarean sections). Data was collected through interviews with puerperal women and review of medical records. A summarization score of quality of delivery care was constructed. There was low frequency of practices that should be encouraged, such as having an accompanying person (1% in the private hospital for both vaginal delivery and C-sections), freedom of movements throughout labor (9.6% of C-sections in the public hospital and 9.9% of vaginal deliveries in the private hospital) and breastfeeding in the delivery room (6.9% of C-sections in the public hospital and 8.0% of C-sections in the private hospital). There was a high frequency of known harmful practices such as enema administration (38.4%); routine pubic shaving; routine intravenous infusion (88.8%); routine use of oxytocin (64.4%), strict bed rest throughout labor (90.1%) and routine supine position in labor (98.7%) in vaginal deliveries. The best summarizing scores were seen in the public maternity hospital. The two maternity hospitals have a high frequency of interventions during birth care. In spite of providing care to higher risk pregnant women, the public maternity hospital has a less interventionist profile than the private one. Procedures carried out on a routine basis should be pondered based on evidence of their benefits.

[What type of delivery for twins?].

PubMed

Vendittelli, F; Accoceberry, M; Savary, D; Laurichesse-Delmas, H; Gallot, D; Jacquetin, B; Lémery, D

2009-12-01

To determine if perinatal and neonatal morbidity and mortality is improved by a planned caesarean section for twins before and at term. A systematic search was conducted in Medline between May 2001 and December 2008. Randomised controlled studies and meta-analysis were researched at first. There is no evidence to support a policy of planned caesarean section or vaginal delivery for twins before term or at term whatever the presentation of the first twin. There is also no evidence to support a policy of caesarean section or vaginal delivery for a patient with a history of prior caesarean section. Vaginal delivery must be made in the presence of an obstetrician, an anaesthesiologist, and a paediatrician in a level maternity adapted to the risks of the future newborn. Otherwise, there is no evidence to support a policy of planned caesarean delivery for twins but the type of delivery has to be decided with the informed patient. Copyright © 2009 Elsevier Masson SAS. All rights reserved.

Characteristics in the first vaginal birth and their association with mode of delivery in the subsequent birth.

PubMed

Chen, Jian Sheng; Ford, Jane B; Ampt, Amanda; Simpson, Judy M; Roberts, Christine L

2013-03-01

The extent to which complications or adverse outcomes in a first vaginal birth may contribute to mode of delivery in the next birth remains unclear. This study examines the impact of the first birth on subsequent mode of delivery. The study population included women with a first vaginal birth and a consecutive second birth. Data were obtained from linked birth and hospital records for the state of New South Wales, Australia 2000-09. The primary outcome was the mode of delivery for the second birth. Planned caesarean was modelled using logistic regression; intrapartum caesarean and instrumental delivery were modelled using multinomial logistic regression. Of the 114 287 second births, 4.2% were planned caesarean, 3.0% were intrapartum caesarean and 4.8% were instrumental deliveries. Adjusted risk factors from the first birth for a planned second birth caesarean were third to fourth degree tear [odds ratio (OR) = 5.0 [95% confidence interval (CI) 4.6, 5.4

Maternal and neonatal factors associated with mode of delivery under a universal newborn hearing screening programme in Lagos, Nigeria

PubMed Central

Olusanya, Bolajoko O; Solanke, Olumuyiwa A

2009-01-01

Background Emerging evidence from a recent pilot universal newborn hearing screening (UNHS) programme suggests that the burden of obstetric complications associated with mode of delivery is not limited to maternal and perinatal mortality but may also include outcomes that undermine optimal early childhood development of the surviving newborns. However, the potential pathways for this association have not been reported particularly in the context of a resource-poor setting. This study therefore set out to establish the pattern of delivery and the associated neonatal outcomes under a UNHS programme. Methods A cross-sectional study in which all consenting mothers who delivered in an inner-city tertiary maternity hospital in Lagos, Nigeria from May 2005 to December 2007 were enrolled during the UNHS programme. Socio-demographic, obstetric and neonatal factors independently associated with vaginal, elective and emergency caesarean deliveries were determined using multinomial logistic regression analyses. Results Of the 4615 mothers enrolled, 2584 (56.0%) deliveries were vaginal, 1590 (34.4%) emergency caesarean and 441 (9.6%) elective caesarean section. Maternal age, parity, social class and all obstetric factors including lack of antenatal care, maternal HIV and multiple gestations were associated with increased risk of emergency caesarean delivery compared with vaginal delivery. Only parity, lack of antenatal care and prolonged/obstructed labour were associated with increased risk of emergency compared with elective caesarean delivery. Infants delivered by vaginal method or by emergency caesarean section were more likely to be associated with the risk of sensorineural hearing loss but less likely to be associated with hyperbilirubinaemia compared with infants delivered by elective caesarean section. Emergency caesarean delivery was also associated with male gender, low five-minute Apgar scores and admission into special care baby unit compared with vaginal or elective caesarean delivery. Conclusions The vast majority of caesarean delivery in this population occur as emergencies and are associated with socio-demographic factors as well as several obstetric complications. Mode of delivery is also associated with the risk of sensorineural hearing loss and other adverse birth outcomes that lie on the causal pathways for potential developmental deficits. PMID:19732443

Decreased rates of nosocomial endometritis and urinary tract infection after vaginal delivery in a French surveillance network, 1997-2003.

PubMed

Ayzac, Louis; Caillat-Vallet, Emmanuelle; Girard, Raphaële; Chapuis, Catherine; Depaix, Florence; Dumas, Anne-Marie; Gignoux, Chantal; Haond, Catherine; Lafarge-Leboucher, Joëlle; Launay, Carine; Tissot-Guerraz, Françoise; Vincent, Agnès; Fabry, Jacques

2008-06-01

To identify independent risk factors for endometritis and urinary tract infection (UTI) after vaginal delivery, and to monitor changes in nosocomial infection rates and derive benchmarks for prevention. Prospective study. We analyzed routine surveillance data for all vaginal deliveries between January 1997 and December 2003 at 66 maternity units participating in the Mater Sud-Est surveillance network. Adjusted odds ratios for risk of endometritis or UTI were obtained using a logistic regression model. The overall incidence rates were 0.5% for endometritis and 0.3% for UTI. There was a significant decrease in the incidence and risk of endometritis but not of UTI during the 7-year period. Significant risk factors for endometritis were fever during labor, parity of 1, and instrumental delivery and/or manual removal of the placenta. Significant risk factors for UTI were urinary infection on admission, premature rupture of membranes (more than 12 hours before admission), blood loss of more than 800 mL, parity of 1, instrumental delivery, and receipt of more than 5 vaginal digital examinations. Each maternity unit received a poster showing graphs of the number of expected and observed cases of UTI and endometritis associated with vaginal deliveries, which enabled each maternity unit to determine their rank within the network and to initiate prevention programs. Although routine surveillance means additional work for maternity units, our results demonstrate the usefulness of regular targeted monitoring of risk factors and of the most common nosocomial infections in obstetrics. Most of the information needed for monitoring is already present in the patients' records.

Risk factors for unscheduled delivery in patients with placenta accreta.

PubMed

Bowman, Zachary S; Manuck, Tracy A; Eller, Alexandra G; Simons, Marilee; Silver, Robert M

2014-03-01

Patients with suspected placenta accreta have improved outcomes with scheduled delivery. Our objective was to identify risk factors for unscheduled delivery in patients with suspected placenta accreta. This was a cohort study of women with antenatally suspected placenta accreta. Women who delivered prior to a planned delivery date were compared with women who had a scheduled delivery. Data were analyzed using a Student t test, χ(2), logistic regression, and survival analyses. Variables included in the analyses were episodes of antenatal vaginal bleeding, preterm premature rupture of membranes (PPROM), uterine contractions, prior cesarean deliveries, interpregnancy interval, parity, and patient demographic factors. A value of P < .05 was considered significant. Seventy-seven women with antenatal suspicion for placenta accreta were identified. Thirty-eight (49.4%) had an unscheduled delivery. Demographics were similar between groups. Unscheduled patients delivered earlier (mean 32.3 vs 35.7 weeks, P < .001) and were significantly more likely to have had vaginal bleeding (86.8% vs 35.9%, P < .001) and uterine activity (47.4% vs 2.6%, P < .001). Each episode of antenatal vaginal bleeding was associated with an increased risk of unscheduled delivery (adjusted odds ratio, 3.8; 95% confidence interval, 1.8-7.8). Risk of earlier delivery was even greater when associated with PPROM (P < .001). Among women with suspected placenta accreta, those with antenatal vaginal bleeding were more likely to require unscheduled delivery. This risk increases further in the setting of PPROM and/or uterine contractions. These clinical factors should be considered when determining the optimal delivery gestational age for women with placental accreta. Copyright © 2014 Mosby, Inc. All rights reserved.

Neonatal morbidity associated with vaginal delivery of noncephalic second twins.

PubMed

Schmitz, Thomas; Korb, Diane; Battie, Catherine; Cordier, Anne-Gaël; de Carne Carnavalet, Céline; Chauleur, Céline; Equy, Véronique; Haddad, Bassam; Lemercier, Delphine; Poncelet, Christophe; Rigonnot, Luc; Goffinet, François

2018-04-01

Management of noncephalic second twin delivery rests on the results of population-based retrospective studies of twin births that have shown higher neonatal mortality and morbidity for second twins with noncephalic, compared with cephalic, presentations after vaginal delivery of the first twin. Because these studies are flawed by data of questionable validity, do not report the obstetrical practices at delivery, and do not allow collection of potential confounding variables, we performed a national prospective study specially designed to evaluate the management of twins' delivery. We sought to assess neonatal mortality and morbidity according to second twin presentation after vaginal birth of the first twin. The Jumeaux Mode d'Accouchement study was a nationwide prospective population-based cohort study of twin deliveries performed in 176 maternity units in France from February 2014 through March 2015. The primary outcome was a composite of intrapartum mortality and neonatal mortality and morbidity. Neonatal outcomes of second twins born ≥32 weeks of gestation after vaginal delivery of the first cephalic or breech twin were compared according to the noncephalic or cephalic second twin presentation. Multivariable logistic regression models controlled for potential confounders. Subgroup analyses were conducted according to the breech or transverse presentation of the noncephalic second twin, and gestational age at delivery, before or after 37 weeks of gestation. Among 3903 second twins enrolled in the study, 2384 (61.1%) were in cephalic and 1519 (38.9%) in noncephalic presentations, of whom 999 (25.6%) were in breech and 520 (13.3%) in transverse presentation. Composite neonatal mortality and morbidity did not differ between the noncephalic and cephalic group (47/1519 [3.1%] vs 59/2384 [2.5%]; adjusted odds ratio, 1.23; 95% confidence interval, 0.81-1.85). No significant difference between groups was shown for the primary outcome in subgroup analyses according to type of noncephalic second twin presentation or gestational age at delivery. Cesarean delivery rates for the second twin were lower in the breech than in the cephalic group (14/999 [1.4%] vs 75/2384 [3.1%], P = .003) and lower in the cephalic than in the transverse group (75/2384 [3.1%] vs 35/520 [6.7%], P < .001). Noncephalic and cephalic second twin presentations after vaginal delivery of the first twin ≥32 weeks of gestation are associated with similar low composite neonatal mortality and morbidity. Vaginal delivery of noncephalic second twin is a reasonable option. Copyright © 2018 Elsevier Inc. All rights reserved.

First delivery and ovariectomy affect biomechanical and structural properties of the vagina in the ovine model.

PubMed

Urbankova, Iva; Callewaert, Geertje; Blacher, Silvia; Deprest, Dries; Hympanova, Lucie; Feola, Andrew; De Landsheere, Laurent; Deprest, Jan

2018-01-08

Animal models are useful for investigating the genesis of pelvic floor dysfunction and for developing novel therapies for its treatment. There is a need for an alternative large-animal model to the nonhuman primate. Therefore we studied the effects of the first vaginal delivery, ovariectomy and systemic hormonal replacement therapy (HRT) on the biomechanical and structural properties of the ovine vagina. We examined the gross anatomical properties of nulliparous, primiparous, ovariectomized multiparous, and ovariectomized hormone-replaced multiparous sheep (six animals per group). We also harvested mid-vaginal and distal vaginal tissue to determine smooth muscle contractility and passive biomechanical properties, for morphometric assessment of the vaginal wall layers, to determine collagen and elastin content, and for immunostaining for α-smooth muscle actin and estrogen receptor-α. There were no regional differences in the nulliparous vagina. One year after the first vaginal delivery, stiffness and contractility of the distal vagina were decreased, whereas the elastin content increased. The mid-vagina of ovariectomized sheep was stiff, and its epithelium was thin and lacked glycogen. HRT decreased the stiffness of the mid-vagina by 45% but had no measurable effect on contractility or elastin content, and increased epithelial thickness and glycogen content. HRT also increased the epithelial thickness and glycogen content of the distal vagina. At this location, there were no changes in morphology or stiffness. In sheep, life events including delivery and ovariectomy affect the biomechanical properties of the vagina in a region-specific way. Vaginal delivery mainly affects the distal region by decreasing stiffness and contractility. HRT can reverse the increase in stiffness of the mid-vagina observed after surgical induction of menopause. These observations are in line with scanty biomechanical measurements in comparable clinical specimens.

Predicting the chance of vaginal delivery after one cesarean section: validation and elaboration of a published prediction model.

PubMed

Fagerberg, Marie C; Maršál, Karel; Källén, Karin

2015-05-01

We aimed to validate a widely used US prediction model for vaginal birth after cesarean (Grobman et al. [8]) and modify it to suit Swedish conditions. Women having experienced one cesarean section and at least one subsequent delivery (n=49,472) in the Swedish Medical Birth Registry 1992-2011 were randomly divided into two data sets. In the development data set, variables associated with successful trial of labor were identified using multiple logistic regression. The predictive ability of the estimates previously published by Grobman et al., and of our modified and new estimates, respectively, was then evaluated using the validation data set. The accuracy of the models for prediction of vaginal birth after cesarean was measured by area under the receiver operating characteristics curve. For maternal age, body mass index, prior vaginal delivery, and prior labor arrest, the odds ratio estimates for vaginal birth after cesarean were similar to those previously published. The prediction accuracy increased when information on indication for the previous cesarean section was added (from area under the receiver operating characteristics curve=0.69-0.71), and increased further when maternal height and delivery unit cesarean section rates were included (area under the receiver operating characteristics curve=0.74). The correlation between the individual predicted vaginal birth after cesarean probability and the observed trial of labor success rate was high in all the respective predicted probability decentiles. Customization of prediction models for vaginal birth after cesarean is of considerable value. Choosing relevant indicators for a Swedish setting made it possible to achieve excellent prediction accuracy for success in trial of labor after cesarean. During the delicate process of counseling about preferred delivery mode after one cesarean section, considering the results of our study may facilitate the choice between a trial of labor or an elective repeat cesarean section. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

An Initiative to Reduce the Episiotomy Rate: Association of Feedback and the Hawthorne Effect With Leapfrog Goals.

PubMed

Zhang-Rutledge, Kathy; Clark, Steven L; Denning, Stacie; Timmins, Audra; Dildy, Gary A; Gandhi, Manisha

2017-07-01

To assess the association of education, performance feedback, and the Hawthorne effect with a reduction in the episiotomy rate in a large academic institution. We describe a prospective observational study of a project conducted between March 2012 and February 2017 to assist clinicians in meeting the Leapfrog Group (www.leapfroggroup.org) target rates for episiotomy. Phases of this project included preintervention (phase 1, March 2012 to April 2014), education and provision of collective department episiotomy rates (phase 2, May 2014 to December 2014), ongoing education with emphasis on a revised Leapfrog target rate (phase 3, January 2015 to February 2016), and provision of individual episiotomy rates to practitioners on a monthly basis (phase 4, March 2016 to February 2017). We analyzed the department episiotomy rates before, during, and after these efforts. Cases of shoulder dystocia were excluded from this analysis. Statistical analysis was performed using a two-tailed Student t test and χ test with P<.05 considered significant. During the study period 1,176 episiotomies were performed in 16,441 vaginal deliveries (7.2%). In phase 2 (2,352 vaginal deliveries), there was a nonsignificant drop in the episiotomy rate with education alone (9.0-8.2%, P=.21). In phase 3 (4,379 vaginal deliveries), the episiotomy rate demonstrated an additional, significant drop to 5.9% (P<.001), but this reduction did not reach the new Leapfrog goal of 5%. In phase 4 (3,160 vaginal deliveries), the hospital episiotomy rate again dropped significantly from 5.9% to 4.37% (P=.007) and met the target rate of 5%. This reduction was sustained over a 12-month time period. During this same time period, the rate of operative vaginal delivery among vaginal births increased (4.5-5.4%, P=.003) and there was no significant change in the rates of third- and fourth-degree perineal laceration (3.8-3.3%, P=.19). Education, performance feedback, and the Hawthorne effect were associated with a reduction in the episiotomy rate in a large academic institution without a reduction in the rate of operative vaginal delivery or an increase in the rate of third- and fourth-degree lacerations.

The optimal mode of delivery for the haemophilia carrier expecting an affected infant is vaginal delivery.

PubMed

Ljung, R

2010-05-01

The optimal mode of delivery of a haemophilia carrier expecting a child is still a matter of uncertainty and debate. The aim of this commentary/review is to suggest that normal vaginal delivery should be the recommended mode of delivery for the majority of carriers, based on review of studies on obstetric aspects of haemophilia. About 2.0-4.0% of all haemophilia boys born in countries with a good standard of health care will suffer from ICH during the neonatal period. This is an average figure including all modes of delivery and regardless of whether the carrier status of the mother or the haemophilia status of the foetus was known or not at the time of delivery. On the basis of current literature, one may conclude that the risk of serious bleeding in the neonate affected with haemophilia is small in conjunction with normal vaginal delivery. It should be possible to further reduce the low frequency of complications if appropriate precautions are taken when planning the delivery in pregnant woman with known carrier status, if the sex of the foetus is known and, even more, when the haemophilia status of the foetus is known. Instrumental delivery such as use of vacuum extraction and foetal scalp monitors must be avoided at delivery of carriers.

Vacuum assisted birth and risk for cerebral complications in term newborn infants: a population-based cohort study.

PubMed

Ekéus, Cecilia; Högberg, Ulf; Norman, Mikael

2014-01-20

Few studies have focused on cerebral complications among newborn infants delivered by vacuum extraction (VE). The aim of this study was to determine the risk for intracranial haemorrhage and/or cerebral dysfunction in newborn infants delivered by VE and to compare this risk with that after cesarean section in labour (CS) and spontaneous vaginal delivery, respectively. Data was obtained from Swedish national registers. In a population-based cohort from 1999 to 2010 including all singleton newborn infants delivered at term after onset of labour by VE (n = 87,150), CS (75,216) or spontaneous vaginal delivery (n = 851,347), we compared the odds for neonatal intracranial haemorrhage, traumatic or non-traumatic, convulsions or encephalopathy. Logistic regressions were used to calculate adjusted (for major risk factors and indication) odds ratios (AOR), using spontaneous vaginal delivery as reference group. The rates of traumatic and non-traumatic intracranial hemorrhages were 0.8/10,000 and 3.8/1,000. VE deliveries provided 58% and 31.5% of the traumatic and non-traumatic cases, giving a ten-fold risk [AOR 10.05 (4.67-21.65)] and double risk [AOR 2.23 (1.57-3.16)], respectively. High birth weight and short mother were associated with the highest risks. Infants delivered by CS had no increased risk for intracranial hemorrhages. The risks for convulsions or encephalopathy were similar among infants delivered by VE and CS, exceeding the OR after non-assisted spontaneous vaginal delivery by two-to-three times. Vacuum assisted delivery is associated with increased risk for neonatal intracranial hemorrhages. Although causality could not be established in this observational study, it is important to be aware of the increased risk of intracranial hemorrhages in VE deliveries, particularly in short women and large infants. The results warrant further studies in decision making and conduct of assisted vaginal delivery.

Pessary or Progesterone to Prevent Preterm delivery in women with short cervical length: the Quadruple P randomised controlled trial.

PubMed

van Zijl, Maud D; Koullali, Bouchra; Naaktgeboren, Christiana A; Schuit, Ewoud; Bekedam, Dick J; Moll, Etelka; Oudijk, Martijn A; van Baal, Wilhelmina M; de Boer, Marjon A; Visser, Henricus; van Drongelen, Joris; van de Made, Flip W; Vollebregt, Karlijn C; Muller, Moira A; Bekker, Mireille N; Brons, Jozien T J; Sueters, Marieke; Langenveld, Josje; Franssen, Maureen T; Schuitemaker, Nico W; van Beek, Erik; Scheepers, Hubertina C J; de Boer, Karin; Tepe, Eveline M; Huisjes, Anjoke J M; Hooker, Angelo B; Verheijen, Evelyn C J; Papatsonis, Dimitri N; Mol, Ben Willem J; Kazemier, Brenda M; Pajkrt, Eva

2017-09-04

Preterm birth is in quantity and in severity the most important topic in obstetric care in the developed world. Progestogens and cervical pessaries have been studied as potential preventive treatments with conflicting results. So far, no study has compared both treatments. The Quadruple P study aims to compare the efficacy of vaginal progesterone and cervical pessary in the prevention of adverse perinatal outcome associated with preterm birth in asymptomatic women with a short cervix, in singleton and multiple pregnancies separately. It is a nationwide open-label multicentre randomized clinical trial (RCT) with a superiority design and will be accompanied by an economic analysis. Pregnant women undergoing the routine anomaly scan will be offered cervical length measurement between 18 and 22 weeks in a singleton and at 16-22 weeks in a multiple pregnancy. Women with a short cervix, defined as less than, or equal to 35 mm in a singleton and less than 38 mm in a multiple pregnancy, will be invited to participate in the study. Eligible women will be randomly allocated to receive either progesterone or a cervical pessary. Following randomization, the silicone cervical pessary will be placed during vaginal examination or 200 mg progesterone capsules will be daily self-administered vaginally. Both interventions will be continued until 36 weeks gestation or until delivery, whichever comes first. Primary outcome will be composite adverse perinatal outcome of perinatal mortality and perinatal morbidity including bronchopulmonary dysplasia, intraventricular haemorrhage grade III and IV, periventricular leukomalacia higher than grade I, necrotizing enterocolitis higher than stage I, Retinopathy of prematurity (ROP) or culture proven sepsis. These outcomes will be measured up until 10 weeks after the expected due date. Secondary outcomes will be, among others, time to delivery, preterm birth rate before 28, 32, 34 and 37 weeks, admission to neonatal intensive care unit, maternal morbidity, maternal admission days for threatened preterm labour and costs. This trial will provide evidence on whether vaginal progesterone or a cervical pessary is more effective in decreasing adverse perinatal outcome in both singletons and multiples. Trial registration number: NTR 4414 . Date of registration January 29th 2014.

Reoccurrence of retained placenta at a subsequent delivery: an observational study.

PubMed

Alufi, Anat; Mizrachi, Yossi; Lurie, Samuel

2017-05-01

To test the generalizability of previously reported increased risk of reoccurrence of retained placenta in yet another setting. In this observational retrospective study we longitudinally followed women who had a vaginal delivery complicated by a partial or complete retained placenta at Edith Wolfson Medical Center between 1 January 2009 and 31 December 2012. The study group included parturient women who had a partial or complete retained placenta after a vaginal delivery (n = 90). The control group included parturient women who did not have a partial or complete retained placenta after a vaginal delivery from the same time period using the same inclusion criteria (n = 90). Retained partial or complete placenta at a previous delivery was found to be an independent risk factor for retained partial or complete placenta in a subsequent delivery (adjusted OR 9.8, 95%CI 1.2 to 80.6, p = 0.032) and for retained partial or complete placenta and/or postpartum hemorrhage in a subsequent delivery (adjusted OR 14.1, 95% CI 1.7 to 111.9, p = 0.012), after controlling for gestational age and induction of labor at previous delivery. Retained partial or complete placenta at an index delivery increases the risk of reoccurrence of retained partial or complete placenta in a subsequent delivery.

[Impact of the external cephalic version on the obstetrical prognosis in a team with a high success rate of vaginal delivery in breech presentation].

PubMed

Coppola, C; Mottet, N; Mariet, A S; Baeza, C; Poitrey, E; Bourtembourg, A; Ramanah, R; Riethmuller, D

2016-10-01

To analyse the impact of external cephalic version (ECV) on caesarean section rate in a team with a high success rate of vaginal delivery in breech presentation. Retrospective monocentric study including 298 patients with a breech presentations between 33 and 35weeks of amenorrhea followed at our university hospital and delivered after 35weeks, between 1st January 2011 and 31st December 2013. Patients were divided into 2 groups: planned ECV (n=216 patients) versus no planned ECV (n=57 patients). Our rate of successful vaginal breech delivery over the period of the study was 61.1%. We performed 165 ECV, with a 21.8% success rate. The average term of the attempt of ECV was 36.7weeks of amenorrhea. The caesarean section rate was not significantly different in the planned ECV group, even after adjustment on age, parity and previous caesarean delivery (adjusted OR=1.67 [0.77-3.61]). Attempt of ECV did not reduce the number of breech presentation at delivery (61.1% versus 61.4% [P=0.55]). Planned ECV in our center with a high level of breech vaginal delivery did not significantly impact our cesarean section rate. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Trends in obstetric anal sphincter injuries over 10 years.

PubMed

Tyagi, V; Perera, M; Guerrero, K

2013-11-01

Obstetric anal sphincter injuries (OASIS) is a known complication of vaginal delivery and has significant public health issues, as it can cause both short- and long-term morbidity in women. The most commonly reported complications include different grades of faecal/flatus incontinence, pain and sexual dysfunction. In our study, we found a rising trend in OASIS rates in vaginal deliveries, with the rising rate of forceps and the falling rate of SVD, which is at least partly due to increased awareness and training in OASIS. However, there is an actual increase in the number of such tears at vaginal deliveries. Midwifery and obstetric practices have certainly changed over the last decade and we discuss the possible factors, which might be contributing to such a rise.

Broad Ligament Haematoma Following Normal Vaginal Delivery.

PubMed

Ibrar, Faiza; Awan, Azra Saeed; Fatima, Touseef; Tabassum, Hina

2017-01-01

A 37-year-old, patient presented in emergency with history of normal vaginal delivery followed by development of abdominal distention, vomiting, constipation for last 3 days. She was para 4 and had normal vaginal delivery by traditional birth attendant at peripheral hospital 3 days back. Imaging study revealed a heterogeneous complex mass, ascites, pleural effusion, air fluid levels with dilatation gut loops. Based upon pelvic examination by senior gynaecologist in combination with ultrasound; a clinical diagnosis of broad ligament haematoma was made. However, vomiting and abdominal distention raised suspicion of intestinal obstruction. Due to worsening abdominal distention exploratory laparotomy was carried out. It was pseudo colonic obstruction and caecostomy was done. Timely intervention by multidisciplinary approach saved patient life with minimal morbidity.

Factors involved in selecting the birth type among primiparous women

PubMed Central

Safari-Moradabadi, Ali; Alavi, Azin; Pormehr-Yabandeh, Asiyeh; Eftekhaari, Tasnim Eghbal; Dadipoor, Sakineh

2018-01-01

BACKGROUND: Mortality and disability rates were reported to be respectively 2-3 and 5-10 times higher in C-sections compared to Vaginal delivery. OBJECTIVES: This study was aimed to explore the factors involved in selecting the birth type among primiparous women. METHODS: The present cross-sectional research was conducted on 220 primiparous women, who visited the health-care centers of Bandar Abbas. They were recruited in their first trimester of pregnancy with a simple randomized clustering method. Data were collected in a researcher-designed questionnaire. Its validity was confirmed by a panel of experts and reliability was tested and approved through the test–retest method. Mean, standard deviation, independent sample t-test, and Chi-squared tests for data analysis were done by SPSS 16. P < 0.05 was considered statistically significant. RESULTS: The mean age of the participants was 27.40 ± 6.07 years. The main barriers to the choice of vaginal delivery were the fear of pain and fear of vaginal area tears and ruptures, fear of injury to fetus, and doctor's recommendation. A statistically significant correlation was observed between the age, education, employment, income, awareness, and the reasons for preferring surgical childbirth. CONCLUSIONS: To reduce the rate of unnecessary cesarean sections (C-section), the following recommendations are suggested: Reducing fear of pain in expectant mothers, modifying wrong beliefs about the culture of natural childbirth, increasing awareness of fewer adverse effects of vaginal delivery including the vaginal tears if the mother abides by all midwife(s) instructions during the delivery procedure, providing educational courses for the necessary movements during the delivery, decreasing surgeons’ payment for C-section, and increasing payment for natural childbirth and implementing barriers for optional delivery to reduce the C-section. PMID:29693036

Risk Factors for the Development of Obstetric Anal Sphincter Injuries in Modern Obstetric Practice.

PubMed

Ramm, Olga; Woo, Victoria G; Hung, Yun-Yi; Chen, Hsuan-Chih; Ritterman Weintraub, Miranda L

2018-02-01

To characterize the rate of obstetric anal sphincter injuries and identify key risk factors of obstetric anal sphincter injuries, including duration of the second stage of labor. This retrospective cohort study included all singleton, term, cephalic vaginal deliveries within Kaiser Permanente Northern California between January 2013 and December 2014 (N=22,741). Incidence of obstetric anal sphincter injuries, defined as third- or fourth-degree perineal lacerations, was the primary outcome. Multiple logistic regression models were conducted to identify obstetric anal sphincter injury risk factors and high-risk subpopulations. The overall incidence rate of obstetric anal sphincter injuries was 4.9% (3.6% of women who delivered spontaneously vs 24.0% of women who had a vacuum-assisted vaginal delivery, P<.001, CI 18.1-22.6%). In bivariate and multivariate analyses, obstetric anal sphincter injury incidence was higher among women with second stage of labor longer than 2 hours, Asian race, nulliparity, vaginal birth after cesarean delivery, episiotomy, and vacuum delivery. Women with a vacuum-assisted vaginal delivery had four times the odds of obstetric anal sphincter injury (adjusted odds ratio [OR] 4.23, 95% CI 3.59-4.98) and those whose second stage of labor lasted at least 180 minutes vs less than 60 minutes had three times the odds of incurring obstetric anal sphincter injury (adjusted OR 3.20, 95% CI 2.62-3.89). Vacuum-assisted vaginal delivery conferred the highest odds of obstetric anal sphincter injury followed by prolonged duration of the second stage of labor, particularly among certain subpopulations. Understanding these risk factors and their complex interactions can inform antepartum and intrapartum decision-making with the goal of reducing obstetric anal sphincter injury incidence.

Frequency and determinants of vaginal infection in postpartum period: a cross-sectional survey from low socioeconomic settlements, Karachi, Pakistan.

PubMed

Ali, Tazeen Saeed; Fikree, Fariyal F; Rahbar, Mohammad H; Mahmud, Sadia

2006-03-01

To determine the frequency and factors associated with perceived vaginal infections among married women in their postpartum period. A cross-sectional study was conducted from July 2000 to October 2000 in five squatter settlements of Karachi, Pakistan. These squatter settlements were selected on the basis of an existing surveillance system run by female community health workers for maternal and child healthcare which identified women who had delivered 42-56 days prior to the date of interview. Vaginal infection was considered present when a mother perceived foul smelling vaginal discharge during the postpartum period. Mothers were interviewed to gain insight into socioeconomic and demographic variables, materials used to staunch lochia, duration of labour, personal and perineal hygiene and past obstetric history. A total of 525 women were interviewed. The estimated prevalence of perceived vaginal infection was 5.1%. Factors associated with perceived vaginal infections included, delivery conducted by a non-medical personnel (AOR 3.5, CI 1.3-9.5) and use of unhygienic cloth or cotton for staunch of lochia (AOR 2.7, CI 1.1-6.2). Among women who reported perceived vaginal infection, a higher proportion were delivered by non-medical personnel, and used unhygienic material (cloth or cotton) for staunch of lochia as compared to women who did not perceive vaginal infection. We recommend deliveries to be conducted by trained personnel and provision of health education for persons who conduct delivery and women to use hygienic material for staunch of lochia during post partum period.

A Rare Case: Rupture of Internal Pudendal and Uterine Artery in a Vaginal Delivery.

PubMed

Chughtai, Novera G; Rizvi, Raheela Mohsin

2018-03-01

The management of puerperal hematomas after normal delivery has always been challenging for obstetricians. Vulvar, vulvovaginal, or paravaginal hematomas are common. On the other hand, retroperitoneal hematomas are uncommon and can be life-threatening. The diagnosis of vascular injury is rarely made preoperatively as atonic or traumatic postpartum hemorrhage (PPH), uterine rupture and amniotic fluid embolism are more common differential diagnoses. Injury to internal pudendal and uterine vessels is extremely rare in cases of vaginal delivery and, therefore, the literature on this topic is very scarce. We present a rare case of both internal pudendal and uterine artery rupture in a normal vaginal delivery, which led to massive postpartum hemorrhage. The diagnosis was made on Magnetic Resonance imaging (MRI) and arterial embolization was performed. This case stresses on the need for careful post-delivery monitoring for revealed postpartum hemorrhage. Vascular injury is a rare life-threatening cause of obstetric shock, and active; and timely operative intervention can prevent morbidity and mortality.

Induction of labor in a contemporary obstetric cohort.

PubMed

Laughon, S Katherine; Zhang, Jun; Grewal, Jagteshwar; Sundaram, Rajeshwari; Beaver, Julie; Reddy, Uma M

2012-06-01

We sought to describe details of labor induction, including precursors and methods, and associated vaginal delivery rates. This was a retrospective cohort study of 208,695 electronic medical records from 19 hospitals across the United States, 2002 through 2008. Induction occurred in 42.9% of nulliparas and 31.8% of multiparas and elective or no recorded indication for induction at term occurred in 35.5% and 44.1%, respectively. Elective induction at term in multiparas was highly successful (vaginal delivery 97%) compared to nulliparas (76.2%). For all precursors, cesarean delivery was more common in nulliparas in the latent compared to active phase of labor. Regardless of method, vaginal delivery rates were higher with a ripe vs unripe cervix, particularly for multiparas (86.6-100%). Induction of labor was a common obstetric intervention. Selecting appropriate candidates and waiting longer for labor to progress into the active phase would make an impact on decreasing the national cesarean delivery rate. Published by Mosby, Inc.

Induction of Labor in a Contemporary Obstetric Cohort

PubMed Central

Laughon, S. Katherine; Zhang, Jun; Grewal, Jagteshwar; Sundaram, Rajeshwari; Beaver, Julie; Reddy, Uma M.

2012-01-01

Objective To describe details of labor induction, including precursors and methods, and associated vaginal delivery rates. Study Design A retrospective cohort study of 208,695 electronic medical records from 19 hospitals across the United States, 2002–2008. Results Induction occurred in 42.9% of nulliparas and 31.8% of multiparas and elective or no recorded indication for induction at term occurred in 35.5% and 44.1%, respectively. Elective induction at term in multiparas was highly successful (vaginal delivery 97%) compared to nulliparas (76.2%). For all precursors, cesarean delivery was more common in nulliparas in the latent compared to active phase of labor. Regardless of method, vaginal delivery rates were higher with a ripe versus unripe cervix, particularly for multiparas (86.6 – 100%). Conclusions Induction of labor was a common obstetric intervention. Selecting appropriate candidates and waiting longer for labor to progress into the active phase would make an impact on decreasing the national cesarean delivery rate. PMID:22520652

Spontaneous vaginal delivery in the birth-chair versus in the conventional dorsal position: a matched controlled comparison.

PubMed

Scholz, H S; Benedicic, C; Arikan, M G; Haas, J; Petru, E

2001-09-17

The aim of the study was to assess the effect of a birth-chair on obstetric outcome. We reviewed the hospital records of 220 consecutive pregnant women who gave birth on a birth-chair at our institution. The control group consisted of 440 pregnant women who preceded and followed the index cases and who had spontaneous vaginal deliveries in the conventional dorsal supine position. The controls were matched for parity and for the attending mid-wife. Patients who delivered in the birth-chair had significantly lower rates of episiotomy and manual separation of the placenta. The umbilical blood cord pH was significantly higher in neonates of the birth-chair group. The duration of labour, rate of perineal and vaginal injury, Apgar scores and rate of admission to a neonatal intermediate care unit were not influenced by the mode of delivery. Our data support previous studies that a birth-chair delivery may be a safe alternative to conventional delivery in the supine position.

Birth experience in women with low, intermediate or high levels of fear. Findings from the First Baby Study

PubMed Central

Elvander, Charlotte; Cnattingius, Sven; Kjerulff, Kristen H.

2013-01-01

Background Fear of childbirth and mode of delivery are two known factors that affect birth experience. The interactions between these two factors are unknown. The aim of this study was to estimate the effects of different levels of fear of birth and mode of delivery on birth experience 1 month after birth. Methods As part of an ongoing prospective study, we interviewed 3006 women in their third trimester and 1 month after first childbirth to assess fear of birth and birth experience. Logistic regression was performed to examine the interactions and associations between fear of birth, mode of delivery and birth experience. Results Compared to women with low levels of fear of birth, women with intermediate levels of fear and women with high levels of fear had a more negative birth experience and were more affected by an unplanned cesarean section or instrumental vaginal delivery. Compared to women with low levels of fears with a non-instrumental vaginal delivery, women with high levels of fear who were delivered by unplanned cesarean section had a 12-fold increased risk of reporting a negative birth experience (odds ratio 12.25; 95% confidence intervals 7.19-20.86). A non-instrumental vaginal delivery was associated with the most positive birth experience among the women in this study. Conclusions This study shows that both levels of prenatal fear of childbirth and mode of delivery are important for birth experience. Women with low fear of childbirth who had a non-instrumental vaginal delivery reported the most positive birth experience. PMID:24344710

Birth experience in women with low, intermediate or high levels of fear: findings from the first baby study.

PubMed

Elvander, Charlotte; Cnattingius, Sven; Kjerulff, Kristen H

2013-12-01

Fear of childbirth and mode of delivery are two known factors that affect birth experience. The interactions between these two factors are unknown. The aim of this study was to estimate the effects of different levels of fear of birth and mode of delivery on birth experience 1 month after birth. As part of an ongoing prospective study, we interviewed 3,006 women in their third trimester and 1 month after first childbirth to assess fear of birth and birth experience. Logistic regression was performed to examine the interactions and associations between fear of birth, mode of delivery and birth experience. Compared with women with low levels of fear of birth, women with intermediate levels of fear, and women with high levels of fear had a more negative birth experience and were more affected by an unplanned cesarean section or instrumental vaginal delivery. Compared with women with low levels of fears with a noninstrumental vaginal delivery, women with high levels of fear who were delivered by unplanned cesarean section had a 12-fold increased risk of reporting a negative birth experience (OR 12.25; 95% CI 7.19-20.86). A noninstrumental vaginal delivery was associated with the most positive birth experience among the women in this study. This study shows that both levels of prenatal fear of childbirth and mode of delivery are important for birth experience. Women with low fear of childbirth who had a noninstrumental vaginal delivery reported the most positive birth experience. © 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc.

Risk and protective factors for obstetric anal sphincter injuries: A retrospective nationwide study.

PubMed

Marschalek, Marie-Louise; Worda, Christof; Kuessel, Lorenz; Koelbl, Heinz; Oberaigner, Willi; Leitner, Hermann; Marschalek, Julian; Husslein, Heinrich

2018-03-14

In view of the reported increase in obstetric anal sphincter injuries, the objective of this study was to evaluate the incidence of such injuries over time and the associated risk and protective factors. This was a retrospective cohort study from a national database of 168 137 primiparous women with term, singleton, cephalic, vaginal delivery between 2008 and 2014. The main outcome measure was obstetric anal sphincter injury. A multivariate regression model was used to identify risk and protective factors. Age >19 years, birthweight >4000 g, and operative vaginal delivery were independent risk factors for obstetric anal sphincter injuries. Mediolateral episiotomy increased the risk for obstetric anal sphincter injuries in spontaneous vaginal birth (number needed to harm 333), whereas it was protective in vacuum delivery (number needed to treat 50). From 2008 to 2014, there was an increase in the rate of obstetric anal sphincter injuries (2.1% vs 3.1%, P < .01), vacuum deliveries (12.1% vs 12.8%, P < .01), and cesarean delivery after labor (17.1% vs 19.4%, P < .01), while forceps deliveries (0.4% vs 0.1%, P < .01) and episiotomy rate decreased (35.9% vs 26.4%, P < .01). Episiotomy may be a risk or protective factor depending on the type of episiotomy and the clinical setting in which it is used. Our study supports a restrictive use of mediolateral episiotomy in spontaneous vaginal deliveries. In vacuum deliveries mediolateral episiotomy may help prevent obstetric anal sphincter injuries. © 2018 the Authors. Birth published by Wiley Periodicals, Inc.

Effect of early oral clindamycin on late miscarriage and preterm delivery in asymptomatic women with abnormal vaginal flora and bacterial vaginosis: a randomised controlled trial.

PubMed

Ugwumadu, Austin; Manyonda, Isaac; Reid, Fiona; Hay, Phillip

2003-03-22

Abnormal vaginal flora and bacterial vaginosis are associated with amplified risks of late miscarriage and spontaneous preterm delivery. We aimed to establish whether antibiotic treatment early in the second trimester might reduce these risks in a general obstetric population. We screened 6120 pregnant women attending hospital for their first antenatal visit--who were at 12-22 weeks' gestation (mean 15.6 weeks)--for bacterial vaginosis or abnormal vaginal flora. We used gram-stained slides of vaginal smears to diagnose abnormal vaginal flora or bacterial vaginosis, in accordance with Nugent's criteria. We randomly allocated 494 women with one of these signs to receive either clindamycin 300 mg or placebo orally twice daily for 5 days. Primary endpoints were spontaneous preterm delivery (birth > or =24 but <37 weeks) and late miscarriage (pregnancy loss > or =13 but <24 weeks). Analysis was intention to treat. Nine women were lost to follow-up or had elective termination. Thus, we analysed 485 women with complete outcome data. Women receiving clindamycin had significantly fewer miscarriages or preterm deliveries (13/244) than did those in the placebo group (38/241; percentage difference 10.4%, 95% CI 5.0-15.8, p=0.0003). Clindamycin also reduced adverse outcomes across the range of abnormal Nugent scores, with maximum effect in women with the highest Nugent score of 10. Treatment of asymptomatic abnormal vaginal flora and bacterial vaginosis with oral clindamycin early in the second trimester significantly reduces the rate of late miscarriage and spontaneous preterm birth in a general obstetric population.

Impact of pregnancy and vaginal delivery on the passive and active mechanics of the rat vagina.

PubMed

Feola, Andrew; Moalli, Pamela; Alperin, Marianna; Duerr, Robbie; Gandley, Robin E; Abramowitch, Steven

2011-01-01

Remodeling of vaginal extracellular matrix and smooth muscle likely plays a critical role in reducing the risk of maternal injury during vaginal delivery by altering the mechanical properties to increase distension and reduce stress. Long-Evans rats were divided into five groups to examine the passive mechanical and active contractile properties throughout pregnancy and postpartum: virgin (n=17), mid-pregnant (Day 14-16, n=12), late-pregnant (Day 20-22, n=14), immediate postpartum (0-2 h after delivery, n=14), and 4 week postpartum (n=15). Longitudinal sections of vaginal tissue were loaded to failure uniaxially for passive mechanical or active contractile properties were examined. For passive mechanics, the tangent modulus decreased 45% by mid-pregnancy and immediately postpartum (p<0.001). The ultimate strain continuously increased up to 43% higher than virgin animals (p=0.007) in the immediate postpartum group. For active mechanics, the maximal contractile force was 36-56% lower through immediate postpartum animals, and was significantly more sensitive to K+ throughout pregnancy and postpartum (p=0.003). The changes observed in the passive and active properties of the rat vagina are consistent with what would be expected from a tissue that is remodeling to maximize its ability to distend at the time of vaginal delivery to facilitate passage of the fetus with minimal injury.

Does meperidine analgesia affect the incidence of obstetric lacerations at vaginal delivery?

PubMed

Mizrachi, Yossi; Leytes, Sophia; Levy, Michal; Ginath, Shimon; Bar, Jacob; Ezri, Tiberiu; Kovo, Michal

2018-03-01

To study whether meperidine analgesia affects the incidence of obstetric lacerations at normal vaginal deliveries. A retrospective cohort study of all women with term vertex singleton pregnancies, who underwent normal vaginal deliveries, in a single tertiary hospital, between 2011 and 2015, was performed. The incidence of various obstetric lacerations was compared between deliveries with meperidine analgesia and deliveries with no analgesia. Deliveries with epidural analgesia and instrumental deliveries were excluded. An intravenous infusion of 75 mg of meperidine was administered together with 25 mg of promethazine. A multivariate logistic regression analysis was performed to assess the association between meperidine analgesia and obstetric lacerations, after controlling for confounders. Overall, 5227 (91.8%) deliveries with no analgesia and 466 (8.1%) deliveries with meperidine analgesia were included. Meperidine analgesia was associated with a decreased risk of first- and second-degree perineal lacerations (adjusted OR = 0.63, 95% CI = 0.49-0.81), and a decreased risk of any suturing (adjusted OR = 0.73, 95% CI = 0.59-0.91), after controlling for confounders. Meperidine analgesia did not affect the risk of severe perineal lacerations or episiotomies. Meperidine analgesia may have a protective effect against first- and second-degree perineal lacerations.

pH-sensitive Eudragit nanoparticles for mucosal drug delivery.

PubMed

Yoo, Jin-Wook; Giri, Namita; Lee, Chi H

2011-01-17

Drug delivery via vaginal epithelium has suffered from lack of stability due to acidic and enzymatic environments. The biocompatible pH-sensitive nanoparticles composed of Eudragit S-100 (ES) were developed to protect loaded compounds from being degraded under the rigorous vaginal conditions and achieve their therapeutically effective concentrations in the mucosal epithelium. ES nanoparticles containing a model compound (sodium fluorescein (FNa) or nile red (NR)) were prepared by the modified quasi-emulsion solvent diffusion method. Loading efficiencies were found to be 26% and 71% for a hydrophilic and a hydrophobic compound, respectively. Both hydrophilic and hydrophobic model drugs remained stable in nanoparticles at acidic pH, whereas they are quickly released from nanoparticles upon exposure at physiological pH. The confocal study revealed that ES nanoparticles were taken up by vaginal cells, followed by pH-responsive drug release, with no cytotoxic activities. The pH-sensitive nanoparticles would be a promising carrier for the vaginal-specific delivery of various therapeutic drugs including microbicides and peptides/proteins. Published by Elsevier B.V.

Development of amino acid substituted gemini surfactant-based mucoadhesive gene delivery systems for potential use as noninvasive vaginal genetic vaccination.

PubMed

Singh, Jagbir; Michel, Deborah; Getson, Heather M; Chitanda, Jackson M; Verrall, Ronald E; Badea, Ildiko

2015-02-01

Recently, we synthesized amino acid- and peptide-substituted gemini surfactants, 'biolipids' that exhibited high transfection efficiency in vitro. In this study, we developed these plasmid DNA and gemini surfactant lipid particles for noninvasive administration in vaginal cavity. Novel formulations of these gene delivery systems were prepared with poloxamer 407 to induce in situ gelling of the formulation and diethylene glycol monoethyl ether to improve their penetration across mucosal tissue. Poloxamer at 16% w/v concentration in diethylene glycol monoethyl ether aqueous solution produced dispersions that gelled near body temperature and had a high yield value, preventing leakage of the formulation from the vaginal cavity. Intravaginal administration in rabbits showed that the glycyl-lysine-substituted gemini surfactant led to a higher gene expression compared with the parent unsubstituted gemini surfactant. This provides a proof-of-concept that amino acid substituted gemini surfactants can be used as noninvasive mucosal (vaginal) gene delivery systems to treat diseases associated with mucosal epithelia.

Prevalence and predictors of urinary/anal incontinence after vaginal delivery: prospective study of Nigerian women.

PubMed

Obioha, Kingsley Chukwu; Ugwu, Emmanuel Onyebuchi; Obi, Samuel Nnamdi; Dim, Cyril Chukwudi; Oguanuo, Theophilus Chimezie

2015-09-01

Urinary and anal incontinence are major public health problems impacting on the quality of life of affected women, with resultant loss of self-esteem. Despite the anticipated magnitude of this public health problem in sub-Saharan Africa, there is paucity of data on the prevalence of urinary and/or anal incontinence after childbirth in the region. This study determined the prevalence and predictors of urinary and anal incontinence after vaginal delivery among women in Enugu, southeastern Nigeria. This was a longitudinal study of 230 consecutive parturients at the University of Nigeria Teaching Hospital, Enugu, Nigeria. Eligible women were followed up immediately, 6 weeks, and 3 months postpartum to assess the development of urinary and/or anal incontinence using validated questionnaires. Overall, 28 women had urinary incontinence, giving a cumulative prevalence rate of 12.2 %. The cumulative prevalence rate was 13.5 % for anal incontinence and 3 % for combined urinary and anal incontinence. Age, social class, parity, prolonged second stage of labor, and neonatal birth weight were significantly associated with postpartum urinary incontinence (P < 0.05). On the other hand, age, parity, prolonged second stage of labor, episiotomy, and instrumental vaginal delivery were significantly associated with postpartum anal incontinence (P < 0.05). Urinary and anal incontinence are common after vaginal delivery in Enugu, Nigeria. Modification of obstetric care and discouraging preventable predisposing factors for incontinence, such as prolonged second stage of labor and vaginal delivery of macrosomic babies, are measures that may reduce the prevalence of postpartum incontinence in our population.

Obstetric Care and Method of Delivery in Mexico: Results from the 2012 National Health and Nutrition Survey

PubMed Central

Heredia-Pi, Ileana; Servan-Mori, Edson E.; Wirtz, Veronika J.; Avila-Burgos, Leticia; Lozano, Rafael

2014-01-01

Objective To identify the current clinical, socio-demographic and obstetric factors associated with the various types of delivery strategies in Mexico. Materials and Methods This is a cross-sectional study based on the 2012 National Health and Nutrition Survey (ENSANUT) of 6,736 women aged 12 to 49 years. Delivery types discussed in this paper include vaginal delivery, emergency cesarean section and planned cesarean section. Using bivariate analyses, sub-population group differences were identified. Logistic regression models were applied, including both binary and multinomial outcome variables from the survey. The logistic regression results identify those covariates associated with the type of delivery. Results 53.1% of institutional births in the period 2006 through 2012 were vaginal deliveries, 46.9% were either a planned or emergency cesarean sections. The highest rates of this procedure were among women who reported a complication during delivery (OR: 4.21; 95%CI: 3.66–4.84), between the ages of 35 and 49 at the time of their last child birth (OR: 2.54; 95%CI: 2.02–3.20) and women receiving care through private healthcare providers during delivery (OR: 2.36; 95%CI: 1.84–3.03). Conclusions The existence of different socio-demographic and obstetric profiles among women who receive care for vaginal or cesarean delivery, are supported by the findings of the present study. The frequency of vaginal delivery is higher in indigenous women, when the care provider is public and, in women with two or more children at time of the most recent child birth. Planned cesarean deliveries are positively associated with years of schooling, a higher socioeconomic level, and higher age. The occurrence of emergency cesarean sections is elevated in women with a diagnosis of a health issue during pregnancy or delivery, and it is reduced in highly marginalized settings. PMID:25101781

Development and in vivo safety assessment of tenofovir-loaded nanoparticles-in-film as a novel vaginal microbicide delivery system.

PubMed

Machado, Alexandra; Cunha-Reis, Cassilda; Araújo, Francisca; Nunes, Rute; Seabra, Vítor; Ferreira, Domingos; das Neves, José; Sarmento, Bruno

2016-10-15

Topical pre-exposure prophylaxis (PrEP) with antiretroviral drugs holds promise in preventing vaginal transmission of HIV. However, significant biomedical and social issues found in multiple past clinical trials still need to be addressed in order to optimize protection and users' adherence. One approach may be the development of improved microbicide products. A novel delivery platform comprising drug-loaded nanoparticles (NPs) incorporated into a thin polymeric film base (NPs-in-film) was developed in order to allow the vaginal administration of the microbicide drug candidate tenofovir. The system was optimized for relevant physicochemical features and characterized for biological properties, namely cytotoxicity and safety in a mouse model. Tenofovir-loaded poly(lactic-co-glycolic acid) (PLGA)/stearylamine (SA) composite NPs with mean diameter of 127nm were obtained with drug association efficiency above 50%, and further incorporated into an approximately 115μm thick, hydroxypropyl methylcellulose/poly(vinyl alcohol)-based film. The system was shown to possess suitable mechanical properties for vaginal administration and to quickly disintegrate in approximately 9min upon contact with a simulated vaginal fluid (SVF). The original osmolarity and pH of SVF was not affected by the film. Tenofovir was also released in a biphasic fashion (around 30% of the drug in 15min, followed by sustained release up to 24h). The incorporation of NPs further improved the adhesive potential of the film to ex vivo pig vaginal mucosa. Cytotoxicity of NPs and film was significantly increased by the incorporation of SA, but remained at levels considered tolerable for vaginal delivery of tenofovir. Moreover, histological analysis of genital tissues and cytokine/chemokine levels in vaginal lavages upon 14days of daily vaginal administration to mice confirmed that tenofovir-loaded NPs-in-film was safe and did not induce any apparent histological changes or pro-inflammatory response. Overall, obtained data support that the proposed delivery system combining the use of polymeric NPs and a film base may constitute an exciting alternative for the vaginal administration of microbicide drugs in the context of topical PrEP. The development of nanotechnology-based microbicides is a recent but promising research field seeking for new strategies to circumvent HIV sexual transmission. Different reports detail on the multiple potential advantages of using drug nanocarriers for such purpose. However, one important issue being frequently neglected regards the development of vehicles for the administration of microbicide nanosystems. In this study, we propose and detail on the development of a nanoparticle-in-film system for the vaginal delivery of the microbicide drug candidate tenofovir. This is an innovative approach that, to our best knowledge, had never been tested for tenofovir. Results, including those from in vivo testing, sustain that the proposed system is safe and holds potential for further development as a vaginal microbicide product. Copyright © 2016 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Position in the second stage of labour and de novo onset of post-partum urinary incontinence.

PubMed

Serati, Maurizio; Di Dedda, Maria Carmela; Bogani, Giorgio; Sorice, Paola; Cromi, Antonella; Uccella, Stefano; Lapenna, Martina; Soligo, Marco; Ghezzi, Fabio

2016-02-01

The aim of this study was to evaluate the role of the maternal position at the time of delivery on the onset of de novo symptoms of urinary incontinence (UI) in the post-partum period. This prospective study evaluated the data of consecutive women undergoing labour and delivery, between January 2014 and July 2014. We included only women with a singleton pregnancy undergoing vaginal delivery. During the study period, patients chose to deliver in the position that they considered the most comfortable. The onset of UI was evaluated according to the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-sf). Overall, 716 primiparous women were included in the study. Sixty women refused the 12-week post-partum interview (8.4%). Women were divided in two groups: 296 women (45.1%) who chose an upright position during delivery (group 1) and 360 women (54.9%) who chose a supine position (group 2). Group 1 had a significantly lower episiotomy rate, but a higher rate of greater than second degree perineal tears. In group 1 we found a significantly lower rate of de novo UI (40.5% vs 48.9%, p = 0.03) and in particular of stress urinary incontinence. Via multivariate analysis, birth position was the only factor correlating with the occurrence of urinary incontinence in the post-partum period (OR: 1.52; 95%CI: 1.06, 2.18; p = 0.02). Upright positions at delivery are related to a lower episiotomy rate and a higher rate of greater than second degree perineal tears. Supine positions are an independent risk factor for the onset of de novo UI.

Perineal Pain Management with Cryotherapy after Vaginal Delivery: A Randomized Clinical Trial.

PubMed

Morais, Ítalo; Lemos, Andréa; Katz, Leila; Melo, Lorena Fernandes Rosendo de; Maciel, Mariano Maia; Amorim, Melania Maria Ramos de

2016-07-01

Introduction Systematic reviews that evaluate the perineal cryotherapy to reduce pain in the vaginal postpartum are inconclusive. Purpose To evaluate clinical effectiveness of cryotherapy in the management of humanized postpartum perineal pain and vaginal edema. Methods A double-bind randomized controlled clinical trial (UTN number: U1111-1131-8433) was conducted in a hospital in Northeastern, Brazil. Women were included following humanized childbirth. All had vaginal deliveries of a single, full-term pregnancy with cephalic presentation. Exclusion criteria included previous perineal lesion, episiotomy during the current delivery, instrumental delivery, uterine curettage and postpartum hemorrhage. In the experimental group, an ice pack was applied six times on the perineum for 20 minutes, reducing the temperature between 10 and 15 ° C, then 60 minutes without exposure to cold. In the non-cryotherapy, a water bag unable to reduce the temperature to this extent was used, compliance with the same application protocol of the first group. Perineal temperature was monitored at zero, 10 and 20 minutes for application in both groups. Evaluations were made immediately before and after the applications and 24 hours after delivery spontaneous, to determine the association between variables. Results A total of 80 women were included in the study, 40 in each group. There was no significant difference in scores of perineal pain and edema between the groups with or without cryotherapy until 24 hours after childbirth. There was no difference between groups when accomplished repeated measures analysis over the 24 hours after delivery, considering the median perineal pain (p = 0.3) and edema (p = 0.9). Perineal cryotherapy did not influence the amount of analgesics used (p = 0.07) and no adverse effect was registered. Conclusion The use of cryotherapy following normal vaginal delivery within the concept of humanized minimally interventionist childbirth had no effect on perineal pain and edema, since it was already substantially lower, nor the need for pain medicaments. Thieme Publicações Ltda Rio de Janeiro, Brazil.

Titrated oral misoprostol solution for induction of labour: a multi-centre, randomised trial.

PubMed

Hofmeyr, G J; Alfirevic, Z; Matonhodze, B; Brocklehurst, P; Campbell, E; Nikodem, V C

2001-09-01

To determine the effects of titrated oral misoprostol solution, compared with vaginal dinoprostone. Open, randomised clinical trial. Academic hospitals in South Africa and Liverpool, UK. Women undergoing induction of labour after 34 weeks of pregnancy were allocated by randomised, sealed opaque envelopes, to induction of labour with titrated oral misoprostol solution, or two doses of vaginal dinoprostone (2mg) administered six hours apart. Failure to deliver within 24 hours of randomisation was the primary outcome on which the sample size was based. The data were analysed by intention-to-treat. Six hundred and ninety-five women were randomly allocated: 346 to oral misoprostol and 349 to vaginal dinoprostone. There were no significant differences in substantive outcomes. Vaginal delivery within 24 hours was not achieved in 38% of women in the oral misoprostol group and 36% in the vaginal dinoprostone group (RR 1.08; 95% CI 0.89-1.31). The caesarean section rates were 16% and 20%, respectively (RR 0.80; 95% CI 0.58-1.11). Hyperstimulation with fetal heart rate changes occurred in 4% of women in the oral misoprostol group and 3% after vaginal dinoprostone (RR 1.32, 95% CI 0.59-2.98). The response to induction of labour in women with unfavourable cervices was somewhat slower with misoprostol when membranes were intact, and with dinoprostone when membranes were ruptured. There were no differences in neonatal outcome between the two groups. This new approach to oral misoprostol administration was successful in minimising the risk of uterine hyperstimulation, which has been a feature of misoprostol use for induction of labour, at the expense of a somewhat slower response in women with intact membranes and unfavourable cervices. Misoprostol is not registered for use in pregnant women, and further research is needed to confirm optimal and safe dosages.

[Manual rotation of occiput posterior presentation].

PubMed

Le Ray, C; Goffinet, F

2011-10-01

Delivery in occiput posterior position is associated with a higher risk of cesarean section, operative vaginal delivery and severe perineal tears. We report the technic of manual rotation described by Tarnier and Chantreuil and used daily in our maternity center. Only five studies were published on this topic; all of them demonstrate that manual rotation decreases the risk of cesarean section. Moreover, it could decrease the risk of prolonged second stage, chorioamnionitis and third and fourth degree tears in comparison with expectant management. However, manual rotation is associated with a two-fold higher risk of cervical and vaginal lacerations. Manual rotation performed with an adequate technic is an efficient and safe manœuvre to avoid complications associated with occiput posterior vaginal delivery. Copyright © 2011. Published by Elsevier SAS.

Recurrence of obstetric third-degree and fourth-degree anal sphincter injuries.

PubMed

Boggs, Edgar W; Berger, Howard; Urquia, Marcelo; McDermott, Colleen D

2014-12-01

To examine outcomes after primary obstetric anal sphincter injuries in a subsequent pregnancy. This was a retrospective analysis of prospectively collated data from a large perinatal database between 2006 and 2010. Primiparous vaginal deliveries with an obstetric anal sphincter injury were identified and tracked to identify their subsequent delivery characteristics and perineal outcomes. A primary obstetric anal sphincter injury occurred in 5.3% of primiparous vaginal deliveries (9,857/186,239); of those patients, 2,093 had a subsequent delivery, and 91.9% delivered vaginally (1,923/2,093). The recurrent obstetric anal sphincter injury rate was also found to be 5.3% (102/1,923). The adjusted odds ratios (ORs) for primary obstetric anal sphincter injuries were significantly increased in large-for-gestational-age neonates for both third-degree laceration (adjusted OR 2.1, 95% confidence interval [CI] 1.9-2.2) and fourth-degree laceration (adjusted OR 2.7, 95% CI 2.3-3.1) and almost all obstetric interventions studied. The adjusted ORs for recurrent obstetric anal sphincter injuries were significant for large-for-gestational-age (25/102, adjusted OR 2.2, 95% CI 1.3-3.6) and instrumental deliveries (15/102, adjusted OR 2.4, 95% CI 1.2-4.6). In this study population, the incidence of recurrent obstetric anal sphincter injuries was similar to that of primary obstetric anal sphincter injuries, and most patients went on to deliver vaginally for subsequent deliveries. The risk of recurrent obstetric anal sphincter injuries was doubled in those who delivered a large-for-gestational-age neonate and in those who had an instrumental delivery.

Neonatal outcome of very preterm twins: policy of planned vaginal or cesarean delivery.

PubMed

Sentilhes, Loïc; Oppenheimer, Anne; Bouhours, Anne-Charlotte; Normand, Estelle; Haddad, Bassam; Descamps, Philippe; Marpeau, Loïc; Goffinet, François; Kayem, Gilles

2015-07-01

The objective of the study was to compare neonatal mortality and morbidity in very preterm twins with the first twin in cephalic presentation in hospitals with a policy of planned vaginal delivery (PVD) and those with a policy of planned cesarean delivery (PCD). Women with preterm cephalic first twins delivered after preterm labor and/or premature preterm rupture of membranes from 26(0/7) to 31(6/7) weeks of gestation were identified from the databases of 6 perinatal centers and classified as PVD or PCD according to the center's management policy from 1999 to 2010. Severe neonatal morbidity was defined as any of the following: intraventricular hemorrhage grades 3-4, periventricular leukomalacia, necrotizing enterocolitis, bronchopulmonary dysplasia, and hospital death. The independent effect of the planned mode of delivery, defined by the center's management policy, was tested and quantified with a 2-level multivariable logistic regression. The PVD group included 248 women, and the PCD group 63. Maternal characteristics did not differ between the 2 groups. The rate of vaginal delivery was 85.9% (213 of 248) vs 20.6% (13 of 63) (P < .001), and the rate of cesarean delivery for the second twin was 1.6% (4 of 248) vs 4.8% (3 of 63) (P = .13) for PVD and PCD. PVD had no independent effect on either newborn hospital mortality or severe neonatal composite morbidity. A policy of planned vaginal delivery of very preterm twins with the first twin in cephalic presentation does not increase either severe neonatal morbidity or mortality. Copyright © 2015 Elsevier Inc. All rights reserved.

Anal incontinence after two vaginal deliveries without obstetric anal sphincter rupture.

PubMed

Persson, Lisa K G; Sakse, Abelone; Langhoff-Roos, Jens; Jangö, Hanna

2017-06-01

To evaluate prevalence and risk factors for long-term anal incontinence in women with two prior vaginal deliveries without obstetric anal sphincter injury (OASIS) and to assess the impact of anal incontinence-related symptoms on quality of life. This is a nation-wide cross-sectional survey study. One thousand women who had a first vaginal delivery and a subsequent delivery, both without OASIS, between 1997 and 2008 in Denmark were identified in the Danish Medical Birth Registry. Women with more than two deliveries in total till 2012 were excluded at this stage. Of the 1000 women randomly identified, 763 were eligible and received a questionnaire. Maternal and obstetric data were retrieved from the national registry. The response rate was 58.3%. In total, 394 women were included for analysis after reviewing responses according to previously defined exclusion criteria. Median follow-up time was 9.8 years after the first delivery and 6.4 years after the second. The prevalence of flatal incontinence, fecal incontinence and fecal urgency were 11.7, 4.1, and 12.3%, respectively. Overall, 20.1% had any degree of anal incontinence and/or fecal urgency. In 6.3% these symptoms affected their quality of life. No maternal or obstetric factors including episiotomy and vacuum extraction were consistently associated with altered risk of anal incontinence in the multivariable analyses. Anal incontinence and fecal urgency is reported by one fifth of women with two vaginal deliveries without OASIS at long-term follow-up. Episiotomy or vacuum extraction did not alter the risk of long-term anal incontinence.

Dystocia as a cause of untimely cesarean section.

PubMed

Djurić, Janko; Arsenijević, Slobodan; Banković, Dragic; Protrka, Zoran; Sorak, Marija; Dimitrijević, Aleksandra; Tanasković, Irena

2012-07-01

One of the most frequent indications for cesarean section is dystocia. It is impossible to predict, difficult to identify and coincident with the rapid expiry of the expected time, so it is important to point out some mistakes in expecting vaginal delivery. The aim of this study was to examine the frequency and the length of dystocia-related cesarean delivery, as well as the vitality of the newborn immediately after birth. A prospective 3-year study was conducted including a total number of 6470 deliveries regardless of whether they were completed using cesarean section after an unsuccessful attempt of spontaneous vaginal delivery or not. The Apgar score, a proved useful tool for the assessment of the vitality of newborn children in the first minute, was used. On the basis of the established indications, 653 (10.10%) of deliveries were completed using cesarean section. Dystocia was the third most common indication for cesarean section (16.38%). Deliveries in which dystocia was established as a diagnosis lasted much longer (p = 0.030) which resulted in weaker vitality of newborn children (p = 0.000) compared to the deliveries ended by spontaneous vaginal delivery. This study shows that deliveries caused by dystocia last much longer and newborn children are of weaker vitality compared to other deliveries caused not by dystocia. Decisions concerning cesarean section must be made in a timely fashion.

Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term.

PubMed

Kelly, Anthony J; Malik, Sidra; Smith, Lee; Kavanagh, Josephine; Thomas, Jane

2009-10-07

Prostaglandins have been used for induction of labour since the 1960s. Initial work focused on prostaglandin F2a as prostaglandin E2 was considered unsuitable for a number of reasons. With the development of alternative routes of administration, comparisons were made between various formulations of vaginal prostaglandins. To determine the effects of vaginal prostaglandins E2 and F2a for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment or other vaginal prostaglandins (except misoprostol). We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2009) and bibliographies of relevant papers. Clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods. We assessed studies and extracted data independently. Sixty-three (10,441 women) have been included.Vaginal prostaglandin E2 compared with placebo or no treatment reduced the likelihood of vaginal delivery not being achieved within 24 hours (18.1% versus 98.9%, risk ratio (RR) 0.19, 95% confidence interval (CI) 0.14 to 0.25, two trials, 384 women). The risk of the cervix remaining unfavourable or unchanged was reduced (21.6% versus 40.3%, RR 0.46, 95% CI 0.35 to 0.62, five trials, 467 women); and the risk of oxytocin augmentation reduced (35.1% versus 43.8%, RR 0.83, 95% CI 0.73 to 0.94, 12 trials, 1321 women) when PGE2 was compared to placebo. There was no evidence of a difference between caesarean section rates, although the risk of uterine hyperstimulation with fetal heart rate changes was increased (4.4% versus 0.49%, RR 4.14, 95% CI 1.93 to 8.90, 14 trials, 1259 women).PGE2 tablet, gel and pessary appear to be as efficacious as each other and the use of sustained release PGE2 inserts appear to be associated with a reduction in instrumental vaginal delivery rates (9.9 % versus 19.5%, RR 0.51, 95% CI 0.35 to 0.76, NNT 10 (6.7 to 24.0), five trials, 661 women) when compared to vaginal PGE2 gel or tablet. PGE2 increases successful vaginal delivery rates in 24 hours and cervical favourability with no increase in operative delivery rates. Sustained release vaginal PGE2 is superior to vaginal PGE2 gel with respect to some outcomes studied.Further research is needed to assess the best vehicle for delivering vaginal prostaglandins and this should, where possible, include some examination of the cost-analysis.

Characteristics Associated With Severe Perineal and Cervical Lacerations During Vaginal Delivery

PubMed Central

Landy, Helain J.; Laughon, S. Katherine; Bailit, Jennifer; Kominiarek, Michelle A.; Gonzalez-Quintero, Victor Hugo; Ramirez, Mildred; Haberman, Shoshana; Hibbard, Judith; Wilkins, Isabelle; Branch, D. Ware; Burkman, Ronald T.; Gregory, Kimberly; Hoffman, Matthew K.; Learman, Lee A.; Hatjis, Christos; VanVeldhuisen, Paul C.; Reddy, Uma M.; Troendle, James; Sun, Liping; Zhang, Jun

2011-01-01

Objective To characterize potentially modifiable risk factors for third- or fourth-degree perineal lacerations and cervical lacerations in a contemporary U.S. obstetric practice. Methods The Consortium on Safe Labor collected electronic medical records from 19 hospitals within 12 institutions (228,668 deliveries from 2002 to 2008). Information on patient characteristics, prenatal complications, labor and delivery data, and maternal and neonatal outcomes were collected. Only women with successful vaginal deliveries of cephalic singletons at 34 weeks of gestation or later were included; we excluded data from sites lacking information about lacerations at delivery and deliveries complicated by shoulder dystocia; 87,267 and 71,170 women were analyzed for third- or fourth-degree and cervical lacerations, respectively. Multivariable logistic regressions were used to adjust for other factors. Results Third- or fourth-degree lacerations occurred in 2,516 women (2,223 nulliparous [5.8%], 293 [0.6%] multiparous) and cervical lacerations occurred in 536 women (324 nulliparous [1.1%], 212 multiparous [0.5%]). Risks for third or fourth-degree lacerations included nulliparity (7.2-fold risk), being Asian or Pacific Islander, increasing birth weight, operative vaginal delivery, episiotomy, and longer second stage of labor. Increasing body mass index was associated with fewer lacerations. Risk factors for cervical lacerations included young maternal age, vacuum vaginal delivery, and oxytocin use among multiparous women, and cerclage regardless of parity. Conclusion Our large cohort of women with severe obstetric lacerations reflects contemporary obstetric practices. Nulliparity and episiotomy use are important risk factors for third- or fourth-degree lacerations. Cerclage increases the risk for cervical lacerations. Many identified risk factors may not be modifiable. PMID:21343766

Factors associated with successful vaginal birth after cesarean section and outcomes in rural area of Anatolia

PubMed Central

Senturk, Mehmet Baki; Cakmak, Yusuf; Atac, Halit; Budak, Mehmet Sukru

2015-01-01

Successful vaginal birth after cesarean section is more comfortable than repeat emergency or elective cesarean section. Antenatal examinations are important in selection for trial of labor, while birth management can be difficult when the patients present at emergency condition. But there is an increased chance of vaginal birth with advanced cervical dilation. This study attempts to evaluate factors associated with success of vaginal birth after cesarean section and to compare the maternal and perinatal outcomes between vaginal birth after cesarean section and intrapartum cesarean section in patients who were admitted to hospital during the active or second stage of labor. A retrospective evaluation was made from the results of 127 patients. Cesarean section was performed in 57 patients; 70 attempted trial of labor. The factors associated with success of vaginal birth after cesarean section were investigated. Maternal and neonatal outcomes were compared between the groups. Vaginal birth after cesarean section was successful in 55% of cases. Advanced cervical opening, effacement, gravidity, parity, and prior vaginal delivery were factors associated with successful vaginal birth. The vaginal birth group had more complications (P<0.01), but these were minor. The rate of blood transfusion and prevalence of changes in hemoglobin level were similar in both groups (P>0.05). In this study, cervical opening, effacement, gravidity, parity, and prior vaginal delivery were important factors for successful vaginal birth after cesarean section. The patients’ requests influenced outcome. Trial of labor should take into consideration the patient’s preference, together with the proper setting. PMID:26203286

Reducing the cesarean delivery rates for breech presentations: administration of spinal anesthesia facilitates manipulation to cephalic presentation, but is it cost saving?

PubMed Central

2014-01-01

Background External cephalic version (ECV) is infrequently performed and 98% of breech presenting fetuses are delivered surgically. Neuraxial analgesia can increase the success rate of ECV significantly, potentially reducing cesarean delivery rates for breech presentation. The current study aims to determine whether the additional cost to the hospital of spinal anesthesia for ECV is offset by cost savings generated by reduced cesarean delivery. Methods In our tertiary hospital, three variables manpower, disposables, and fixed costs were calculated for ECV, ECV plus anesthetic doses of spinal block, vaginal delivery and cesarean delivery. Total procedure costs were compared for possible delivery pathways. Manpower data were obtained from management payroll, fixed costs by calculating cost/lifetime usage rate and disposables were micro-costed in 2008, expressed in 2013 NIS. Results Cesarean delivery is the most expensive option, 11670.54 NIS and vaginal delivery following successful ECV under spinal block costs 5497.2 NIS. ECV alone costs 960.21 NIS, ECV plus spinal anesthesia costs 1386.97 NIS. The highest individual cost items for vaginal, cesarean delivery and ECV were for manpower. Expensive fixed costs for cesarean delivery included operating room trays and postnatal hospitalization (minimum 3 days). ECV with spinal block is cheaper due to lower expected cesarean delivery rate and its lower associated costs. Conclusions The additional cost of the spinal anesthesia is offset by increased success rates for the ECV procedure resulting in reduction in the cesarean delivery rate. PMID:24564984

Vaginal delivery of breech presentation.

PubMed

Kotaska, Andrew; Menticoglou, Savas; Gagnon, Robert

2009-06-01

To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth. Trial of labour in an appropriate setting or delivery by pre-emptive Caesarean section for women with a singleton breech fetus at term. Reduced perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short- and long-term maternal morbidity and mortality. Medline was searched for randomized trials, prospective cohort studies, and selected retrospective cohort studies comparing planned Caesarean section with a planned trial of labour; selected epidemiological studies comparing delivery by Caesarean section with vaginal breech delivery; and studies comparing long-term outcomes in breech infants born vaginally or by Caesarean section. Additional articles were identified through bibliography tracing up to June 1, 2008. The evidence collected was reviewed by the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the criteria and classifications of the Canadian Task Force on Preventive Health Care. This guideline was compared with the 2006 American College of Obstetrician's Committee Opinion on the mode of term singleton breech delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The Management of Breech Presentation. The document was reviewed by Canadian and International clinicians with particular expertise in breech vaginal delivery. The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS: 1. Vaginal breech birth can be associated with a higher risk of perinatal mortality and short-term neonatal morbidity than elective Caesarean section. (I) 2. Careful case selection and labour management in a modern obstetrical setting may achieve a level of safety similar to elective Caesarean section. (II-1) 3. Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus. (I) 4. With careful case selection and labour management, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. Many recent retrospective and prospective reports of vaginal breech delivery that follow specific protocols have noted excellent neonatal outcomes. (II-1) 5. Long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity. (I) RECOMMENDATIONS: LABOUR SELECTION CRITERIA: 1. For a woman with suspected breech presentation, pre- or early labour ultrasound should be performed to assess type of breech presentation, fetal growth and estimated weight, and attitude of fetal head. If ultrasound is not available, Caesarean section is recommended. (II-1A) 2. Contraindications to labour include a. Cord presentation (II-3A) b. Fetal growth restriction or macrosomia (I-A) c. Any presentation other than a frank or complete breech with a flexed or neutral head attitude (III-B) d. Clinically inadequate maternal pelvis (III-B) e. Fetal anomaly incompatible with vaginal delivery (III-B) 3. Vaginal breech delivery can be offered when the estimated fetal weight is between 2500 g and 4000 g. (II-2B) LABOUR MANAGEMENT: 4. Clinical pelvic examination should be performed to rule out pathological pelvic contraction. Radiologic pelvimetry is not necessary for a safe trial of labour; good progress in labour is the best indicator of adequate fetal-pelvic proportions. (III-B) 5. Continuous electronic fetal heart monitoring is preferable in the first stage and mandatory in the second stage of labour. (I-A) When membranes rupture, immediate vaginal examination is recommended to rule out prolapsed cord. (III-B) 6. In the absence of adequate progress in labour, Caesarean section is advised. (II-1A) 7. Induction of labour is not recommended for breech presentation. (II-3B) Oxytocin augmentation is acceptable in the presence of uterine dystocia. (II-1A) 8. A passive second stage without active pushing may last up to 90 minutes, allowing the breech to descend well into the pelvis. Once active pushing commences, if delivery is not imminent after 60 minutes, Caesarean section is recommended. (I-A) 9. The active second stage of labour should take place in or near an operating room with equipment and personnel available to perform a timely Caesarean section if necessary. (III-A) 10. A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery. (III-A) DELIVERY TECHNIQUE: 11. The health care provider for a planned vaginal breech delivery needs to possess the requisite skills and experience. (II-1A) 12. An experienced obstetrician-gynaecologist comfortable in the performance of vaginal breech delivery should be present at the delivery to supervise other health care providers, including a trainee. (I-A) 13. The requirements for emergency Caesarean section, including availability of the hospital operating room team and the approximate 30-minute timeline to commence a laparotomy, must be in accordance with the recommendations of the SOGC Policy Statement, "Attendance at Labour and Delivery" (CPG No. 89; update in press, 2009). (III-A) 14. The health care provider should have rehearsed a plan of action and should be prepared to act promptly in the rare circumstance of a trapped after-coming head or irreducible nuchal arms: symphysiotomy or emergency abdominal rescue can be life saving. (III-B) 15. Total breech extraction is inappropriate for term singleton breech delivery. (II-2A) 16. Effective maternal pushing efforts are essential to safe delivery and should be encouraged. (II-1A) 17. At the time of delivery of the after-coming head, an assistant should be present to apply suprapubic pressure to favour flexion and engagement of the fetal head. (II-3B) 18. Spontaneous or assisted breech delivery is acceptable. Fetal traction should be avoided, and fetal manipulation must be applied only after spontaneous delivery to the level of the umbilicus. (III-A) 19. Nuchal arms may be reduced by the Løvset or Bickenbach manoeuvres. (III-B) 20. The fetal head may deliver spontaneously, with the assistance of suprapubic pressure, by Mauriceau-Smellie-Veit manoeuvre, or with the assistance of Piper forceps. (III-B) SETTING AND CONSENT: 21. In the absence of a contraindication to vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a trial of labour and elective Caesarean section, and informed consent should be obtained. A woman's choice of delivery mode should be respected. (III-A) 22. The consent discussion and chosen plan should be well documented and communicated to labour-room staff. (III-B) 23. Hospitals offering a trial of labour should have a written protocol for eligibility and intrapartum management. (III-B) 24. Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care. (III-A) 25. The Society of Obstetricians and Gynaecologists of Canada (SOGC), in collaboration with the Association of Professors of Obstetrics and Gynaecology (APOG), The College of Family Physicians of Canada (CFPC), and The Canadian Association of Midwives (CAM) should revise the training requirements at the undergraduate and postgraduate levels. SOGC will continue to promote training of current health care providers through the MOREOB, ALARM (Advances in Labour and Risk Management), and other courses. (III-A) 26. Theoretical and hands-on breech birth training simulation should be part of basic obstetrical skills training programs such as ALARM, ALSO (Advanced Life Support Training in Obstetrics), and MOREOB to prepare health care providers for unexpected vaginal breech births. (III-B).

An inflatable ergonomic 3-chamber fundal pressure belt to assist vaginal delivery.

PubMed

Acanfora, Luisa; Rampon, Michela; Filippeschi, Marco; Marchi, Marco; Montisci, Massimo; Viel, Guido; Cosmi, Erich

2013-01-01

To evaluate whether Baby-guard-a new medical device with an ergonomic 3-chamber inflatable abdominal belt-can reduce complications associated with vaginal delivery. A randomized controlled single-blind prospective study of 80 pregnant women delivering at term was conducted at San Giuseppe Hospital, Empoli, Italy. In the study group (n=40), the abdominal belt was inflated to optimal therapeutic pressures. In the control group (n=40), the abdominal belt was inflated to minimal, non-therapeutic pressures. Factors relating to maternal, fetal, and labor complications during vaginal delivery were evaluated. Compared with the control group, women in the study group experienced a lower incidence of perineal and cervical lacerations (P<0.001); reduced use of the Kristeller maneuver (P<0.001); shorter duration of the second stage of labor (P<0.001); less psychologic and physical fatigue (P<0.001); fewer maternal requests for cesarean delivery during labor (P<0.001); fewer vacuum extractions (P<0.01); and fewer cesarean deliveries (P<0.02). No neonatal intensive care unit admissions were recorded in the study group versus 7 in the control group (P<0.012). Use of the ergonomic 3-chamber inflatable abdominal belt system reduced the incidence of risks associated with vaginal labor. Clinical trials.gov identifier: NCT01566331. Copyright © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Vaginal microbial flora and outcome of pregnancy.

PubMed

Donati, Laura; Di Vico, Augusto; Nucci, Marta; Quagliozzi, Lorena; Spagnuolo, Terryann; Labianca, Antonietta; Bracaglia, Marina; Ianniello, Francesca; Caruso, Alessandro; Paradisi, Giancarlo

2010-04-01

The vaginal microflora of a healthy asymptomatic woman consists of a wide variety of anaerobic and aerobic bacterial genera and species dominated by the facultative, microaerophilic, anaerobic genus Lactobacillus. The activity of Lactobacillus is essential to protect women from genital infections and to maintain the natural healthy balance of the vaginal flora. Increasing evidence associates abnormalities in vaginal flora during pregnancy with preterm labor and delivery with potential neonatal sequelae due to prematurity and poor perinatal outcome. Although this phenomenon is relatively common, even in populations of women at low risk for adverse events, the pathogenetic mechanism that leads to complications in pregnancy is still poorly understood. This review summarizes the current knowledge and uncertainties in defining alterations of vaginal flora in non-pregnant adult women and during pregnancy, and, in particular, investigates the issue of bacterial vaginosis and aerobic vaginitis. This could help specialists to identify women amenable to treatment during pregnancy leading to the possibility to reduce the preterm birth rate, preterm premature rupture of membranes, chorioamnionitis, neonatal, puerperal and maternal-fetal infectious diseases. Vaginal ecosystem study with the detection of pathogens is a key instrument in the prevention of preterm delivery, pPROM, chorioamnionitis, neonatal, puerperal and maternal-fetal infections.

A new reconstructive technique for posterior vaginal wall defects, a case report.

PubMed

Zetlitz, Elisabeth; Manook, Miriam; MacLeod, Alison; Hamilton, Stuart

2013-10-01

Post-partum vaginal laxity is a problem encountered by many women. More uncommon is a resulting vaginal defect. In most cases of laxity, a period of extensive physiotherapy can strengthen the pelvic muscles enough for symptoms to be minimized. However, this is not the case once there is a tissue defect. To present a new reconstructive method for patients with posterior vaginal wall defects. We present a case of a 38-year-old female who, 12 years prior to presentation, had a vaginal delivery. Due to complications during the delivery, she sustained pelvic trauma and developed a posterior vaginal wall defect. She had a sizable soft tissue defect, causing sexual, urinary, and confidence problems. Fat was harvested from the patient's abdomen and injected into the defect after more conservative treatment options were exhausted. The defect was corrected successfully using the minimally invasive Coleman fat grafting technique. This is to our knowledge the first case in the literature where a posterior vaginal defect has been corrected using Coleman fat grafting, and we believe that this treatment method may be of benefit to more patients. © 2013 International Society for Sexual Medicine.

Sulfonate-modified phenylboronic acid-rich nanoparticles as a novel mucoadhesive drug delivery system for vaginal administration of protein therapeutics: improved stability, mucin-dependent release and effective intravaginal placement.

PubMed

Li, ChunYan; Huang, ZhiGang; Liu, ZheShuo; Ci, LiQian; Liu, ZhePeng; Liu, Yu; Yan, XueYing; Lu, WeiYue

Effective interaction between mucoadhesive drug delivery systems and mucin is the basis of effective local placement of drugs to play its therapeutic role after mucosal administration including vaginal use, which especially requires prolonged drug presence for the treatment of gynecological infectious diseases. Our previous report on phenylboronic acid-rich nanoparticles (PBNPs) demonstrated their strong interaction with mucin and mucin-sensitive release profiles of the model protein therapeutics interferon (IFN) in vitro, but their poor stability and obvious tendency to aggregate over time severely limited future application. In this study, sulfonate-modified PBNPs (PBNP-S) were designed as a stable mucoadhesive drug delivery system where the negative charges conferred by sulfonate groups prevented aggregation of nanoparticles and the phenylboronic acid groups ensured effective interaction with mucin over a wide pH range. Results suggested that PBNP-S were of spherical morphology with narrow size distribution (123.5 nm, polydispersity index 0.050), good stability over a wide pH range and 3-month storage and considerable in vitro mucoadhesion capability at vaginal pH as shown by mucin adsorption determination. IFN could be loaded to PBNP-S by physical adsorption with high encapsulation efficiency and released in a mucin-dependent manner in vitro. In vivo near-infrared fluorescent whole animal imaging and quantitative vaginal lavage followed by enzyme-linked immunosorbent assay (ELISA) assay of IFN demonstrated that PBNP-S could stay in the vagina and maintain intravaginal IFN level for much longer time than IFN solution (24 hours vs several hours) without obvious histological irritation to vaginal mucosa after vaginal administration to mice. In summary, good stability, easy loading and controllable release of protein therapeutics, in vitro and in vivo mucoadhesive properties and local safety of PBNP-S suggested it as a promising nanoscale mucoadhesive drug delivery system for vaginal administration of protein therapeutics.

[Anatomy of the levator ani muscle and implications for obstetrics and gynaecology].

PubMed

Nyangoh Timoh, K; Bessede, T; Zaitouna, M; Peschaud, F; Chevallier, J-M; Fauconnier, A; Benoit, G; Moszkowicz, D

2015-01-01

Pelvic floor disorders include urogenital and anorectal prolapse, urinary and faecal incontinence. These diseases affect 25% of patients. Most of time, treatment is primarily surgical with a high post-operative risk of recurrence, especially for pelvic organ prolapse. Vaginal delivery is the major risk factor for pelvic floor disorders through levator ani muscle injury or nerve damage. After vaginal delivery, 20% of patients experiment elevator ani trauma. These injuries are more common in case of instrumental delivery by forceps, prolonged second phase labor, increased neonatal head circumference and associated anal sphincter injuries. Moreover, 25% of patients have temporary perineal neuropathy. Recently, pelvic three-dimensional reconstructions from RMI data allowed a better understanding of detailed levator ani muscle morphology and gave birth to a clear new nomenclature describing this muscle complex to be developed. Radiologic and anatomic studies have allowed exploring levator ani innervation leading to speculate on the muscle and nerve damage mechanisms during delivery. We then reviewed the levator ani muscle anatomy and innervation to better understand pelvic floor dysfunction observed after vaginal delivery. Copyright © 2015. Published by Elsevier SAS.

Role of Lactobacillus Species in the Intermediate Vaginal Flora in Early Pregnancy: A Retrospective Cohort Study

PubMed Central

Farr, Alex; Kiss, Herbert; Hagmann, Michael; Machal, Susanne; Holzer, Iris; Kueronya, Verena; Husslein, Peter Wolf; Petricevic, Ljubomir

2015-01-01

Background Poor obstetrical outcomes are associated with imbalances in the vaginal flora. The present study evaluated the role of vaginal Lactobacillus species in women with intermediate vaginal flora with regard to obstetrical outcomes. Methods We retrospectively analysed data from all women with singleton pregnancies who had undergone routine screening for asymptomatic vaginal infections at our tertiary referral centre between 2005 and 2014. Vaginal smears were Gram-stained and classified according to the Nugent scoring system as normal flora (score 0–3), intermediate vaginal flora (4–6), or bacterial vaginosis (7–10). Only women with intermediate vaginal flora were investigated. Women with a Nugent score of 4 were categorised into those with and without Lactobacilli. Follow-up smears were obtained 4–6 weeks after the initial smears. Descriptive data analysis, the Welch’s t-test, the Fisher’s exact test, and multiple regression analysis with adjustment for confounders were performed. Gestational age at delivery and birth weight were the outcome measures. Results At antenatal screening, 529/8421 women presented with intermediate vaginal flora. Amongst these, 349/529 (66%) had a Nugent score of 4, 94/529 (17.8%) a Nugent score of 5, and 86/529 (16.2%) a Nugent score of 6. Amongst those with a Nugent score of 4, 232/349 (66.5%) women were in the Lactobacilli group and 117/349 (33.5%) in the Non-Lactobacilli group. The preterm delivery rate was significantly lower in the Lactobacilli than in the Non-Lactobacilli group (OR 0.34, CI 0.21–0.55; p<0.001). Mean birth weight was 2979 ± 842 g and 2388 ± 1155 g in the study groups, respectively (MD 564.12, CI 346.23–781.92; p<0.001). On follow-up smears, bacterial vaginosis rates were 9% in the Lactobacilli and 7.8% in the Non-Lactobacilli group. Conclusions The absence of vaginal Lactobacillus species and any bacterial colonisation increases the risks of preterm delivery and low birth weight in women with intermediate vaginal flora in early pregnancy. PMID:26658473

Role of Lactobacillus Species in the Intermediate Vaginal Flora in Early Pregnancy: A Retrospective Cohort Study.

PubMed

Farr, Alex; Kiss, Herbert; Hagmann, Michael; Machal, Susanne; Holzer, Iris; Kueronya, Verena; Husslein, Peter Wolf; Petricevic, Ljubomir

2015-01-01

Poor obstetrical outcomes are associated with imbalances in the vaginal flora. The present study evaluated the role of vaginal Lactobacillus species in women with intermediate vaginal flora with regard to obstetrical outcomes. We retrospectively analysed data from all women with singleton pregnancies who had undergone routine screening for asymptomatic vaginal infections at our tertiary referral centre between 2005 and 2014. Vaginal smears were Gram-stained and classified according to the Nugent scoring system as normal flora (score 0-3), intermediate vaginal flora (4-6), or bacterial vaginosis (7-10). Only women with intermediate vaginal flora were investigated. Women with a Nugent score of 4 were categorised into those with and without Lactobacilli. Follow-up smears were obtained 4-6 weeks after the initial smears. Descriptive data analysis, the Welch's t-test, the Fisher's exact test, and multiple regression analysis with adjustment for confounders were performed. Gestational age at delivery and birth weight were the outcome measures. At antenatal screening, 529/8421 women presented with intermediate vaginal flora. Amongst these, 349/529 (66%) had a Nugent score of 4, 94/529 (17.8%) a Nugent score of 5, and 86/529 (16.2%) a Nugent score of 6. Amongst those with a Nugent score of 4, 232/349 (66.5%) women were in the Lactobacilli group and 117/349 (33.5%) in the Non-Lactobacilli group. The preterm delivery rate was significantly lower in the Lactobacilli than in the Non-Lactobacilli group (OR 0.34, CI 0.21-0.55; p<0.001). Mean birth weight was 2979 ± 842 g and 2388 ± 1155 g in the study groups, respectively (MD 564.12, CI 346.23-781.92; p<0.001). On follow-up smears, bacterial vaginosis rates were 9% in the Lactobacilli and 7.8% in the Non-Lactobacilli group. The absence of vaginal Lactobacillus species and any bacterial colonisation increases the risks of preterm delivery and low birth weight in women with intermediate vaginal flora in early pregnancy.

Comparing provision and appropriateness of health care between immigrants and non-immigrants in Germany using the example of neuraxial anaesthesia during labour: cross-sectional study

PubMed Central

Razum, Oliver; Reiss, Katharina; Breckenkamp, Jürgen; Kaufner, Lutz; Brenne, Silke; Bozorgmehr, Kayvan; Borde, Theda; David, Matthias

2017-01-01

Objective Research on health services for immigrants has mostly been concerned with access barriers but rarely with appropriateness and responsiveness of care. We assessed whether appropriateness and responsiveness of care depend on migration status, using provision of neuraxial anaesthesia (NA) during labour as indicator. In relation to their migration status, we analysed whether (1) women undergoing elective or secondary/urgent secondary caesarean sections (ESCS) appropriately receive NA (instead of general anaesthesia), (2) women delivering vaginally appropriately receive NA and (3) women objecting to NA, for example, for religious reasons, may deliver vaginally without receiving NA (provider responsiveness). Design Cross-sectional study. Setting Three obstetric hospitals in Berlin, Germany. Methods Questionnaire survey covering 6391 women with migration history (first and second generations) and non-immigrant women giving birth; data linkage with routine obstetric data. We assessed the effects of migrant status, German language proficiency, religion and education on the provision of NA (primary outcome) after adjusting for other maternal and obstetric parameters. Results The chance of receiving NA for elective/ESCS was independent of migrant status after controlling for confounding variables (adjusted OR (aOR) 0.93, 95% CI 0.65 to 1.33). In vaginal deliveries, first (but not second) generation women (aOR 0.79, 95% CI 0.65 to 0.95), women with low German language skills (aOR 0.77, 95% CI 0.58 to 0.99) and women with low educational attainment (aOR 0.62, 95% CI 0.47 to 0.82) had lower chances of receiving NA; there was no evidence of overprovision among women with strong affinity to Islam (aOR 0.77, 95% CI 0.63 to 0.94). Conclusions We found evidence for underprovision of care among first-generation immigrants, among women with low German language proficiency and particularly among all women with low educational attainment, irrespective of migration status. There was no evidence for overprovision of care to immigrant women, either inappropriately (general anaesthesia for ESCS) or because of low provider responsiveness (no opt-out for NA in vaginal delivery). PMID:28827247

Progesterone bioavailability with a progesterone-releasing silicone vaginal ring in IVF candidates.

PubMed

Dragonas, C; Maltaris, T; Binder, H; Kat, M; Mueller, A; Cupisti, S; Hoffmann, I; Beckmann, M W; Dittrich, Ralf

2007-06-27

A vaginal ring made of silicone polymers and barium sulfate, and containing 1 g of pure micronized progesterone, was developed for luteal supplementation in women undergoing cycles of in vitro fertilization (IVF). The ring, modeled on the Estring, was designed as a means of providing continuous intravaginal delivery of progesterone. Bioavailability of progesterone in the blood was demonstrated for 24 hours in IVF candidates who had an endogenous progesterone deficiency after treatment with gonadotropin-releasing hormone (GnRH) analogues. After the first 4 h of increasing release of progesterone from the ring (with mean serum levels of 1.39 +/- 0.8 ng/ml after 4 h), only a slight increase in serum progesterone levels (with a mean peak of 1.5 +/- 0.45 ng/ml after 24 h) was observed during the rest of the test period. Gonadotropin levels were not affected after insertion of the ring. The ring was well tolerated by the patients. The maximum serum progesterone level was lower in comparison with other forms of progesterone application, but it should be sufficiently high, due to the uterine first-pass effect. This study demonstrated that progesterone administration through a silicone ring for luteal support is feasible in IVF treatment. As the vaginal ring is very well tolerated by the patients, these findings may encourage the pharmaceutical industry to design an appropriate progesterone ring for luteal support.

Cup detachment during vacuum-assisted vaginal delivery and birth outcome.

PubMed

Krispin, Eyal; Aviram, Amir; Salman, Lina; Chen, Rony; Wiznitzer, Arnon; Gabbay-Benziv, Rinat

2017-11-01

To determine the perinatal outcome associated with cup detachment during vacuum-assisted vaginal delivery (VAVD). A retrospective cohort study of all women attempting VAVD in a tertiary hospital (2012-2014). Singleton-term pregnancies were included. Antepartum fetal death and major fetal structural or chromosomal abnormalities were excluded. Primary outcome was neonatal birth trauma (subgaleal hematoma, subarachnoid hematoma, subdural hematoma, skull fracture, and/or erb's palsy). Secondary outcomes were maternal complications or other neonatal morbidities. Outcomes were compared between women after ≥1 cup detachment (study group) and the rest (control group). Logistic regression analysis was utilized to adjust results to potential confounders. Overall, 1779 women attempted VAVD during study period. Of them, in 146 (8.2%), the cup detached prior to delivery; 130/146 (89%) had a single detachment. After detachment, 4 (2.7%) delivered by cesarean section, 77 (52.7%) delivered after cup reapplication, and 65 (44.6%) delivered spontaneously. Women in the study group were more likely to undergo VAVD due to prolonged second stage, and were characterized by lower rates of metal cup use. Neonates in the detachment group had higher rates of subarachnoid hematoma and composite neonatal birth trauma (2.7 vs. 0.1% and 4.8 vs. 1.8%, respectively, p < 0.05). This remained significant after adjustment to potential confounders (subarachnoid hematoma aOR = 45.44, 95% CI 6.42-321.62 and neonatal birth trauma aOR = 2.62, 95% CI 1.1-6.22, p < 0.05 for all). Other neonatal and maternal morbidities were similar between groups. Cup detachment is associated with a higher rate of adverse neonatal outcome. Cup reapplication should be considered carefully.

Short hospitalization after caesarean delivery: effects on maternal pain and stress at discharge.

PubMed

Zanardo, Vincenzo; Giliberti, Lara; Volpe, Francesca; Simbi, Alphonse; Guerrini, Pietro; Parotto, Matteo; Straface, Gianluca

2018-09-01

To characterize predischarge maternal pain and stress after caesarean delivery and short hospitalization. This is a descriptive study with 60 women in the postoperative period of caesarean section and 60 control women after vaginal delivery. Pain and stress were measured by McGill Pain Questionnaire (MGPQ) and by the Stress Measure (Psychological Stress Measure (PSM)), respectively, at mother-infant dyad discharge, scheduled at 36 hours after delivery. Caesarean section was the delivery modality with the highest MGPQ pain and sensorial, evaluative and mixed pain descriptive categories scores. The pain location involved lower abdomen, with associated localizations at back, breast and shoulders. Conversely, vaginal delivery was the delivery modality with the highest stress scores. This study provides important information on the quality of care implications of early discharge practices in puerperae after caesarean delivery, a critical time characterized by qualitatively and quantitatively high pain and stress.

Association of the Duration of Active Pushing With Obstetric Outcomes.

PubMed

Grobman, William A; Bailit, Jennifer; Lai, Yinglei; Reddy, Uma M; Wapner, Ronald J; Varner, Michael W; Caritis, Steve N; Prasad, Mona; Tita, Alan T N; Saade, George; Sorokin, Yoram; Rouse, Dwight J; Blackwell, Sean C; Tolosa, Jorge E

2016-04-01

To estimate the associations between the duration of active pushing during the second stage of labor and maternal and neonatal outcomes. We performed an observational study in which data were obtained by trained abstractors from maternal and neonatal charts of deliveries at 25 hospitals over a 3-year period. In this secondary analysis, women with no prior cesarean delivery who had a term, singleton, cephalic gestation and reached complete dilation were analyzed. The duration of pushing, defined as the time from initiation of pushing to either vaginal delivery or the decision to proceed with a cesarean delivery, was determined. The primary maternal outcome was cesarean delivery and the primary neonatal outcome was a composite that included: mechanical ventilation, proven sepsis, brachial plexus palsy, clavicular fracture, skull fracture, other fracture, seizures, hypoxic-ischemic encephalopathy, or death. Nulliparous and parous women were analyzed separately in univariable and then multivariable analyses. A total of 53,285 women were analyzed. In both nulliparous and parous women, longer duration of pushing was associated with increased odds of both cesarean delivery and the neonatal adverse outcome composite. Nevertheless, even after 4 hours of pushing, approximately 78% of nulliparous women who continued with active pushing had a vaginal delivery and more than 97% did not have the composite adverse neonatal outcome. Similarly, after more than 2 hours of pushing, approximately 82% of parous women who continued active pushing delivered vaginally and more than 97% did not have the adverse neonatal outcome. A longer duration of pushing is associated with an increased relative risk, but small absolute difference in risk, of neonatal complications. Approximately 78% of nulliparous women delivered vaginally even after 4 hours of pushing.

Effect of maternal death reviews and training on maternal mortality among cesarean delivery: post-hoc analysis of a cluster-randomized controlled trial.

PubMed

Zongo, Augustin; Dumont, Alexandre; Fournier, Pierre; Traore, Mamadou; Kouanda, Séni; Sondo, Blaise

2015-02-01

To explore the differential effect of a multifaceted intervention on hospital-based maternal mortality between patients with cesarean and vaginal delivery in low-resource settings. We reanalyzed the data from a major cluster-randomized controlled trial, QUARITE (Quality of care, Risk management and technology in obstetrics). These subgroup analyses were not pre-specified and were treated as exploratory. The intervention consisted of an initial interactive workshop and quarterly educational clinically oriented and evidence-based outreach visits focused on maternal death reviews (MDR) and best practices implementation. The trial originally recruited 191,167 patients who delivered in each of the 46 participating hospitals in Mali and Senegal, between 2007 and 2011. The primary endpoint was hospital-based maternal mortality. Subgroup-specific Odds Ratios (ORs) of maternal mortality were computed and tested for differential intervention effect using generalized linear mixed model between two subgroups (cesarean: 40,975; and vaginal delivery: 150,192). The test for homogeneity of intervention effects on hospital-based maternal mortality among the two delivery mode subgroups was statistically significant (p-value: 0.0201). Compared to the control, the adjusted OR of maternal mortality was 0.71 (95% CI: 0.58-0.82, p=0.0034) among women with cesarean delivery. The intervention had no significant effect among women with vaginal delivery (adjusted OR 0.87, 95% CI 0.69-1.11, p=0.6213). This differential effect was particularly marked for district hospitals. Maternal deaths reviews and on-site training on emergency obstetric care may be more effective in reducing maternal mortality among high-risk women who need a cesarean section than among low-risk women with vaginal delivery. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Mode of delivery after one caesarean section: audit of current practice in a health region.

PubMed Central

Paterson, C M; Saunders, N J

1991-01-01

OBJECTIVE--To audit the subsequent obstetric management of women who had had one previous baby delivered by caesarean section. DESIGN--Retrospective analysis of a regional obstetric database. SETTING--Data derived from the 17 obstetric units in North West Thames region. SUBJECTS--1059 women who delivered a singleton fetus of at least 37 weeks' gestation with a cephalic presentation in 1988 who had a history of one previous caesarean section and no other deliveries. MAIN OUTCOME MEASURES--Mode of delivery, postnatal morbidity, and duration of hospital stay. RESULTS--395 (37%) women were delivered by elective repeat caesarean section and 664 (63%) were allowed a trial of labour. Maternal height and birth weight of the previous infant differed significantly between those who were and those who were not allowed to labour. 471 (71%) of those allowed to labour achieved a vaginal delivery. In individual units there was no significant correlation between the proportion of patients allowed to labour and the rate of the successful trial of labour. There was a trend towards greater success rates in units that allowed a longer duration of labour (p less than 0.05) and units with greater use of oxytocin for augmentation of labour (not significant). Both elective and intrapartum caesarean section was associated with a significantly higher rate of postnatal infection than vaginal delivery (14.7% and 16.0% v 3.4%). CONCLUSIONS--In patients with a history of caesarean section there is no evidence that the likelihood of successful vaginal delivery after trial of labour is modified by the proportion of such patients allowed the option of attempted vaginal delivery. Until selection criteria of adequate prognostic value can be identified a more liberal approach to allowing women a trial of labour seems justified. PMID:1932972

Double balloon catheter for induction of labour in Chinese women with previous caesarean section: one-year experience and literature review.

PubMed

Cheuk, Queenie K Y; Lo, T K; Lee, C P; Yeung, Anita P C

2015-06-01

To evaluate the efficacy and safety of double balloon catheter for induction of labour in Chinese women with one previous caesarean section and unfavourable cervix at term. Retrospective cohort study. A regional hospital in Hong Kong. Women with previous caesarean delivery requiring induction of labour at term and with an unfavourable cervix from May 2013 to April 2014. Primary outcome was to assess rate of successful vaginal delivery (spontaneous or instrument-assisted) using double balloon catheter. Secondary outcomes were double balloon catheter induction-to-delivery and removal-to-delivery interval; cervical score improvement; oxytocin augmentation; maternal or fetal complications during cervical ripening, intrapartum and postpartum period; and risk factors associated with unsuccessful induction. All 24 Chinese women tolerated double balloon catheter well. After double balloon catheter expulsion or removal, the cervix successfully ripened in 18 (75%) cases. The improvement in Bishop score 3 (interquartile range, 2-4) was statistically significant (P<0.001). Overall, 18 (75%) cases were delivered vaginally. The median insertion-to-delivery and removal-to-delivery intervals were 19 (interquartile range, 13.4-23.0) hours and 6.9 (interquartile range, 4.1-10.8) hours, respectively. Compared with cases without, the interval to delivery was statistically significantly shorter in those with spontaneous balloon expulsion or spontaneous membrane rupture during ripening (7.8 vs 3.0 hours; P=0.025). There were no major maternal or neonatal complications. The only factor significantly associated with failed vaginal birth after caesarean was previous caesarean section for failure to progress (P<0.001). This is the first study using double balloon catheter for induction of labour in Asian Chinese women with previous caesarean section. Using double balloon catheter, we achieved a vaginal birth after caesarean rate of 75% without major complications.

Acute common peroneal neuropathy due to hand positioning in normal labor and delivery.

PubMed

Radawski, Melissa M; Strakowski, Jeffrey A; Johnson, Ernest W

2011-08-01

Foot drop has been described as an infrequent complication from common peroneal nerve injury related to external compression and forceful knee flexion while pushing during vaginal delivery. Past recommendations include placing the hands at the posterior thighs rather than the legs to avoid this complication. A 32-year-old woman developed unilateral foot drop after vaginal delivery. Electromyography was diagnostic for an acute compression neuropathy of the common peroneal nerve above the knee. The patient's likely mechanism of injury occurred during delivery from external compression by the patient's dominant hand to the distal posterior thigh while under epidural anesthesia. Labor and delivery teams should be aware that nerve injury is also possible at the distal thigh with excessive external pressure.

Engineering a degradable polyurethane intravaginal ring for sustained delivery of dapivirine.

PubMed

Kaur, Manpreet; Gupta, Kavita M; Poursaid, Azadeh E; Karra, Prasoona; Mahalingam, Alamelu; Aliyar, Hyder A; Kiser, Patrick F

2011-06-01

We describe the engineering of a degradable intravaginal ring (IVR) for the delivery of the potent HIV-1 reverse transcriptase inhibitor dapivirine. The degradable polymer used in fabricating the device incorporated poly(caprolactone) ester blocks in a poly(tetramethylene ether) glycol ABA type polyurethane backbone. The polymer was designed to maintain its structure for 1 month during usage and then degrade in the environment post-disposal. In vitro release of dapivirine showed zero-order kinetics for up to 1 month and significant levels of drug release into engineered vaginal tissue. The mechanical properties of the degradable IVR were comparable to those of a widely used contraceptive intravaginal ring upon exposure to simulated vaginal conditions. Incubation under simulated vaginal conditions for a month caused minimal degradation with minimal effect on the mechanical properties of the ring and polymer. The cytotoxicity evaluation of the drug-loaded IVRs against Vk2/E6E7 human vaginal epithelial cells, Lactobacillus jensenii, and engineered vaginal tissue constructs showed the degradable polyurethane to be non-toxic. In vitro evaluation of inflammatory potential monitored through the levels of inflammatory cytokines IL-8, IL-1α, IL-6, IL-1β, and MIP-3α when engineered EpiVaginal™ tissue was incubated with the polyurethanes suggested that the degradable polyurethane was comparable to commercial medical grade polyurethane. These results are encouraging for further development of this degradable IVR for topical vaginal delivery of microbicides.

Exploring Women's Preferences for the Mode of Delivery in Twin Gestations: Results of the Twin Birth Study.

PubMed

Murray-Davis, Beth; McVittie, Jennifer; Barrett, Jon F; Hutton, Eileen K

2016-12-01

The Twin Birth Study, an international, multi-center randomized controlled trial was conducted to compare the risks of planned cesarean with planned vaginal delivery for twin pregnancies. The aim of this component of the trial was to understand participants' perspectives of study participation and preferences for the mode of delivery. A mixed-methods questionnaire was distributed to study participants 3 months after giving birth. The questionnaire contained Likert scales and open-ended questions about the experience of being enrolled in a clinical trial and of childbirth, including the mode of delivery. Quantitative data were analyzed using SAS to generate descriptive statistics. Qualitative data were analyzed to identify categories and themes. Ninety-one percent of trial participants completed the questionnaire. Across all groups, the majority of women would participate in a study like this one again if given the opportunity. Main benefits of participating were as follows: benefits to one and one's babies, altruism, and receiving quality care. Randomization for the mode of delivery was challenging for women because of the desire to be involved in decision-making. Findings related to childbirth experience and the mode of delivery demonstrated a preference for vaginal birth across all groups. Those who had a vaginal birth were more satisfied with their birth experience. This study provides evidence to inform practitioners about what women who have twin pregnancies like or dislike about birth and their desire for involvement in decision-making. Vaginal birth was preferred across all study groups and was associated with greater satisfaction with childbirth experience. © 2016 Wiley Periodicals, Inc.

Exploring full cervical dilatation caesarean sections-A retrospective cohort study.

PubMed

Corry, Edward M A; Ramphul, Meenakshi; Rowan, Ann M; Segurado, Ricardo; Mahony, Rhona M; Keane, Declan P

2018-05-01

The rate of caesarean sections at full cervical dilatation with their high risk of morbidity continues to rise mirroring the overall increase in caesarean section rates internationally. The objectives of this study were to determine the rate of full dilatation caesarean section in a tertiary referral unit and evaluate key labour, maternal and fetal factors potentially linked to those deliveries. We also assessed maternal and fetal morbidity at full dilatation sections. Where possible, these were compared with successful operative vaginal deliveries carried out in theatre to determine key differences. Retrospective cohort study. We reviewed the rate of full dilatation caesarean section over a 10-year period. We analysed deliveries (caesarean sections or operative vaginal deliveries) in single cephalic pregnancies ≥34 weeks with contemporaneously collected data from our unit's electronic database for 2015. The rate of full dilatation caesarean section increased by over a third in the ten-year period (56/6947 (0.80%) vs 92/7378 (1.24%), p = 0.01). Of 84 full dilatation caesarean sections who met the inclusion criteria, 63 (75%) were nulliparous and the mean maternal age was 33 (±5) years. Oxytocin was used in the second stage in less than half of second stage caesarean sections (22 out of a recorded 57, 38.6%). There were more fetal head malposition (occipito-posterior, or occipito-transverse) at full dilatation caesarean section compared to successful operative vaginal deliveries (41/46 (89.1%) vs 2/21 (9.5), p < 0.001). The rate of significant postpartum haemorrhage (defined as estimated blood loss ≥1000 ml) was similar in both full dilatation caesarean section and operative vaginal deliveries. There was no difference in the mean birthweight at full dilatation caesarean sections compared to operative vaginal delivery (3.88 kg (2.80-5.33 kg) vs 3.48 kg (1.53-4.40 kg)). There was no difference in neonatal morbidity. Fetal head malposition is associated with a higher risk of full dilatation caesarean section. Interestingly, maternal and fetal morbidity were similar between full dilatation caesarean sections and anticipated difficult operative vaginal deliveries carried out in theatre. The management of labour in terms of the decision to use oxytocin judiciously in hope of correcting inefficient uterine contractions and continuous labour ward training, particularly the diagnosis of malposition and its correction may be beneficial in reducing the rate of full dilation caesarean sections. Copyright © 2018 Elsevier B.V. All rights reserved.

Association between vaginal birth after cesarean delivery and primary cesarean delivery rates.

PubMed

Rosenstein, Melissa G; Kuppermann, Miriam; Gregorich, Steven E; Cottrell, Erika K; Caughey, Aaron B; Cheng, Yvonne W

2013-11-01

To estimate the association between vaginal birth after cesarean delivery (VBAC) rates and primary cesarean delivery rates in California hospitals. Hospital VBAC rates were calculated using birth certificate and discharge data from 2009, and hospitals were categorized by quartile of VBAC rate. Multivariable logistic regression analysis was performed to estimate the odds of cesarean delivery among low-risk nulliparous women with singleton pregnancies at term in vertex presentation (nulliparous term singleton vertex) by hospital VBAC quartile while controlling for many patient-level and hospital-level confounders. There were 468,789 term singleton births in California in 2009 at 255 hospitals, 125,471 of which were low-risk nulliparous term singleton vertex. Vaginal birth after cesarean delivery rates varied between hospitals, with a range of 0-44.6%. Rates of cesarean delivery among low-risk nulliparous term singleton vertex women declined significantly with increasing VBAC rate. When adjusted for maternal and hospital characteristics, low-risk nulliparous term singleton vertex women who gave birth in hospitals in the highest VBAC quartile had an odds ratio of 0.55 (95% confidence interval 0.46-0.66) of cesarean delivery compared with women at hospitals with the lowest VBAC rates. Each percentage point increase in a hospital's VBAC rate was associated with a 0.65% decrease in the low-risk nulliparous term singleton vertex cesarean delivery rate. Hospitals with higher rates of VBAC have lower rates of primary cesarean delivery among low-risk nulliparous women with singleton pregnancies at term in vertex presentation. II.

First trimester vaginal bleeding and adverse pregnancy outcomes among Chinese women: from a large cohort study in China.

PubMed

Sun, Lu; Tao, Fangbiao; Hao, Jiahu; Su, Puyu; Liu, Fang; Xu, Rong

2012-08-01

To examine the effect of first trimester vaginal bleeding on adverse pregnancy outcomes including preterm delivery, low birth weight and small for gestational age. This is a prospective population-based cohort study. A questionnaire survey was conducted on 4342 singleton pregnancies by trained doctors. Binary logistic regression was used to estimate risk ratios (RRs) and 95% confidence intervals (95% CI). Vaginal bleeding occurred among 1050 pregnant women, the incidence of vaginal bleeding was 24.2%, 37.4% of whom didn't see a doctor, 62.6% of whom saw a doctor for vaginal bleeding. Binary logistic regression demonstrated that bleeding with seeing a doctor was significantly associated with preterm birth (RR 1.84, 95% CI 1.25-2.69) and bleeding without seeing a doctor was related to increased of low birth weight (RR 2.52, 95% CI 1.34-4.75) and was 1.97-fold increased of small for gestational age (RR 1.97, 95% CI 1.19-3.25). These results suggest that first trimester vaginal bleeding is an increased risk of low birth weight, preterm delivery and small for gestational age. Find ways to reduce the risk of vaginal bleeding and lower vaginal bleeding rate may be helpful to reduce the incidence of preterm birth, low birth weight and small for gestational age.

[Risk factors of teenage pregnancies, deliveries and post-partum in the department of Loiret].

PubMed

Alouini, S; Randriambololona, D; Randriamboavonjy, R

2015-05-01

To evaluate the obstetric outcome of teenage pregnancies compared to adult women in the department of Loiret. A retrospective study of adolescents (10-19 years) delivered after 22 weeks compared to adult women aged 20-35 years (controls) from the first January to the 31 December 2012 in a maternity level 3. The two groups were compared by the Chi(2) test or the exact test of Fisher. A P-value < 0.05 was considered significant. Adolescent had less prenatal consultations than controls (4 versus 7). They used more tobacco during pregnancy than adult controls. Urinary infections and preterm threat and births were more frequent in the adolescent group compared to the controls (P=0.04 and 0.018). However, the gestational diabetes was less frequent in the adolescent group versus controls (P=0.0005, OR: 0.16 [IC95%: 0.03-0.54]). The adolescent group represented 2.38 of total deliveries. The rate of vaginal deliveries and caesarean section was similar in the two groups. Vaginal tears were significantly more frequent among adolescents than controls (P=0.0019). The adolescents were more likely to preterm delivery and to have urinary infections than the adult women (controls). They are less likely to have gestational diabetes than older women. The rates of vaginal deliveries are comparable; however, the adolescents are more likely to experience vaginal tears than controls. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Self-emulsifying drug delivery systems: Design of a novel vaginal delivery system for curcumin.

PubMed

Köllner, S; Nardin, I; Markt, R; Griesser, J; Prüfert, F; Bernkop-Schnürch, A

2017-06-01

The aim of this study was to develop a vaginal self-emulsifying delivery system for curcumin being capable of spreading, of permeating the mucus gel layer and of protecting the drug being incorporated in oily nanodroplets towards mucus interactions and immobilization. The emulsifying properties of curcumin loaded SEDDS containing 30% Cremophor RH40, 20% Capmul PG-8, 30% Captex 300, 10% DMSO and 10% tetraglycol (SEDD formulation A) as well as 25% PEG 200, 35% Cremophor RH40, 20% Captex 355, 10% Caprylic acid and 10% Tween 80 (SEDD formulation B) after diluting 1+2 with artificial vaginal fluid were characterized regarding droplet size and zeta potential. Collagen swelling test was used to examine the irritation potential of SEDDS. Additionally to mucus binding studies, permeation studies in the mucus were performed. Furthermore, spreading potential of the novel developed formulations was compared with a commercial available o/w cream (non-ionic hydrophilic cream) on vaginal mucosa. SEDDS displayed a mean droplet size between 38 and 141nm and a zeta potential of -0.3 to -1.6mV. The collagen swelling test indicated no significant irritation potential of both formulations over 24h. An immediate interaction of unformulated curcumin with the mucus was determined, whereas both SEDDS facilitated drug permeation through the mucus layer. Formulation B showed a 2.2-fold improved transport ratio of curcumin compared to SEDD formulation A. In comparison to the vaginal cream, SEDD formulation A and B were able to spread over the vaginal mucosa and cover the tissue to a 17.8- and 14.8-fold higher extent, respectively. According to these results, SEDDS seems to be a promising tool for vaginal application. Copyright © 2017 Elsevier B.V. All rights reserved.

Transient swelling, spreading, and drug delivery by a dissolved anti-HIV microbicide-bearing film

NASA Astrophysics Data System (ADS)

Tasoglu, Savas; Rohan, Lisa C.; Katz, David F.; Szeri, Andrew J.

2013-03-01

There is a widespread agreement that more effective drug delivery vehicles with more alternatives, as well as better active pharmaceutical ingredients (APIs), must be developed to improve the efficacy of microbicide products. For instance, in tropical regions, films are more appropriate than gels due to better stability of drugs at extremes of moisture and temperature. Here, we apply fundamental fluid mechanical and physicochemical transport theory to help better understand how successful microbicide API delivery depends upon properties of a film and the human reproductive tract environment. Several critical components of successful drug delivery are addressed. Among these are: elastohydrodynamic flow of a dissolved non-Newtonian film; mass transfer due to inhomogeneous dilution of the film by vaginal fluid contacting it along a moving boundary (the locally deforming vaginal epithelial surface); and drug absorption by the epithelium. Local rheological properties of the film are dependent on local volume fraction of the vaginal fluid. We evaluated this experimentally, delineating the way that constitutive parameters of a shear-thinning dissolved film are modified by dilution. To develop the mathematical model, we integrate the Reynolds lubrication equation with a mass conservation equation to model diluting fluid movement across the moving vaginal epithelial surface and into the film. This is a complex physicochemical phenomenon that is not well understood. We explore time- and space-varying boundary flux model based upon osmotic gradients. Results show that the model produces fluxes that are comparable to experimental data. Further experimental characterization of the vaginal wall is required for a more precise set of parameters and a more sophisticated theoretical treatment of epithelium.

Human Milk Bacterial and Glycosylation Patterns Differ by Delivery Mode.

PubMed

Hoashi, Marina; Meche, Lawrence; Mahal, Lara K; Bakacs, Elizabeth; Nardella, Deanna; Naftolin, Frederick; Bar-Yam, Naomi; Dominguez-Bello, Maria G

2016-07-01

Mammals have evolved to nourish their offspring exclusively with maternal milk for around half of the lactation period, a crucial developmental window. In view of oral-breast contact during lactation and the differences in oral microbiota between cesarean section (C-section) and vaginally delivered infants, we expected differences in milk composition by delivery mode. We performed a cross-sectional study of banked human milk and found changes related to time since delivery in bacterial abundance and glycosylation patterns only in milk from women who delivered vaginally. The results warrant further research into the effects of delivery mode on milk microbes, milk glycosylation, and postpartum infant development. © The Author(s) 2015.

Developing a Questionnaire for Iranian Women's Attitude on Medical Ethics in Vaginal Childbirth.

PubMed

Mirzaee Rabor, Firoozeh; Taghipour, Ali; Mirzaee, Moghaddameh; Mirzaii Najmabadi, Khadigeh; Fazilat Pour, Masoud; Fattahi Masoum, Seyed Hosein

2015-12-01

Vaginal delivery is one of the challenging issues in medical ethics. It is important to use an appropriate instrument to assess medical ethics attitudes in normal delivery, but the lack of tool for this purpose is clear. The aim of this study was to develop and validate a questionnaire for the assessment of women's attitude on medical ethics application in normal vaginal delivery. This methodological study was carried out in Iran in 2013 - 2014. Medical ethics attitude in vaginal delivery questionnaire (MEAVDQ) was developed using the findings of a qualitative data obtained from a grounded theory research conducted on 20 women who had vaginal childbirth, in the first phase. Then, the validation criteria of this tool were tested by content and face validity in the second phase. Exploratory factor analysis was used for construct validity and reliability was also tested by Cronbach's alpha coefficient in the third phase of this study. SPSS version 13 was used in this study. The sample size for construct validity was 250 females who had normal vaginal childbirth. In the first phase of this study (tool development), by the use of four obtained categories and nine subcategories from grounded theory and literature review, three parts (98-items) of this tool were obtained (A, B and J). Part A explained the first principle of medical ethics, part B pointed to the second and third principles of medical ethics, and part J explained the fourth principle of medical ethics. After evaluating and confirming its face and content validity, 75 items remained in the questionnaire. In construct validity, by the employment of exploratory factor analysis, in parts A, B and J, 3, 7 and 3 factors were formed, respectively; and 62.8%, 64% and 51% of the total variances were explained by the obtained factors in parts A, B and J, respectively. The names of these factors in the three parts were achieved by consideration of the loading factor and medical ethics principles. The subscales of MEAVDQ showed significant reliability. In parts A, B and J, Cronbach's alpha coefficients were 0.76, 0.72 and 0.68, respectively and for the total questionnaire, it was 0.72. The results of the test-retest were satisfactory for all the items (ICC = 0.60 - 0.95). The present study showed that the 59-item MEAVDQ was a valid and reliable questionnaire for the assessment of women's attitudes toward medical ethics application in vaginal childbirth. This tool might assist specialists in making a judgment and plan appropriate for women in vaginal delivery management.

Sphincter tears in primiparous women: Is age a factor?

PubMed Central

BOWLING, C. Bryce; WHEELER, Thomas L.; GERTEN, Kimberly A.; CHAPMAN, Victoria R.; BURGIO, Kathryn L.; RICHTER, Holly E.

2011-01-01

Introduction and Hypothesis Anal sphincter tears during vaginal delivery may result in serious sequelae. We examined whether younger primiparous patients were at increased risk for sphincter tears during vaginal delivery. Methods Data from an obstetric automated record were analyzed. Primiparous women delivering term infants (n = 5,937) were included to test for an association between age and sphincter tear rates. Three age groups were considered: young adolescents (≤16 years), older adolescents (17-20 years) and adults (≥21 years). Results No significant difference was found in tear rates among age cohorts (9.2%, 8.0%, and 9.6% respectively; p = 0.12). Logistic regression modeling revealed that young adolescents were not more likely to have sphincter tears compared to older cohorts. Conclusions Younger adolescents may not be at increased risk of anal sphincter tears. Decisions regarding interventions to decrease sphincter tears during vaginal delivery should not be made on the basis of maternal age alone. PMID:18985267

[Incidence of fetal macrosomia: maternal and fetal morbidity].

PubMed

Rodríguez-Rojas, R R; Cantú-Esquivel, M G; Benavides-de la Garza, L; Benavides-de Anda, L

1996-06-01

The macrosomia is an obstetric eventuality associated to high maternal-fetal morbidity-mortality. This assay was planned in order to know the incidence of macrosomia in our institution, the relation between vaginal and abdominal deliveries and the fetal-maternal morbidity we reviewed 3590 records and we found 5.6% incidence of macrosomia in the global obstetric population. There was 58% of vaginal deliveries, 68% of the newborn were male. The main complications were in the C. sections, 2 laceration of the hysterectomy, and 2 peroperative atonias. In the vaginal deliveries, the lacerations of III and IV grade were 9 of each grade. The main fetal complications were 5 slight to severe asphyxia and 4 shoulder dystocias. This assay concludes that the macrosomia in our service is similar to the already published ones, a 42% were C. section and the maternal-fetal morbidity was low.

VAGINAL BIRTH AFTER A PREVIOUS CAESAREAN SECTION: CURRENT TRENDS AND OUTLOOK IN GHANA.

PubMed

Seffah, J D; Adu-Bonsaffoh, K

2014-01-01

The optimal mode of subsequent delivery of women with prior caesarean birth remains a subject of intense research and debate in contemporary obstetric practice especially in low resource settings like West Africa where there are obvious systemic and management-related challenges associated with trial of scar. However, there is evidence that vaginal birth after caesarean section (VBAC) is safe in appropriately selected women in addition to adequate intrapartum monitoring and ready access to theatre when emergency CS is indicated. The primary objective of the study was to determine the current trends and performance of VBAC in Ghana after decades of practice of trial of labour after caesarean section (TOLAC) in the mist of inherent challenges in deciding the optimal mode of childbirth for women with a previous caesarean birth. The secondary objective was to relate evidence based practice of TOLAC to obstetric practice in low resource settings like Ghana and provide recommendations for improving maternal and newborn health among women with prior caesarean birth. This was a retrospective study of the records of patients who had had a prior caesarean delivery and who then proceeded to deliver the next babies at the Korle Bu Teaching Hospital (KBTH) between Jan 2010 and Dec 2014. The data on demography, antenatal care, labour and delivery and outcomes were collected from the Labour and Recovery wards and the Biostatistics unit of the Maternity unit of the Hospital. Excluded were women with a previous CS who had multiple pregnancies and those with incomplete notes as well as those whose delivery plans were not predetermined antenatally.. The data were analyzed using SPSS version 20. There were 53,581 deliveries during the study period. Vaginal delivery was obtained in 31,870 (59.5%) pregnancies and 21,711(40.5%) had CS. Also, 6261 (11.7%) had had a prior CS and 2472 (39.5%) of these were selected for TOLAC while 2119 (33.8) were scheduled for planned repeat CS. There was an inverse trend between the annual caesarean sections rates and the proportion of women with one previous CS scheduled for TOLAC. There was a statistically significant difference between women who had successful or failed VBAC regarding maternal age, parity, number of ANC visits, gestational age at delivery, birth weight, Apgar score at 1 min and Apgar score at 5 min. Birth weights of less than 1.5kg, and 3.5Kg or greater were associated significantly with higher incidence failed TOLAC and emergency repeat CS. However, birth weights ranging from 2.0 to 3.49kg were associated with significantly lower incidence of failed TOLAC and emergency repeat CS. Birth weight of 2.5-2.99kg was associated with the lowest incidence of failed TOLAC and repeat CS. . There is a significantly high vaginal birth after caesarian section (VBAC) success rate among carefully selected women undergoing trial of scar in Ghana although a decreasing trend towards trial of labor after caesarian section (TOLAC) and a rising CS rate were determined. TOLAC remains a viable option for child birth in low resource settings like West Africa even though there are specific clinical and management related challenges to overcome. Adequate patient education and counselling in addition to appropriate patient selection for TOLAC remains the cornerstone to achieving high VBAC success rate with minimal adverse outcomes in such settings.

Postpartum Sterilization

MedlinePlus

... a few hours or days following delivery. For women who have had a cesarean delivery, it is done right after the baby is born. How is postpartum sterilization performed? For women who have had a vaginal delivery, a small ...

Complications of Delivery Among Mothers with Spina Bifida.

PubMed

Shepard, Courtney L; Yan, Phyllis L; Kielb, Stephanie J; Wittmann, Daniela A; Quint, Elisabeth H; Kraft, Kate H; Hollingsworth, John M

2018-06-13

To determine rates and types of peripartum morbidity among delivering women with spina bifida (SB) compared to those without SB. The rates of pregnancy and delivery among women with SB have been significantly increasing. Current knowledge of peripartum outcomes for these women is limited. Using 2004-2013 National Inpatient Sample data, we identified all hospitalizations for delivery, distinguishing between women with and without SB. Using a code-based algorithm, we determined whether a complication occurred during the hospitalization. We then fit a series of multivariable logistic models to examine for associations between a complication occurrence during vaginal or cesarean delivery and a woman's SB status. We identified 38,319,814 weighted admissions for delivery, 9,516 of which were made by women with SB. Women with SB had a significantly higher rate of cesarean delivery than women without this diagnosis (53% v 32%, p<0.001). The 46.7% of women with SB who delivered vaginally did not have significantly increased odds of a complication associated with their delivery compared to women without SB [odds ratio (OR) 1.15, 95% confidence interval (CI) 0.99 to 1.34, p=0.066]. However, women with SB who underwent a cesarean delivery did have higher odds of morbidity compared to those without (OR 1.49, 95% CI 1.25 to 1.78, p<0.001). Common complications included preterm delivery, urinary tract infection, hematologic event, and blood transfusion. Compared to women without SB, those with SB deliver more frequently by cesarean section and have higher odds of morbidity associated with cesarean delivery, but not vaginal delivery. Copyright © 2018. Published by Elsevier Inc.

Pelvic floor dysfunction in the immediate puerperium, and 1 month and 3 months after vaginal or cesarean delivery.

PubMed

Colla, Cássia; L Paiva, Luciana; Ferla, Lia; B Trento, Maria J; M P de Vargas, Isadora; A Dos Santos, Bianca; Ferreira, Charles F; L Ramos, José G

2018-06-07

To identify and assess postpartum pelvic floor dysfunction (PFD) between vaginal delivery, elective cesarean delivery (ECD), and intrapartum cesarean delivery (ICD). The present prospective observational study included women aged at least 18 years with no history of pelvic surgery or lower urinary tract malformation, and who had not undergone pelvic floor muscle (PFM) training in the preceding 12 months, who underwent delivery at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil between August 1, 2016, and May 31, 2017. Participants were assessed at 48 hours (phase 1), 1 month (phase 2), and 3 months (phase 3) after delivery. Assessments included the International Consultation on Incontinence Questionnaire, Short Form (ICIQ-SF); the Jorge-Wexner anal incontinence scale; a self-rated visual analog scale for pelvic pain; the pelvic organ prolapse quantification (POP-Q) system; and a PFM perineometer. A total of 227 women were assessed in phase 1 (141 vaginal deliveries; 28 ICDs; and 58 ECDs), 79 in phase 2, and 41 in phase 3. The ICIQ-SF, Jorge-Wexner scale, visual analog scale, and perineometer measurements did not identify significant differences in relation to the type of delivery (P>0.05). The type of delivery was not associated with differences in the short-term development of postpartum PFD. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Demonstration of vaginal colonization with GusA-expressing Lactobacillus jensenii following oral delivery in rhesus macaques

PubMed Central

Lagenaur, Laurel A; Lee, Peter P; Hamer, Dean H; Sanders-Beer, Brigitte E

2012-01-01

The vaginal microbiome, which harbors beneficial Lactobacillus strains, is believed to be a major host defense mechanism for preventing infections of the urogenital tract. It has been suggested that the gastrointestinal tract serves as a reservoir for lactobacilli that colonize the vagina. Using rhesus macaques, we examined whether oral delivery of human vaginal Lactobacillus jensenii-1153-1646, a GusA-producing strain, would result in colonization of the rectum and the vagina. Lactobacilli were identified from the vagina tracts of three macaques on the basis of β-glucuronidase enzyme production, 16S rRNA gene sequence and DNA homology using a repetitive sequence-based polymerase chain reaction. PMID:21907793

Association of Mycoplasma hominis and Ureaplasma urealyticum with some indicators of nonspecific vaginitis.

PubMed

Cedillo-Ramírez, L; Gil, C; Zago, I; Yáñez, A; Giono, S

2000-01-01

The purpose of this study was to determine the isolation rates of Mycoplasma hominis and Ureaplasma urealyticum from three populations of women and also to relate the presence of these microorganisms with some indicators of nonspecific vaginitis. Three hundred vaginal swabs were taken from delivery, pregnant and control (not pregnant) women. Cultures were done in E broth supplemented with arginine or urea. M. hominis was isolated in 5% at delivery, 12% from pregnant and 5% from control women and U. urealyticum was isolated in 21%, 31% and 28% respectively. There was statistical difference in the isolation rate of M. hominis in pregnant women respect to the other groups. Both microorganisms were more frequently isolated in women with acid vaginal pH, amine-like odor in KOH test, clue cells and leucorrhea. M. hominis was isolated in 17% and U. urealyticum in 52% from women with nonspecific vaginitis. M. hominis was isolated in 2% and U. urealyticum in 13% from women without nonspecific vaginitis. Although the presence of clue cells and amine-like odor in KOH test have relationship with Gardnerella vaginalis, these tests could also suggest the presence of these mycoplasmas.

Obesity May Be Protective against Severe Perineal Lacerations

PubMed Central

Garretto, Diana; Lin, Brian B.; Syn, Helen L.; Judge, Nancy; Beckerman, Karen; Atallah, Fouad; Friedman, Arnold; Brodman, Michael; Bernstein, Peter S.

2016-01-01

Objective. To determine if there is an association between BMI and 3rd- or 4th-degree perineal lacerations in normal spontaneous and operative vaginal deliveries. Study Design. We performed a retrospective case control study using a large obstetric quality improvement database over a six-year period. Cases were identified as singleton gestations with third- and fourth-degree lacerations. Controls were obtained randomly from the database of patients without third- or fourth-degree lacerations in a 1 : 1 ratio. Univariate and multivariate logistic regression analyses were performed. Results. Of 32,607 deliveries, 22,011 (67.5%) charts with BMI documented were identified. Third- or fourth-degree lacerations occurred in 2.74% (n = 605) of patients. 37% (n = 223) were identified in operative vaginal deliveries. In the univariate analysis, obesity, older maternal age, non-Asian race, and birth weight <4000 g were all protective against 3rd- and 4th-degree lacerations. After controlling for age, race, mode of vaginal delivery, and birth weight, obesity remained significant. Conclusion. Being obese may protect against third- and fourth-degree lacerations independent of parity, race, birth weight, and mode of delivery. PMID:27274869

Respiratory morbidity in twins by birth order, gestational age and mode of delivery.

PubMed

Bricelj, Katja; Tul, Natasa; Lasic, Mateja; Bregar, Andreja Trojner; Verdenik, Ivan; Lucovnik, Miha; Blickstein, Isaac

2016-10-01

To evaluate the relationship between respiratory morbidity in twins by gestational age, birth order and mode of delivery. All twin deliveries at <37 weeks, registered in a national database, in the period 2003-2012 were classified into four gestational age groups: 33-36, 30-32, 28-29, and <28 weeks. Outcome variables included transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS) and need for assisted ventilation. A total of 1836 twins were born vaginally, and 2142 twins were born by cesarean delivery, for a grand total of 3978 twins. TTN did not appear to be related to birth order and to the mode of delivery. In contrast, RDS was more frequent among the second born twins in the vaginal birth groups born at 30-36 weeks [odds ratio (OR) 2.5, 95% confidence interval (CI) 1.2-5.1 and OR 2.0, 95% CI 1.2-3.5 for 33-36 weeks and 30-32 weeks, respectively], whereas this trend was seen in the cesarean birth groups born earlier (OR 3.8, 95% CI 1.1-13.0 for 28-29 weeks). Cesarean delivery significantly increased the frequency of RDS in twin A as well as in twin B compared with vaginal birth, but only at gestational ages <30 weeks. Mode of delivery and birth order have a gestational age dependent effect on the incidence of RDS.

General or Spinal Anaesthetic for Vaginal Surgery in Pelvic Floor Disorders (GOSSIP): a feasibility randomised controlled trial.

PubMed

Purwar, B; Ismail, K M; Turner, N; Farrell, A; Verzune, M; Annappa, M; Smith, I; El-Gizawy, Zeiad; Cooper, J C

2015-08-01

Spinal anaesthesia (SA) and general anaesthesia (GA) are widely used techniques for vaginal surgery for pelvic floor disorders with inconclusive evidence of the superiority of either. We conducted a randomised controlled trial (RCT) to assess the feasibility of a full scale RCT aiming to examine the effect of anaesthetic mode for vaginal surgery on operative, patient reported and length of hospital stay (LOHS) outcomes. Patients undergoing vaginal surgery, recruited through a urogynaecology service in a University teaching hospital, were randomised to receive either GA or SA. Patients were followed up for 12 weeks postoperatively. Pain was measured on a visual analogue scale; nausea was assessed with a four-point verbal rating scale. Patient's subjective perception of treatment outcome, quality of life (QoL) and functional outcomes were assessed using the International Consultation on Incontinence Modular Questionnaire (ICIQ) on vaginal symptoms and the SF-36 questionnaire. Sixty women were randomised, 29 to GA and 31 to SA. The groups were similar in terms of age and type of vaginal surgery performed. No statistically significant differences were noted between the groups with regard to pain, nausea, quality of life (QoL), functional outcomes as well as length of stay in the postoperative recovery room, use of analgesia postoperatively and LOHS. This study has demonstrated that a full RCT is feasible and should focus on the length of hospital stay in a subgroup of patients undergoing vaginal surgery where SA may help to facilitate enhanced recovery or day surgery.

Clinical use of vaginal or rectally applied microbicides in patients suffering from HIV/AIDS.

PubMed

Gupta, Satish Kumar; Nutan

2013-10-22

Microbicides, primarily used as topical pre-exposure prophylaxis, have been proposed to prevent sexual transmission of HIV. This review covers the trends and challenges in the development of safe and effective microbicides to prevent sexual transmission of HIV Initial phases of microbicide development used such surfactants as nonoxynol-9 (N-9), C13G, and sodium lauryl sulfate, aiming to inactivate the virus. Clinical trials of microbicides based on N-9 and C31G failed to inhibit sexual transmission of HIV. On the contrary, N-9 enhanced susceptibility to sexual transmission of HIV-1. Subsequently, microbicides based on polyanions and a variety of other compounds that inhibit the binding, fusion, or entry of virus to the host cells were evaluated for their efficacy in different clinical setups. Most of these trials failed to show either safety or efficacy for prevention of HIV transmission. The next phase of microbicide development involved antiretroviral drugs. Microbicide in the form of 1% tenofovir vaginal gel when tested in a Phase IIb trial (CAPRISA 004) in a coitally dependent manner revealed that tenofovir gel users were 39% less likely to become HIV-infected compared to placebo control. However, in another trial (VOICE MTN 003), tenofovir gel used once daily in a coitally independent mode failed to show any efficacy to prevent HIV infection. Tenofovir gel is currently in a Phase III safety and efficacy trial in South Africa (FACTS 001) employing a coitally dependent dosing regimen. Further, long-acting microbicide-delivery systems (vaginal ring) for slow release of such antiretroviral drugs as dapivirine are also undergoing clinical trials. Discovering new markers as correlates of protective efficacy, novel long-acting delivery systems with improved adherence in the use of microbicides, discovering new compounds effective against a broad spectrum of HIV strains, developing multipurpose technologies incorporating additional features of efficacy against other sexually transmitted infections, and contraception will help in moving the field of microbicide development forward.

Clinical use of vaginal or rectally applied microbicides in patients suffering from HIV/AIDS

PubMed Central

Gupta, Satish Kumar; Nutan

2013-01-01

Microbicides, primarily used as topical pre-exposure prophylaxis, have been proposed to prevent sexual transmission of HIV. This review covers the trends and challenges in the development of safe and effective microbicides to prevent sexual transmission of HIV Initial phases of microbicide development used such surfactants as nonoxynol-9 (N-9), C13G, and sodium lauryl sulfate, aiming to inactivate the virus. Clinical trials of microbicides based on N-9 and C31G failed to inhibit sexual transmission of HIV. On the contrary, N-9 enhanced susceptibility to sexual transmission of HIV-1. Subsequently, microbicides based on polyanions and a variety of other compounds that inhibit the binding, fusion, or entry of virus to the host cells were evaluated for their efficacy in different clinical setups. Most of these trials failed to show either safety or efficacy for prevention of HIV transmission. The next phase of microbicide development involved antiretroviral drugs. Microbicide in the form of 1% tenofovir vaginal gel when tested in a Phase IIb trial (CAPRISA 004) in a coitally dependent manner revealed that tenofovir gel users were 39% less likely to become HIV-infected compared to placebo control. However, in another trial (VOICE MTN 003), tenofovir gel used once daily in a coitally independent mode failed to show any efficacy to prevent HIV infection. Tenofovir gel is currently in a Phase III safety and efficacy trial in South Africa (FACTS 001) employing a coitally dependent dosing regimen. Further, long-acting microbicide-delivery systems (vaginal ring) for slow release of such antiretroviral drugs as dapivirine are also undergoing clinical trials. Discovering new markers as correlates of protective efficacy, novel long-acting delivery systems with improved adherence in the use of microbicides, discovering new compounds effective against a broad spectrum of HIV strains, developing multipurpose technologies incorporating additional features of efficacy against other sexually transmitted infections, and contraception will help in moving the field of microbicide development forward. PMID:24174883

Mother-to-Infant Transmission of Intestinal Bifidobacterial Strains Has an Impact on the Early Development of Vaginally Delivered Infant's Microbiota

PubMed Central

Makino, Hiroshi; Kushiro, Akira; Ishikawa, Eiji; Kubota, Hiroyuki; Gawad, Agata; Sakai, Takafumi; Oishi, Kenji; Martin, Rocio; Ben-Amor, Kaouther; Knol, Jan; Tanaka, Ryuichiro

2013-01-01

Objectives Bifidobacterium species are one of the major components of the infant's intestine microbiota. Colonization with bifidobacteria in early infancy is suggested to be important for health in later life. However, information remains limited regarding the source of these microbes. Here, we investigated whether specific strains of bifidobacteria in the maternal intestinal flora are transmitted to their infant's intestine. Materials and Methods Fecal samples were collected from healthy 17 mother and infant pairs (Vaginal delivery: 12; Cesarean section delivery: 5). Mother's feces were collected twice before delivery. Infant's feces were collected at 0 (meconium), 3, 7, 30, 90 days after birth. Bifidobacteria isolated from feces were genotyped by multilocus sequencing typing, and the transitions of bifidobacteria counts in infant's feces were analyzed by quantitative real-time PCR. Results Stains belonging to Bifidobacterium adolescentis, Bifidobacterium bifidum, Bifidobacterium catenulatum, Bifidobacterium longum subsp. longum, and Bifidobacterium pseudocatenulatum, were identified to be monophyletic between mother's and infant's intestine. Eleven out of 12 vaginal delivered infants carried at least one monophyletic strain. The bifidobacterial counts of the species to which the monophyletic strains belong, increased predominantly in the infant's intestine within 3 days after birth. Among infants delivered by C-section, monophyletic strains were not observed. Moreover, the bifidobacterial counts were significantly lower than the vaginal delivered infants until 7 days of age. Conclusions Among infants born vaginally, several Bifidobacterium strains transmit from the mother and colonize the infant's intestine shortly after birth. Our data suggest that the mother's intestine is an important source for the vaginal delivered infant's intestinal microbiota. PMID:24244304

DEFENSE HEALTH CARE: Access to Care for Beneficiaries Who Have Not Enrolled in TRICARE’s Managed Care Option

DTIC Science & Technology

2006-12-01

Higher than Medicare Reimbursement Rates CPT codea Procedure or service performed Ratio of TRICARE to Medicare reimbursement 20250 Biopsy ...59350 Hysterorrhaphy of ruptured uterus 1.205 59409 Vaginal delivery only (with or without episiotomy and/or forceps ) 1.184 59410 Vaginal delivery only...with or without episiotomy and/or forceps ); including postpartum car 1.156 59412 External cephalic version, with or without tocolysis 1.139 59414

Association of the Duration of Active Pushing With Obstetric Outcomes

PubMed Central

Grobman, William A.; Bailit, Jennifer; Lai, Yinglei; Reddy, Uma M.; Wapner, Ronald J.; Varner, Michael W.; Caritis, Steve N.; Prasad, Mona; Tita, Alan T.N.; Saade, George; Sorokin, Yoram; Rouse, Dwight J.; Blackwell, Sean C.; Tolosa, Jorge E.

2016-01-01

Objective To estimate the associations between the duration of active pushing during the second stage of labor and maternal and neonatal outcomes. Methods We performed an observational study in which data were obtained by trained abstractors from maternal and neonatal charts of deliveries at 25 hospitals over a 3-year period. In this secondary analysis, women with no prior cesarean delivery who had a term, singleton, cephalic gestation and reached complete dilation were analyzed. The duration of pushing, defined as the time from initiation of pushing to either vaginal delivery or the decision to proceed with a cesarean, was determined. The primary maternal outcome was cesarean delivery and the primary neonatal outcome was a composite that included: mechanical ventilation, proven sepsis, brachial plexus palsy, clavicular fracture, skull fracture, other fracture, seizures, hypoxic ischemic encephalopathy, or death. Nulliparous and parous women were analyzed separately in univariable and then multivariable analyses. Results Fifty three thousand two hundred eighty five women were analyzed. In both nulliparous and parous women, longer duration of pushing was associated with increased odds of both cesarean delivery and the neonatal adverse outcome composite. Nevertheless, even after 4 hours of pushing, approximately 78% of nulliparous women who continued with active pushing had a vaginal delivery and over 97% did not have the composite adverse neonatal outcome. Similarly, after more than 2 hours of pushing, approximately 82% of parous women who continued active pushing delivered vaginally and over 97% did not have the adverse neonatal outcome. Conclusion A longer duration of pushing is associated with an increased relative risk, but small absolute difference in risk, of neonatal complications. Approximately 78% of nulliparous women delivered vaginally even after 4 hours of pushing. PMID:26959213

Analgesia/anesthesia for external cephalic version.

PubMed

Weiniger, Carolyn F

2013-06-01

Professional society guidelines recommend that women with breech presentation be delivered surgically due to a higher incidence of fetal risks compared with vaginal delivery. An alternative is attempted external cephalic version, which if successful, enables attempted vaginal delivery. Attitudes towards external cephalic version (ECV) will be considered in this review, along with pain relief methods and their impact on ECV success rates. Articles suggest that ECV is infrequently offered, due to both physician and patient factors. Success of ECV is higher in multiparous women, complete breech, posterior placenta, or smaller fetus. Preterm ECV performance does not increase vaginal delivery rates. Neuraxial techniques (spinal or epidural) significantly increase ECV success rates, as do moxibustion and hypnosis. Four reviews summarized studies considering ECV and neuraxial techniques. These reviews suggest that neuraxial techniques using high (surgical) doses of local anesthetic are efficacious compared with control groups not using anesthesia, whereas techniques using low-doses are not. Low-dose versus high-dose neuraxial analgesia/anesthesia has not been directly compared in a single study. Based on currently available data, the rate of cephalic presentation is not increased using neuraxial techniques, but vaginal delivery rates are higher. ECV appears to be a low-risk procedure. The logistics of routine ECV and provision of optimal neuraxial techniques for successful ECV require additional research. Safety aspects of neuraxial anesthesia for ECV require further investigation.

Birth mode-dependent association between pre-pregnancy maternal weight status and the neonatal intestinal microbiome.

PubMed

Mueller, Noel T; Shin, Hakdong; Pizoni, Aline; Werlang, Isabel C; Matte, Ursula; Goldani, Marcelo Z; Goldani, Helena A S; Dominguez-Bello, Maria Gloria

2016-04-01

The intestinal microbiome is a unique ecosystem that influences metabolism in humans. Experimental evidence indicates that intestinal microbiota can transfer an obese phenotype from humans to mice. Since mothers transmit intestinal microbiota to their offspring during labor, we hypothesized that among vaginal deliveries, maternal body mass index is associated with neonatal gut microbiota composition. We report the association of maternal pre-pregnancy body mass index on stool microbiota from 74 neonates, 18 born vaginally (5 to overweight or obese mothers) and 56 by elective C-section (26 to overweight or obese mothers). Compared to neonates delivered vaginally to normal weight mothers, neonates born to overweight or obese mothers had a distinct gut microbiota community structure (weighted UniFrac distance PERMANOVA, p < 0.001), enriched in Bacteroides and depleted in Enterococcus, Acinetobacter, Pseudomonas, and Hydrogenophilus. We show that these microbial signatures are predicted to result in functional differences in metabolic signaling and energy regulation. In contrast, among elective Cesarean deliveries, maternal body mass index was not associated with neonatal gut microbiota community structure (weighted UniFrac distance PERMANOVA, p = 0.628). Our findings indicate that excess maternal pre-pregnancy weight is associated with differences in neonatal acquisition of microbiota during vaginal delivery, but not Cesarean delivery. These differences may translate to altered maintenance of metabolic health in the offspring.

Birth mode-dependent association between pre-pregnancy maternal weight status and the neonatal intestinal microbiome

PubMed Central

Mueller, Noel T.; Shin, Hakdong; Pizoni, Aline; Werlang, Isabel C.; Matte, Ursula; Goldani, Marcelo Z.; Goldani, Helena A. S.; Dominguez-Bello, Maria Gloria

2016-01-01

The intestinal microbiome is a unique ecosystem that influences metabolism in humans. Experimental evidence indicates that intestinal microbiota can transfer an obese phenotype from humans to mice. Since mothers transmit intestinal microbiota to their offspring during labor, we hypothesized that among vaginal deliveries, maternal body mass index is associated with neonatal gut microbiota composition. We report the association of maternal pre-pregnancy body mass index on stool microbiota from 74 neonates, 18 born vaginally (5 to overweight or obese mothers) and 56 by elective C-section (26 to overweight or obese mothers). Compared to neonates delivered vaginally to normal weight mothers, neonates born to overweight or obese mothers had a distinct gut microbiota community structure (weighted UniFrac distance PERMANOVA, p < 0.001), enriched in Bacteroides and depleted in Enterococcus, Acinetobacter, Pseudomonas, and Hydrogenophilus. We show that these microbial signatures are predicted to result in functional differences in metabolic signaling and energy regulation. In contrast, among elective Cesarean deliveries, maternal body mass index was not associated with neonatal gut microbiota community structure (weighted UniFrac distance PERMANOVA, p = 0.628). Our findings indicate that excess maternal pre-pregnancy weight is associated with differences in neonatal acquisition of microbiota during vaginal delivery, but not Cesarean delivery. These differences may translate to altered maintenance of metabolic health in the offspring. PMID:27033998

Risk of retained placenta in women previously delivered by caesarean section: a population-based cohort study.

PubMed

Belachew, J; Cnattingius, S; Mulic-Lutvica, A; Eurenius, K; Axelsson, O; Wikström, A K

2014-01-01

To evaluate whether women with a caesarean section at their first delivery have an increased risk of retained placenta at their second delivery. Population-based cohort study. Sweden. All women with their first and second singleton deliveries in Sweden during the years 1994-2006 (n = 258,608). Women with caesarean section or placental abruption in their second pregnancy were not included in the study population. The risk of retained placenta at second delivery was estimated for women with a first delivery by caesarean section (n = 19,458), using women with a first vaginal delivery as reference (n = 239,150). Risks were calculated as odds ratios by unconditional logistic regression analysis with 95% confidence intervals (95%) after adjustments for maternal, delivery, and infant characteristics. Retained placenta with normal (≤1000 ml) and heavy (>1000 ml) bleeding. The overall rate of retained placenta was 2.07%. In women with a previous caesarean section and in women with previous vaginal delivery, the corresponding rates were 3.44% and 1.96%, respectively. Compared with women with a previous vaginal delivery, women with a previous caesarean section had an increased risk of retained placenta (adjusted OR 1.45; 95% CI 1.32-1.59), and the association was more pronounced for retained placenta with heavy bleeding (adjusted OR 1.61; 95% CI 1.44-1.79). Our report shows an increased risk for retained placenta in women previously delivered by caesarean section, a finding that should be considered in discussions of mode of delivery. © 2013 Royal College of Obstetricians and Gynaecologists.

Route of delivery and neonatal birth trauma.

PubMed

Moczygemba, Charmaine K; Paramsothy, Pangaja; Meikle, Susan; Kourtis, Athena P; Barfield, Wanda D; Kuklina, Elena; Posner, Samuel F; Whiteman, Maura K; Jamieson, Denise J

2010-04-01

We sought to examine rates of birth trauma in 2 groupings (all International Classification of Diseases, Ninth Revision codes for birth trauma, and as defined by the Agency for Healthcare Research and Quality Patient Safety Indicator [PSI]) among infants born by vaginal and cesarean delivery. Data on singleton infants were obtained from the 2004-2005 Healthcare Cost and Utilization Project Nationwide Inpatient Sample. The rates of Agency for Healthcare Research and Quality PSI and all birth trauma were 2.45 and 25.85 per 1000 births, respectively. Compared with vaginal, cesarean delivery was associated with increased odds of PSI birth trauma (odds ratio [OR], 1.71), primarily due to an increased risk for "other specified birth trauma" (OR, 2.61). Conversely, cesarean delivery was associated with decreased odds of all birth trauma (OR, 0.55), due to decreased odds of clavicle fractures (OR, 0.07), brachial plexus (OR, 0.10), and scalp injuries (OR, 0.55). Infants delivered by cesarean are at risk for different types of birth trauma from infants delivered vaginally. Copyright 2010 Mosby, Inc. All rights reserved.

Perinatal outcome and long-term follow-up of extremely low birth weight infants depending on the mode of delivery.

PubMed

Minguez-Milio, José Angel; Alcázar, Juan Luis; Aubá, María; Ruiz-Zambrana, Alvaro; Minguez, José

2011-10-01

To assess the effect of the mode of delivery (vaginal or cesarean section) on survival, morbidity, and long-term psychomotor development of extremely low birth weight (ELBW) infants. A longitudinal observational study including 138 ELBW infants (73 born by c-section and 65 vaginally) was conducted. We analyzed the survival and short-term morbidity. We also studied the long-term neurocognitive and motor development using the McCarthy Scales of Children's Abilities (MSCA). Mortality was significantly higher in newborns delivered vaginally (49.3%) than those delivered by c-section (23.1%). Newborns delivered vaginally had a higher incidence of retinopathy and peri-intraventricular hemorrhage (P-IVH). Children who died had lower gestational age at birth and lower birth weight. After multivariate analysis only birth weight, gestational age at birth and P-IVH were independently associated to mortality. Regarding the long-term evaluation (MSCA), we observed that children born by c-section had lower incidence of abnormal results. The mode of delivery does not affect survival. Cesarean section provides lower morbidity and better prognosis for neurodevelopment long-term outcome in ELBW infants.

Increased risk of mother-to-infant transmission of hepatitis C virus by intrapartum infantile exposure to maternal blood.

PubMed

Steininger, Christoph; Kundi, Michael; Jatzko, Gerlinde; Kiss, Herbert; Lischka, Andreas; Holzmann, Heidemarie

2003-02-01

Virological and clinical data from 73 hepatitis C virus (HCV)-infected pregnant women who gave birth to 75 children were merged retrospectively, by logistic regression analysis, to investigate risk factors for vertical transmission of HCV. Eighty-two percent of the HCV-infected mothers were HCV-RNA-positive during pregnancy, and 10% were coinfected with human immunodeficiency virus (HIV). Nine children were HCV infected, 1 was HIV infected, but none was HIV-HCV coinfected. Among vaginal deliveries, the mean HCV load of mothers who transmitted HCV to their infants was higher than that of those who did not (8.1 x 10(5) vs. 1.4 x 10(4) copies/mL; P=.056). A reduction in umbilical cord-blood pH (relative risk, 3.9; P=.04) or the occurrence of perineal or vaginal laceration (relative risk, 6.4; P=.028) during vaginal delivery significantly increased the risk of vertical HCV transmission. In conclusion, high maternal viremia, infantile hypoxia, and intrapartum exposure to virus-contaminated maternal blood increased the risk of HCV transmission during vaginal deliveries. Consequently, cesarean section may reduce the risk of vertical HCV transmission in selected cases.

Committee Opinion no. 513: vaginal placement of synthetic mesh for pelvic organ prolapse.

PubMed

2011-12-01

Since 2004, use of synthetic mesh has increased in vaginal surgery for the treatment of pelvic organ prolapse. However, concerns exist about the safety and efficacy of transvaginally placed mesh. Based on the currently available limited data, although many patients undergoing mesh-augmented vaginal repairs heal well without problems, there seems to be a small but significant group of patients who experience permanent and life-altering sequelae, including pain and dyspareunia, from the use of vaginal mesh. The American College of Obstetricians and Gynecologists and the American Urogynecologic Society provide background information on the use of vaginally placed mesh for the treatment of pelvic organ prolapse and offer recommendations for practice.

Vaginal placement of synthetic mesh for pelvic organ prolapse.

PubMed

2012-01-01

Since 2004, use of synthetic mesh has increased in vaginal surgery for the treatment of pelvic organ prolapse. However, concerns exist about the safety and efficacy of transvaginally placed mesh. Based on the currently available limited data, although many patients undergoing mesh-augmented vaginal repairs heal well without problems, there seems to be a small but significant group of patients who experience permanent and life-altering sequelae, including pain and dyspareunia, from the use of vaginal mesh. The American College of Obstetricians and Gynecologists and the American Urogynecologic Society provide background information on the use of vaginally placed mesh for the treatment of pelvic organ prolapse and offer recommendations for practice.

Does vacuum delivery carry a higher risk of shoulder dystocia? Review and meta-analysis of the literature.

PubMed

Dall'Asta, Andrea; Ghi, Tullio; Pedrazzi, Giuseppe; Frusca, Tiziana

2016-09-01

Vacuum extractor has been increasingly used over the last decades and is acknowledged as a risk factor for shoulder dystocia (SD). In this meta-analysis we assess the actual risk of SD following a vacuum delivery compared to spontaneous vaginal delivery (SVD) and forceps. Systematic literature search (English literature only) on MEDLINE, EMBASE, ScienceDirect, the Cochrane library and ClinicalTrials.gov conducted up to May 2015. Key search terms included: Operative/Vacuum/Forceps delivery [Mesh] and shoulder dystocia and subheadings. 2 stage-process study selection. We included only studies where data concerning the occurrence of SD following operative vaginal delivery were reported as adjusted odds ratio (AOR) and no significant difference in confounding factors for SD was recorded. Included trials clustered according to the delivery mode (1) vacuum vs. SVD, (2) forceps vs. vacuum. Methodological quality of each study evaluated with the Newcastle-Ottawa System (NOS). 87 potentially relevant papers. After applying inclusion and exclusion criteria only 7 were selected for the meta-analysis. Vacuum delivery appeared associated with a higher risk of SD than SVD in both fixed and random model (OR 2.87 and 2.98 respectively). No difference in the rate of SD was found between vacuum and forceps (p>0.05). Vacuum extractor carries an increased risk of SD compared with spontaneous vaginal delivery whereas the occurrence of SD does not seem to vary following vacuum or forceps. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Does vaginal delivery cause more damage to the pelvic floor than cesarean section as determined by 3D ultrasound evaluation? A systematic review.

PubMed

de Araujo, Camila Carvalho; Coelho, Suelene A; Stahlschmidt, Paulo; Juliato, Cassia R T

2018-05-01

Pregnancy and delivery are well-established risk factors for pelvic floor dysfunction (PFD), but the physiopathology, such as the delivery route, is not well understood. This study evaluated the impact of delivery route on the pelvic floor muscles via 3D ultrasound. This review is registered in the PROSPERO database. The criteria for inclusion were prospective studies with 3D translabial ultrasound assessment in primigravida women during pregnancy and postpartum published in English, Spanish or Portuguese between 1980 and 2016. We excluded studies that did not include the topic of urogenital hiatus measurement and literature reviews. The MeSH terms were obstetric delivery, postpartum period, labor, parturition, three-dimensional images, ultrasonography, pelvic floor, and pelvic floor disorders. The search retrieved 155 articles. After analysis, 6 articles were included. Four studies showed that vaginal delivery (VD) was associated with a larger hiatal area. One study associated the hiatal area with levator ani muscle (LAM) defects in VD. Four articles evaluated the bladder neck, 3 of which showed a significant increase in bladder neck mobility associated with VD and 1 showed decreased bladder neck elevation, not associated with the delivery mode; the first 3 articles all evaluated LAM injuries and showed an association between VD and LAM injury. Women who underwent VD presented defects of the puborectalis muscle. Vaginal delivery was associated with a higher number of LAM injuries, puborectalis defects, increased bladder neck mobility, and enlargement of the hiatal area.

[Vaginism - a surgical or consultative problem? (author's transl)].

PubMed

Wenderlein, J M

1982-04-01

For the last one hundred years or so doctors have been confronted with the phenomenon of vaginism as a functional sexual disturbance. 70 years ago the psychogenetic nature of this disturbance was recognized, and yet gynaecologists and surgeons are still suggesting and practising surgical and mechanical interventions at the vaginal orifice. This is indeed regrettable - and not only because such attempts remain unsuccessful: in this manner doctors are fixed on the idea of an organic cause of the disturbance instead of motivating the patients to undergo consultative treatment. Vaginism may even entail psychosocial advantages for the women in some cases.

The impact of manual rotation of the occiput posterior position on spontaneous vaginal delivery rate: study protocol for a randomized clinical trial (RMOS).

PubMed

Verhaeghe, C; Parot-Schinkel, E; Bouet, P E; Madzou, S; Biquard, F; Gillard, P; Descamps, P; Legendre, G

2018-02-14

The frequency of posterior presentations (occiput of the fetus towards the sacrum of the mother) in labor is approximately 20% and, of this, 5% remain posterior until the end of labor. These posterior presentations are associated with higher rates of cesarean section and instrumental delivery. Manual rotation of a posterior position in order to rotate the fetus to an anterior position has been proposed in order to reduce the rate of instrumental fetal delivery. No randomized study has compared the efficacy of this procedure to expectant management. We therefore propose a monocentric, interventional, randomized, prospective study to show the superiority of vaginal delivery rates using the manual rotation of the posterior position at full dilation over expectant management. Ultrasound imaging of the presentation will be performed at full dilation on all the singleton pregnancies for which a clinical suspicion of a posterior position was raised at more than 37 weeks' gestation (WG). In the event of an ultrasound confirming a posterior position, the patient will be randomized into an experimental group (manual rotation) or a control group (expectative management with no rotation). For a power of 90% and the hypothesis that vaginal deliveries will increase by 20%, (10% of patients lost to follow-up) 238 patients will need to be included in the study. The primary endpoint will be the rate of spontaneous vaginal deliveries (expected rate without rotation: 60%). The secondary endpoints will be the rate of fetal extractions (cesarean or instrumental) and the maternal and fetal morbidity and mortality rates. The intent-to-treat study will be conducted over 24 months. Recruitment started in February 2017. To achieve the primary objective, we will perform a test comparing the number of spontaneous vaginal deliveries in the two groups using Pearson's chi-squared test (provided that the conditions for using this test are satisfactory in terms of numbers). In the event that this test cannot be performed, we will use Fisher's exact test. Given that the efficacy of manual rotation has not been proven with a high level of evidence, the practice of this technique is not systematically recommended by scholarly societies and is, therefore, rarely performed by obstetric gynecologists. If our hypothesis regarding the superiority of manual rotation is confirmed, our study will help change delivery practices in cases of posterior fetal position. An increase in the rates of vaginal delivery will help decrease the short- and long-term rates of morbidity and mortality following cesarean section. Manual rotation is a simple and effective method with a success rate of almost 90%. Several preliminary studies have shown that manual rotation is associated with reduced rates for fetal extraction and maternal complications: Shaffer has shown that the cesarean section rate is lower in patients for whom a manual rotation is performed successfully (2%) with a 9% rate of cesarean sections when manual rotation is performed versus 41% when it is not performed. Le Ray has shown that manual rotation significantly reduces vaginal delivery rates via fetal extraction (23.2% vs 38.7%, p < 0.01). However, manual rotation is not systematically performed due to the absence of proof of its efficacy in retrospective studies and quasi-experimental before/after studies. ClinicalTrials.gov, Identifier: NCT03009435 . Registered on 30 December 2016.

Evaluation of common vaginal tunic ligation during field castration in draught colts.

PubMed

Carmalt, J L; Shoemaker, R W; Wilson, D G

2008-09-01

The objective of this study was to determine if ligation of the common vaginal tunic could prevent or reduce the incidence of omental herniation and eventration in draught colts undergoing routine field castration. It was found that common vaginal tunic ligation, while not completely preventing omental herniation and evisceration, significantly reduced the incidence of these complications and should be considered in those males deemed at increased risk of significant post castration complications.

Retention of Vaginal Breech Delivery Skills Taught in Simulation.

PubMed

Stone, Heather; Crane, Joan; Johnston, Kathy; Craig, Catherine

2018-02-01

The optimal frequency of conducting simulation training for high-acuity, low-frequency events in obstetrics and gynaecology residency programs is unknown. This study evaluated retention over time of vaginal breech delivery skills taught in simulation, by comparing junior and senior residents. In addition, the residents' subjective comfort level to perform this skill clinically was assessed. This prospective cohort study included 22 obstetrics and gynaecology residents in a Canadian residency training program. Digital recordings were completed for pre-training, immediate post-training, and delayed (10-26 weeks later) post-training intervals of a vaginal breech delivery simulation, with skill assessment by a blinded observer using a binary checklist. Residents also completed questionnaires to assess their subjective comfort level at each interval. Junior and senior residents had significant improvements in vaginal breech delivery skills from the pre-training assessment to both the immediate post-training assessment (junior, P <0.001; senior, P <0.001) and the delayed post-training assessment (P <0.001 and P = 0.001, respectively). There was a significant decline in skills between the immediate and delayed post-training sessions for junior and senior residents (P = 0.003 and P <0.001, respectively). Both junior and senior residents gained more comfort immediately after the training (P <0.001 and P <0.001, respectively), without a significant change between immediate post-training and delayed post-training comfort levels (P = 0.19 and P = 0.11, respectively). Residents retained vaginal breech delivery skills taught in simulation 10-26 weeks later, although a decline in skills occurred over this time period. Comfort level was positively affected and retained. These results will aid in determining the frequency of simulation teaching for high-acuity, low-frequency events in a residency simulation curriculum. Copyright © 2018 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.

Prevention of shoulder dystocia: A randomized controlled trial to evaluate an obstetric maneuver.

PubMed

Poujade, Olivier; Azria, Elie; Ceccaldi, Pierre-François; Davitian, Carine; Khater, Carine; Chatel, Paul; Pernin, Emilie; Aflak, Nizar; Koskas, Martin; Bourgeois-Moine, Agnès; Hamou-Plotkine, Laurence; Valentin, Morgane; Renner, Jean-Paul; Roy, Carine; Estellat, Candice; Luton, Dominique

2018-08-01

Shoulder dystocia is a major obstetric emergency defined as a failure of delivery of the fetal shoulder(s). This study evaluated whether an obstetric maneuver, the push back maneuver performed gently on the fetal head during delivery, could reduce the risk of shoulder dystocia. We performed a multicenter, randomized, single-blind trial to compare the push back maneuver with usual care in parturient women at term. The primary outcome, shoulder dystocia, was considered to have occurred if, after delivery of the fetal head, any additional obstetric maneuver, beginning with the McRoberts maneuver, other than gentle downward traction and episiotomy was required. We randomly assigned 522 women to the push back maneuver group (group P) and 523 women to the standard vaginal delivery group (group S). Finally, 473 women assigned to group P and 472 women assigned to group S delivered vaginally. The rate of shoulder dystocia was significantly lower in group P (1·5%) than in group S (3·8%) (odds ratio [OR] 0·38 [0·16-0·92]; P = 0·03). After adjustment for predefined main risk factors, dystocia remained significantly lower in group P than in group S. There were no significant between-group differences in neonatal complications, including brachial plexus injury, clavicle fracture, hematoma and generalized asphyxia. In this trial in 945 women who delivered vaginally, the push back maneuver significantly decreased the risk of shoulder dystocia, as compared with standard vaginal delivery. Copyright © 2018 Elsevier B.V. All rights reserved.

[Immediate fetal-maternal morbidity of first instrumental vaginal delivery using Thierry's spatulas. A prospective continuous study of 195 fetal extractions].

PubMed

Parant, O; Simon-Toulza, C; Capdet, J; Fuzier, V; Arnaud, C; Rème, J-M

2009-10-01

To investigate the immediate fetal-maternal morbidity related to Thierry's spatula for first instrumental vaginal delivery. We conducted a prospective observational study in Toulouse university hospital, including primiparas who vaginally delivered a live singleton cephalic infant>36 WG, between December 2005 and June 2006. Instrumental deliveries were performed using short spatulas in all cases. Outcome measures were: perineal complications (episiotomy, laceration and associated lesions, urinary retention, pain at H48), neonatal morbidity (cutaneous injuries, neonatal transfer, cord pH, Apgar score). Instrumental deliveries were compared with spontaneous vaginal deliveries (SVD). Six hundred and eight primiparas were included, distributed in 195 extractions (32%) and 413 SVD (68%). Spatulas allowed fetal extraction in all cases. Main differences between the two groups were: length of labour, occiput posterior position (12.8% for spatulas vs 1.7% for SVD; p<0.0001), episiotomy rate (97.9% vs 51.3%; p<0.0001), severe perineal lacerations (3.6% vs 0.2%; p=0.0007), post-partum morbidity (pain, hematoma, and urinary retention). No case of early severe neonatal complication was related to the use of the spatulas. Perineal complications (severe lacerations) associated with spatulas are increased with regard to SVD, but comparable to that reported with forceps. The main disadvantage is the high frequency of episiotomy, which should not be systematic. Neonatal morbidity is reduced. Comparative studies (spatulas vs. other procedures) are needed to confirm these data, but spatulas remain a multipurpose instrument which should continue to be taught.

Vaginal delivery after previous caesarean section: is X-ray pelvimetry necessary?

PubMed

Thubisi, M; Ebrahim, A; Moodley, J; Shweni, P M

1993-05-01

To determine whether antepartum X-ray pelvimetry (XRP) reliably identified women suitable for a trial labour or repeat elective caesarean section after one previous section. A prospective controlled trial in which women were randomly allocated to either an antepartum XRP group who had XRP at 36 weeks gestation to determine mode of delivery, or a control group who had a trial labour without antepartum XRP. Following delivery, all controls had postpartum XRP. Department of Obstetrics and Gynaecology, King Edward VIII Hospital, Durban, South Africa. Three hundred-six women with a history of one previous caesarean section. Mode of delivery, birthweight and maternal and perinatal mortality and morbidity in the two groups. In the antepartum XRP group, 23 of 144 (16%) of women delivered vaginally compared with 60 of 144 (42%) controls (P < 0.0001). Of the 84 women with adequate antepartum XRP only 23 (27.7%) delivered vaginally. In the control group, 33 of 60 (55%) women who had vaginal deliveries had inadequate postpartum XRP and would have had a caesarean section if this information was known in the antepartum period; 62 of 84 (74%) caesarean sections in the control group had adequate postpartum XRP. Birthweight of the infants was similar in the two groups. There were no maternal or perinatal deaths. Maternal morbidity was similar in the two groups. Neonatal morbidity was minimal. Antepartum XRP is not necessary prior to a trial labour in women with one previous caesarean section. It increases the caesarean section rate and is a poor predictor of the outcome of labour.

Lactobacillus-deficient vaginal microbiota dominate post-partum women in rural Malawi.

PubMed

Doyle, Ronan; Gondwe, Austridia; Fan, Yue-Mei; Maleta, Kenneth; Ashorn, Per; Klein, Nigel; Harris, Kathryn

2018-01-05

The bacterial community found in the vagina is an important determinant of a woman's health and disease. A healthy vaginal microbiota is associated with a lower species richness and high proportions of one of a number of different Lactobacillus spp.. When disrupted the resulting abnormal vaginal microbiota is associated with a number of disease states and poor pregnancy outcomes. Studies up until now have concentrated on relatively small numbers of American and European populations which may not capture the full complexity of the community, nor adequately predict what constitutes a healthy microbiota in all populations. In this study we sampled and characterised the vaginal microbiota from a cohort of 1107 women in rural Malawi found on vaginal swabs taken post-partum. We found a population dominated by Gardnerella vaginalis and devoid of the most common vaginal Lactobacillus species, even if the vagina was sampled over a year post-partum. The Lactobacillus -deficient anaerobic community commonly labelled community state type (CST) 4 could be sub-divided into four further communities. A Lactobacillus iners dominated vaginal microbiota became more common the longer after delivery the vagina was sampled, but G. vaginalis remained the dominant organism. These results outline the difficulty in all-encompassing definitions of what a healthy or abnormal vaginal microbiota is post-partum. Previous identification of community state types and associations between bacterial species, bacterial vaginosis and adverse birth outcomes may not represent the complex heterogeneity of the microbiota present. Importance A bacterial community in the vaginal tract that is dominated by small number of bacterial Lactobacillus species and when they are not present, there is a greater incidence of inflammatory conditions and adverse birth outcomes. A switch to a vaginal bacterial community lacking in Lactobacillus species is common after pregnancy. In this study we characterised the vaginal microbiota after delivery of a large group of women from a resource poor, under-sampled population in rural Malawi. The majority of women were found to have a Lactobacillus -deficient community and even after a year after delivery the majority of women still did not have Lactobacillus present in their vaginal microbiota. The effect of becoming pregnant again for those who do not revert to a Lactobacillus dominant community is unknown and could suggest that not all Lactobacillus -deficient community structures are adverse. A better understanding is needed of this complex community state type. Copyright © 2018 Doyle et al.

IMPACT OF VAGINAL PARITY AND AGING ON THE ARCHITECTURAL DESIGN OF PELVIC FLOOR MUSCLES

PubMed Central

Alperin, Marianna; Cook, Mark; Tuttle, Lori J.; Esparza, Mary C.; Lieber, Richard L.

2016-01-01

Background Vaginal delivery and aging are key risk factors for pelvic floor muscle dysfunction, which is a critical component of pelvic floor disorders. However, alterations in the PFM intrinsic structure due to childbirth and aging that lead to muscle dysfunction remain elusive. Objectives To determine the impact of vaginal deliveries and aging on human cadaveric PFM architecture, the strongest predictor of active muscle function. Study Design Coccygeus, iliococcygeus and pubovisceralis were obtained from younger, ≤ 51 years, vaginally nulliparous (N=5) and vaginally parous (N=6), and older, >51 years, vaginally nulliparous (N=6) and vaginally parous (N=6) donors without history of PFDs. Architectural parameters, predictive of muscle’s excursion and force-generating capacity, were determined using validated methods. Intramuscular collagen content was quantified by hydroxyproline assay. Main effects of parity and aging and the interactions were determined using two-way ANOVA, with Tukey’s post-hoc testing with significance level of 0.05. Results The mean age of younger and older donors differed by ~40 years (P=0.001), but was similar between nulliparous and parous donors within each age group (P>0.9). Median parity was 2 (range 1–3) in younger and older vaginally parous groups, P=0.7. The main impact of parity was increased fiber length in the more proximal coccygeus (P=0.03), and iliococcygeus (P=0.04). Aging changes manifested as decreased physiological cross sectional area across all pelvic floor muscles, P<0.05, which substantially exceeded the age-related decline in muscle mass. Physiological cross sectional area was lower in younger vaginally parous, compared to younger vaginally nulliparous pelvic floor muscles, however the differences did not reach statistical significance. Pelvic floor muscles’ collagen content was not altered by parity, but increased dramatically with aging, P<0.05. Conclusions Increased fiber length in more proximal pelvic floor muscles likely represents an adaptive response to the chronically increased load placed on these muscles by the displaced apical structures, presumably as a consequence of vaginal delivery. In younger specimens, a consistent trend towards decrease in force generating capacity of all pelvic floor muscles in parous group suggests a potential mechanism for clinically identified pelvic floor muscle weakness in vaginally parous women. The substantial decrease in predicted muscle force production and fibrosis with aging represent likely mechanisms for the pelvic floor muscle dysfunction in older women. PMID:26953079

Luteal phase bleeding after IVF cycles: comparison between progesterone vaginal gel and intramuscular progesterone and correlation with pregnancy outcomes

PubMed Central

Jabara, Sami; Barnhart, Kurt; Schertz, Joan C; Patrizio, Pasquale

2009-01-01

Background: To compare luteal phase bleeding and pregnancy outcomes in normogonadotropic patients receiving progesterone vaginal gel (PVG) or intramuscular progesterone (IMP) injections. Methods: In this retrospective cohort study, data from 270 patients (292 cycles) undergoing day-3 fresh embryo transfer were analyzed. PVG, 90 mg daily (170 cycles) or IMP, 50 mg daily (122 cycles) began at egg retrieval. Results: Luteal phase bleeding was significantly more common in the PVG than the IMP group. No significant differences were observed in biochemical pregnancy or spontaneous abortion rates between the two groups. Patients who bled before the pregnancy test had significantly lower total and clinical pregnancy rates than non-bleeders. Total and ongoing pregnancy/delivery rates were higher in the PVG than IMP group, but did not achieve statistical significance. Conclusion: Luteal phase bleeding was more common in the PVG group than the IMP group, but pregnancy was successful in more patients in the PVG group. Luteal phase bleeding is prevented or delayed during IMP treatment, but patients who bled before the pregnancy test, whether using the gel or injected progesterone, had significantly reduced pregnancy rates compared with non-bleeders. PMID:20485581

In Situ Forming Polymeric Drug Delivery Systems

PubMed Central

Madan, M.; Bajaj, A.; Lewis, S.; Udupa, N.; Baig, J. A.

2009-01-01

In situ forming polymeric formulations are drug delivery systems that are in sol form before administration in the body, but once administered, undergo gelation in situ, to form a gel. The formation of gels depends on factors like temperature modulation, pH change, presence of ions and ultra violet irradiation, from which the drug gets released in a sustained and controlled manner. Various polymers that are used for the formulation of in situ gels include gellan gum, alginic acid, xyloglucan, pectin, chitosan, poly(DL-lactic acid), poly(DL-lactide-co-glycolide) and poly-caprolactone. The choice of solvents like water, dimethylsulphoxide, N-methyl pyrrolidone, triacetin and 2-pyrrolidone for these formulations depends on the solubility of polymer used. Mainly in situ gels are administered by oral, ocular, rectal, vaginal, injectable and intraperitoneal routes. The in situ gel forming polymeric formulations offer several advantages like sustained and prolonged action in comparison to conventional drug delivery systems. The article presents a detailed review of these types of polymeric systems, their evaluation, advancements and their commercial formulations. From a manufacturing point of view, the production of such devices is less complex and thus lowers the investment and manufacturing cost. PMID:20490289

[Evaluation by focus groups on women's expectations and perceptions during the birth process].

PubMed

Ferreiro-Losada, M T; Díaz-Sanisidro, E; Martínez-Romero, M D; Rial-Boubeta, A; Varela-Mallou, J; Clavería-Fontán, A

2013-01-01

Delivery care giving is undergoing excessive interventionism today, not supported by scientific evidence, neglecting organisational aspects and individualisation. This study analyses the perception of mothers during their delivery, postpartum and breastfeeding periods in the Galician Health Service, in order to inform and help to improve this service. A total of 14 focus group meetings were held (one in each Galician public hospital), consisting of women who, in 2008, delivered by vaginal delivery or those who were not scheduled for a caesarean section. The process of birth analysis can identify a sequence of important elements both positive and negative, for mothers, and may lead to suggestions for improvement. Their experiences and opinions, especially in aspects such as participation in decision-making, mechanisation of labour and lactation, may help to conduct an assessment of the maternity ward operating. When investigating expectations and demands from users, information from perceived quality is received, and also mothers' experience is shared. Mothers call for humanity, empathy, information and participation. Facing the implementation of these elements, the key processes for working harder are the dilation stage and hospital staying. Copyright © 2012 SECA. Published by Elsevier Espana. All rights reserved.

Personal birth preferences and actual mode of delivery outcomes of obstetricians and gynaecologists in South West England; with comparison to regional and national birth statistics.

PubMed

Lightly, Katie; Shaw, Elisabeth; Dailami, Narges; Bisson, Dina

2014-10-01

To determine personal birth preferences of obstetricians in various clinical scenarios, in particular elective caesarean section for maternal request. To determine actual rates of modes of deliveries amongst the same group. To compare the obstetrician's mode of delivery rates, to the general population. Following ethical approval, a piloted online survey link was sent via email to 242 current obstetricians and gynaecologists, (consultants and trainees) in South West England. Mode of delivery results were compared to regional and national population data, using Hospital Episode Statistics and subjected to statistical analysis. The response rate was 68%. 90% would hypothetically plan a vaginal delivery, 10% would consider a caesarean section in an otherwise uncomplicated primiparous pregnancy. Of the 94/165 (60%) respondents with children (201 children), mode of delivery for the first born child; normal vaginal delivery 48%, caesarean section 26.5% (elective 8.5%, emergency 18%), instrumental 24.5% and vaginal breech 1%. Only one chose an elective caesarean for maternal request. During 2006-2011 obstetricians have the same overall actual modes of birth as the population (p=0.9). Ten percent of obstetricians report they would consider requesting caesarean section for themselves/their partner, which is the lowest rate reported within UK studies. However only 1% actually had a caesarean solely for maternal choice. When compared to regional/national statistics obstetricians currently have modes of delivery that are not significantly different than the population and suggests that they choose non interventional delivery if possible. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

[Procedure of breech presentation delivery in correlation with newborns vitality during period 2002-2005].

PubMed

Izetbegović, Sebija

2006-01-01

This retrospective study conducted on the basis of 2002 -2005 history of disease protocol of the delivery room aiming to present a vitality of newborns with breech presentation with regards to the manner of completing deliveries as well as number of mother's previous deliveries. In a two year period, there was a total of 7017 deliveries, out of which 245 (3.49%) were breech presentation cases. Out of these 245 deliveries, 9 pregnant women were admitted with foetus mortus in utero, therefore, for the purpose of further observation we used the figure of 236 pregnant women with breech presentation. Out of that number, 129 pregnancies (54.66%) were delivered by operation, whereas 107 (45.33%) pregnancies were vaginal, supported manually. Vaginal deliveries with some kind of manual support (Bracht, Veit-Smellie-Muller were presented with total of 107 pregnant women of which 50 (46.72%) were cases of first delivery, 44 (41.12%) were second delivery, 6 (5.6%) were third delivery, 2 (1.86%) were fourth delivery, 3 (2.8%) fifth delivery, 1 (0.93%) was sixth delivery and 1 (0.93%) was seventh delivery.

Recurrent obstetric anal sphincter injury and the risk of long-term anal incontinence.

PubMed

Jangö, Hanna; Langhoff-Roos, Jens; Rosthøj, Susanne; Sakse, Abelone

2017-06-01

Women with an obstetric anal sphincter injury are concerned about the risk of recurrent obstetric anal sphincter injury in their second pregnancy. Existing studies have failed to clarify whether the recurrence of obstetric anal sphincter injury affects the risk of anal and fecal incontinence at long-term follow-up. The objective of the study was to evaluate whether recurrent obstetric anal sphincter injury influenced the risk of anal and fecal incontinence more than 5 years after the second vaginal delivery. We performed a secondary analysis of data from a postal questionnaire study in women with obstetric anal sphincter injury in the first delivery and 1 subsequent vaginal delivery. The questionnaire was sent to all Danish women who fulfilled inclusion criteria and had 2 vaginal deliveries 1997-2005. We performed uni- and multivariable analyses to assess how recurrent obstetric anal sphincter injury affects the risk of anal incontinence. In 1490 women with a second vaginal delivery after a first delivery with obstetric anal sphincter injury, 106 had a recurrent obstetric anal sphincter injury. Of these, 50.0% (n = 53) reported anal incontinence compared with 37.9% (n = 525) of women without recurrent obstetric anal sphincter injury. Fecal incontinence was present in 23.6% (n = 25) of women with recurrent obstetric anal sphincter injury and in 13.2% (n = 182) of women without recurrent obstetric anal sphincter injury. After adjustment for third- or fourth-degree obstetric anal sphincter injury in the first delivery, maternal age at answering the questionnaire, birthweight of the first and second child, years since first and second delivery, and whether anal incontinence was present before the second pregnancy, the risk of flatal and fecal incontinence was still increased in patients with recurrent obstetric anal sphincter injury (adjusted odds ratio, 1.68 [95% confidence interval, 1.05-2.70), P = .03, and adjusted odds ratio, 1.98 [95% confidence interval, 1.13-3.47], P = .02, respectively). More women with recurrent obstetric anal sphincter injury reported affected the quality of life because of anal incontinence (34.9%, n = 37) compared with women without recurrent obstetric anal sphincter injury (24.2%, n = 335), although this difference did not reach statistical significance after adjustment (adjusted odds ratio, 1.53 [95% confidence interval, 0.92-2.56] P = .10). Women opting for vaginal delivery after obstetric anal sphincter injury should be informed about the risk of recurrence, which is associated with an increased risk of long-term flatal and fecal incontinence. Copyright © 2017 Elsevier Inc. All rights reserved.

New suturing technique for robotic-assisted vaginal cuff closure during single-site hysterectomy.

PubMed

Shin, So-Jin; Chung, Hyewon; Kwon, Sang-Hoon; Cha, Soon-Do; Cho, Chi-Heum

2017-06-01

To describe a simple and efficient technique for suturing the vaginal cuff in robotic-assisted single-site hysterectomy using barbed suture and a straight needle. Consecutive patients undergoing robotic-assisted single-site hysterectomy from February 2014 to August 2015 at Dong San Hospital, Keimyung University were included. Surgeons used two barbed sutures in a running fashion to close the vaginal cuff. A barbed suture was exclusively used with a straightened needle in upward direction from posterior vaginal cuff to anterior vaginal cuff which played a pivotal role for closure. A total of 100 patients underwent robotic-assisted single-site hysterectomy. The total operation time was 132.5 min and vaginal cuff closure time was 12.0 min. There were no postoperative complications; vaginal cuff dehiscence, vaginal cuff infection, and vaginal bleeding that require surgical intervention or admission. The use of barbed suture with straightened needle to close the vaginal cuff in robotic-assisted single-site hysterectomy is easy to perform and demonstrates safety and efficacy. This technique offers secure, fast, and effective incision closure.

Non-technical skills for obstetricians conducting forceps and vacuum deliveries: qualitative analysis by interviews and video recordings.

PubMed

Bahl, Rachna; Murphy, Deirdre J; Strachan, Bryony

2010-06-01

Non-technical skills are cognitive and social skills required in an operational task. These skills have been identified and taught in the surgical domain but are of particular relevance to obstetrics where the patient is awake, the partner is present and the clinical circumstances are acute and often stressful. The aim of this study was to define the non-technical skills of an operative vaginal delivery (forceps or vacuum) to facilitate transfer of skills from expert obstetricians to trainee obstetricians. Qualitative study using interviews and video recordings. The study was conducted at two university teaching hospitals (St. Michael's Hospital, Bristol and Ninewells Hospital, Dundee). Participants included 10 obstetricians and eight midwives identified as experts in conducting or supporting operative vaginal deliveries. Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting forceps and vacuum deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by the three researchers and then compared for consistency of interpretation. The experts reviewed the coded data for respondent validation and clarification. The themes that emerged were used to identify the non-technical skills required for conducting an operative vaginal delivery. The final skills list was classified into seven main categories. Four categories (situational awareness, decision making, task management, and team work and communication) were similar to the categories identified in surgery. Three further categories unique to obstetrics were also identified (professional relationship with the woman, maintaining professional behaviour and cross-monitoring of performance). This explicitly defined skills taxonomy could aid trainees' understanding of the non-technical skills to be considered when conducting an operative vaginal delivery and potentially reduce morbidity and improve the experience of delivery for the mother. Copyright 2010 Elsevier Ireland Ltd. All rights reserved.

Self-testing of vaginal pH to prevent preterm delivery: a controlled trial.

PubMed

Bitzer, Eva-Maria; Schneider, Andrea; Wenzlaff, Paul; Hoyme, Udo B; Siegmund-Schultze, Elisabeth

2011-02-01

From 2004 to 2006, in a model project carried out by four German health insurers, expectant mothers were offered self-testing of vaginal pH in order to prevent preterm delivery. They were given pH test gloves on request so that they could measure their vaginal pH twice a week from the 12(th) to the 32(nd) week of gestation. They were instructed to consult with a gynecologist after any positive result. All further diagnostic or therapeutic decisions were at the discretion of the treating gynecologist. We assessed the effectiveness of the screening intervention, using delivery before the 37th week of gestation as the primary endpoint. In this prospective, controlled trial, we collected data on deliveries from 2004 to 2006 that were covered by the four participating insurers in five German federal states. We compared the outcomes of pregnancy in women who did and did not request test gloves (intervention group, [IG], and control group, [CG]). The data were derived from claims data of the participating insurers, as well as from a nationwide quality assurance auditing program for obstetrics and perinatal care. Propensity score matching and multivariate adjustment were used to control for the expected self-selection bias. The study sample comprised 149 082 deliveries. 13% of the expectant mothers requested test gloves, about half of them up to the 16(th) week of gestation. As expected, women with an elevated risk of preterm birth requested test gloves more often. Delivery before the 37(th) week of gestation was slightly more common in the intervention group than in the control group (IG 7.97%, CG 7.52%, relative risk 1.06, 95% confidence interval 1.00-1.12). This result was of borderline statistical significance in the propensity score matched analysis, but it was not statistically significant in the multivariate model. This trial did not demonstrate the efficacy of self-testing of vaginal pH for the prevention of preterm delivery (< 37 weeks of gestation).

Increased rates of cesarean sections and large families: a potentially dangerous combination.

PubMed

Saleh, Ahmed M; Dudenhausen, Joachim W; Ahmed, Badreldeen

2017-07-26

Rates of cesarean sections have been on the rise over the past three decades all over the world, despite the ideal rate of 10-15% that had been set by the World Health Organization (WHO) in 1985, in Fortaleza, Brazil. This epidemic increase in the rate of cesarean delivery is due to many factors which include, cesarean delivery on request, advanced maternal age at first pregnancy, decrease in number of patients who are willing to try vaginal birth after cesarean delivery, virtual disappearance of vaginal breech delivery, perceived increase in the weight of the fetus and increase in the number of women with chronic medical conditions such as Diabetes Mellitus and congenital heart disease in the reproductive age. There is no doubt that cesarean delivery is a safe procedure and it is getting safer and safer for many reasons. However, like all other surgical procedures it is not without risks both to the mother and the new born. There is a substantial increase in the incidence of morbidly adherent placenta and the risk of scar pregnancy. In the Middle East and many African and Asian countries women tend to have large families. The number of previous cesarean section deliveries is directly proportional to the risk of developing morbidly adherent placenta. Morbidly adherent placenta is the most common cause of emergency postpartum hysterectomy, which is often associated with multiple surgical complications, severe maternal morbidity and mortality. The increased rates of cesarean sections lead to increased rates of scar pregnancies, which can have lethal consequences. Cesarean delivery has a negative impact on the infant immune system. This effect on the infant led to the introduction of a new concept called "Vaginal seeding". This refers to the practice of transferring some maternal vaginal fluid to the infant born via cesarean section in an effort to enhance its immune system.

Fetal head circumference, operative delivery, and fetal outcomes: a multi-ethnic population-based cohort study

PubMed Central

2013-01-01

Background Operative delivery procedures, such as primary cesarean section, vacuum-assisted, and forceps-assisted vaginal delivery increase maternal and fetal morbidity, and the cost of care. We evaluated whether large fetal head circumference (FHC) independently increases risk of such interventions, as well as fetal distress or low Apgar score, in anatomically normal infants. Methods We conducted a population-based retrospective cohort study using Washington State birth certificate data. We included singleton, term infants born to nulliparous mothers from 2003–2009. We compared mode of delivery and fetal outcomes in 10,750 large-FHC (37-41 cm) infants relative to 10,750 average-FHC (34 cm) infants, frequency matched by birth-year. Results Large-FHC infants were nearly twice as likely to be delivered by primary cesarean section as average-FHC infants (unadjusted relative risk [RR] 1.84, 95% confidence interval [CI]: 1.77, 1.92). The RR for primary cesarean section associated with large-FHC was largest for mothers aged 19 years or less (RR 2.28; 95% CI: 1.99, 2.61), and smallest for mothers aged 35 years or greater (RR 1.51; 95% CI: 1.37, 1.66) [test of homogeneity, p < 0.001]. Large-FHC infants were at increased risk of vacuum-assisted vaginal delivery (RR 1.55; 95% CI: 1.43, 1.69), and forceps-assisted vaginal delivery (RR 1.61; 95% CI: 1.32, 1.97). There was no difference in risk of fetal distress (RR 0.97; 95% CI: 0.89, 1.07) for large-FHC versus average-FHC infants. Risk estimates were unaffected by adjustment for potential confounders. Conclusions Nulliparous mothers of large-FHC infants are at increased risk of primary cesarean section, vacuum-assisted and forceps-assisted vaginal delivery relative to mothers of average-FHC infants. Maternal age modifies the association between FHC and primary cesarean section. PMID:23651454

Chitosan Ascorbate Nanoparticles for the Vaginal Delivery of Antibiotic Drugs in Atrophic Vaginitis

PubMed Central

Vigani, Barbara; Puccio, Antonella; Ferrari, Franca

2017-01-01

The aim of the present work was the development of chitosan ascorbate nanoparticles (CSA NPs) loaded into a fast-dissolving matrix for the delivery of antibiotic drugs in the treatment of atrophic vaginitis. CSA NPs loaded with amoxicillin trihydrate (AX) were obtained by ionotropic gelation in the presence of pentasodium tripolyphosphate (TPP). Different CSA:TPP and CSA:AX weight ratios were considered and their influence on the particle size, polydispersion index and production yield were investigated. CSA NPs were characterized for mucoadhesive, wound healing and antimicrobial properties. Subsequently, CSA NPs were loaded in polymeric matrices, whose composition was optimized using a DoE (Design of Experiments) approach (simplex centroid design). Matrices were obtained by freeze-drying aqueous solutions of three hydrophilic excipients, polyvinylpirrolidone, mannitol and glycin. They should possess a mechanical resistance suitable for the administration into the vaginal cavity and should readily dissolve in the vaginal fluid. In addition to antioxidant properties, due to the presence of ascorbic acid, CSA NPs showed in vitro mucoadhesive, wound healing and antimicrobial properties. In particular, nanoparticles were characterized by an improved antimicrobial activity with respect to a chitosan solution, prepared at the same concentration. The optimized matrix was characterized by mechanical resistance and by the fast release in simulated vaginal fluid of nanoparticles characterized by unchanged size. PMID:29048359

Hemoglobin Differences in Uncomplicated Monochorionic Twins in Relation to Birth Order and Mode of Delivery.

PubMed

Verbeek, Lianne; Zhao, Depeng P; Te Pas, Arjan B; Middeldorp, Johanna M; Hooper, Stuart B; Oepkes, Dick; Lopriore, Enrico

2016-06-01

To determine the differences in hemoglobin (Hb) levels in the first 2 days after birth in uncomplicated monochorionic twins in relation to birth order and mode of delivery. All consecutive uncomplicated monochorionic pregnancies with two live-born twins delivered at our center were included in this retrospective study. We recorded Hb levels at birth and on day 2, and analyzed Hb levels in association with birth order, mode of delivery, and time interval between delivery of twin 1 and 2. A total of 290 monochorionic twin pairs were analyzed, including 171 (59%) twins delivered vaginally and 119 (41%) twins born by cesarean section (CS). In twins delivered vaginally, mean Hb levels at birth and on day 2 were significantly higher in second-born twins compared to first-born twins: 17.8 versus 16.1 g/dL and 18.0 versus 14.8 g/dL, respectively (p < .01). Polycythemia was detected more often in second-born twins (12%, 20/166) compared to first-born twins (1%, 2/166; p < .01). Hb differences within twin pairs delivered by CS were not statistically or clinically significant. We found no association between inter-twin delivery time intervals and Hb differences. Second-born twins after vaginal delivery have higher Hb levels and more often polycythemia than their co-twin, but not when born by CS.

[Macrosomia, shoulder dystocia and elongation of the brachial plexus: what is the role of caesarean section?

PubMed

Kehila, Mehdi; Derouich, Sadok; Touhami, Omar; Belghith, Sirine; Abouda, Hassine Saber; Cheour, Mariem; Chanoufi, Mohamed Badis

2016-01-01

The delivery of a macrosomic infant is associated with a higher risk for maternofoetal complications. Shoulder dystocia is the most feared fetal complication, leading sometimes to a disproportionate use of caesarean section. This study aims to evaluate the interest of preventive caesarean section. We conducted a retrospective study of 400 macrosomic births between February 2010 and December 2012. We also identified cases of infants with shoulder dystocia occurred in 2012 as well as their respective birthweight. Macrosomic infants weighed between 4000g and 4500g in 86.25% of cases and between 4500 and 5000 in 12.25% of cases. Vaginal delivery was performed in 68% of cases. Out of 400 macrosomic births, 9 cases with shoulder dystocia were recorded (2.25%). All of these cases occurred during vaginal delivery. The risk for shoulder dystocia invaginal delivery has increased significantly with the increase in birth weight (p <10-4). The risk for elongation of the brachial plexus was 11 per thousand vaginal deliveries of macrosomic infants. This risk was not correlated with birthweight (p = 0.38). The risk for post-traumatic sequelae was 0.71%. Shoulder dystocia affectd macrosoic infants in 58% of cases. Shoulder dystocia is not a complication exclusively associated with macrosomia. Screening for risky deliveries and increasing training of obstetricians on maneuvers in shoulder dystocia seem to be the best way to avoid complications.

[External cephalic version in cases of breech presentation: renaissance of a well-known procedure?].

PubMed

Schmidt, M; Callies, R; Kuhn, U; Willruth, A; Kimmig, R

2009-01-01

About 3-4% of all pregnant women will have a fetus presenting by the breech at term. External cephalic version offers the opportunity to reduce the rate of caesarean sections caused by breech presentation. We analysed retrospectively 51 cases of external cephalic version at our clinic. External cephalic version was performed 51 times between 37 and 41 weeks of pregnancy. External cephalic version was successful in 32/51 cases (62,7%) with a consecutive rate of vaginal delivery of 71,9%. The best results were seen at 37 weeks of pregnancy with 81,25% of successful versions followed by 76,9% of vaginal deliveries. Complications were rare. There was just 1 case of emergency caesarean section due to persisting fetal bradycardia. External cephalic version is an effective and safe treatment to enable vaginal delivery of cephalic presentation. For this operation, 37 weeks of pregnancy can be considered the best time. 2009 S. Karger AG, Basel.

Phaeochromocytoma in pregnancy: safe vaginal delivery, is it possible?

PubMed

Kapoor, Garima; Salhan, Sudha; Sarda, Nivedita; Sarda, A K; Aggarwal, Deepika

2013-04-01

Pheochromocytoma in pregnancy is rare (1 in 50,000 full term pregnancies). Recognition of the condition is central to improving outcome (maternal and foetal mortality is reduced from 58% and 56%, respectively to 2% and 11-15%, respectively). An antenatal patient in third trimester diagnosed as pheochromocytoma has been described. Diagnosis of pheochromocytoma was confirmed by urinary VMA levels and demonstration of right adrenal mass on ultrasound. A multidisciplinary approach was used and the patient received antihypertensives for 10 days. Vaginal delivery was conducted under epidural analgesia and the patient was kept under close surveillance. She delivered a healthy baby girl weighing 2.5 kg. The intrapartum and the postpartum period were uneventful. Adrenalectomy was done at 6 weeks postpartum. Using multidisciplinary approach and individualised management decreases both maternal and foetal morbidity and mortality. Selected multigravidae cases and those with previous history of short uncomplicated labour, may be considered for vaginal delivery under epidural analgesia and with back up facilities available to manage hypertensive crisis.

Novel vaginal drug delivery system: deformable propylene glycol liposomes-in-hydrogel.

PubMed

Vanić, Željka; Hurler, Julia; Ferderber, Kristina; Golja Gašparović, Petra; Škalko-Basnet, Nataša; Filipović-Grčić, Jelena

2014-03-01

Deformable propylene glycol-containing liposomes (DPGLs) incorporating metronidazole or clotrimazole were prepared and evaluated as an efficient drug delivery system to improve the treatment of vaginal microbial infections. The liposome formulations were optimized based on sufficient trapping efficiencies for both drugs and membrane elasticity as a prerequisite for successful permeability and therapy. An appropriate viscosity for vaginal administration was achieved by incorporating the liposomes into Carbopol hydrogel. DPGLs were able to penetrate through the hydrogel network more rapidly than conventional liposomes. In vitro studies of drug release from the liposomal hydrogel under conditions simulating human treatment confirmed sustained and diffusion-based drug release. Characterization of the rheological and textural properties of the DPGL-containing liposomal hydrogels demonstrated that the incorporation of DPGLs alone had no significant influence on mechanical properties of hydrogels compared to controls. These results support the great potential of DPGL-in-hydrogel as an efficient delivery system for the controlled and sustained release of antimicrobial drugs in the vagina.

Pregnancy- and delivery-induced biomechanical changes in rat vagina persist postpartum

PubMed Central

Alperin, Marianna; Feola, Andrew; Duerr, Robert; Moalli, Pamela; Abramowitch, Steven

2010-01-01

Introduction and hypothesis We sought to define changes in vaginal distensibility (VD) induced by pregnancy and vaginal delivery using a novel in vivo biomechanical testing protocol. Methods Under sedation, a balloon was inserted into the vagina of 27 virgin, pregnant and 4-week postpartum Long–Evans rats and incrementally distended. Pressure–volume curves were generated with slopes characterizing VD (higher slope = less distensible). One-way ANOVA with a Bonferroni post-hoc test were used for statistical analyses. Results Mean pressures at an infusion volume of 1 cc were lower in pregnant and postpartum rats than in virgins (P<0.001). VD was increased in pregnant vs. virgin rats (P<0.001) and did not recover to virgin levels post partum (P<0.001). Conclusions We have developed a test that measures VD in vivo under clinically relevant loading conditions. The increased VD in the late postpartum period defines a persistent change in biomechanical behavior of the vagina related to pregnancy and vaginal delivery. PMID:20424824

Women's knowledge and attitude towards mode of delivery and frequency of cesarean section on mother's request in six public and private hospitals in Tehran, Iran, 2012.

PubMed

Ghotbi, Fatemeh; Akbari Sene, Azadeh; Azargashb, Eznollah; Shiva, Farideh; Mohtadi, Mina; Zadehmodares, Shahrzad; Farzaneh, Farah; Yasai, Fakhr-al-Molouk

2014-05-01

The rate of cesarean section (CS) has been reported to be as high as 40% among Iranian women in the year 2009. The aim of this study was to determine the rate of cesarean delivery on mother's request (CDMR) and to determine maternal attitude and knowledge about various modes of delivery in private and public (university) hospitals in Tehran. All primiparous mothers delivering in six selected hospitals between April 2010 and March 2011 were included. Trained investigators handed a predesigned questionnaire to mothers 1 day after delivery to be filled out in the presence of the investigator. From 600 deliveries, 501 (83.5%) were CS and 99 (16.5%) were normal vaginal delivery. The CS rates in university hospitals versus private hospitals were 78.5% and 91.9%, respectively. In total, mothers' knowledge scores were poor, intermediate, and good in 55.6%, 37.9%, and 6.5% of cases, respectively, and no significant difference in knowledge was observed between mothers attending private or public hospitals. The overall rate of CDMR was 20.8%; and the most frequent reason was fear of pain. Women with CDMR were at higher marital age, education, insurance coverage, and socioeconomic status compared with the women with vaginal delivery. Prompt action is needed to reduce the unacceptably high rate of unwarranted cesarean deliveries. Improving women's knowledge about the risks and benefits of different modes of delivery can lead to a positive maternal attitude towards vaginal delivery. © 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.

Does the maternal vaginal microbiota play a role in seeding the microbiota of neonatal gut and nose?

PubMed

Sakwinska, O; Foata, F; Berger, B; Brüssow, H; Combremont, S; Mercenier, A; Dogra, S; Soh, S-E; Yen, J C K; Heong, G Y S; Lee, Y S; Yap, F; Meaney, M J; Chong, Y-S; Godfrey, K M; Holbrook, J D

2017-10-13

The acquisition and early maturation of infant microbiota is not well understood despite its likely influence on later health. We investigated the contribution of the maternal microbiota to the microbiota of infant gut and nose in the context of mode of delivery and feeding. Using 16S rRNA sequencing and specific qPCR, we profiled microbiota of 42 mother-infant pairs from the GUSTO birth cohort, at body sites including maternal vagina, rectum and skin; and infant stool and nose. In our study, overlap between maternal vaginal microbiota and infant faecal microbiota was minimal, while the similarity between maternal rectal microbiota and infant microbiota was more pronounced. However, an infant's nasal and gut microbiota were no more similar to that of its own mother, than to that of unrelated mothers. These findings were independent of delivery mode. We conclude that the transfer of maternal vaginal microbes play a minor role in seeding infant stool microbiota. Transfer of maternal rectal microbiota could play a larger role in seeding infant stool microbiota, but approaches other than the generally used analyses of community similarity measures are likely to be needed to quantify bacterial transmission. We confirmed the clear difference between microbiota of infants born by Caesarean section compared to vaginally delivered infants and the impact of feeding mode on infant gut microbiota. Only vaginally delivered, fully breastfed infants had gut microbiota dominated by Bifidobacteria. Our data suggest that reduced transfer of maternal vaginal microbial is not the main mechanism underlying the differential infant microbiota composition associated with Caesarean delivery. The sources of a large proportion of infant microbiota could not be identified in maternal microbiota, and the sources of seeding of infant gut and nasal microbiota remain to be elucidated.

[Pregnancy outcome during the bombing of Yugoslavia from March 24 to June 9, 1999].

PubMed

Krstić, Dragan; Marinković, Darko; Mirković, Ljiljana; Krstić, Jelena

2006-04-01

The aim of this study was to evaluate pregnancy outcome during the bombing of Yugoslavia in the period from March 24 to June 9, 1999. A retrospective study included a total of 81 spontaneous abortion following XII gestation week, and 1448 deliveries, hospitalized in the regional hospital. The analyzed were: the incidence of spontaneous abortion, Cesarean section, post-term delivery, vaginal delivery following the previous Cesarean section within the period from March 24 to June 9, 1999, and compared to the same periods in 1998 and 2000 by the use of chi2 and Kolgomorov-Smirnov tests. Under the conditions of a three-month stress imposed by the bombing, significantly increased were the incidence of spontaneous abortion and vaginal delivery following the previous Cesarean section, while the incidence of Cesarean section and post-term delivery were decreased, but the incidence of perinatal outcome was paradoxically improved. The analysis of findings on admittance revealed that iterative Cesarean section was performed electively, close to the expected term of delivery, and vaginal delivery following the previous Cesarean section mainly two weeks before that term with the admittance finding confirming a high active stage pregnancy. Within the bombing, statistically significantly was increased the percentage of abortions after XII gestation week, and the biological duration of pregnancy was reduced. The reduced duration of pregnancy complete with the accelerated fetal mutation (also caused by the stress) resulted in better perinatal outcome, and statistically significantly lower percentage of Cesarean section.

Wide differences in mode of delivery within Europe: risk-stratified analyses of aggregated routine data from the Euro-Peristat study.

PubMed

Macfarlane, A J; Blondel, B; Mohangoo, A D; Cuttini, M; Nijhuis, J; Novak, Z; Ólafsdóttir, H S; Zeitlin, J

2016-03-01

To use data from routine sources to compare rates of obstetric intervention in Europe both overall and for subgroups at higher risk of intervention. Retrospective analysis of aggregated routine data. Thirty-one European countries or regions contributing data on mode of delivery to the Euro-Peristat project. Births in participating countries in 2010. Countries provided aggregated data about overall rates of obstetric intervention and about caesarean section rates for specified subgroups. Mode of delivery. Rates of caesarean section ranged from 14.8% to 52.2% of all births and rates of instrumental vaginal delivery ranged from 0.5% to 16.4%. Overall, there was no association between rates of instrumental vaginal delivery and rates of caesarean section, but similarities were observed between some countries that are geographically close and may share common traditions of practice. Associations were observed between caesarean section rates for women with breech and vertex births and with singleton and multiple births but patterns of association for women who had and had not had previous caesarean sections were more complex. The persisting wide variations in caesarean section and instrumental vaginal delivery rates point to a lack of consensus about practice and raise questions for further investigation. Further research is needed to explore the impact of differences in clinical guidelines, healthcare systems and their financing and parents' and professionals' attitudes to care at delivery. © 2015 Royal College of Obstetricians and Gynaecologists.

Vaginal Microbiomes Associated With Aerobic Vaginitis and Bacterial Vaginosis.

PubMed

Kaambo, Evelyn; Africa, Charlene; Chambuso, Ramadhani; Passmore, Jo-Ann Shelley

2018-01-01

A healthy vaginal microbiota is considered to be significant for maintaining vaginal health and preventing infections. However, certain vaginal bacterial commensal species serve an important first line of defense of the body. Any disruption of this microbial barrier might result in a number of urogenital conditions including aerobic vaginitis (AV) and bacterial vaginosis (BV). The health of the vagina is closely associated with inhabitant microbiota. Furthermore, these microbes maintain a low vaginal pH, prevent the acquisition of pathogens, stimulate or moderate the local innate immune system, and further protect against complications during pregnancies. Therefore, this review will focus on vaginal microbial "health" in the lower reproductive tract of women and on the physiological characteristics that determine the well-being of reproductive health. In addition, we explore the distinct versus shared characteristics of BV and AV, which are commonly associated with increased risk for preterm delivery.

Vaginal Microbiomes Associated With Aerobic Vaginitis and Bacterial Vaginosis

PubMed Central

Kaambo, Evelyn; Africa, Charlene; Chambuso, Ramadhani; Passmore, Jo-Ann Shelley

2018-01-01

A healthy vaginal microbiota is considered to be significant for maintaining vaginal health and preventing infections. However, certain vaginal bacterial commensal species serve an important first line of defense of the body. Any disruption of this microbial barrier might result in a number of urogenital conditions including aerobic vaginitis (AV) and bacterial vaginosis (BV). The health of the vagina is closely associated with inhabitant microbiota. Furthermore, these microbes maintain a low vaginal pH, prevent the acquisition of pathogens, stimulate or moderate the local innate immune system, and further protect against complications during pregnancies. Therefore, this review will focus on vaginal microbial “health” in the lower reproductive tract of women and on the physiological characteristics that determine the well-being of reproductive health. In addition, we explore the distinct versus shared characteristics of BV and AV, which are commonly associated with increased risk for preterm delivery. PMID:29632854

The Role of Chronic Mesh Infection in Delayed-Onset Vaginal Mesh Complications or Recurrent Urinary Tract Infections: Results From Explanted Mesh Cultures.

PubMed

Mellano, Erin M; Nakamura, Leah Y; Choi, Judy M; Kang, Diana C; Grisales, Tamara; Raz, Shlomo; Rodriguez, Larissa V

2016-01-01

Vaginal mesh complications necessitating excision are increasingly prevalent. We aim to study whether subclinical chronically infected mesh contributes to the development of delayed-onset mesh complications or recurrent urinary tract infections (UTIs). Women undergoing mesh removal from August 2013 through May 2014 were identified by surgical code for vaginal mesh removal. Only women undergoing removal of anti-incontinence mesh were included. Exclusion criteria included any women undergoing simultaneous prolapse mesh removal. We abstracted preoperative and postoperative information from the medical record and compared mesh culture results from patients with and without mesh extrusion, de novo recurrent UTIs, and delayed-onset pain. One hundred seven women with only anti-incontinence mesh removed were included in the analysis. Onset of complications after mesh placement was within the first 6 months in 70 (65%) of 107 and delayed (≥6 months) in 37 (35%) of 107. A positive culture from the explanted mesh was obtained from 82 (77%) of 107 patients, and 40 (37%) of 107 were positive with potential pathogens. There were no significant differences in culture results when comparing patients with delayed-onset versus immediate pain, extrusion with no extrusion, and de novo recurrent UTIs with no infections. In this large cohort of patients with mesh removed for a diverse array of complications, cultures of the explanted vaginal mesh demonstrate frequent low-density bacterial colonization. We found no differences in culture results from women with delayed-onset pain versus acute pain, vaginal mesh extrusions versus no extrusions, or recurrent UTIs using standard culture methods. Chronic prosthetic infections in other areas of medicine are associated with bacterial biofilms, which are resistant to typical culture techniques. Further studies using culture-independent methods are needed to investigate the potential role of chronic bacterial infections in delayed vaginal mesh complications.

The Effect of Labor on the Intraocular Pressure in Healthy Women.

PubMed

Meshi, Amit; Armarnik, Sharon; Mimouni, Michael; Segev, Fani; Segal, Ori; Kaneti, Hagai; Assia, Ehud I; Geffen, Noa

2017-01-01

To investigate the effect of modern vaginal labor using epidural anesthesia on the intraocular pressure (IOP) and on the mean ocular perfusion pressure (MOPP) in healthy women. In this prospective observational study, eligible candidates were healthy pregnant women for vaginal delivery with epidural anesthesia, with a singleton pregnancy, who were admitted to the delivery room in the first phase of the first stage of labor. Demographic data as well as medical and obstetric history were obtained at baseline, followed by performance of a biomicroscopic examination. IOP, maternal heart rate, systolic blood pressure, and diastolic blood pressure were measured in the first, second and third stages of labor, 24±2 and 48±2 hours postpartum. IOP was not measured during the contraction phase of stage 2. MOPP was expressed as the difference between the arterial blood pressure and the IOP. Measurements were performed throughout the different stages of labor and were compared with baseline values. Thirty healthy white women were enrolled. Four women dropped out due to unexpected cesarean sections. The average age was 31.8±4.7 years. Nineteen participants received oxytocin during delivery. Twenty-three women were placed in a supine position, whereas 3 in a left decubitus position. No statistically significant changes were recorded in IOP (P=0.50) or MOPP (P=0.17) throughout the different stages of vaginal labor in this study. Vaginal delivery under epidural anesthesia is unlikely to cause significant damage to the optic nerve in healthy women.

Evaluation of the vaginal flora in pregnant women receiving opioid maintenance therapy: a matched case-control study.

PubMed

Farr, Alex; Kiss, Herbert; Hagmann, Michael; Holzer, Iris; Kueronya, Verena; Husslein, Peter W; Petricevic, Ljubomir

2016-08-05

Vaginal infections are a risk factor for preterm delivery. In this study, we sought to evaluate the vaginal flora of pregnant women receiving opioid maintenance therapy (OMT) in comparison to non-dependent, non-maintained controls. A total of 3763 women with singleton pregnancies who underwent routine screening for asymptomatic vaginal infections between 10 + 0 and 16 + 0 gestational weeks were examined. Vaginal smears were Gram-stained, and microscopically evaluated for bacterial vaginosis, candidiasis, and trichomoniasis. In a retrospective manner, data of 132 women receiving OMT (cases) were matched for age, ethnicity, parity, education, previous preterm delivery, and smoking status to the data of 3631 controls. The vaginal flora at antenatal screening served as the primary outcome measure. Secondary outcome measures were gestational age and birth weight. In the OMT group, 62/132 (47 %) pregnant women received methadone, 39/132 (29.5 %) buprenorphine, and 31/132 (23.5 %) slow-release oral morphine. Normal or intermediate flora was found in 72/132 OMT women (54.5 %) and 2865/3631 controls [78.9 %; OR 0.49 (95 % CI, 0.33-0.71); p < 0.001]. Candidiasis occurred more frequently in OMT women than in controls [OR 2.11 (95 % CI, 1.26-3.27); p < 0.001]. Findings were inconclusive regarding bacterial vaginosis (± candidiasis) and trichomoniasis. Compared to infants of the control group, those of women with OMT had a lower mean birth weight [MD -165.3 g (95 % CI, -283.6 to -46.9); p = 0.006]. Pregnant women with OMT are at risk for asymptomatic vaginal infections. As recurrent candidiasis is associated with preterm delivery, the vulnerability of this patient population should lead to consequent antenatal infection screening at early gestation.

Invasive Obstetric Procedures and Cesarean Sections in Women With Known Herpes Simplex Virus Status During Pregnancy.

PubMed

Stankiewicz Karita, Helen C; Moss, Nicholas J; Laschansky, Ellen; Drolette, Linda; Magaret, Amalia S; Selke, Stacey; Gardella, Carolyn; Wald, Anna

2017-01-01

Neonatal herpes is a potentially devastating infection that results from acquisition of herpes simplex virus (HSV) type 1 or 2 from the maternal genital tract at the time of vaginal delivery. Current guidelines recommend (1) cesarean delivery if maternal genital HSV lesions are present at the time of labor and (2) antiviral suppressive therapy for women with known genital herpes to decrease HSV shedding from the genital tract at the time of vaginal delivery. However, most neonatal infections occur in infants born to women without a history of genital HSV, making current prevention efforts ineffective for this group. Although routine serologic HSV testing of women during pregnancy could identify women at higher risk of intrapartum viral shedding, it is uncertain how this knowledge might impact intrapartum management, and a potential concern is a higher rate of cesarean sections among women known to be HSV-2 seropositive. To assess the effects of prenatal HSV-2 antibody testing, history of genital herpes, and use of suppressive antiviral medication on the intrapartum management of women, we investigated the frequency of invasive obstetric procedures and cesarean deliveries. We conducted a retrospective cohort study of pregnant women delivering at the University of Washington Medical center in Seattle, Washington. We defined the exposure of interest as HSV-2 antibody positivity or known history of genital herpes noted in prenatal records. The primary outcome was intrapartum procedures including fetal scalp electrode, artificial rupture of membranes, intrauterine pressure catheter, or operative vaginal delivery (vacuum or forceps). The secondary outcome was incidence of cesarean birth. Univariate and multivariable logistic regressions were performed. From a total of 449 women included in the analysis, 97 (21.6%) were HSV-2 seropositive or had a history of genital herpes (HSV-2/GH). Herpes simplex virus-2/GH women not using suppressive antiviral therapy were less likely to undergo intrapartum procedures than women without HSV-2/GH (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.25-0.95; P = .036), but this relationship was attenuated after adjustment for potential confounders (adjusted OR, 0.69; 95% CI, 0.34-1.41; P = .31). There was no difference in intrapartum procedures for women on suppressive therapy versus women without HSV-2/GH (OR, 1.17; 95% CI, 0.66-2.07; P = .60). Similar proportions of cesarean sections were performed within each group of women: 25% without history of HSV-2/GH, 30% on suppressive treatment, and 28.1% without suppressive treatment (global, P = .73). In this single-site study, provider awareness of genital herpes infection either by HSV serotesting or history was associated with fewer invasive obstetric procedures shown to be associated with neonatal herpes, but it was not associated with an increased rate of cesarean birth.

Changes of uterine blood flow after vaginal radical trachelectomy (VRT) in patients with early-stage uterine invasive cervical cancer.

PubMed

Umemura, Kota; Ishioka, Shin-ichi; Endo, Toshiaki; Baba, Tsuyoshi; Ezaka, Yoshiaki; Nagasawa, Kunihiko; Takahashi, Madoka; Mizuuchi, Masahito; Iwami, Nanako; Adachi, Hidefumi; Takeda, Noriko; Tamagawa, Mitsuharu; Saito, Tsuyoshi

2010-08-05

Vaginal radical trachectomy (RT) ligates and cuts several arteries supplying the uterus. Changes of blood supply to the uterus in two patients who experienced pregnancy and delivery were studied by using 3-D CT scanning. Effects of changes of blood supply to the uterus on the pregnancy courses were also examined. Vascular distribution in the uterus was studied in two patients who received vaginal RT after delivery. Effects of changes of vascular distribution after vaginal RT were studied with respect to pregnancy courses and cervical functions. New arterial vascularization from the ascending branches of uterine arteries or other arteries occurred, and these new vessels seemed to supply blood to the remaining cervix. Differences of fetal growth and histopathological changes in the placenta between the two patients could not be detected. Ligation and cutting of several supplying arteries by RT induces new arterial vascularization and it does not seem to affect fetal growth and placental function.

Optimal timing of misoprostol administration in nulliparous women undergoing office hysteroscopy: a randomized double-blind placebo-controlled study.

PubMed

Fouda, Usama M; Gad Allah, Sherine H; Elshaer, Hesham S

2016-07-01

To determine the optimal timing of vaginal misoprostol administration in nulliparous women undergoing office hysteroscopy. Randomized double-blind placebo-controlled study. University teaching hospital. One hundred twenty nulliparous patients were randomly allocated in a 1:1 ratio to the long-interval misoprostol group or the short-interval misoprostol group. In the long-interval misoprostol group, two misoprostol tablets (400 μg) and two placebo tablets were administered vaginally at 12 and 3 hours, respectively, before office hysteroscopy. In the short-interval misoprostol group, two placebo tablets and two misoprostol tablets (400 μg) were administered vaginally 12 and 3 hours, respectively, before office hysteroscopy. The severity of pain was assessed by the patients with the use of a 100-mm visual analog scale (VAS). The operators assessed the ease of the passage of the hysteroscope through the cervical canal with the use of a 100-mm VAS as well. Pain scores during the procedure were significantly lower in the long-interval misoprostol group (37.98 ± 13.13 vs. 51.98 ± 20.68). In contrast, the pain scores 30 minutes after the procedure were similar between the two groups (11.92 ± 7.22 vs. 13.3 ± 6.73). Moreover, the passage of the hysteroscope through the cervical canal was easier in the long-interval misoprostol group (48.9 ± 17.79 vs. 58.28 ± 21.85). Vaginal misoprostol administration 12 hours before office hysteroscopy was more effective than vaginal misoprostol administration 3 hours before office hysteroscopy in relieving pain experienced by nulliparous patients undergoing office hysteroscopy. NCT02316301. Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

The Sheep as a Model of Preclinical Safety and Pharmacokinetic Evaluations of Candidate Microbicides

PubMed Central

Cameron, David; Dias, Nicola; Holding, Jeremy; Muntendam, Alex; Oostebring, Freddy; Dreier, Peter; Rohan, Lisa; Nuttall, Jeremy

2015-01-01

When developing novel microbicide products for the prevention of HIV infection, the preclinical safety program must evaluate not only the active pharmaceutical ingredient but also the product itself. To that end, we applied several relatively standard toxicology study methodologies to female sheep, incorporating an assessment of the pharmacokinetics, safety, tolerability, and local toxicity of a dapivirine-containing human vaginal ring formulation (Dapivirine Vaginal Ring-004). We performed a 3-month general toxicology study, a preliminary pharmacokinetic study using drug-loaded vaginal gel, and a detailed assessment of the kinetics of dapivirine delivery to plasma, vaginal, and rectal fluid and rectal, vaginal, and cervical tissue over 28 days of exposure and 3 and 7 days after removal of the ring. The findings of the general toxicology study supported the existing data from both preclinical and clinical studies in that there were no signs of toxicity related to dapivirine. In addition, the presence of the physical dapivirine ring did not alter local or systemic toxicity or the pharmacokinetics of dapivirine. Pharmacokinetic studies indicated that the dapivirine ring produced significant vaginal tissue levels of dapivirine. However, no dapivirine was detected in cervical tissue samples using the methods described here. Plasma and vaginal fluid levels were lower than those in previous clinical studies, while there were detectable dapivirine levels in the rectal tissue and fluid. All tissue and fluid levels tailed off rapidly to undetectable levels following removal of the ring. The sheep represents a very useful model for the assessment of the safety and pharmacokinetics of microbicide drug delivery devices, such as the vaginal ring. PMID:25845860

Comparing provision and appropriateness of health care between immigrants and non-immigrants in Germany using the example of neuraxial anaesthesia during labour: cross-sectional study.

PubMed

Razum, Oliver; Reiss, Katharina; Breckenkamp, Jürgen; Kaufner, Lutz; Brenne, Silke; Bozorgmehr, Kayvan; Borde, Theda; David, Matthias

2017-08-21

Research on health services for immigrants has mostly been concerned with access barriers but rarely with appropriateness and responsiveness of care. We assessed whether appropriateness and responsiveness of care depend on migration status, using provision of neuraxial anaesthesia (NA) during labour as indicator. In relation to their migration status, we analysed whether (1) women undergoing elective or secondary/urgent secondary caesarean sections (ESCS) appropriately receive NA (instead of general anaesthesia), (2) women delivering vaginally appropriately receive NA and (3) women objecting to NA, for example, for religious reasons, may deliver vaginally without receiving NA (provider responsiveness). Cross-sectional study. Three obstetric hospitals in Berlin, Germany. Questionnaire survey covering 6391 women with migration history (first and second generations) and non-immigrant women giving birth; data linkage with routine obstetric data. We assessed the effects of migrant status, German language proficiency, religion and education on the provision of NA (primary outcome) after adjusting for other maternal and obstetric parameters. The chance of receiving NA for elective/ESCS was independent of migrant status after controlling for confounding variables (adjusted OR (aOR) 0.93, 95% CI 0.65 to 1.33). In vaginal deliveries, first (but not second) generation women (aOR 0.79, 95% CI 0.65 to 0.95), women with low German language skills (aOR 0.77, 95% CI 0.58 to 0.99) and women with low educational attainment (aOR 0.62, 95% CI 0.47 to 0.82) had lower chances of receiving NA; there was no evidence of overprovision among women with strong affinity to Islam (aOR 0.77, 95% CI 0.63 to 0.94). We found evidence for underprovision of care among first-generation immigrants, among women with low German language proficiency and particularly among all women with low educational attainment, irrespective of migration status. There was no evidence for overprovision of care to immigrant women, either inappropriately (general anaesthesia for ESCS) or because of low provider responsiveness (no opt-out for NA in vaginal delivery). © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Comparable risk of childhood asthma after vaginal delivery and emergency caesarean section.

PubMed

Brix, Nis; Stokholm, Lonny; Jonsdottir, Fjola; Kristensen, Kim; Secher, Niels Jørgen

2017-01-01

Caesarean section is thought to be a risk factor for childhood asthma, but this association may be caused by confounding from, for instance, familial factors. To address this problem, we used twin pairs to assess the risk of childhood asthma after emergency caesarean section. The study was a register-based nation-wide matched cohort study using twin pairs to minimise residual confounding. Included were twin pairs in which the first twin was delivered vaginally and the second by emergency caesarean section during the study period from January 1997 through December 2012. In total, 464 twin pairs (928 twins) were included. In 30 pairs, the first twin (vaginal delivery) was diagnosed with asthma, but the second twin (emergency caesarean section) was not. In 20 pairs, the second twin (emergency caesarean section) was diagnosed with asthma, but the first twin (vaginal delivery) was not. In 11 pairs, both twins developed asthma. In the unadjusted analysis, emergency caesarean section did not affect the risk of asthma (odds ratio = 0.67 (95% confidence interval: 0.38-1.17); p = 0.16). After adjusting for birth weight, gender, umbilical cord pH, Apgar score at 5 min. and neonatal respiratory morbidity, the risk of childhood asthma following emergency caesarean section remained unchanged. Emergency caesarean section was not associated with childhood asthma. none. not relevant.

Vaginal Film Drug Delivery of the Pyrimidinedione IQP-0528 for the Prevention of HIV Infection

PubMed Central

Ham, Anthony S.; Rohan, Lisa Cencia; Boczar, Ashlee; Yang, Lu; Buckheit, Karen W; Buckheit, Robert W.

2015-01-01

Purpose Polymeric quick dissolving films were developed as a solid dosage topical microbicide formulation for the vaginal delivery of the highly potent and non-toxic, dual-acting HIV nonnucleoside reverse transcriptase inhibitor (NNRTI) pyrimidinedione, IQP-0528. Methods Formulated from approved excipients, a polyvinyl alcohol (PVA) based film was manufactured via solvent casting methods. The film formulations were evaluated based upon quantitative physicochemical evaluations defined by a Target Product Profile (TPP) Results Films dosed with 0.1 % (w/w) of IQP-0528 disintegrated within 10 minutes with over 50% of drug released and near 100% total drug released after 30 minutes. The IQP-0528 films were found to be non-toxic in in vitro CEM-SS and PBMC cell-based assays and biologically active with sub-nanomolar efficacy against HIV-1 infection. In a 12 month stability protocol, the IQP-0528 films demonstrated no significant degradation at International Conference on Harmonization (ICH) recommended standard (25°C / 65% relative humidity (R.H.)) and accelerated (40°C / 75% R.H.) environmental conditions. Conclusions Based on the above evaluations, a vaginal film formulation has been identified as a potential solid dosage form for the vaginal delivery of the topical microbicide candidate IQP-0528. PMID:22392331

Long-term impacts of vaginal birth with mediolateral episiotomy on sexual and pelvic dysfunction and perineal pain.

PubMed

Doğan, Bülent; Gün, İsmet; Özdamar, Özkan; Yılmaz, Ali; Muhçu, Murat

2017-02-01

To investigate whether spontaneous vaginal birth with mediolateral episiotomy has any long-term impact on urinary and/or fecal incontinence, sexual dysfunction and perineal pain in primiparous women. This matched case-control study included 150 women between 25 and 35 years old who had a singleton childbirth at least five years previously. Patients were grouped as; women who had a spontaneous vaginal delivery with mediolateral episiotomy (Group 1), an elective cesarean delivery (Group 2), and who had no delivery (Group 3). Controls were matched for age and delivery time. Urinary/fecal incontinence were questioned and Female Sexual Function Index (FSFI) questionnaire was completed. Total FSFI and domain scores were compared. Statistical evaluation was performed using One-way ANOVA test or χ 2 test. Statistical significance was defined as p < 0.05. No women had urinary/fecal incontinence nor sexual dysfunction. Mean total FSFI points in Group 1 were significantly lower than in Groups 2 and 3 (p = 0.001). There were significant differences in sexual desire between groups 1 and 3 (p = 0.005), in arousal and in orgasm between both groups 1 and 2 (p = 0.001 and p = 0.038, respectively) and groups 1 and 3 (p = 0.001 and p = 0.001, respectively). There was no significant difference between groups 2 and 3 in any parameters or total points. Vaginal delivery with mediolateral episiotomy is not associated with urinary and/or fecal incontinence and sexual dysfunction but associated with a decreased sexual functioning as well as sexual desire, arousal and orgasm within postpartum five years.

Cost-effectiveness of Carbetocin versus Oxytocin for Prevention of Postpartum Hemorrhage Resulting from Uterine Atony in Women at high-risk for bleeding in Colombia.

PubMed

Gil-Rojas, Yaneth; Lasalvia, Pieralessandro; Hernández, Fabián; Castañeda-Cardona, Camilo; Rosselli, Diego

2018-05-01

 To assess the cost-effectiveness of carbetocin versus oxytocin for prevention of postpartum hemorrhage (PPH) due to uterine atony after vaginal delivery/cesarean section in women with risk factors for bleeding.  A decision tree was developed for vaginal delivery and another one for cesarean, in which a sequential analysis of the results was obtained with the use of carbetocin and oxytocin for prevention of PPH and related consequences. A third-party payer perspective was used; only direct medical costs were considered. Incremental costs and effectiveness in terms of quality-adjusted life years (QALYs) were evaluated for a one-year time horizon. The costs were expressed in 2016 Colombian pesos (1 USD = 3,051 Col$).  In the vaginal delivery model, the average cost of care for a patient receiving prophylaxis with uterotonic agents was Col$ 347,750 with carbetocin and Col$ 262,491 with oxytocin, while the QALYs were 0.9980 and 0.9979, respectively. The incremental cost-effectiveness ratio is above the cost-effectiveness threshold adopted by Colombia. In the model developed for cesarean section, the average cost of a patient receiving prophylaxis with uterotonics was Col$ 461,750 with carbetocin, and Col$ 481,866 with oxytocin, and the QALYs were 0.9959 and 0.9926, respectively. Carbetocin has lower cost and is more effective, with a saving of Col$ 94,887 per avoided hemorrhagic event.  In case of elective cesarean delivery, carbetocin is a dominant alternative in the prevention of PPH compared with oxytocin; however, it presents higher costs than oxytocin, with similar effectiveness, in cases of vaginal delivery. Thieme Revinter Publicações Ltda Rio de Janeiro, Brazil.

Shortening the induction delivery interval with prostaglandins: a randomized controlled trial of solo or in combination

PubMed Central

Mahendru, Rajiv; Yadav, Shweta

2011-01-01

Objective To compare the efficacy and safety of misoprostol alone with dinoprostone followed by misoprostol, all inserted intravaginally in induction of labor at term and the obstetrical outcome. Material and Methods A pilot study comprising 111 primigravidae, >37 gestational weeks with singleton pregnancy in cephalic presentation having an unfavorable Bishop score admitted for labor induction, were considered and randomly allocated into two groups. In group I (n=55) with intravaginal 25mcg misoprostol 4 hourly (six doses at the most) and and group II (n=56), with dinoprostone 0.5mg followed eight hours later by 25mcg misoprostol induction to vaginal delivery time was found to be significantly different, being 14.8 h in group-I and shorter in group-II with a mean of 11.6 h. Vaginal delivery rates within 12 h (groups-I and −II: 47.2%, as compared to 60.7%, respectively) were found to be higher with dinoprostone-misoprostol induction, as well as vaginal delivery rates in 24 h, 80.0% and 91.1%. The need for oxytocin augmentation was more frequent in the misoprostol than in the dinoprostone-misoprostol group, (61.8%, and 39.3%), and all these observations were statistically significant. Abnormal foetal heart rate pattern occurred more frequently (18.2%) in group-I in contrast to 5.3% in group-II, as was the incidence rate of (18.2%) who had passage of meconium in group-I, this rate being significantly different from group-II having meconium passage in 3 cases, a rate of 5.3%. Conclusion Using dinoprostone followed by vaginal misoprostol is safe and effective for induction of labor with less need for oxytocin augmentation and shorter induction delivery interval. PMID:24591967

Intrapartum intervention rates and perinatal outcomes following induction of labour compared to expectant management at term from an Australian perinatal centre.

PubMed

Zhao, Yi; Flatley, Christopher; Kumar, Sailesh

2017-02-01

Induction of labor (IOL) is a common obstetric intervention, yet its impact on intervention rates and perinatal outcomes is conflicting. To evaluate the impact of IOL on intrapartum intervention rates and perinatal outcomes in women with singleton pregnancies at term. This was a retrospective, cross-sectional study of term singleton deliveries at the Mater Mother's Hospital in Brisbane, Australia in 2007-2013. The IOL cohort was compared to an expectantly managed group. Of the final cohort (44 698 women), 64.4% had expectant management and 35.6% had IOL. Multivariate analyses showed that IOL was associated with lower odds of spontaneous vaginal delivery from ≥37 weeks gestation. The risk of emergency caesarean for non-reassuring fetal status was also higher in the IOL cohort at 40 and 41 weeks gestation. For women who were managed expectantly, the highest rate of spontaneous vaginal delivery and the lowest rate of emergency caesareans occurred at 39 weeks gestation. For women who underwent IOL, the nadir emergency caesarean rate and the highest spontaneous vaginal delivery rate was also at 39 weeks. Rates of neonatal intensive car unit admission were higher in the IOL group at 37 weeks (adjusted odds ratio (aOR) 3.11, 95% CI: 2.62-3.68) and 38 weeks (aOR 1.78, 95% CI: 1.55-2.04) and lower at >42 weeks (OR 0.35, 95% CI: 0.14-0.81) respectively. IOL compared to expectant management is associated with lower spontaneous vaginal delivery rates and increased risk of emergency caesarean for intrapartum fetal compromise with broadly comparable perinatal outcomes. © 2017 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Determination of a cutoff value for pelvic floor distensibility using the Epi-no balloon to predict perineal integrity in vaginal delivery: ROC curve analysis. Prospective observational single cohort study.

PubMed

Zanetti, Miriam Raquel Diniz; Petricelli, Carla Dellabarba; Alexandre, Sandra Maria; Paschoal, Aline; Araujo Júnior, Edward; Nakamura, Mary Uchiyama

2016-04-01

Several risk factors are involved in perineal lacerations during vaginal delivery. However, little is known about the influence of perineal distensibility as a protective factor. The aim here was to determine a cutoff value for pelvic floor distensibility measured using the Epi-no balloon, which could be used as a predictive factor for perineal integrity in vaginal delivery. Prospective observational single cohort study conducted in a maternity hospital. A convenience sample of 227 consecutive at-term parturients was used. All women had a single fetus in the vertex presentation, with up to 9.0 cm of dilation. The maximum dilation of the Epi-no balloon was measured using a tape measure after it had been inflated inside the vagina up to the parturients' maximum tolerance. The receiver operating characteristic (ROC) curve was used to obtain the Epi-no circumference measurement with best sensitivity and specificity. Among the 161 patients who were included in the study, 50.9% underwent episiotomy, 21.8% presented lacerations and 27.3% retained an intact perineum. Age > 25.9 years; number of pregnancies > 3.4; number of deliveries > 2.2 and circumference measured by Epi-no > 21.4 cm were all directly correlated with an intact perineum. Circumference measurements using the Epi-no balloon that were greater than 20.8 cm showed sensitivity and specificity of 70.5% and 66.7% (area under curve = 0.713), respectively, as a predictive factor for an intact perineum in vaginal delivery. Circumferences greater than 20.8 cm achieved using the Epi-no balloon are a predictive factor for perineal integrity in parturients.

Providing lipid-based nutrient supplement during pregnancy does not reduce the risk of maternal P falciparum parasitaemia and reproductive tract infections: a randomised controlled trial.

PubMed

Nkhoma, Minyanga; Ashorn, Per; Ashorn, Ulla; Dewey, Kathryn G; Gondwe, Austrida; Mbotwa, John; Rogerson, Stephen; Taylor, Steve M; Maleta, Kenneth

2017-01-17

Maternal infections are associated with maternal and foetal adverse outcomes. Nutrient supplementation during pregnancy may reduce the occurrence of infections by improving maternal immunity. We aimed to investigate the impact of small-quantity lipid-based nutrient supplement (SQ-LNS) on the occurrence of Plasmodium falciparum parasitaemia during pregnancy and trichomoniasis, vaginal candidiasis and urinary tract infection (UTI) after delivery. Pregnant Malawian women enrolled in the iLiNS-DYAD trial receiving daily supplementation with SQ-LNS, multiple micronutrients (MMN) or iron & folic acid (IFA) from <20 gestation weeks (gw) were assessed for P. falciparum parasitaemia at 32 gw using rapid diagnostic testing (RDT), at 36 gw using polymerase chain reaction (PCR) and at delivery using both RDT and PCR; and at one week after delivery for trichomoniasis and vaginal candidiasis using wet mount microscopy and for UTI using urine dipstick analysis. The prevalence of each infection by intervention group was estimated at the prescribed time points and the global null hypothesis was tested using logistic regression. Adjusted analyses were performed using preselected covariates. The prevalence of P. falciparum parasitaemia was 10.7% at 32 gw, 9% at 36 gw, and 8.3% by RDT and 20.2% by PCR at delivery. After delivery the prevalence of trichomoniasis was 10.5%, vaginal candidiasis was 0.5%, and UTI was 3.1%. There were no differences between intervention groups in the prevalence of any of the infections. In this population, SQ-LNS did not influence the occurrence of maternal P. falciparum parasitaemia, trichomoniasis, vaginal candidiasis or UTI. Identifier: NCT01239693 (10 November 2010).

Vaginal delivery to reduce the risk of hypothermia to newborn

NASA Astrophysics Data System (ADS)

Zulala, Nuli Nuryanti; Sitaresmi, Mei Neni; Sulistyaningsih

2017-08-01

The prevalence of hypothermia in the world is in the range of 8.5% to 52%, while in Indonesia it is around 47%. Hypothermia has caused 6.3% of neonatal deaths. The method in the process of giving birth determines the way to take care of the newborn. This study aims to observe the effect of the method of delivery on the hypothermia in newborn. This research has obtained an approval from the Ethics Committee of Aisyiyah University, Yogyakarta. This prospective cohort study was conducted to 74 newborns in November 2016. The research subjects were divided into the group of Caesarian section (n = 28) and the group of vaginal delivery (n = 46). Axillary temperature was measured using a digital thermometer at 1st minute, 30th minute, 60th minute, 6th hour, 12th hour and 24th hour. The average temperature difference between the caesarian section group and vaginal delivery group at the 1st minute was at 36°C vs. 36.4° C, at 30th minute at 35.7°C vs. 36.5°C, at 60th minute at 36°C vs. 36.5°C), at 6th hour at 36.2 °C vs. 36.6°C), 12th hour at 36.4°C vs. 36.7°C, and at 24th hour at 36.7°C vs. 36.8°C. The results of the study showed that vaginal delivery could reduce the risk of hypothermia by 1.5 times compared to caesarian section (ρ-value 0.004 CI 95% 1.154 to 1.880)

Vaginal distribution and retention of a multiparticulate drug delivery system, assessed by gamma scintigraphy and magnetic resonance imaging.

PubMed

Mehta, Samata; Verstraelen, Hans; Peremans, Kathelijne; Villeirs, Geert; Vermeire, Simon; De Vos, Filip; Mehuys, Els; Remon, Jean Paul; Vervaet, Chris

2012-04-15

For any new vaginal dosage form, the distribution and retention in the vagina has to be assessed by in vivo evaluation. We evaluated the vaginal distribution and retention of starch-based pellets in sheep as live animal model by gamma scintigraphy (using Indium-111 DTPA as radiolabel) and in women via magnetic resonance imaging (MRI, using a gadolinium chelate as contrast agent). A conventional cream formulation was used as reference in both studies. Cream and pellets were administered to sheep (n=6) in a two period-two treatment study and to healthy female volunteers (n=6) via a randomized crossover trial. Pellets (filled into hard gelatin capsule) and cetomacrogol cream, both labeled with Indium-111 DTPA (for gamma scintigraphy) or with gadolinium chelate (for MRI) were evaluated for their intravaginal distribution and retention over a 24h period. Spreading in the vagina was assessed based on the part of the vagina covered with formulation (expressed in relation to the total vaginal length). Vaginal retention of the formulation was quantified based on the radioactivity remaining in the vaginal area (sheep study), or qualitatively evaluated (women study). Both trials indicated a rapid distribution of the cream within the vagina as complete coverage of the vaginal mucosa was seen 1h after dose administration. Clearance of the cream was rapid: about 10% activity remained in the vaginal area of the sheep 12h post-administration, while after 8h only a thin layer of cream was detected on the vaginal mucosa of women. After disintegration of the hard gelatin capsule, the pellet formulation gradually distributed over the entire vaginal mucosa. Residence time of the pellets in the vagina was longer compared to the semi-solid formulation: after 24h 23 ± 7% radioactivity was detected in the vaginal area of the sheep, while in women the pellet formulation was still detected throughout the vagina. A multi-particulate system containing starch-based pellets was identified as a promising novel vaginal drug delivery system, resulting in complete coverage of the vaginal mucosa and long retention time. Copyright © 2012 Elsevier B.V. All rights reserved.

Vaginal birth after cesarean: new insights on maternal and neonatal outcomes.

PubMed

Guise, Jeanne-Marie; Denman, Mary Anna; Emeis, Cathy; Marshall, Nicole; Walker, Miranda; Fu, Rongwei; Janik, Rosalind; Nygren, Peggy; Eden, Karen B; McDonagh, Marian

2010-06-01

To systematically review the evidence about maternal and neonatal outcomes relating to vaginal birth after cesarean (VBAC). Relevant studies were identified from multiple searches of MEDLINE, DARE, and the Cochrane databases (1980 to September 2009) and from recent systematic reviews, reference lists, reviews, editorials, Web sites, and experts. Inclusion criteria limited studies to the English-language and human studies conducted in the United States and developed countries specifically evaluating birth after previous cesarean delivery. Studies focusing on high-risk maternal or neonatal conditions, including breech vaginal delivery, or fewer than 10 patients were excluded. Poor-quality studies were not included in analyses. We identified 3,134 citations and reviewed 963 articles for inclusion; 203 articles met the inclusion criteria and were quality rated. Overall rates of maternal harms were low for both trial of labor and elective repeat cesarean delivery. Although rare in both elective repeat cesarean delivery and trial of labor, maternal mortality was significantly increased for elective repeat cesarean delivery at 0.013% compared with 0.004% for trial of labor. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between trial of labor and elective repeat cesarean delivery. The rate of uterine rupture for all women with prior cesarean was 0.30%, and the risk was significantly increased for trial of labor (0.47% compared with 0.03% for elective repeat cesarean delivery). Perinatal mortality was also significantly increased for trial of labor (0.13% compared with 0.05% for elective repeat cesarean delivery). Overall the best evidence suggests that VBAC is a reasonable choice for the majority of women. Adverse outcomes were rare for both elective repeat cesarean delivery and trial of labor. Definitive studies are lacking to identify patients who are at greatest risk for adverse outcomes.

Impact of maternal age on delivery outcomes following spontaneous labour at term.

PubMed

Omih, Edwin Eseoghene; Lindow, Stephen

2016-10-01

Pregnancy in women of advancing maternal age is linked to incrementally worsening perinatal outcome. The aim of this study is to assess the impact of maternal age on delivery outcome in women that spontaneously labour at term. This was a retrospective study of women that spontaneously labour at term. Women with singletons in spontaneous onset labour beyond 37 weeks of gestation were divided into five maternal age groups: <19 years, 20-24 years, 25-29 years, 30-34 years and >35 years by their age at delivery. The main outcome variables are augmentation of labour, caesarean section, assisted vaginal delivery, and perineal trauma, while admission of the newborn into the neonatal unit within 24 h following delivery was the secondary outcome measure. A total of 30,022 met the inclusion criteria with primiparae and multiparae accounting for 46 and 54%, respectively. Increasing age in primiparae was associated with; augmentation of labour OR 2.05 (95% CI 1.73-2.43), second degree perineal tear 1.35 (1.12-1.61), assisted vaginal delivery 1.92 (1.53-2.41) and caesarean section 4.23 (3.19-5.12). While that for multiparae; augmentation of labour OR 1.93 (1.05-3.52), perineal trauma 2.50 (1.85-3.34), assisted vaginal delivery 4.95 (91.82-13.35) and caesarean section 1.64 (1.13-2.38). The secondary outcome measure did not reach statistical significance. Increasing maternal age is an independent risk factor for operative delivery, and perineal trauma. However, maternal age has no significant effect on admission of infants into the NICU during the first 24 h following delivery.

The impact of occiput posterior fetal head position on the risk of anal sphincter injury in forceps-assisted vaginal deliveries.

PubMed

Benavides, Lorena; Wu, Jennifer M; Hundley, Andrew F; Ivester, Thomas S; Visco, Anthony G

2005-05-01

A forceps-assisted vaginal delivery is a well-recognized risk factor for anal sphincter injury. Some studies have shown that occiput posterior (OP) fetal head position is also associated with an increased risk for third- or fourth-degree lacerations. The objective of this study was to assess whether OP position confers an incrementally increased risk for anal sphincter injury above that present with forceps deliveries. This was a retrospective cohort study of 588 singleton, cephalic, forceps-assisted vaginal deliveries performed at our institution between January 1996 and October 2003. Maternal demographics, labor and delivery characteristics, and neonatal factors were examined. Statistical analysis consisted of univariate statistics, Student t test, chi2, and logistic regression. The prevalence of occiput anterior (OA) and OP positions was 88.4% and 11.6%, respectively. The groups were similar in age, marital status, body mass index, use of epidural, frequency of inductions, episiotomies, and shoulder dystocias. The OA group had a higher frequency of rotational forceps (16.2% vs 5.9%, P = .03), greater birth weights (3304 +/- 526 g vs 3092 +/- 777 g, P = .004), and a larger percentage of white women (48.8% vs 34.3%, P = .04). Overall, 35% of forceps deliveries resulted in a third- or fourth-degree laceration. Anal sphincter injury occurred significantly more often in the OP group compared with the OA group (51.5% vs 32.9%, P = .003), giving an odds ratio of 2.2 (CI: 1.3-3.6). In a logistic regression model that controlled for occiput posterior position, maternal body mass index, race, length of second stage, episiotomy, birth weight, and rotational forceps, OP head position was 3.1 (CI: 1.6-6.2) times more likely to be associated with anal sphincter injury than OA head position. Forceps-assisted vaginal deliveries have been associated with a greater risk for anal sphincter injury. Within this population of forceps deliveries, an OP position further increases the risk of third- or fourth-degree lacerations when compared with an OA position.

First birth Caesarean section and subsequent fertility: a population-based study in the USA, 2000-2008.

PubMed

Kjerulff, K H; Zhu, J; Weisman, C S; Ananth, C V

2013-12-01

Is first birth Caesarean delivery associated with a lower likelihood of subsequent childbearing when compared with first birth vaginal delivery? In this study of US women whose first delivery was in 2000, those who had a Caesarean delivery were less likely to have a subsequent live birth than those who delivered vaginally. Some studies have reported lower birth rates subsequent to Caesarean delivery in comparison with vaginal delivery, while other studies have reported no difference. We conducted a retrospective cohort study of 52 498 women who had a first singleton live birth in the State of Pennsylvania, USA in 2000 and were followed to the end of 2008 via Pennsylvania birth certificate records to identify subsequent live births during the 8- to 9-year follow-up period. Birth certificate records of first singleton births were linked to the hospital discharge data for each mother and newborn, and linked to all birth certificate records for each mother's subsequent deliveries which occurred in 2000 to the end of 2008. Poisson regression models were used to evaluate the association between first birth factors and whether or not there was a subsequent live birth during the follow-up period. Over an average of 8.5 years of follow-up, 40.2% of women with a Caesarean first birth did not have a subsequent live birth, compared with 33.1% of women with a vaginal first birth (risk ratio (RR): 1.21, 95% confidence interval (CI): 1.18-1.25). Adjustment for the demographic confounders of maternal age, race, education, marital status and health insurance coverage attenuated the RR to 1.16 (95% CI: 1.13-1.19). Specific pregnancy and childbirth-related complications associated with not having a subsequent live birth included diabetes-related disorders, abnormalities of organs and soft tissues of the pelvis, fetal abnormalities, premature or prolonged rupture of membranes, hypertensive disorders, amnionitis, fetal distress and other maternal health problems. However, adjustment for the pregnancy and childbirth complications had little effect on the RR of not having a subsequent live birth (RR = 1.15, 95% CI: 1.11-1.19). We were unable to distinguish between women who did not have a subsequent live birth and those who moved out of the state, which may have introduced a selection bias if those who had Caesarean births were more likely to emigrate than those who delivered vaginally. In addition we were unable to measure pre-pregnancy body mass index, weight gain during pregnancy and prior infertility, which would have been helpful in our efforts to reduce selection bias. The results of this study provide further corroboration of previous studies that have reported reduced fertility subsequent to Caesarean section in comparison with vaginal delivery. This study was funded by the US National Institute of Child Health and Human Development (NICHD, R01-HD052990). No competing interests are declared.

Vaginal rings for delivery of HIV microbicides

PubMed Central

Malcolm, R Karl; Fetherston, Susan M; McCoy, Clare F; Boyd, Peter; Major, Ian

2012-01-01

Following the successful development of long-acting steroid-releasing vaginal ring devices for the treatment of menopausal symptoms and contraception, there is now considerable interest in applying similar devices to the controlled release of microbicides against HIV. In this review article, the vaginal ring concept is first considered within the wider context of the early advances in controlled-release technology, before describing the various types of ring device available today. The remainder of the article highlights the key developments in HIV microbicide-releasing vaginal rings, with a particular focus on the dapivirine ring that is presently in late-stage clinical testing. PMID:23204872

Vaginal rings for delivery of HIV microbicides.

PubMed

Malcolm, R Karl; Fetherston, Susan M; McCoy, Clare F; Boyd, Peter; Major, Ian

2012-01-01

Following the successful development of long-acting steroid-releasing vaginal ring devices for the treatment of menopausal symptoms and contraception, there is now considerable interest in applying similar devices to the controlled release of microbicides against HIV. In this review article, the vaginal ring concept is first considered within the wider context of the early advances in controlled-release technology, before describing the various types of ring device available today. The remainder of the article highlights the key developments in HIV microbicide-releasing vaginal rings, with a particular focus on the dapivirine ring that is presently in late-stage clinical testing.

A prospective randomized trial comparing Foley catheter, oxytocin, and combination Foley catheter-oxytocin for labour induction with unfavourable cervix.

PubMed

El Khouly, Nabih I

2017-04-01

The purpose of this study was to evaluate the effectiveness and safety of transcervical Foley catheter with and without oxytocin versus oxytocin alone for labour induction with unfavourable cervix. This trial enrolled 108 women with singleton pregnancies presented for labour induction with unfavourable cervix. Patients were randomly assigned to receive Foley catheter alone (I), Foley catheter plus oxytocin (II) or oxytocin alone (III). Outcomes were analysed in terms of success of induction, induction delivery interval, route of delivery, dose and duration of oxytocin, and complications. Successful normal vaginal delivery was more common in group I (p = .02) compared to group III. Induction delivery time was statistically shorter in group II and group III (p < .001). Patients in group I required significantly less oxytocin dose and duration (p < .001). This led to our conclusion that induction of labour with Foley catheter without oxytocin increases success rate of normal vaginal delivery; however, it has a longer induction delivery interval with similar complications.

Impact of vaginal parity and aging on the architectural design of pelvic floor muscles.

PubMed

Alperin, Marianna; Cook, Mark; Tuttle, Lori J; Esparza, Mary C; Lieber, Richard L

2016-09-01

Vaginal delivery and aging are key risk factors for pelvic floor muscle dysfunction, which is a critical component of pelvic floor disorders. However, alterations in the pelvic floor muscle intrinsic structure that lead to muscle dysfunction because of childbirth and aging remain elusive. The purpose of this study was to determine the impact of vaginal deliveries and aging on human cadaveric pelvic floor muscle architecture, which is the strongest predictor of active muscle function. Coccygeus, iliococcygeus, and pubovisceralis were obtained from younger donors who were ≤51 years old, vaginally nulliparous (n = 5) and vaginally parous (n = 6) and older donors who were >51 years old, vaginally nulliparous (n = 6) and vaginally parous (n = 6), all of whom had no history of pelvic floor disorders. Architectural parameters, which are predictive of muscle's excursion and force-generating capacity, were determined with the use of validated methods. Intramuscular collagen content was quantified by hydroxyproline assay. Main effects of parity and aging and the interactions were determined with the use of 2-way analysis of variance, with Tukey's post-hoc testing and a significance level of .05. The mean age of younger and older donors differed by approximately 40 years (P = .001) but was similar between nulliparous and parous donors within each age group (P > .9). The median parity was 2 (range, 1-3) in younger and older vaginally parous groups (P = .7). The main impact of parity was increased fiber length in the more proximal coccygeus (P = .03) and iliococcygeus (P = .04). Aging changes manifested as decreased physiologic cross-sectional area across all pelvic floor muscles (P < .05), which substantially exceeded the age-related decline in muscle mass. The physiologic cross-sectional area was lower in younger vaginally parous, compared with younger vaginally nulliparous, pelvic floor muscles; however, the differences did not reach statistical significance. Pelvic floor muscle collagen content was not altered by parity but increased dramatically with aging (P < .05). Increased fiber length in more proximal pelvic floor muscles likely represents an adaptive response to the chronically increased load placed on these muscles by the displaced apical structures, presumably as a consequence of vaginal delivery. In younger specimens, a consistent trend towards decrease in force-generating capacity of all pelvic floor muscles in the parous group suggests a potential mechanism for clinically identified pelvic floor muscle weakness in vaginally parous women. The substantial decrease in predicted muscle force production and fibrosis with aging represent likely mechanisms for the pelvic floor muscle dysfunction in older women. Copyright © 2016 Elsevier Inc. All rights reserved.

Vaginal progesterone, but not 17α-hydroxyprogesterone caproate, has antiinflammatory effects at the murine maternal-fetal interface

PubMed Central

Furcron, Amy-Eunice; Romero, Roberto; Plazyo, Olesya; Unkel, Ronald; Xu, Yi; Hassan, Sonia S.; Chaemsaithong, Piya; Mahajan, Arushi; Gomez-Lopez, Nardhy

2016-01-01

OBJECTIVE Progestogen (vaginal progesterone or 17-alpha-hydroxyprogesterone caproate [17OHP-C]) administration to patients at risk for preterm delivery is widely used for the prevention of preterm birth (PTB). The mechanisms by which these agents prevent PTB are poorly understood. Progestogens have immunomodulatory functions; therefore, we investigated the local effects of vaginal progesterone and 17OHP-C on adaptive and innate immune cells implicated in the process of parturition. STUDY DESIGN Pregnant C57BL/6J mice received vaginal progesterone (1 mg per 200 μL, n = 10) or Replens (control, 200 μL, n = 10) from 13 to 17 days postcoitum (dpc) or were subcutaneously injected with 17OHP-C (2 mg per 100 μL, n = 10) or castor oil (control, 100 μL, n = 10) on 13, 15, and 17 dpc. Decidual and myometrial leukocytes were isolated prior to term delivery (18.5 dpc) for immunophenotyping by flow cytometry. Cervical tissues were collected to determine matrix metalloproteinase (MMP)-9 activity by in situ zymography and visualization of collagen content by Masson’s trichrome staining. Plasma concentrations of progesterone, estradiol, and cytokines (interferon [IFN]-γ, interleukin (IL)-1β, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12p70, KC/GRO, and tumor necrosis factor-α) were quantified by enzyme-linked immunosorbent assays. Pregnant mice pretreated with vaginal progesterone or Replens were injected with 10 μg of an endotoxin on 16.5 dpc (n = 10 each) and monitored via infrared camera until delivery to determine the effect of vaginal progesterone on the rate of PTB. RESULTS The following results were found: (1) vaginal progesterone, but not 17OHP-C, increased the proportion of decidual CD4+ T-regulatory cells; (2) vaginal progesterone, but not 17OHP-C, decreased the proportion of decidual CD8+CD25+Foxp3+ T cells and macrophages; (3) vaginal progesterone did not cause an M1→M2 macrophage polarization but reduced the proportion of myometrial IFNγ+ neutrophils and cervical active MMP-9-positive neutrophils and monocytes; (4) 17OHP-C did not reduce the proportion of myometrial IFNy-positive neutrophils; however, it increased the abundance of cervical active MMP-9-positive neutrophils and monocytes; (5) vaginal progesterone immune effects were associated with reduced systemic concentrations of IL-1β but not with alterations in progesterone or estradiol concentrations; and (6) vaginal progesterone pretreatment protected against endotoxin-induced PTB (effect size 50%, P = .008). CONCLUSION Vaginal progesterone, but not 17OHP-C, has local antiinflammatory effects at the maternal-fetal interface and the cervix and protects against endotoxin-induced PTB. PMID:26264823

Anal incontinence after childbirth

PubMed Central

Eason, Erica; Labrecque, Michel; Marcoux, Sylvie; Mondor, Myrto

2002-01-01

Background Incontinence of stool and flatus are frequent complications of childbirth. We examined the prevalence and possible causes of these adverse outcomes in a large cohort of women. Methods We studied 949 pregnant women who gave birth in 5 hospitals in 1995/96 in the province of Quebec. These women, participants in a randomized controlled trial of prenatal perineal massage, completed a self-administered questionnaire 3 months after giving birth. Results Three months after delivery 29 women (3.1%) reported incontinence of stool, and 242 (25.5%) had involuntary escape of flatus. Incontinence of stool was more frequent among women who delivered vaginally and had third- or fourth-degree perineal tears than among those who delivered vaginally and had no anal sphincter tears (7.8% v. 2.9%). Forceps delivery (adjusted risk ratio [RR] 1.45, 95% confidence interval [CI] 1.01–2.08) and anal sphincter tears (adjusted RR 2.09, 95% CI 1.40–3.13) were independent risk factors for incontinence of flatus or stool or both. Anal sphincter injury was strongly and independently associated with first vaginal birth (RR 39.2, 95% CI 5.4–282.5), median episiotomy (adjusted RR 9.6, 95% CI 3.2–28.5), forceps delivery (adjusted RR 12.3, 95% CI 3.0–50.4) and vacuum-assisted delivery (adjusted RR 7.4, 95% CI 1.9–28.5) but not with birth weight (adjusted RR for birth weight 4000 g or more: 1.4, 95% CI 0.6–3.0) or length of the second stage of labour (adjusted RR for second stage 1.5 hours or longer compared with less than 0.5 hours: 1.2, 95% CI 0.5–2.7). Interpretation Anal incontinence is associated with forceps delivery and anal sphincter laceration. Anal sphincter laceration is strongly predicted by first vaginal birth, median episiotomy, and forceps or vacuum delivery but not by birth weight or length of the second stage of labour. PMID:11868640

Anal incontinence after childbirth.

PubMed

Eason, Erica; Labrecque, Michel; Marcoux, Sylvie; Mondor, Myrto

2002-02-05

Incontinence of stool and flatus are frequent complications of childbirth. We examined the prevalence and possible causes of these adverse outcomes in a large cohort of women. We studied 949 pregnant women who gave birth in 5 hospitals in 1995/96 in the province of Quebec. These women, participants in a randomized controlled trial of prenatal perineal massage, completed a self-administered questionnaire 3 months after giving birth. Three months after delivery 29 women (3.1%) reported incontinence of stool, and 242 (25.5%) had involuntary escape of flatus. Incontinence of stool was more frequent among women who delivered vaginally and had third- or fourth-degree perineal tears than among those who delivered vaginally and had no anal sphincter tears (7.8% v. 2.9%). Forceps delivery (adjusted risk ratio [RR] 1.45, 95% confidence interval [CI] 1.01-2.08) and anal sphincter tears (adjusted RR 2.09, 95% CI 1.40-3.13) were independent risk factors for incontinence of flatus or stool or both. Anal sphincter injury was strongly and independently associated with first vaginal birth (RR 39.2, 95% CI 5.4-282.5), median episiotomy (adjusted RR 9.6, 95% CI 3.2-28.5), forceps delivery (adjusted RR 12.3, 95% CI 3.0-50.4) and vacuum-assisted delivery (adjusted RR 7.4, 95% CI 1.9-28.5) but not with birth weight (adjusted RR for nirth weight 4000 g or more: 1.4, 95% CI 0.6-3.0) or length of the second stage of labour (adjusted RR for second stage 1.5 hours or longer compared with less than 0.5 hours: 1.2, 95% CI 0.5-2.7). Anal incontinence is associated with forceps delivery and anal sphincter laceration. Anal sphincter laceration is strongly predicted by first vaginal birth, median episiotomy, and forceps or vacuum delivery but not by birth weight or length of the second stage of labour.

Maternal and neonatal outcomes of vaginal breech delivery for singleton term pregnancies in a carefully selected Cameroonian population: a cohort study

PubMed Central

Dohbit, Julius Sama; Foumane, Pascal; Mamoudou, Fadimatou; Temgoua, Mazou N; Tankeu, Ronni; Aletum, Veronica; Mboudou, Emile

2017-01-01

Background and objectives Vaginal breech delivery (VBD) is known to be associated with more perinatal and maternal complications. Very few studies on the subject have been carried out in poor-resource settings. The aim of this study was to determine maternal and neonatal outcomes in carefully selected cases of VBD for singleton term pregnancies in a tertiary centre in Cameroon. Design A retrospective cohort study. Setting A tertiary hospital in Yaounde, Cameroon. Participants Cases of VBD of newborns weighing 2500–3500 g were matched in a ratio of 1:4 to consecutive vaginal cephalic deliveries (VCDs) of newborns weighing 2500–3500 g over a 5-year period. Both groups were matched for maternal age and parity. We excluded cases of multiple gestations, footling breech, clinically inadequate maternal pelvis, preterm delivery, post-term pregnancies, fetal demise prior to the onset of labour, placenta praevia and fetal anomaly incompatible with vaginal delivery. Outcome measures Neonatal and maternal adverse outcomes of VBD observed till 6 weeks after delivery analysed using Bonferroni correction. Results Fifty-three (53) VBDs were matched against 212 VCD. Unlike women who had VCD, those who underwent VBD were more likely to have prolonged labour (OR 8.05; 95% CI 3.00 to 11.47; P<0.001), and their newborns were more likely to suffer from birth asphyxia (OR 10.24; 95% CI 4.92 to 21.31; P<0.001). Conclusion The study infers a strong association between VBD of singleton term pregnancies and maternofetal morbidity when specific protocols are applied. This, however, failed to translate into higher differences in perinatal mortality. This finding does not discount the role of VBD in low-income countries, but we emphasise the need for specific precautions like close monitoring of labour and adequate anticipation for neonatal resuscitation in order to reduce these complications. PMID:29170287

Anal sphincter injury in vaginal deliveries complicated by shoulder dystocia.

PubMed

Hehir, Mark P; Rubeo, Zachary; Flood, Karen; Mardy, Anne H; O'Herlihy, Colm; Boylan, Peter C; D'Alton, Mary E

2018-03-01

Shoulder dystocia is an obstetric emergency that occurs in 0.2-3% of all cephalic vaginal deliveries. We hypothesized that because of the difficult nature of deliveries complicated by shoulder dystocia, the condition may be associated with anal sphincter injury. We sought to identify risk factors for obstetric anal sphincter injury in women with shoulder dystocia. This retrospective analysis included all cases of shoulder dystocia from 2007 to 2011 at two large tertiary referral centers, in the USA and Ireland. Details of maternal demographics, intrapartum characteristics, and delivery outcomes in cases of shoulder dystocia were analyzed. Univariate and multivariate analyses were used to describe the association between shoulder dystocia and anal sphincter injury. There were 685 cases of shoulder dystocia, and the rate of shoulder dystocia was similar at both institutions. The incidence of anal sphincter injury was 8.8% (60 out of 685). The rate was 14% (45 out of 324) in nulliparas and 4.2% (15 out of 361) in multiparas. Women with sphincter injury were more likely to be nulliparous (75% [45 out of 60] vs 45% [279 out of 625]; p < 0.0001), have had an operative vaginal delivery (50% [30 out of 60] vs 36% [226 out of 625]; p = 0.03) and require internal maneuvers (50% [30 out of 60] vs 32% [198 out of 625], p = 0.004) than those with an intact sphincter. On multivariate regression analysis, these predictors of sphincter injury remained significant when adjusted for other risk factors. Episiotomy was negatively associated with sphincter injury on multivariate regression analysis. In a retrospective cohort of 685 women with shoulder dystocia, the risk of anal sphincter injury is 9%. Risk factors include nulliparity, operative vaginal delivery, and use of internal maneuvers, whereas episiotomy was found to have a protective effect against anal sphincter injury during cases of shoulder dystocia.

Vaginal progesterone as maintenance treatment after an episode of preterm labour (PROMISE) study: a multicentre, double-blind, randomised, placebo-controlled trial.

PubMed

Palacio, M; Cobo, T; Antolín, E; Ramirez, M; Cabrera, F; Mozo de Rosales, F; Bartha, J L; Juan, M; Martí, A; Oros, D; Rodríguez, À; Scazzocchio, E; Olivares, J M; Varea, S; Ríos, J; Gratacós, E

2016-11-01

To evaluate whether maintenance treatment with vaginal progesterone after an arrested preterm labour reduces the incidence of preterm delivery. Multicentre, randomised, double-blind, placebo-controlled trial. Twelve tertiary care centres in Spain. A total of 265 women with singleton pregnancy, preterm labour successfully arrested with tocolytic treatment, and cervical length of <25 mm. Randomisation was stratified by gestational age (from 24.0 to <31.0 weeks of gestation and from 31.0 to <34.0 weeks of gestation) and centre. Patients were randomly assigned, in a 1 : 1 ratio, to either daily vaginal capsules of 200 mg progesterone or placebo until delivery or 36.6 weeks of gestation, whichever occurred first. Primary outcome was delivery before 34.0 and 37.0 weeks of gestation. Secondary outcomes were discharge-to-delivery time, readmissions because of preterm labour, emergency service use, and neonatal morbidity and mortality. From June 2008 through June 2012, 1419 women were screened: 472 met the inclusion criteria and 265 were randomised. The final analysis included 258 women: 126 in the progesterone group and 132 in the placebo group. There were no significant differences between the progesterone and placebo groups in terms of delivery at <34 weeks of gestation [9/126 (7.1%) versus 10/132 (7.6%), P = 0.91] or <37 weeks of gestation [36/126 (28.6%) versus 29/132 (22.0%), P = 0.22]. There were no differences observed between groups when considering the two strata of gestational age at inclusion. A maintenance treatment of 200 mg of daily vaginal progesterone capsules in women discharged home after an episode of arrested preterm labour did not significantly reduce the rate of preterm delivery. Maintenance progesterone in 258 women after arrested PTL showed no benefit. © 2016 Royal College of Obstetricians and Gynaecologists.

Development and characterization of polymer-coated liposomes for vaginal delivery of sildenafil citrate.

PubMed

Refai, Hanan; Hassan, Doaa; Abdelmonem, Rehab

2017-11-01

Vaginal administration of sildenafil citrate has shown recently to develop efficiently the uterine lining with subsequent successful embryo implantation following in vitro fertilization. The aim of the present study was to develop sildenafil-loaded liposomes coated with bioadhesive polymers for enhanced vaginal retention and improved drug permeation. Three liposomal formulae were prepared by thin-film method using different phospholipid:cholesterol ratios. The optimal liposomal formulation was coated with bioadhesive polymers (chitosan and HPMC). A marked increase in liposomal size and zeta potential was observed for all coated liposomal formulations. HPMC-coated liposomes showed the greater bioadhesion and higher entrapment efficiency than chitosan-coated formulae. The in vitro release studies showed prolonged release of sildenafil from coated liposomes as compared to uncoated liposomes and sildenafil solution. Ex vivo permeation study revealed the enhanced permeation of coated relative to uncoated liposomes. Chitosan-coated formula demonstrated highest drug permeation and was thus selected for further investigations. Transmission electron microscopy (TEM) and Fourier transform infrared spectroscopy (FTIR) confirmed the successful coating of the liposomes by chitosan. Histopathological in vivo testing proved the efficacy of chitosan-coated liposomes to improve blood flow to the vaginal endometrium and to increase endometrial thickness. Chitosan-coated liposomes can be considered as potential novel drug delivery system intended for the vaginal administration of sildenafil, which would prolong system's retention at the vaginal site and enhance the permeation of sildenafil to uterine blood circulation.

How satisfied are mothers with 1-day hospital stays for routine delivery?

PubMed

Klingner, J M; Solberg, L I; Knudson-Schumacher, S; Carlson, R R; Huss, K L

1999-01-01

Payers and health plans are encouraging shorter hospital stays after routine vaginal delivery. To assess the satisfaction of mothers who had 1-day or 2-day stays after routine delivery. We mailed questionnaires to mothers 7 to 9 months after delivery. The self-administered survey contained questions about the mothers' satisfaction with the care they received, clinical complications, and the mothers' preparedness after discharge. A mixed-staff, network-model managed care plan in Minnesota that encourages but does not require 1-day hospital stays after routine delivery. All plan members who delivered a baby vaginally in the first quarter of 1995 (n = 1009). 56% of the mothers responded to the survey. Of these, 202 had 1-day stays and 292 had 2-day stays. Mothers with 1-day stays were more likely than mothers with 2-day stays to report that their length of stay was "too short" (75% vs. 37%; P < 0.001), and 81% of mothers with 1-day stays would want to stay longer if they had another child. The frequency of self-reported maternal or infant complications did not differ substantially between the two groups. More mothers with 1-day stays than mothers with 2-day stays received home health care visits (44% vs. 10%; P < 0.001). Although length of stay does not seem to be related to clinical outcomes after vaginal delivery, mothers with 1-day stays are less satisfied with their length of stay.

Association between sonographic measurement of fetal head circumference and labor outcome.

PubMed

Aviram, Amir; Yogev, Yariv; Bardin, Ron; Hiersch, Liran; Wiznitzer, Arnon; Hadar, Eran

2016-01-01

To evaluate the association between sonographically measured head circumference (HC) and labor outcome. In a retrospective study at a tertiary medical center in Israel, data were reviewed for all term singleton deliveries between July 2007 and December 2012 with HC measurements up to 7days before delivery. HC was compared between women with operative vaginal delivery (OVD) or cesarean delivery for prolonged second stage and those with normal vaginal delivery. The impact of HC above the 75th percentile on pregnancy outcome was analyzed. The study included 2351 women, of whom 2045 (87.0%) had a normal vaginal delivery, 259 (11.0%) underwent OVD, and 47 (2.0%) cesarean. Each 10mm increase in HC was associated with increased risk for obstetric intervention because of a prolonged second stage (adjusted odds ratio [aOR] 1.26; 95% confidence interval [CI] 1.08-1.46). HC above the 75th percentile was independently associated with increased odds of OVD (aOR 1.77; 95% CI 1.30-2.41), 1-minute Apgar score less than 7 (aOR 2.91; 95% CI 1.50-5.66), and neonatal asphyxia (aOR 2.19; 95% CI 1.02-4.71). Term HC above the 75th percentile was associated with increased rates of obstetric interventions because of a prolonged second stage and might be associated with neonatal asphyxia. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis: aerobic vaginitis.

PubMed

Donders, Gilbert G G; Vereecken, Annie; Bosmans, Eugene; Dekeersmaecker, Alfons; Salembier, Geert; Spitz, Bernard

2002-01-01

To define an entity of abnormal vaginal flora: aerobic vaginitis. Observational study. University Hospital Gasthuisberg, Leuven, Belgium. 631 women attending for routine prenatal care or attending vaginitis clinic. Samples were taken for fresh wet mount microscopy of vaginal fluid, vaginal cultures and measurement of lactate, succinate and cytokine levels in vaginal fluid. Smears deficient in lactobacilli and positive for clue cells were considered to indicate a diagnosis of bacterial vaginosis. Aerobic vaginitis was diagnosed if smears were deficient in lactobacilli, positive for cocci or coarse bacilli, positive for parabasal epithelial cells, and/or positive for vaginal leucocytes (plus their granular aspect). Genital complaints include red inflammation, yellow discharge, vaginal dyspareunia. Group B streptococci, escherichia coli, staphylococcus aureus and trichomonas vaginalis are frequently cultured. Vaginal lactate concentration is severely depressed in women with aerobic vaginitis, as in bacterial vaginosis, but vaginal succinate is not produced. Also in contrast to bacterial vaginosis, aerobic vaginitis produces a host immune response that leads to high production of interleukin-6, interleukin-1-beta and leukaemia inhibitory factor in the vaginal fluid. Aerobic vaginitis is associated with aerobic micro-organisms, mainly group B streptococci and E. coli. Its characteristics are different from those of bacterial vaginosis and elicit an important host response. The most severe form of aerobic vaginitis equals desquamative inflammatory vaginitis. In theory, aerobic vaginitis may be a better candidate than bacterial vaginosis as the cause of pregnancy complications, such as ascending chorioamnionitis, preterm rupture of the membranes and preterm delivery.

Management of breech presentation at term: a retrospective cohort study of 10 years of experience.

PubMed

Burgos, J; Rodríguez, L; Cobos, P; Osuna, C; Del Mar Centeno, M; Larrieta, R; Martínez-Astorquiza, T; Fernández-Llebrez, L

2015-10-01

To evaluate the impact of management of childbirth (external cephalic version (ECV) plus planned vaginal delivery (PVD)) of breech presentation at term (⩾37 weeks of gestation). This retrospective cohort study was based on data collected of singleton breech presentations at term in the Obstetrics and Gynaecology Service, Cruces University Hospital (Biscay, Spain), from January 2003 to December 2012. We attended 2377 singleton breech pregnancies at term. We attended 1684 singleton breech term deliveries, attempting vaginal delivery after selection in 52.9% of cases and were successful in 57.5% of attempts. A total of 1360 ECV were attempted, with a success rate of 50.3% of those attempted. The use of ECV has decreased the rate of breech presentation at delivery by 39.0%, the rate of breech presentation as a caesarean section (CS) indication by 47.1% (CS due to breech presentation/total of CS) and the rate of CS for breech presentation out of the total of deliveries by 39.1% (CS due to breech presentation/total of deliveries). Early postnatal parameters (5-min Apgar score, umbilical cord arterial pH and acid-base analysis) were significantly lower following PVD compared with planned CS for breech presentation. However, we did not find any differences in the rates of admissions to the neonatal unit or neonatal mortality. Management of breech presentation with a protocol that includes ECV, careful selection criteria and active management of vaginal delivery achieve a great decrease in the rate of CS for breech presentation.

First-time mothers and changes in personality in relation to mode of delivery.

PubMed

Wiklund, Ingela; Edman, Gunnar; Larsson, Christina; Andolf, Ellika

2009-08-01

This paper is a report of a study conducted to examine changes in personality from late pregnancy to early motherhood in primiparas having vaginal or caesarean deliveries. Birth of the first child is a major life event, possibly influencing personality. The physiological and emotional processes that start in pregnant women have a major impact on the evolving mother-child relationship. Knowledge about changes in personality during pregnancy and motherhood is scarce. A prospective, group-comparative cohort study including 314 healthy primiparas having either 'caesarean section on maternal request' (n = 74) or 'spontaneous vaginal delivery group' (n = 240). The self-report inventory Karolinska Personality Scales was mailed to participants at 37-39 gestational weeks in pregnancy and 9 months after delivery. Data were collected from January 2003 to June 2006. All mean values of the personality variables were within the normal range. There was a statistically significant increase in Impulsivity (P = 0.046) and decrease in Socialization (P = 0.004). The scores developed differently depending on mode of delivery. Thus, women in the vaginal delivery group increased their scores on the Psychic anxiety and Guilt scales, while those in the caesarean delivery group decreased their scores. Although women in both groups became more impulsive and less socialized, personality remained comparatively stable in the transition from late pregnancy to motherhood. As interactive therapeutic midwife/client relationships and maternal/social role preparation have been shown to have a great effect on progress in becoming a mother, knowledge about how personality may affect this process is important so that healthcare professionals can attempt to reduce women's anxiety levels during pregnancy.

Carbetocin versus oxytocin for prevention of postpartum hemorrhage after vaginal delivery in high risk women.

PubMed

Maged, Ahmed Mohamed; Hassan, AbdelGany M A; Shehata, Nesreen A A

2016-01-01

To compare effectiveness and tolerability of carbetocin versus oxytocin in prevention of postpartum hemorrhage (PPH) after vaginal delivery. A prospective double-blinded randomized study conducted on 200 pregnant women randomized into two groups: Group 1 (100 women) received single 100 μg IM dose of carbetocin and Group 2 received of 5 IU oxytocin IM. Both groups received their drug after fetal and before placental delivery. There was a statistically significant difference between the two study groups regarding amount of bleeding (337.73 ± 118.77 versus 378 ± 143.2), occurrence of PPH (4 versus 16%), need for other uterotonics (23 versus 37%) and hemoglobin difference between before and after delivery (0.55 ± 0.35 versus 0.96 ± 0.62) (all being lower in carbetocin group) and measured hemoglobin 24 h after delivery (being higher in carbetocin group); however, there was no significant difference between the two study groups regarding occurrence of major PPH and the need for blood transfusion. Women in carbetocin group showed a statistically significant lower systolic and diastolic blood pressure immediately after delivery and at 30 and 60 min than women in oxytocin group. There was no significant difference between the two study groups regarding occurrence of nausea, vomiting, flushing, dizziness, headache, shivering, metallic taste, dyspnea, palpitation and itching. Women in carbetocin group experienced tachycardia more than women in oxytocin group. Carbitocin is a better alternative to traditional oxytocin in prevention of PPH after vaginal delivery with minimal hemodynamic changes and similar side effects.

Maternal and neonatal outcomes in women with colorectal endometriosis.

PubMed

Thomin, A; Belghiti, J; David, C; Marty, O; Bornes, M; Ballester, M; Roman, H; Daraï, E

2018-05-01

To evaluate delivery and neonatal outcomes in women with resected or in situ bowel endometriosis. Retrospective cohort study. France. Analysis of 72 pregnancies from 67 women followed for colorectal endometriosis from 2001 to 2014 in six centres including two university expert centres for endometriosis. Univariate analysis of maternal and neonatal outcomes. Routes for delivery and rate of complications. The colorectal surgery group comprised 41 women and the in situ colorectal group, 26 women. Overall, half of the women underwent caesarean section. A high incidence of postoperative complications (39%) was observed after caesarean section with no difference between the groups. Surgical difficulties at newborn extraction (22%) and postoperative complications (39%) occurred more often in women with anterior deep infiltrating endometriosis (respectively 63 versus 11%, P = 0.007 and 67% versus 26%, P = 0.046) independently of prior surgery for endometriosis. In the remaining half, vaginal delivery required an operative procedure in 28% of the women with a significant increase in postpartum complications compared with those who did not require a procedure (P = 0.001). Overall, the incidence of postpartum complications was lower after vaginal delivery (14%) than after caesarean section (39%) (P = 0.03). Pregnant women with colorectal endometriosis, irrespective of prior surgery, should be informed of the high risk of delivery by caesarean section. Vaginal delivery is preferrable in this setting because of the lower incidence of postpartum complications. Due to the incidence of postpartum complications whatever the route of delivery, women should receive level III maternal care. © 2016 Royal College of Obstetricians and Gynaecologists.

Predictive value of ultrasound assessed fetal head position in primiparous women with prolonged first stage of labor.

PubMed

Torkildsen, Erik A; Salvesen, Kjell Å; VON Brandis, Philip; Eggebø, Torbjørn M

2012-11-01

To examine how well ultrasound-assessed occipitoposterior (OP) position or high sagittal (HS) position in primiparous women with a prolonged first stage of labor predicts a vaginal delivery and the duration of labor. Prospective observational study. Stavanger University Hospital, a secondary referral center in Norway. 105 primiparous women with prolonged first stage of labor. Ultrasound assessment of fetal head position. Main outcome measures. Vaginal delivery vs. cesarean section and duration of labor. Twenty-five fetuses (24%) were delivered with cesarean section (CS), 45 (43%) had an operative vaginal delivery and 35 (33%) delivered spontaneously. Eleven (27%) of 41 fetuses in OP position at the time of inclusion were born in OP position. Ten (24%) of the 41 fetuses in OP position at inclusion were delivered with CS compared with 15/64 (23%) fetuses in other positions (p= 0.91). Twenty-eight fetuses were in sagittal position and 12 in HS position, assessed with ultrasound at the time of diagnosed prolonged labor. Seven (58%) of 12 in HS position delivered vaginally and five (42%) had a CS (p= 0.89). Time from inclusion to labor was not significant longer either for fetuses in OP compared with non-OP positions or for fetuses in HS compared with non-HS positions. Most fetuses in OP or HS positions in the first stage of labor will rotate spontaneously and have a high probability of being delivered vaginally. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology.

Antenatal use of a novel vaginal birth training device by term primiparous women in Singapore.

PubMed

Kok, J; Tan, K H; Koh, S; Cheng, P S; Lim, W Y; Yew, M L; Yeo, G S H

2004-07-01

To study the use, safety and effectiveness of a novel antenatal vaginal birth training device (EPI-NO) in primiparous women. Antenatal use of the EPI-NO vaginal birth trainer was prospectively studied in 31 primiparous booked patients who were delivered by obstetricians from July to December 2002 at the KK Women's and Children's Hospital. This was studied in relation to episiotomy rate, perineal trauma and analgesic requirements during the postpartum period. A patient questionnaire form was used to assess their perception of pain and how well they coped with its use. For comparison, perineal trauma was also studied retrospectively in 60 consecutive obstetrician-booked primiparous term patients who had normal vaginal delivery (NVD) and who did not use EPI-NO during the same study period. The mean length of usage was for 2.1 weeks (standard deviation [sd] 1.2 weeks). The mean frequency of use was 5.3 episodes per week (sd 2.1, range 1 to 7). There was no laceration and vaginal infection arising from its usage. There was a case of minimal bleeding post-usage. There were 20 (64.5 percent) NVDs, four (12.9 percent) forceps deliveries, five vacuum deliveries (16.1 percent) and two (6.5 percent) Caesarean sections. Of the 29 vaginal delivery cases, 19 (65.5 percent) had episiotomy, eight (27.6 percent) had lacerations, and two (6.9 percent) did not sustain laceration. The reasons for episiotomy in the 19 cases were nine cases of pending tearing of vagina/perineum, nine cases of instrumental vaginal deliveries, and one to shorten second stage. There was no third degree tear. 21 (67.7 percent) out of 30 required a painkiller. The majority of patients (17; 54.8 percent) appeared to be comfortable with the use of EPI-NO. All coped well with vaginal examination after using EPI-NO perineal training. Comparing among term primiparous NVD cases with (n value equals 20) and without (n value equals 60) EPI-NO, the perineal trauma rate (90.0 percent vs 96.6 percent, p value equals 0.24) was slightly but not significantly lower in the EPI-NO group. The episiotomy rate was significantly lower (50.0 percent vs 93.3 percent, p value is less than 0.0001) and the extent of perineal trauma in the patient appeared to be less severe in cases using EPI-NO. EPI-NO appeared to be safe and acceptable to the majority of users. Although birth training with EPI-NO significantly decreases the rate of episiotomies in term primiparous patients, and the degree of perineal tissue injury appeared to be less in the EPI-NO group especially among those with lacerations, the overall perineal trauma rate was slightly but not significantly lower, in view of the higher spontaneous laceration rate in the EPI-NO group.

Third and Fourth Degree Perineal Injury After Vaginal Delivery: Does Race Make a Difference?

PubMed Central

de Silva, Kanoe-Lehua; Tsai, Pai-Jong Stacy; Kon, Leanne M; Kessel, Bruce; Seto, Todd; Kaneshiro, Bliss

2014-01-01

Severe perineal injury (third and fourth degree laceration) at the time of vaginal delivery increases the risk of fecal incontinence, chronic perineal pain, and dyspareunia.1–5 Studies suggest the prevalence of severe perineal injury may vary by racial group.6 The purpose of the current study was to examine rates of severe perineal injury in different Asian and Pacific Islander subgroups. A retrospective cohort study was performed among all patients who had a vaginal delivery at Queens Medical Center in Honolulu, Hawai‘i between January 1, 2002 and December 31, 2003. Demographic and health related variables were obtained for each participant. Maternal race/ethnicity (Japanese, Filipino, Chinese, other Asian, Part-Hawaiian/Hawaiian, Micronesian, other Pacific Islander, Caucasian, multiracial [non-Hawaiian], and other) was self-reported by the patient at the time admission. The significance of associations between racial/ethnic groups and demographic and health related variables was determined using chi-square tests for categorical variables and analysis of variance for continuous factors. Multiple logistic regression was performed to adjust for potential confounders when examining severe laceration rates. A total of 1842 subjects met inclusion criteria. The proportion of severe perineal lacerations did not differ significantly between racial groups. In the multiple logistic regression analysis, operative vaginal delivery was related to both race and severe perineal laceration. However, despite adjusting for this variable, race was not associated with an increased risk of having a severe laceration (P = .70). The results of this study indicate the risk of severe perineal laceration does not differ based on maternal race/ethnicity. PMID:24660124

[Birth weight discordance in dichorionic twins: diagnosis, obstetrical and neonatal prognosis].

PubMed

Mottet, N; Guillaume, M; Martin, A; Ramanah, R; Riethmuller, D

2014-09-01

To describe neonatal and obstetrical prognosis in dichorionic (DC) twins with a birth weight discordance under 20% and evaluate the influence of intrauterine growth restriction on the management. We studied retrospectively 67 DC twins birth between July 2002 and July 2012 at our university labour ward. Birth weight discordance was considered slight between 20-25%, moderate between 25-30%, and severe over 30%. Prevalence of birth weight discordance in DC twins is estimated at 11.4% in our study. Eighty percent of severe discordance was diagnosed before delivery, 41% for moderate discordance and 20% for slight discordance. We note 30% of pre eclampsia in our population with 44% in the severe discordance group. Mean gestational age was 35.1 weeks for slight and moderate discordances, and 33 weeks for severe discordance. Caesarean section rate was 48% for severe discordance and only 36% for slight discordance. Vaginal delivery rate is 56.7%. More than half of patient with a severe discordance gave birth vaginally. Intrauterine growth restriction rate under the 10th percentile was 18.7%. Prevalence of IUGR was 24% in sever discordance group, 23.5% in the moderate discordance group and 10% in the slight group. Neonatal morbidity rate was 20.8% mainly in children with IUGR. Neonatal mortality and morbidity rate are mainly increased in severe discordant twins. These pregnancies are at high risk of maternal morbidity. Vaginal delivery must be preferred for slight and moderate discordances. In case of severe discordance, vaginal delivery should be considered depending on the degree of intrauterine growth retardation. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Types of pelvic floor dysfunctions in nulliparous, vaginal delivery, and cesarean section female patients with obstructed defecation syndrome identified by echodefecography.

PubMed

Murad-Regadas, Sthela M; Regadas, Francisco Sérgio P; Rodrigues, Lusmar V; Oliveira, Leticia; Barreto, Rosilma G L; de Souza, Marcellus H L P; Silva, Flavio Roberto S

2009-10-01

This study aims to show pelvic floor dysfunctions in women with obstructed defecation syndrome (ODS), comparing nulliparous to those with vaginal delivery or cesarean section using the echodefecography (ECD). Three hundred seventy female patients with ODS were reviewed retrospectively and were divided in Group I-105 nulliparous, Group II-165 had at least one vaginal delivery, and Group III-comprised of 100 patients delivered only by cesarean section. All patients had been submitted to ECD to identify pelvic floor dysfunctions. No statistical significance was found between the groups with regard to anorectocele grade. Intussusception was identified in 40% from G I, 55.0% from G II, and 30.0% from G III, with statistical significance between Groups I and II. Intussusception was associated with significant anorectocele in 24.8%, 36.3%, and 18% patients from G I, II, and III, respectively. Anismus was identified in 39.0% from G I, 28.5% from G II, and 60% from G III, with statistical significance between Groups I and III. Anismus was associated with significant anorectocele in 22.8%, 15.7%, and 24% patients from G I, II, and III, respectively. Sigmoidocele/enterocele was identified in 7.6% from G I, 10.9% G II, and was associated with significant rectocele in 3.8% and 7.3% patients from G I and II, respectively. The distribution of pelvic floor dysfunctions showed no specific pattern across the groups, suggesting the absence of a correlation between these dysfunctions and vaginal delivery.

Mode of delivery and risk of intracranial haemorrhage in newborns with severe haemophilia A: a multicentre study in Gulf region.

PubMed

Nazir, H F; Al Lawati, T; Beshlawi, I; AlSharidah, S; Elshinawy, M; Alkasim, F; Khanani, M F; Tarawa, A; Al Subhi, T; Alrawas, A; Al Riyami, W; Al Kindi, S; Al Saadi, K; Al-Lamki, S; Wali, Y

2016-05-01

The optimum mode of delivery in a known carrier of a haemophilia A is still an issue of debate. This study was conducted to report a multicentre experience in Gulf Cooperation Council (GCC) on the incidence of intracranial haemorrhage (ICH) in newborns with severe haemophilia A delivered by different modalities. We have conducted a retrospective/prospective multicentre cohort study including a total of seven hospitals distributed in four GCC countries between 1998 and Jan 2015. A total of 163 patient with severe haemophilia A (factor VIII <1%) were enrolled in this study, age ranged between 2 weeks to 18 years. Most of the patients were born by spontaneous vaginal delivery (SVD) (131, 80.4%), whereas 26 patients (16%) were born by CS and only six patients were born by instrumental delivery (3.7%), five of them by vacuum and one was delivered using forceps. Five out of 163 patients developed ICH during the first 2 weeks of life (3.1%). Two of them were born by SVD (2/131; 1.5%) and two were born by instrumental delivery (2/6; 33.3%). Only one patient among those who were born by caesarean section developed ICH (1/26; 3.8%). Assisted vaginal delivery was associated with a significant risk of ICH, in comparison to SVD and CS (P = 0.0093). Normal vaginal delivery is still considered a safe journey through the birth canal for haemophilic newborns particularly in this area of the world. Larger prospective studies might be needed to define an evidence-based optimal mode of delivery for the haemophilia carrier expecting an affected child. © 2015 John Wiley & Sons Ltd.

Episiotomy: the final cut?

PubMed

Steiner, Naama; Weintraub, Adi Y; Wiznitzer, Arnon; Sergienko, Ruslan; Sheiner, Eyal

2012-12-01

To investigate whether episiotomy prevents 3rd or 4th degree perineal tears in critical conditions such as shoulder dystocia, instrumental deliveries (vacuum or forceps), persistent occiput-posterior position, fetal macrosomia (>4,000 g), and non-reassuring fetal heart rate (NRFHR) patterns. A retrospective study comparing 3rd and 4th degree perineal tears during vaginal deliveries with or without episiotomy, in selected critical conditions was performed. Multiple gestations, preterm deliveries (<37 weeks' gestation) and cesarean deliveries were excluded from the analysis. Stratified analysis (using the Mantel-Haenszel technique) was used to obtain the weighted odds ratio (OR), while controlling for these variables. During the study period, there were 168,077 singleton vaginal deliveries. Of those, 188 (0.1%) had 3rd or 4th degree perineal tears. Vaginal deliveries with episiotomy had statistically significant higher rates of 3rd or 4th degree perineal tears than those without episiotomy (0.2 vs. 0.1%; P<0.001). The association between episiotomy and severe perineal tears remained significant even in the critical conditions. Stratified analysis revealed that the adjusted ORs for 3rd or 4th degree perineal tears in these critical conditions (Macrosomia OR=2.3; instrumental deliveries OR=1.8; NRFHR patterns OR=2.1; occipito-posterior position OR=2.3; and shoulder dystocia OR=2.3) were similar to the crude OR (OR=2.3). Mediolateral episiotomy is an independent risk factor for 3rd or 4th degree perineal tears, even in critical conditions such as shoulder dystocia, instrumental deliveries, occiput-posterior position, fetal macrosomia, and NRFHR. Prophylactic use of episiotomy in these conditions does not seem beneficial if performed to prevent 3rd or 4th degree perineal tears.

Odon device for instrumental vaginal deliveries: results of a medical device pilot clinical study.

PubMed

Schvartzman, Javier A; Krupitzki, Hugo; Merialdi, Mario; Betrán, Ana Pilar; Requejo, Jennifer; Nguyen, My Huong; Vayena, Effy; Fiorillo, Angel E; Gadow, Enrique C; Vizcaino, Francisco M; von Petery, Felicitas; Marroquin, Victoria; Cafferata, María Luisa; Mazzoni, Agustina; Vannevel, Valerie; Pattinson, Robert C; Gülmezoglu, A Metin; Althabe, Fernando; Bonet, Mercedes

2018-03-12

A prolonged and complicated second stage of labour is associated with serious perinatal complications. The Odon device is an innovation intended to perform instrumental vaginal delivery presently under development. We present an evaluation of the feasibility and safety of delivery with early prototypes of this device from an early terminated clinical study. Hospital-based, multi-phased, open-label, pilot clinical study with no control group in tertiary hospitals in Argentina and South Africa. Multiparous and nulliparous women, with uncomplicated singleton pregnancies, were enrolled during the third trimester of pregnancy. Delivery with Odon device was attempted under non-emergency conditions during the second stage of labour. The feasibility outcome was delivery with the Odon device defined as successful expulsion of the fetal head after one-time application of the device. Of the 49 women enrolled, the Odon device was inserted successfully in 46 (93%), and successful Odon device delivery as defined above was achieved in 35 (71%) women. Vaginal, first and second degree perineal tears occurred in 29 (59%) women. Four women had cervical tears. No third or fourth degree perineal tears were observed. All neonates were born alive and vigorous. No adverse maternal or infant outcomes were observed at 6-weeks follow-up for all dyads, and at 1 year for the first 30 dyads. Delivery using the Odon device is feasible. Observed genital tears could be due to the device or the process of delivery and assessment bias. Evaluating the effectiveness and safety of the further developed prototype of the BD Odon Device™ will require a randomized-controlled trial. ANZCTR ACTRN12613000141741 Registered 06 February 2013. Retrospectively registered.

[Is it already time to legalize the usage of Cytotec (Misoprostol) in the obstetrics' practice?].

PubMed

Bozhinova, S

2007-01-01

Cytotec (Misoprostol) is a prostaglandin E1 9(PgE1) analogue. Despite that it is not officially registered for obstetric and gynaecological targets, Cytotec (C) is widely used in this sphere. The author aims to study the effect and results from C application used for delivery (birth) induction, as well as means for cervical maturation. In order to reach this aim, beside the group of 45 pregnant women to who we applied C, we also reviewed the existing literature, which reported proves for C efficacy, pharma-kynetics and the safe aspects of its application (usage) in pregnancy. C was used with 45 pregnant women, divided in two groups: I group--27 pregnant women with oral application and II group--18 pregnant women with vaginal application. C was given per os in dosage 50 microg at 4 hours, the maximum dosage being 200 microg. When applied in the vagina, the dosage was twice 50 microg, every 6 hours. Four hours after the second dosage, if the effective delivery activity was not sufficient, we continued with sub-lingual application in dosage 50 microg every 4 hours till the regular delivery activity was reached. The vaginal delivery (childbirth) till the 24th hour of C application is considered as a successful induction. The delivery (childbirth) continuation, though with insignificant difference, is less under vaginal application. Uterine contractions begin (start) 30-35 minutes earlier under C application. Sectio Caesarea has smaller frequency under C application, in comparison with the general population frequency for the same period (year 2006 and the first half of 2007). The C induction is successful in 40 (88.89%), and with 7 (25.93%) the per oral application was prolonged via oxytocine infusion, and with half of the patients the vaginal application was continued via sun-lingual one. The author reaches the conclusion, that Cytotec is an effective and safe means for delivery (childbirth) induction, and that when dosage and application manner are set-up, the individual characterics of the patients should be taken into account. Mother-fetal results are the best under single dosage of 50 microg, applied in per oral, vaginal or sub-lingual way. Due to the wide application of Cytotec medicine, it is already high time to legalize it and to standardize the protocols from its application.

Postpartum surveillance of bacteriuria in term vaginal deliveries.

PubMed Central

Orrett, F. A.; Premanand, N.

1998-01-01

This study examined the prevalence of bacteriuria in early postpartum period after term vaginal delivery in Trinidad, West Indies. Asymptomatic bacteriuria occurred in 58 (34.5%) of 168 patients tested. The prevalence of bacteriuria was significantly higher in non-catheterized patients than in catheterized patients and occurred more commonly in patients who were 20 to 29 years old and who were primigravida rather than multigravida. Forty-four patients had a history of urinary tract infection; 18 (40.9%) of these patients had positive urine cultures. Although 10 patients had a vaginal discharge in the late third trimester, none presented with postpartum bacteriuria. Because of the high prevalence of postpartum bacteriuria and the potential to progress to pyelonephritis and chronic renal disease, quantitative urine cultures for all postnatal patients and curative treatment for all positive cultures are recommend. PMID:9549982

The sheep as a model of preclinical safety and pharmacokinetic evaluations of candidate microbicides.

PubMed

Holt, Jonathon D S; Cameron, David; Dias, Nicola; Holding, Jeremy; Muntendam, Alex; Oostebring, Freddy; Dreier, Peter; Rohan, Lisa; Nuttall, Jeremy

2015-07-01

When developing novel microbicide products for the prevention of HIV infection, the preclinical safety program must evaluate not only the active pharmaceutical ingredient but also the product itself. To that end, we applied several relatively standard toxicology study methodologies to female sheep, incorporating an assessment of the pharmacokinetics, safety, tolerability, and local toxicity of a dapivirine-containing human vaginal ring formulation (Dapivirine Vaginal Ring-004). We performed a 3-month general toxicology study, a preliminary pharmacokinetic study using drug-loaded vaginal gel, and a detailed assessment of the kinetics of dapivirine delivery to plasma, vaginal, and rectal fluid and rectal, vaginal, and cervical tissue over 28 days of exposure and 3 and 7 days after removal of the ring. The findings of the general toxicology study supported the existing data from both preclinical and clinical studies in that there were no signs of toxicity related to dapivirine. In addition, the presence of the physical dapivirine ring did not alter local or systemic toxicity or the pharmacokinetics of dapivirine. Pharmacokinetic studies indicated that the dapivirine ring produced significant vaginal tissue levels of dapivirine. However, no dapivirine was detected in cervical tissue samples using the methods described here. Plasma and vaginal fluid levels were lower than those in previous clinical studies, while there were detectable dapivirine levels in the rectal tissue and fluid. All tissue and fluid levels tailed off rapidly to undetectable levels following removal of the ring. The sheep represents a very useful model for the assessment of the safety and pharmacokinetics of microbicide drug delivery devices, such as the vaginal ring. Copyright © 2015, American Society for Microbiology. All Rights Reserved.

Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term.

PubMed

Kelly, A J; Kavanagh, J; Thomas, J

2003-01-01

Prostaglandins have been used for induction of labour since the 1960s. Initial work focused on prostaglandin F2a as prostaglandin E2 was considered unsuitable for a number of reasons. With the development of alternative routes of administration, comparisons were made between various formulations of vaginal prostaglandins. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. To determine the effects of vaginal prostaglandins E2 and F2a for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment or other vaginal prostaglandins (except misoprostol). The Cochrane Pregnancy and Childbirth Group trials register (May 2003) and bibliographies of relevant papers. Clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods. A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. In total, 101 studies were considered: 43 excluded and 57 (10,039 women) included. One study is awaiting assessment. Vaginal prostaglandin E2 compared with placebo or no treatment reduced the likelihood of vaginal delivery not being achieved within 24 hours (18% versus 99%, relative risk (RR) 0.19, 95% confidence interval (CI) 0.14 to 0.25, 2 trials, 384 women), there was no evidence of a difference between caesarean section rates although the risk of uterine hyperstimulation with fetal heart rate changes was increased (4.6% versus 0.51%, RR 4.14, 95% CI 1.93 to 8.90, 13 trials, 1203 women). Comparison of vaginal prostaglandin F2a with placebo showed similar caesarean section rates but the cervical score was more likely to be improved (15% versus 60%, RR 0.25, 95% CI 0.13 to 0.49, 5 trials, 467 women), and the risk of oxytocin augmentation reduced (53.9% versus 89.1%, RR 0.60, 95% CI 0.43 to 0.84, 11 trials, 1265 women) with the use of vaginal PGF2a. There were insufficient data to make meaningful conclusions for the comparison of vaginal PGE2 and PGF2a.PGE2 tablet, gel and pessary appear to be as efficacious as each other. Lower dose regimens, as defined in the review, appear as efficacious as higher dose regimens. The primary aim of this review was to examine the efficacy of vaginal prostaglandin E2 and F2a. This is reflected by an increase in successful vaginal delivery rates in 24 hours, no increase in operative delivery rates and significant improvements in cervical favourability within 24 to 48 hours. Further research is needed to quantify the cost-analysis of induction of labour with vaginal prostaglandins, with special attention to different methods of administration.

Partial restoration of the microbiota of cesarean-born infants via vaginal microbial transfer.

PubMed

Dominguez-Bello, Maria G; De Jesus-Laboy, Kassandra M; Shen, Nan; Cox, Laura M; Amir, Amnon; Gonzalez, Antonio; Bokulich, Nicholas A; Song, Se Jin; Hoashi, Marina; Rivera-Vinas, Juana I; Mendez, Keimari; Knight, Rob; Clemente, Jose C

2016-03-01

Exposure of newborns to the maternal vaginal microbiota is interrupted with cesarean birthing. Babies delivered by cesarean section (C-section) acquire a microbiota that differs from that of vaginally delivered infants, and C-section delivery has been associated with increased risk for immune and metabolic disorders. Here we conducted a pilot study in which infants delivered by C-section were exposed to maternal vaginal fluids at birth. Similarly to vaginally delivered babies, the gut, oral and skin bacterial communities of these newborns during the first 30 d of life was enriched in vaginal bacteria--which were underrepresented in unexposed C-section-delivered infants--and the microbiome similarity to those of vaginally delivered infants was greater in oral and skin samples than in anal samples. Although the long-term health consequences of restoring the microbiota of C-section-delivered infants remain unclear, our results demonstrate that vaginal microbes can be partially restored at birth in C-section-delivered babies.

The Vaginal Eukaryotic DNA Virome and Preterm Birth.

PubMed

Wylie, Kristine M; Wylie, Todd N; Cahill, Alison G; Macones, George A; Tuuli, Methodius G; Stout, Molly J

2018-05-05

Despite decades of attempts to link infectious agents to preterm birth, an exact causative microbe or community of microbes remains elusive. Culture-independent sequencing of vaginal bacterial communities demonstrates community characteristics are associated with preterm birth, although none are specific enough to apply clinically. Viruses are important components of the vaginal microbiome and have dynamic relationships with vaginal bacterial communities. We hypothesized that vaginal eukaryotic DNA viral communities (the "vaginal virome") either alone or in the context of bacterial communities are associated with preterm birth. The objective of this study was to use high-throughput sequencing to examine the vaginal eukaryotic DNA virome in a cohort of pregnant women and examine associations between vaginal community characteristics and preterm birth. This is a nested case-control study within a prospective cohort study of women with singleton pregnancies, not on supplemental progesterone, and without cervical cerclage in situ. Serial mid-vaginal swabs were obtained at routine prenatal visits. DNA was extracted, bacterial communities were characterized by 16S rRNA gene sequencing, and eukaryotic viral communities were characterized by enrichment of viral nucleic acid with the ViroCap targeted sequence capture panel followed by nucleic acid sequencing. Viral communities were analyzed according to presence/absence of viruses, diversity, dynamics over time, and association with bacterial community data obtained from the same specimens. Sixty subjects contributed 128 vaginal swabs longitudinally across pregnancy. Twenty-four patients delivered preterm. Participants were predominantly African-American (65%). Six families of eukaryotic DNA viruses were detected in the vaginal samples. At least 1 virus was detected in 80% of women. No specific virus or group of viruses was associated with preterm delivery. Higher viral richness was significantly associated with preterm delivery in the full group and in the African American subgroup (P=0.0005 and P=0.0003, respectively). Having both high bacterial diversity and high viral diversity in the first trimester was associated with the highest risk for preterm birth. Higher vaginal viral diversity is associated with preterm birth. Changes in vaginal virome diversity appear similar to changes in the vaginal bacterial microbiome over pregnancy, suggesting that underlying physiology of pregnancy may regulate both bacterial and viral communities. Copyright © 2018 Elsevier Inc. All rights reserved.

Assessment of hot flushes and vaginal dryness among obese women undergoing bariatric surgery.

PubMed

Goughnour, S L; Thurston, R C; Althouse, A D; Freese, K E; Edwards, R P; Hamad, G G; McCloskey, C; Ramanathan, R; Bovbjerg, D H; Linkov, F

2016-01-01

Menopausal symptoms are associated with a negative impact on the quality of life, leading women to seek medical treatment. Obesity has been linked to higher levels of menopausal symptoms such as hot flushes. This assessment will explore whether the prevalence and bother of hot flushes and vaginal dryness change from pre- to post-bariatric surgery among obese midlife women. This study is a longitudinal analysis of data from 69 women (ages 35-72 years) undergoing bariatric surgery with reported reproductive histories and menopausal symptoms at preoperative and 6-month postoperative visits. Prevalence of and degree of bother of hot flushes and vaginal dryness at pre- and post-surgery were compared using McNemar's test and Wilcoxon signed-rank test. The reported degree of bother of symptoms associated with hot flushes decreased from pre- to post-surgery (p < 0.01). There was no significant change in the prevalence of hot flushes or vaginal dryness in the overall study sample. The degree of bother of symptoms associated with hot flushes among midlife women may decrease after bariatric surgery. These results highlight important secondary gains, including less bothersome menopausal symptoms, for women who choose bariatric surgery for weight loss.

Biomechanical and morphological properties of the multiparous ovine vagina and effect of subsequent pregnancy.

PubMed

Rynkevic, Rita; Martins, Pedro; Hympanova, Lucie; Almeida, Henrique; Fernandes, Antonio A; Deprest, Jan

2017-05-24

Pelvic floor soft tissues undergo changes during the pregnancy. However, the degree and nature of this process is not completely characterized. This study investigates the effect of subsequent pregnancy on biomechanical and structural properties of ovine vagina. Vaginal wall from virgin, pregnant (in their third pregnancy) and parous (one year after third vaginal delivery) Swifter sheep (n=5 each) was harvested. Samples for biomechanics and histology, were cut in longitudinal axis (proximal and distal regions). Outcome measurements describing Young's modulus, ultimate stress and elongation were obtained from stress-strain curves. For histology samples were stained with Miller's Elastica staining. Collagen, elastin and muscle cells and myofibroblasts contents were estimated, using image processing techniques. Statistical analyses were performed in order to determine significant differences among experimental groups. Significant regional differences were identified. The proximal vagina was stiffer than distal, irrespective the reproductive status. During the pregnancy proximal vagina become more compliant than in parous (+47.45%) or virgin sheep (+64.35%). This coincided with lower collagen (-15 to -21%), higher elastin (+30 to +60%), and more smooth muscle cells (+17 to +37%). Vaginal tissue from parous ewes was weaker than of virgins, coinciding with lower collagen (-10%), higher elastin (+50%), more smooth muscle cells (+20%). It could be proposed that after pregnancy biomechanical properties of vagina do not recover to those of virgins. Since elastin has a significant influence on the compliance of soft tissues and collagen is the main "actor" regarding strength, histological analysis performed in this study justifies the mechanical behavior observed. Copyright © 2017 Elsevier Ltd. All rights reserved.

Birth position and obstetric anal sphincter injury: a population-based study of 113 000 spontaneous births.

PubMed

Elvander, Charlotte; Ahlberg, Mia; Thies-Lagergren, Li; Cnattingius, Sven; Stephansson, Olof

2015-10-09

The association between birth position and obstetric anal sphincter injury (OASIS) in spontaneous vaginal deliveries is unclear. The study was based on the Stockholm-Gotland Obstetric Database (Sweden) from Jan 1(st) 2008 to Oct 22(nd) 2014 and included 113 279 singleton spontaneous vaginal births with no episiotomy. We studied risk of OASIS with respect to the following birth positions: a) sitting, b) lithotomy, c) lateral, d) standing on knees, e) birth seat, f) supine, g) squatting, h) standing and i) all fours. All analyses were stratified for parity. General linear models were used to calculate risk ratios (RR) adjusted for maternal, pregnancy and fetal characteristics. The rates of OASIS among nulliparous women, parous women and women undergoing vaginal birth after a caesarean (VBAC) were 5.7%, 1.3% and 10.6%, respectively. The rates varied by birth position: from 3.7 to 7.1% in nulliparous women, 0.6% to 2.6% in parous women and 5.6% to 18.2% in women undergoing VBAC. Regardless of parity, the lowest rates were found among women giving birth in standing position and the highest rates among women birthing in the lithotomy position. Compared with sitting position, the lithotomy position involved an increased risk of OASIS among nulliparous (adjusted RR 1.17, 95% CI 1.06-1.29) and parous women (adjusted RR 1.66, 95% CI 1.35-2.05). Birth seat and squatting position involved an increased risk of OASIS among parous women (adjusted RR [95% CI] 1.36 [1.03-1.80] and 2.16 [1.15-4.07], respectively). Independent risk factors for OASIS were maternal age, head circumference ≥35 cm, birth weight ≥4000 g, length of gestation ≥ 40 weeks, prolonged second stage of labour, non-occiput anterior presentation and oxytocin augmentation. Compared with sitting position, lateral position has a slightly protective effect in nulliparous women whilst an increased risk is noted among women in the lithotomy position, irrespective of parity. Squatting and birth seat position involve an increase in risk among parous women.

Maternal and Perinatal Outcomes by Mode of Delivery in Senegal and Mali: A Cross-Sectional Epidemiological Survey

PubMed Central

Briand, Valérie; Dumont, Alexandre; Abrahamowicz, Michal; Sow, Amadou; Traore, Mamadou; Rozenberg, Patrick; Watier, Laurence; Fournier, Pierre

2012-01-01

Objective In the context of rapid changes regarding practices related to delivery in Africa, we assessed maternal and perinatal adverse outcomes associated with the mode of delivery in 41 referral hospitals of Mali and Senegal. Study Design Cross-sectional survey nested in a randomised cluster trial (1/10/2007–1/10/2008). The associations between intended mode of delivery and (i) in-hospital maternal mortality, (ii) maternal morbidity (transfusion or hysterectomy), (iii) stillbirth or neonatal death before Day 1 and (iv) neonatal death between 24 hours after birth and hospital discharge were examined. We excluded women with immediate life threatening maternal or fetal complication to avoid indication bias. The analyses were performed using hierarchical logistic mixed models with random intercept and were adjusted for women's, newborn's and hospitals' characteristics. Results Among the 78,166 included women, 2.2% had a pre-labor cesarean section (CS) and 97.8% had a trial of labor. Among women with a trial of labor, 87.5% delivered vaginally and 12.5% had intrapartum CS. Pre-labor CS was associated with a marked reduction in the risk of stillbirth or neonatal death before Day 1 as compared with trial of labor (OR = 0.2 [0.16–0.36]), though we did not show that maternal mortality (OR = 0.3 [0.07–1.32]) and neonatal mortality after Day 1 (OR = 1.3 (0.66–2.72]) differed significantly between groups. Among women with trial of labor, intrapartum CS and operative vaginal delivery were associated with higher risks of maternal mortality and morbidity, and neonatal mortality after Day 1, as compared with spontaneous vaginal delivery. Conclusions In referral hospitals of Mali and Senegal, pre-labor CS is a safe procedure although intrapartum CS and operative vaginal delivery are associated with increased risks in mothers and infants. Further research is needed to determine what aspects of obstetric care contribute to a delay in the provision of intrapartum interventions so that practices may be made safer when they are needed. PMID:23056633

Transcutaneous electrical nerve stimulation (TENS) for pain control after vaginal delivery and cesarean section.

PubMed

Kayman-Kose, Seda; Arioz, Dagistan Tolga; Toktas, Hasan; Koken, Gulengul; Kanat-Pektas, Mine; Kose, Mesut; Yilmazer, Mehmet

2014-10-01

The present study aims to determine the efficiency and reliability of transcutaneous electrical nerve stimulation (TENS) in the management of pain related with uterine contractions after vaginal delivery and the pain related with both abdominal incision uterine contractions after cesarean section. A hundred healthy women who underwent cesarean section under general anesthesia were randomly assigned to the placebo group (Group 1) or the TENS group (Group 2), while 100 women who delivered by vaginal route without episiotomy were randomized into the placebo group (Group 3) or the TENS group (Group 4). The patients in Group 2 had statistically lower visual analog scale (VAS) and verbal numerical scale (VNS) scores than the patients in Group 1 (p < 0.001 for both). The patients in Group 4 had statistically lower VAS and VNS scores than the patients in Group 3 (p = 0.022 and p = 0.005, respectively). The analgesic requirement at the eighth hour of cesarean section was significantly lower in the patients who were treated with TENS (p = 0.006). The need for analgesics at the eighth hour of vaginal delivery was statistically similar in the patients who were treated with TENS and the patients who received placebo (p = 0.830). TENS is an effective, reliable, practical and easily available modality of treatment for postpartum pain.

RECTAL-SPECIFIC MICROBICIDE APPLICATOR: EVALUATION AND COMPARISON WITH A VAGINAL APPLICATOR USED RECTALLY

PubMed Central

Carballo-Diéguez, Alex; Giguere, Rebecca; Dolezal, Curtis; Bauermeister, José; Leu, Cheng-Shiun; Valladares, Juan; Rohan, Lisa C.; Anton, Peter A.; Cranston, Ross D.; Febo, Irma; Mayer, Kenneth; McGowan, Ian

2014-01-01

An applicator designed for rectal delivery of microbicides was tested for acceptability by 95 young men who have sex with men, who self-administered 4mL of placebo gel prior to receptive anal intercourse over 90 days. Subsequently, 24 of the participants self-administered rectally 4mL of tenofovir or placebo gel over 7 days using a vaginal applicator, and compared both applicators on a Likert scale of 1–10, with 10 the highest rating. Participants reported high likelihood to use either applicator in the future (mean scores 9.3 and 8.8 respectively, p= ns). Those who tested both liked the vaginal applicator significantly more than the rectal applicator (7.8 vs. 5.2, p=0.003). Improvements in portability, conspicuousness, aesthetics, tip comfort, product assembly and packaging were suggested for both. This rectal-specific applicator was not superior to a vaginal applicator. While likelihood of future use is reportedly high, factors that decrease acceptability may erode product use over time in clinical trials. Further attention is needed to develop user-friendly, quick-acting rectal microbicide delivery systems. PMID:24858481

Influence of the duration of the second stage of labor on the likelihood of obstetric anal sphincter injury

PubMed Central

AIKEN, Catherine E.; AIKEN, Abigail R.; PRENTICE, Andrew

2014-01-01

Background Duration of the second stage of labor has been suggested as an independent risk factor for clinically detectable obstetric anal sphincter injury in low-risk nulliparous women. Methods A retrospective 5-year cohort study in a UK obstetrics center including high-risk delivery unit and low-risk birthing center. 4831 nulliparous women with vertex-presenting, single, live-born infants at term were included. The cohort was stratified according to spontaneous or instrumental delivery. Binary logistic regression models were used to examine the association between duration of second stage and sphincter injury. Results 325 of 4831 women (6.7%) sustained sphincter injuries. In spontaneously delivering women, there was no association between duration of the second stage and the likelihood of sustaining sphincter injuries. Factors associated with increased likelihood of sustaining sphincter injury included older maternal age, higher birthweight and Southeast Asian ethnicity. By contrast, for women undergoing instrumental delivery, a longer second stage was associated with an increased sphincter injury risk of 6% per 15 minutes in the second stage of labor prior to delivery. Conclusions For spontaneous vaginal deliveries, duration of the second stage of labor is not an independent risk factor for obstetric anal sphincter injuries. The association between prolonged second stage and sphincter injury for instrumental deliveries is likely explained by the risk posed by the use of the instruments themselves or by delay in initiating instrumental assistance. Attempts to modify the duration of the second stage for prevention of sphincter injuries are unlikely to be beneficial and may be detrimental. PMID:25439012

Breech delivery in very preterm and very low birthweight infants in The Netherlands.

PubMed

Gravenhorst, J B; Schreuder, A M; Veen, S; Brand, R; Verloove-Vanhorick, S P; Verweij, R A; van Zeben-van der Aa, D M; Ens-Dokkum, M H

1993-05-01

To study the relation between various perinatal factors and the sequelae of very preterm birth, applying logistic regression analysis. In a nationwide collaborative study in the Netherlands, perinatal and follow up data were collected on 899 liveborn singleton nonmalformed infants with gestational age less than 32 weeks or birthweight less than 1500 g born in 1983. Neonatal mortality rate and total handicap rates (minor and major) in surviving children at two years and five years of age. Comparing breech with vertex presentation, the odds ratio for neonatal mortality (adjusted for duration of pregnancy, birthweight, maternal hypertension and prolonged rupture of membranes) is 1.6 (P < 0.05). Comparing abdominal versus vaginal delivery, the odds ratio indicates equal risks. When breech and vertex presentation are analysed separately it appears that breech presenting infants have a significantly lower mortality risk when born by caesarean section compared with vaginal delivery. However, comparing abdominal versus vaginal delivery in breech presentation, the odds ratio for handicap at five years (0.9) is not significantly different from 1. The data presented suggest a reduced neonatal mortality rate in breech presenting infants born by caesarean section but because of the observational design of the study the statistical analysis described only identifies a possible trend and cannot prove the issue.

[Clinical evaluation of flomoxef in the treatment of chorioamnionitis and changes in the fetal fibronectin level in vaginal secretion].

PubMed

Chimura, T; Hirayama, T; Oda, T; Saitou, N; Morisaki, N

1993-02-01

Flomoxef (FMOX) was administered as an initial treatment for chorioamnionitis complicating possible spontaneous abortion or premature delivery and preterm PROM (premature rupture of the membranes), and the clinical effectiveness of the drug, and the usefulness of fetal fibronectin (FFN) as a diagnostic marker of premature delivery were evaluated. 1. Clinical effects of drip infusion of FMOX (2-4 g/day) with and without tocolysis for the treatment of chorioamnionitis were evaluated in 43 patients with possible spontaneous abortion or premature delivery and those with preterm PROM (n = 43). Changes in the FFN level in the vaginal secretion were also studied in 11 patients. 2. It was possible to prevent premature delivery in 7 (26.9%) of 26 patients, and the latent period of preterm PROM was longer than 8 days in 6 (46.2%) of 13 patients. 3. The FFN level decreased slightly in patients for whom FMOX was effective, and the outcome was satisfactory in those whose FFN levels were less than 200 ng/ml. However, the outcome was poor in those whose FFN levels were higher than 1,000 ng/ml. These findings suggest that changes in the FFN level in the vaginal secretion reflect the clinical course of chorioamnionitis as do changes in CRP.

Patient satisfaction with childbirth after external cephalic version.

PubMed

Bogner, Gerhard; Hammer, Barbara Eva; Schausberger, Christiane; Fischer, Thorsten; Reisenberger, Klaus; Jacobs, Volker

2014-03-01

To assess acceptance and impact of external cephalic version (ECV) for breech presentation at term on maternal satisfaction with childbirth. Retrospective study on n = 131 women with breech presentation comparing maternal satisfaction after ECV and consecutive childbirth (n = 66; 50.4% of these successful attempts in n = 33; 50%) against the group without ECV and primary caesarean section (CS) (n = 65; 49.6%) instead using a questionnaire. Women with successful ECV tolerated side effects of the intervention better than after unsuccessful ECV (pain, tocolytics, mental and physical state, for all p < 0.001). They were not more satisfied with childbirth than women who experienced an unsuccessful ECV (p = 0.37). However, they would undergo the procedure again (p = 0.003) and would recommend it to other women (p < 0.001). Only women with spontaneous vaginal deliveries after successful version were more satisfied with childbirth than women with planned CS (p = 0.05). Women with version attempts tend to perceive childbirth as being less problematic with fewer complications (9.5 vs. 19%, p = 0.12). Unsuccessful ECVs had no negative impact on satisfaction with childbirth (p = 0.072). Attempting ECV seems to be an option for increasing the rate of vaginal births with breech presentation without negative impact on maternal satisfaction regarding consecutive childbirth.

W/O/W multiple emulsions containing nitroimidazole derivates for vaginal delivery.

PubMed

Ozer, Ozgen; Ozyazici, Mine; Tedajo, Muriel; Taner, Memduh S; Köseoglu, Kamil

2007-03-01

The aim of our study was to formulate a stable multiple emulsions containing two nitroimidazole derivates, metronidazole (MT) and ornidazole (OR), for vaginal therapy. MT and OR were located internal and external phases of multiple emulsion, respectively, and the in vitro release studies were realized in phosphate (pH 7) and lactate buffer (pH 4.5) solutions to investigate better the effect of pH and location of active substance on the release. The imaging studies were realized in rabbits following labeling MT and OR with Technethium-99m ((99m)Tc) to evaluate the in vivo absorption characteristics. The percentage of MT and OR released from the multiple emulsions in alkaline media were 3.2- and 2.8-fold greater than that observed in acidic media, respectively, when they were introduced in the internal phase of the multiple emulsions. The absorption rate of MT from vaginal epithelium was faster than OR. We observed that especially in alkaline medium a high release was found that was convenient for the vaginal infections seen in the alkaline pH. We concluded that W/O/W multiple emulsions were locally effective in vagina and they could be introduced as a new drug carrier system for vaginal delivery.

Post natal use of analgesics: comparisons between conventional postnatal wards and a maternity hotel.

PubMed

Nordeng, Hedvig; Eskild, Anne; Nesheim, Britt-Ingjerd

2010-04-01

To investigate factors related to analgesic use after delivery, and especially whether rates of analgesic use were different in a midwife-managed maternity hotel as compared to conventional postnatal wards. One maternity hotel and two conventional postnatal wards at Ullevål University Hospital in Oslo, Norway. Data were obtained from hospital records for 804 women with vaginal deliveries. Postnatal analgesic use. Overall, approximately half the women used analgesics after vaginal delivery in both conventional postnatal wards and maternity hotel. The factors that were significantly associated with use of analgesics postnatally in multivariate analysis were multiparity, having a non-Western ethnicity, smoking in pregnancy, younger age, instrumental delivery, analgesic use during labour, maternal complications post partum, and duration of postnatal stay 4 days or more. The use of analgesics is determined by socio-demographic and obstetric factors rather than the organisation of the ward.

Prevention of childbirth injuries to the pelvic floor.

PubMed

Heit, M; Mudd, K; Culligan, P

2001-08-01

The majority of childbirth injuries to the pelvic floor occur after the first vaginal delivery. Cesarean sections performed after the onset of labor may not protect the pelvic floor. Elective cesarean section is the only true primary prevention strategy for childbirth injuries to the pelvic floor. Alternative primary prevention strategies include elective cesarean section for women with nonmodifiable risks for childbirth injuries to the pelvic floor, antepartum pelvic floor exercises, or intrapartum pudendal nerve monitoring. Secondary prevention strategies must focus on modifying obstetric practices that predispose women to pelvic floor injury. These factors are best delineated for anal incontinence and include restrictive use of episiotomy, mediolateral episiotomy when necessary, spontaneous over forceps-assisted vaginal delivery, vacuum extraction over forceps delivery, and antepartum perineal massage. Finally, tertiary prevention strategies should address the mode of delivery made for women with childbirth injuries to the pelvic floor who desire future fertility.

Misrecognition of need: women's experiences of and explanations for undergoing cesarean delivery.

PubMed

Tully, Kristin P; Ball, Helen L

2013-05-01

International rates of operative delivery are consistently higher than the World Health Organization determined is appropriate. This suggests that factors other than clinical indications contribute to cesarean section. Data presented here are from interviews with 115 mothers on the postnatal ward of a hospital in Northeast England during February 2006 to March 2009 after the women underwent either unscheduled or scheduled cesarean childbirth. Using thematic content analysis, we found women's accounts of their experiences largely portrayed cesarean section as everything that they had wanted to avoid, but necessary given their situations. Contrary to popular suggestion, the data did not indicate impersonalized medical practice, or that cesareans were being performed 'on request.' The categorization of cesareans into 'emergency' and 'elective' did not reflect maternal experiences. Rather, many unscheduled cesareans were conducted without indications of fetal distress and most scheduled cesareans were not booked because of 'choice.' The authoritative knowledge that influenced maternal perceptions of the need to undergo operative delivery included moving forward from 'prolonged' labor and scheduling cesarean as a prophylactic to avoid anticipated psychological or physical harm. In spontaneously defending themselves against stigma from the 'too posh to push' label that is currently common in the media, women portrayed debate on the appropriateness of cesarean childbirth as a social critique instead of a health issue. The findings suggest the 'need' for some cesareans is due to misrecognition of indications by all involved. The factors underlying many cesareans may actually be modifiable, but informed choice and healthful outcomes are impeded by lack of awareness regarding the benefits of labor on the fetal transition to extrauterine life, the maternal desire for predictability in their parturition and recovery experiences, and possibly lack of sufficient experience for providers in a variety of vaginal delivery scenarios (non-progressive labor, breech presentation, and/or after previous cesarean). Copyright © 2013 Elsevier Ltd. All rights reserved.

Reduction in resource use with the misoprostol vaginal insert vs the dinoprostone vaginal insert for labour induction: a model-based analysis from a United Kingdom healthcare perspective.

PubMed

Draycott, T; van der Nelson, H; Montouchet, C; Ruff, L; Andersson, F

2016-02-10

In view of the increasing pressure on the UK's maternity units, new methods of labour induction are required to alleviate the burden on the National Health Service, while maintaining the quality of care for women during delivery. A model was developed to evaluate the resource use associated with misoprostol vaginal inserts (MVIs) and dinoprostone vaginal inserts (DVIs) for the induction of labour at term. The one-year Markov model estimated clinical outcomes in a hypothetical cohort of 1397 pregnant women (parous and nulliparous) induced with either MVI or DVI at Southmead Hospital, Bristol, UK. Efficacy and safety data were based on published and unpublished results from a phase III, double-blind, multicentre, randomised controlled trial. Resource use was modelled using data from labour induction during antenatal admission to patient discharge from Southmead Hospital. The model's sensitivity to key parameters was explored in deterministic multi-way and scenario-based analyses. Over one year, the model results indicated MVI use could lead to a reduction of 10,201 h (28.9%) in the time to vaginal delivery, and an increase of 121% and 52% in the proportion of women achieving vaginal delivery at 12 and 24 h, respectively, compared with DVI use. Inducing women with the MVI could lead to a 25.2% reduction in the number of midwife shifts spent managing labour induction and 451 fewer hospital bed days. These resource utilisation reductions may equate to a potential 27.4% increase in birthing capacity at Southmead Hospital, when using the MVI instead of the DVI. Resource use, in addition to clinical considerations, should be considered when making decisions about labour induction methods. Our model analysis suggests the MVI is an effective method for labour induction, and could lead to a considerable reduction in resource use compared with the DVI, thereby alleviating the increasing burden of labour induction in UK hospitals.

Mucus-Penetrating Nanoparticles for Vaginal Drug Delivery Protect Against Herpes Simplex Virus

PubMed Central

Ensign, Laura M.; Tang, Benjamin C.; Wang, Ying-Ying; Tse, Terence A.; Hoen, Timothy; Cone, Richard; Hanes, Justin

2013-01-01

Incomplete coverage and short duration of action limit the effectiveness of vaginally administered drugs, including microbicides for preventing sexually transmitted infections. We investigated vaginal distribution, retention, and safety of nanoparticles with surfaces modified to enhance transport through mucus. We show that mucus-penetrating particles (MPPs) provide uniform distribution over the vaginal epithelium, whereas conventional nanoparticles (CPs) that are mucoadhesive are aggregated by mouse vaginal mucus, leading to poor distribution. Moreover, when delivered hypotonically, MPPs were transported advectively (versus diffusively) through mucus deep into vaginal folds (rugae) within minutes. By penetrating into the deepest mucus layers, more MPPs were retained in the vaginal tract after 6 h compared to CPs. After 24 h, when delivered in a conventional vaginal gel, patches of a model drug remained on the vaginal epithelium, whereas the epithelium was coated with drug delivered by MPP. We then developed MPPs composed of acyclovir monophosphate (ACVp). When administered prior to vaginal herpes simplex virus 2 (HSV-2) challenge, ACVp-MPPs protected 53% of mice, compared to only 16% protected by soluble drug. Overall, MPPs improved vaginal drug distribution and retention, provided more effective protection against vaginal viral challenge than soluble drug, and were non-toxic when administered daily for one week. PMID:22700955

The relationship of Candida colonization of the oral and vaginal mucosae of mothers and oral mucosae of their newborns at birth.

PubMed

Al-Rusan, Rund M; Darwazeh, Azmi M G; Lataifeh, Isam M

2017-04-01

Vaginal Candida colonization is common during pregnancy. Vaginal Candida may transmit vertically to the mouth of newborns during labor. The aim of this study was to assess and compare oral Candida colonization between vaginally born newborns and cesarean-born newborns and to investigate the association of the mother's vaginal and oral Candida colonization and the newborn's oral colonization at the time of delivery. Culture swabs were collected from the oral and vaginal mucosae of 100 pregnant women and from the oral mucosa of their 100 full-term newborns. Fifty (50%) of the mothers gave birth vaginally and the other 50 (50%) by cesarean section. The prevalence of oral and vaginal Candida in pregnant mothers was 49% and 40%, respectively. Oral Candida colonization in newborns was 7%. Oral Candida was isolated from 5 of 50 (10%) in the vaginally born group and from 2 of 50 (4%) in the cesarean-born group (P = .44). In vaginally born group, oral Candida was isolated from 5 of 20 (25%) in those born to mothers with vaginal colonization of Candida, and 0 of 30 (0.0%) in mothers without vaginal colonization of Candida (P = .007). The mother's vaginal Candida may constitute an important source of oral Candida in the newborns, particularly in those delivered vaginally. Copyright © 2017 Elsevier Inc. All rights reserved.

Delivery mode and intraventricular hemorrhage risk in very-low-birth-weight infants: Observational data of the German Neonatal Network.

PubMed

Humberg, Alexander; Härtel, Christoph; Paul, Pia; Hanke, Kathrin; Bossung, Verena; Hartz, Annika; Fasel, Laura; Rausch, Tanja K; Rody, Achim; Herting, Egbert; Göpel, Wolfgang

2017-05-01

Very-low-birth-weight infants (VLBWI) are frequently delivered by cesarean section (CS). However, it is unclear at what gestational age the benefits of spontaneous delivery outweigh the perinatal risks, i.e. intraventricular hemorrhage (IVH) or death. To assess the short-term outcome of VLBWI on IVH according to mode of delivery in a population-based cohort of the German Neonatal Network (GNN). A total cohort of 2203 singleton VLBWI with a birth weight <1500g and gestational age between 22 0/7 and 36 6/7 weeks born and discharged between 1st of January 2009 and 31st of December 2015 was available for analysis. VLBWI were stratified into three categories according to mode of delivery: (1) planned cesarean section (n=1381), (2) vaginal delivery (n=632) and (3) emergency cesarean section (n=190). Outcome was assessed in univariate and logistic regression analyses. Prevalence of IVH was significantly higher in the vaginal delivery (VD) (26.6%) and emergency CS group (31.1%) as compared to planned CS (17.2%), respectively. In a logistic regression analysis including known risk factors for IVH, vaginal delivery (OR 1.725 [1.325-2.202], p≤0.001) and emergency cesarean section (OR 1.916 [1.338-2.746], p≤0.001) were independently associated with IVH risk. In the subgroup of infants >30 weeks of gestation prevalence for IVH was not significantly different in VD and planned CS (5.3% vs. 4.4%). Our observational data demonstrate that elective cesarean section is associated with a reduced risk of IVH in preterm infants <30 weeks gestational age when presenting with preterm labor. Copyright © 2017 Elsevier B.V. All rights reserved.

A comparison between early maternal and neonatal complications of restrictive episiotomy and routine episiotomy in primiparous vaginal delivery

PubMed Central

Shahraki, Azar Danesh; Aram, Shahnaz; Pourkabirian, Soodabeh; Khodaee, Sepideh; Choupannejad, Shekofeh

2011-01-01

BACKGROUND: Routine episiotomy is a controversial issue among gynecologists. The aim of this study was to compare early maternal and neonatal complications of restrictive episiotomy and routine episiotomy in primiparus vaginal delivery. METHODS: In this descriptive cross-sectional study, two groups of primiparus normal vaginal delivery (NVD) cases with routine and restrictive episiotomy were studied. Immediately and in the first 24 and 48 hours after delivery, specific charts were used to compare the two groups in terms of perineal laceration size, neonatal Apgar score and post-delivery. For data analysis, SPSS was used to conduct student t-test and Kruskal-Wallis test. A p-value < 0.05 was considered significant. RESULTS: Forty primiparus pregnant women were studied in each group. Episiotomy was performed in 7.5% of the restrictive group. Perineal laceration was measured as 3.68 ± 0.47 cm and 1.21 ± 1.1 in routine and restrictive episiotomy groups, respectively (p < 0.05). Intact perineum or first-degree laceration was seen in 80% of the restrictive group. However, second- and third-degree laceration were respectively observed in 75% and 15% of the routine episiotomy group (p < 0.05). Pain relief (immediately, 24 and 48 hours after delivery) was significantly higher in the restrictive group (p < 0.05). On the contrary, no significant difference in Apgar scores at the first and fifth minutes after birth was found between the two groups (p > 0.05). CONCLUSIONS: Restrictive episiotomy results in low maternal complications. Therefore, avoiding routine episiotomy in unnecessary conditions would increase the rate of intact perineal and minor perineal trauma and reduce postpartum delivery pain with no adverse effects neither on maternal nor neonatal morbidities. PMID:22973367

Minimizing genital tract trauma and related pain following spontaneous vaginal birth.

PubMed

Albers, Leah L; Borders, Noelle

2007-01-01

Genital tract trauma is common following vaginal childbirth, and perineal pain is a frequent symptom reported by new mothers. The following techniques and care measures are associated with lower rates of obstetric lacerations and related pain following spontaneous vaginal birth: antenatal perineal massage for nulliparous women, upright or lateral positions for birth, avoidance of Valsalva pushing, delayed pushing with epidural analgesia, avoidance of episiotomy, controlled delivery of the baby's head, use of Dexon (U.S. Surgical; Norwalk, CT) or Vicryl (Ethicon, Inc., Somerville, NJ) suture material, the "Fleming method" for suturing lacerations, and oral or rectal ibuprofen for perineal pain relief after delivery. Further research is warranted to determine the role of prenatal pelvic floor (Kegel) exercises, general exercise, and body mass index in reducing obstetric trauma, and also the role of pelvic floor and general exercise in pelvic floor recovery after childbirth.

Vaginal colonization by Escherichia coli as a risk factor for very low birth weight delivery and other perinatal complications.

PubMed

Krohn, M A; Thwin, S S; Rabe, L K; Brown, Z; Hillier, S L

1997-03-01

This study evaluated the relationship of vaginal Escherichia coli colonization to birth weight <1500 g and other perinatal complications in a cross-sectional study of 2646 women at the University of Washington Medical Center, Seattle, between October 1992 and January 1995. Vaginal E. coli colonization was more strongly associated with delivery at <34 weeks (relative risk [RR], 1.7; 95% confidence interval [CI], 1.3-2.3) and very low birth weight (RR, 1.9; 95% CI, 1.3-2.7) than with prematurity between 34 and 36 weeks or low birth weight. Heavy growth of E. coli had a higher risk of very low birth weight than light growth (RR, 2.4; 95% CI, 1.0-6.2). It may be important to screen and treat pregnant women for genital tract colonization with E. coli during prenatal care.

Predictive factors for the success of McRoberts' manoeuvre and suprapubic pressure in relieving shoulder dystocia: a cross-sectional study.

PubMed

Lok, Zara Lin Zau; Cheng, Yvonne Kwun Yue; Leung, Tak Yeung

2016-10-29

McRoberts' and suprapubic pressure are often recommended as the initial choices of manoeuvres to manage shoulder dystocia, as they are believed to be less invasive compared to other manoeuvres. However, their success rates range from 23 to 40 %. This study aims to investigate the predictive factors for the success of McRoberts' manoeuvre with or without suprapubic pressure (M+/-S). All cases of shoulder dystocia in a tertiary hospital in South East Asia were recruited from 1995 to 2009. Subjects were analysed according to either 'success' or 'failure' of M+/-S. Maternal and fetal antenatal and intrapartum factors were compared by univariate and multivariate analysis. Among 198 cases of shoulder dystocia, M+/-S as the primary manoeuvre was successful in 25.8 %. The other 74.2 % needed either rotational or posterior arm manoeuvres or combination of manoeuvres. Instrumental delivery was the single most significant factor associated with an increased risk of failed M+/-S on logistic regression (p < 0.001, OR 4.88, 95 % CI 2.05-11.60). The success rate of M+/-S was only 15.0 % if shoulder dystocia occurred after instrumental delivery but was 47.7 % after spontaneous vaginal delivery. When shoulder dystocia occurs after instrumental vaginal delivery, the chance of failure of M+/-S is 85 %, which is 4.7 times higher than that after spontaneous vaginal delivery. Hence all operators performing instrumental delivery should be proficient in performing all manoeuvres to relieve shoulder dystocia when M+/-S cannot do so.

A novel and dedicated multidisciplinary service to manage breech presentation at term; 3 years of experience in a tertiary care maternity unit.

PubMed

Hickland, Patrick; Gargan, Phyl; Simpson, Jacquie; McCabe, Niamh; Costa, Janitha

2017-08-09

In order to provide uniform and unbiased multidisciplinary counselling on the options available, including vaginal breech delivery (VBD) and external cephalic version (ECV), the latter of which could then be performed, a weekly Breech Clinic was introduced to a tertiary care maternity unit in Northern Ireland in June 2013, replacing the traditional ECV Clinic introduced in June 2012. Retrospective data collection was undertaken using clinic proformas, Northern Ireland Maternity System data and case notes of women who attended the clinics (ECV and Breech) from June 2012 to May 2015. There were 434 referrals to the clinic over the 3-year period; 356 women attended. The proportion of women attending increased from 69% to 85% since the introduction of the Breech Clinic. Two hundred and thirty-two were deemed eligible and 179 of these underwent ECV after counselling. Although the proportion of women undergoing ECV decreased from 69% to 46%, 11 women opted for and achieved VBD during the 2 years of the Breech Clinic, compared with one woman in the year of the ECV Clinic. Seventy-one of the attempted ECVs were successful, with 61 women having a normal vaginal delivery. Notably, the success rate of ECV increased from 33% to 42%. The number of caesarean sections performed solely for breech at term decreased from 199 in the 12 months before the introduction of ECV clinic, to 188 during the ECV clinic, and 154 in the final 12 months of Breech Clinic. A dedicated service to counsel women on the management of breech presentation can decrease caesarean sections for breech presentation through increased uptake and success of ECV, and encouraging suitable women to opt for VBD when ECV is unsuccessful, contraindicated or declined.

The effect of medical and operative birth interventions on child health outcomes in the first 28 days and up to 5 years of age: A linked data population-based cohort study.

PubMed

Peters, Lilian L; Thornton, Charlene; de Jonge, Ank; Khashan, Ali; Tracy, Mark; Downe, Soo; Feijen-de Jong, Esther I; Dahlen, Hannah G

2018-03-25

Spontaneous vaginal birth rates are decreasing worldwide, while cesarean delivery, instrumental births, and medical birth interventions are increasing. Emerging evidence suggests that birth interventions may have an effect on children's health. Therefore, the aim of our study was to examine the association between operative and medical birth interventions on the child's health during the first 28 days and up to 5 years of age. In New South Wales (Australia), population-linked data sets were analyzed, including data on maternal characteristics, child characteristics, mode of birth, interventions during labor and birth, and adverse health outcomes of the children (ie, jaundice, feeding problems, hypothermia, asthma, respiratory infections, gastrointestinal disorders, other infections, metabolic disorder, and eczema) registered with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification codes. Logistic regression analyses were performed for each adverse health outcome. Our analyses included 491 590 women and their children; of those 38% experienced a spontaneous vaginal birth. Infants who experienced an instrumental birth after induction or augmentation had the highest risk of jaundice, adjusted odds ratio (aOR) 2.75 (95% confidence interval [CI] 2.61-2.91) compared with spontaneous vaginal birth. Children born by cesarean delivery were particularly at statistically significantly increased risk for infections, eczema, and metabolic disorder, compared with spontaneous vaginal birth. Children born by emergency cesarean delivery showed the highest association for metabolic disorder, aOR 2.63 (95% CI 2.26-3.07). Children born by spontaneous vaginal birth had fewer short- and longer-term health problems, compared with those born after birth interventions. © 2018 the Authors. Birth published by Wiley Periodicals, Inc.

Reproductive history and progression of lower urinary tract symptoms in women: results from a population-based cohort study.

PubMed

Maserejian, Nancy N; Curto, Teresa; Hall, Susan A; Wittert, Gary; McKinlay, John B

2014-04-01

To examine whether reproductive history and related conditions are associated with the development and persistence of lower urinary tract symptoms (LUTS) other than urinary incontinence in a racially and/or ethnically diverse population-based sample of women. The Boston Area Community Health Survey enrolled 3201 women aged 30-79 years of black, Hispanic, or white race and/or ethnicity. Baseline and 5-year follow-up interviews were completed by 2534 women (conditional response rate, 83.4%). The association between reproductive history factors and population-weighted estimates of LUTS progression and persistence was tested using multivariable logistic regression models. Between baseline and 5-year follow-up, 23.9% women had LUTS progression. In age-adjusted models, women who had delivered ≥2 childbirths had higher odds of LUTS progression, but the association was completely accounted for by vaginal child delivery (eg, 2 vaginal childbirths vs none, multivariable-adjusted odds ratio = 2.21; 95% CI, 1.46-3.35; P <.001). No increased odds of LUTS progression were found for women with only 1 vaginal delivery or who only had cesarean section(s). Uterine prolapse was associated with higher odds of LUTS progression (multivariable-adjusted odds ratio = 3.05; 95% CI, 1.43-6.50; P = .004). Gestational diabetes was associated with approximately twice the odds of LUTS progression, but only among younger women (interaction P = .003). In this cohort study, ≥2 vaginal child deliveries, uterine prolapse, and among younger women, gestational diabetes were robust predictors of LUTS progression. Clinicians should assess the presence of bothersome urinary frequency, urgency, and voiding symptoms among women who have had multiple vaginal childbirths or gestational diabetes. Copyright © 2014 Elsevier Inc. All rights reserved.

FG90 chitosan as a new polymer for metronidazole mucoadhesive tablets for vaginal administration.

PubMed

Perioli, Luana; Ambrogi, Valeria; Pagano, Cinzia; Scuota, Stefania; Rossi, Carlo

2009-07-30

Topical administration of the antibacterial metronidazole (MET) represents the most common therapy in the treatment of bacterial vaginosis (BV). The formulations generally available for BV therapy are creams, gels, vaginal lavages and vaginal suppositories. In this study, a new dosage form, containing MET, was developed with the aim to realize vaginal mucoadhesive tablets by including bioadhesive polymers as chitosan (FG90C), polyvinylpyrrolidone (PVPK90) and polycarbophil (PCPAA1), blended in different ratios. All formulations were characterized by studies of DSC, friability, hardness, hydration, mucoadhesion, in vitro release and antibacterial activity. All polymer mixtures employed were used to prepare tablets with the compactness and hardness so as allow the application on vaginal mucosa. FG90C performances improved in particular when mixed to PVPK90 (1:1 ratio). This kind of delivery system is suitable for formulating MET for topical application representing a good alternative to traditional dosage forms for vaginal topical administration.

Advanced age is a risk factor for higher grade perineal lacerations during delivery in nulliparous women.

PubMed

Hornemann, Amadeus; Kamischke, Axel; Luedders, Doerte W; Beyer, Daniel A; Diedrich, Klaus; Bohlmann, Michael K

2010-01-01

To identify risk factors for the development of severe perineal lacerations and to give recommendations for their prevention in nulliparous women. A retrospective case-control analysis of deliveries at our University Hospital was performed. Multiparae, Caesarean sections, twin pregnancies, fetal breech position and preterm deliveries were excluded. Univariate and multivariate step forward regression analyses were performed; correlations between contributors were further analyzed by Spearman Rank Correlation. Differences between the degree of lacerations and maternal age were further analyzed with Friedman ANOVA followed by Dunn's Multiple Comparison Test. A total of 2,967 deliveries fitted our inclusion criteria, 50 (1.7%) mothers had higher-grade lacerations. Mediolateral and median episiotomy, advanced maternal age, vaginal operative delivery, higher fetal birth weight and abnormal cephalic presentation were associated with severe lacerations. Advanced maternal age plays an important role in the development of anal sphincter tears in nulliparous women. Episiotomy and operative vaginal deliveries should be restrictively performed when possible. To identify further preventive approaches in patients with accumulated risk factors prospective randomized studies are needed.

Prophylaxis and treatment of HIV-1 infection in pregnancy: Swedish recommendations 2013.

PubMed

Navér, Lars; Albert, Jan; Böttiger, Ylva; Carlander, Christina; Flamholc, Leo; Gisslén, Magnus; Josephson, Filip; Karlström, Olof; Lindborg, Lena; Svedhem-Johansson, Veronica; Svennerholm, Bo; Sönnerborg, Anders; Yilmaz, Aylin; Pettersson, Karin

2014-06-01

Prophylaxis and treatment with antiretroviral drugs and elective caesarean section delivery have resulted in very low mother-to-child transmission of HIV during recent years. Updated general treatment guidelines and increasing knowledge about mother-to-child transmission have necessitated regular revisions of the recommendations for the prophylaxis and treatment of HIV-1 infection in pregnancy. The Swedish Reference Group for Antiviral Therapy (RAV) updated the recommendations from 2010 at an expert meeting on 11 September 2013. The most important revisions are the following: (1) ongoing efficient treatment at confirmed pregnancy may, with a few exceptions, be continued; (2) if treatment is initiated during pregnancy, the recommended first-line therapy is essentially the same as for non-pregnant women; (3) raltegravir may be added to achieve rapid reduction in HIV RNA; (4) vaginal delivery is recommended if at > 34 gestational weeks and HIV RNA is < 50 copies/ml and no obstetric contraindications exist; (5) if HIV RNA is < 50 copies/ml and delivery is at > 34 gestational weeks, intravenous zidovudine is not recommended regardless of the delivery mode; (6) if HIV RNA is > 50 copies/ml close to delivery, it is recommended that the mother should undergo a planned caesarean section, intravenous zidovudine, and oral nevirapine, and the infant should receive single-dose nevirapine at 48-72 h of age and post-exposure prophylaxis with 2 drugs; (7) if delivery is preterm at < 34 gestational weeks, a caesarean section delivery should if possible be performed, with intravenous zidovudine and oral nevirapine given to the mother, and single-dose nevirapine given to the infant at 48-72 h of age, as well as post-exposure prophylaxis with 2 additional drugs.

Do Italian women prefer cesarean section? Results from a survey on mode of delivery preferences

PubMed Central

2013-01-01

Background About 20 million cesareans occur each year in the world and rates have steadily increased in almost all middle- and high-income countries over the last decades. Maternal request is often argued as one of the key forces driving this increase. Italy has the highest cesarean rate of Europe, yet there are no national surveys on the views of Italian women about their preferences on route of delivery. This study aimed to assess Italian women´s preference for mode of delivery, as well as reasons and factors associated with this preference, in a nationally representative sample of women. Methods This cross sectional survey was conducted between December 2010-March 2011. An anonymous structured questionnaire asked participants what was their preferred mode of delivery and explored the reasons for this preference by assessing their agreement to a series of statements. Participants were also asked to what extent their preference was influenced by a series of possible sources. The 1st phase of the study was carried out among readers of a popular Italian women´s magazine (Io Donna). In a 2nd phase, the study was complemented by a structured telephone interview. Results A total of 1000 Italian women participated in the survey and 80% declared they would prefer to deliver vaginally if they could opt. The preference for vaginal delivery was significantly higher among older (84.7%), more educated (87.6%), multiparous women (82.3%) and especially among those without any previous cesareans (94.2%). The main reasons for preferring a vaginal delivery were not wanting to be separated from the baby during the first hours of life, a shorter hospital stay and a faster postpartum recovery. The main reasons for preferring a cesarean were fear of pain, convenience to schedule the delivery and because it was perceived as being less traumatic for the baby. The source which most influenced the preference of these Italian women was their obstetrician, followed by friends or relatives. Conclusion Four in five Italian women would prefer to deliver vaginally if they could opt. Factors associated with a higher preference for cesarean delivery were youth, nulliparity, lower education and a previous cesarean. PMID:23530472

[Face presentation: retrospective study of 32 cases at term].

PubMed

Ducarme, G; Ceccaldi, P-F; Chesnoy, V; Robinet, G; Gabriel, R

2006-05-01

To determine the etiologic factors, circumstances of diagnosis, obstetrical management and complications of face presentation and to value the maternal and foetal prognosis of this presentation. Thirty-two cases of face presentation have been observed in the maternity wards of Reims and Troyes over the last 12 years. The incidence of face presentation was 0.7 per 1000 deliveries. Spontaneous vaginal delivery occurred with mento-anterior presentation 73% of the time and caesarean section was performed in 100% of mento-posterior presentation. There was no increasing rate of foetal or maternal mortality and morbidity with vaginal delivery. Face presentation is an unusual complication of pregnancy with obstetric factors that predispose the foetus to face presentation. The low foetal and maternal mortality and morbidity substantiate the effectiveness of conservative management in face presentation.

Different labour outcomes in primiparous women that have been subjected to childhood sexual abuse or rape in adulthood: a case–control study in a clinical cohort

PubMed Central

Nerum, H; Halvorsen, L; Straume, B; Sørlie, T; Øian, P

2013-01-01

Objective To compare the duration and outcome of the first labour in women who have been subjected to childhood sexual abuse (CSA) and women who have been raped in adulthood (RA). Design Case–control study in a clinical cohort. Setting University Hospital of North Norway. Sample In all, 373 primiparas: 185 subjected to CSA, 47 to RA and 141 controls without a history of abuse. Methods Data on birth outcomes were retrieved from the patient files. Information on sexual abuse was reported in consultation with specialised midwives in the mental health team. Birth outcomes were analysed by multinominal regression analysis. Main outcome measures Vaginal births, delivery by caesarean section, operative vaginal delivery and duration of labour. Results As compared with controls, the RA group showed a significantly higher risk for caesarean section (adjusted OR 9.9, 95% CI 3.4–29.4) and operative vaginal delivery (adjusted OR 12.2, 95% CI 4.4–33.7). There were no significant differences between the CSA and the control group. The RA group displayed significantly longer duration of labour in all phases as compared with the control and CSA groups. Conclusions There were major differences in the duration of labour and birth outcomes in the two abuse groups. Despite a higher proportion of obstetric risk factors at onset of labour in the CSA group, women subjected to CSA had shorter labours and less risk for caesarean section and operative vaginal deliveries than women subjected to RA. The best care for birthing women subjected to sexual abuse needs to be explored in further studies. PMID:23157417

High-intensity focused ultrasound treatment of placenta accreta after vaginal delivery: a preliminary study.

PubMed

Bai, Y; Luo, X; Li, Q; Yin, N; Fu, X; Zhang, H; Qi, H

2016-04-01

To evaluate the safety and efficiency of high-intensity focused ultrasound (HIFU) in the treatment of placenta accreta after vaginal delivery. Enrolled into this study between September 2011 and September 2013 were 12 patients who had been diagnosed with placenta accreta following vaginal delivery and who had stable vital signs. All patients were treated using an ultrasound-guided HIFU treatment system. As indication of the effectiveness of the treatment we considered decreased vascular index on color Doppler imaging, decrease in size of residual placenta compared with pretreatment size on assessment by three-dimensional ultrasound with Virtual Organ Computer-aided Analysis, reduced signal intensity and degree of enhancement on magnetic resonance imaging and avoidance of hysterectomy following treatment. To assess the safety of HIFU treatment, we recorded side effects, hemorrhage, infection, sex steroid levels, return of menses and subsequent pregnancy. Patients were followed up in this preliminary study until December 2013. The 12 patients receiving HIFU treatment had an average postpartum hospital stay of 6.8 days and an average period of residual placental involution of 36.9 days. HIFU treatment did not apparently increase the risk of infection or hemorrhage and no patient required hysterectomy. In all patients menstruation recommenced after an average of 80.2 days, and sex steroid levels during the middle luteal phase of the second menstrual cycle were normal. Two patients became pregnant again during the follow-up period. This preliminary study suggests that ultrasound-guided HIFU is a safe and effective non-invasive method to treat placenta accreta patients after vaginal delivery who have stable vital signs and desire to preserve fertility. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

The effect of an elective cesarean section on maternal request on peripartum anxiety and depression in women with childbirth fear: a systematic review.

PubMed

Olieman, Renske M; Siemonsma, Femke; Bartens, Margaux A; Garthus-Niegel, Susan; Scheele, Fedde; Honig, Adriaan

2017-06-19

Obstetricians are often reluctant to grant requests for an elective cesarean section (ECS) due to childbirth fear. To date, it is unknown if an ECS on request improves mental well-being in the mother in the peripartum period and if possible beneficial effects on anxiety and depression could outweigh the increased risk of complications associated with a surgical delivery. A systematic review was conducted to explore the effect of ECS on request on peripartum anxiety and depression. We searched on PubMed, PsychoInfo and Embase. Studies were included with primary data on anxiety and/or depression postpartum in women with childbirth fear who had requested an ECS. After full-text evaluation of 65 papers and quality analysis of four papers, three papers were included. Of one paper additional and yet unpublished data were provided. Studies varied in outcome measures, hence no meta-analysis was performed. Women who requested an ECS had higher antepartum depression and anxiety levels but no different postpartum depression levels than women who delivered vaginally. One study of good quality examined the effect of vaginal delivery in women preferring ECS: These women had significantly higher symptom levels of post-traumatic stress disorder (PTSD) and depression than women with normal vaginal delivery. The prospect of an ECS does not lower antepartum anxiety and/or depression levels in women requesting an ECS. If women resolutely persist in wishing an ECS despite adequate counselling and/or psychiatric treatment, the risk of developing depressive and PTSD symptoms in case of vaginal delivery should be taken into account, and an ECS may be considered as a valid alternative.

Prevention of preterm delivery with vaginal progesterone in women with preterm labour (4P): randomised double-blind placebo-controlled trial.

PubMed

Martinez de Tejada, B; Karolinski, A; Ocampo, M C; Laterra, C; Hösli, I; Fernández, D; Surbek, D; Huespe, M; Drack, G; Bunader, A; Rouillier, S; López de Degani, G; Seidenstein, E; Prentl, E; Antón, J; Krähenmann, F; Nowacki, D; Poncelas, M; Nassif, J C; Papera, R; Tuma, C; Espoile, R; Tiberio, O; Breccia, G; Messina, A; Peker, B; Schinner, E; Mol, B W; Kanterewicz, L; Wainer, V; Boulvain, M; Othenin-Girard, V; Bertolino, M V; Irion, O

2015-01-01

To evaluate the effectiveness of 200 mg of daily vaginal natural progesterone to prevent preterm birth in women with preterm labour. Multicentre, randomised, double-blind, placebo-controlled trial. Twenty-nine centres in Switzerland and Argentina. A total of 385 women with preterm labour (24(0/7) to 33(6/7) weeks of gestation) treated with acute tocolysis. Participants were randomly allocated to either 200 mg daily of self-administered vaginal progesterone or placebo within 48 hours of starting acute tocolysis. Primary outcome was delivery before 37 weeks of gestation. Secondary outcomes were delivery before 32 and 34 weeks, adverse effects, duration of tocolysis, re-admissions for preterm labour, length of hospital stay, and neonatal morbidity and mortality. The study was ended prematurely based on results of the intermediate analysis. Preterm birth occurred in 42.5% of women in the progesterone group versus 35.5% in the placebo group (relative risk [RR] 1.2; 95% confidence interval [95% CI] 0.93-1.5). Delivery at <32 and <34 weeks did not differ between the two groups (12.9 versus 9.7%; [RR 1.3; 95% CI 0.7-2.5] and 19.7 versus 12.9% [RR 1.5; 95% CI 0.9-2.4], respectively). The duration of tocolysis, hospitalisation, and recurrence of preterm labour were comparable between groups. Neonatal morbidity occurred in 44 (22.8%) cases on progesterone versus 35 (18.8%) cases on placebo (RR: 1.2; 95% CI 0.82-1.8), whereas there were 4 (2%) neonatal deaths in each study group. There is no evidence that the daily administration of 200 mg vaginal progesterone decreases preterm birth or improves neonatal outcome in women with preterm labour. © 2014 Royal College of Obstetricians and Gynaecologists.

Vaginal delivery after Misgav-Ladach cesarean section--is the risk of uterine rupture acceptable?

PubMed

Hudić, Igor; Fatusić, Zlatan; Kamerić, Lejla; Misić, Mladen; Serak, Indira; Latifagić, Anela

2010-10-01

To evaluate whether the single-layer closure as is a routine by the Misgav-Ladach method compared to the double-layer closure as used by the Dörfler cesarean method is associated with an increased risk of uterine rupture in the subsequent pregnancy and delivery. The analysis is retrospective and is based on medical documentation of the Clinic for Gynecology and Obstetrics, University Clinical Centre, Tuzla, Bosnia and Herzegovina. All patients with one previous cesarean section who attempted vaginal birth following cesarean section were managed from 1 January 2002 to 31 December 2008. Exclusion criteria included multiple gestation, greater than one previous cesarean section, previous incision other than low transverse, gestational age at delivery less than 37 weeks and induction of delivery. We identified 448 patients who met inclusion criteria. We found that 303 patients had a single-layer closure (Misgav-Ladach) and 145 had a double-layer closure (Dörffler) of the previous uterine incision. There were 35 cases of uterine rupture. Of those patients with previous single-layer closure, 5.28% (16/303) had a uterine rupture compared to 13.11% (19/145) in the double-layer closure group (p<0.05). We have not found that a Misgav-Ladach cesarean section method (single-layer uterine closure) might be more likely to result in uterine rupture in women who attempted a vaginal birth after a previous cesarean delivery. This cesarean section method should find its confirmation in everyday clinical practice.

Delivery-associated presence of supramolecular fibronectin-fibrin complexes in puerperal and cord plasma.

PubMed

Lis-Kuberka, Jolanta; Berghausen-Mazur, Marta; Kątnik-Prastowska, Iwona; Orczyk-Pawiłowicz, Magdalena

2018-05-15

The variable fibronectin (FN) molecular forms are known to be engaged in coagulation and fibrinolysis pathways as well as tissue remodeling and repair processes. Some of them seem to be indispensable molecules within intensive biological processes associated with delivery. The aim of the study was to evaluate the FN molecular status in maternal and cord plasma after vaginal birth and cesarean section (C-section). The study included nonpregnant women's plasma samples (n = 31) and puerperal and cord plasma samples collected from 49 mothers who delivered healthy newborns at term by vaginal birth (n = 25) and C-section (n = 24). The maternal and cord plasma FN concentrations and presence and relative ratios of different FN-fibrin complexes were determined by ELISA and sodium dodecyl sulfate (SDS) -agarose immunoblotting, respectively. FN concentration in puerperal plasma after vaginal birth (232.08 ± 71.8 mg/L) and C-section (228.17 ± 71.2 mg/L) was significantly higher than in the plasma of nonpregnant women (190.00 ± 48.75 mg/L). In contrast, FN concentration in cord plasma of the C-section group (101.95 ± 30.3 mg/L) was significantly lower than that of the vaginal birth group (121.80 ± 22.2 mg/L). Immunoblotting of puerperal and cord plasma distinguished the most abundant dimeric plasma FN form, the 220-280-kDa FN degradation products and 750-1900-kDa FN-fibrin complexes, which occurred more frequently and in higher amounts in puerperal and cord plasma groups than the nonpregnant women group, although independently of the mode of delivery. Occurrence and relative amount of delivery-associated FN-fibrin complexes in both puerperal and cord plasmas might be bound with the physiological adaptive mechanisms reducing the risk of hemorrhage and intensive remodeling and repair processes after delivery.

Hygroscopic dilators vs balloon catheter ripening of the cervix for induction of labor in nulliparous women at term: Retrospective study

PubMed Central

Shindo, Ryosuke; Yonemoto, Naohiro; Yamamoto, Yuriko; Kasai, Junko; Kasai, Michi; Miyagi, Etsuko

2017-01-01

Objective To compare the efficacy and safety of hygroscopic dilators and balloon catheters for ripening of the cervix in induction of labor. Study design This retrospective, observational study used data from the Successive Pregnancy Birth Registry System of the Japan Society of Obstetrics and Gynecology from 2012 to 2014. Nulliparous women in whom labor was induced by mechanical methods of cervical ripening at term were enrolled. The eligible women were divided into dilator, balloon <40 mL, balloon ≧40 mL, and overlapping groups. Results The groups included 4645, 4100, 6615, and 1992 women, respectively. In the overlapping group, which included the women in whom delivery was most difficult, the vaginal delivery rate was lower and the intrauterine infection and neonatal mortality rates were higher than those in the dilator group. No difference in the vaginal delivery rate was observed among the dilator, balloon <40 mL, and balloon ≧40 mL groups (74.6%, 72.3%, and 73.8%, respectively; p>0.05). The vaginal instrumental delivery rate was higher in the two-balloon groups than in the dilator group. The volume of intrapartum hemorrhage was lowest in the dilator group. No significant difference in the frequencies of uterine rupture and intrauterine infection were observed among the dilator and two-balloon groups. With regard to neonatal outcomes, the frequency of a low Apgar score was statistically significantly lower in the dilator group than in the two-balloon groups. Moreover, the frequency of neonatal death tended to be lower in the dilator group than in the two-balloon groups. Conclusion With regard to cervical ripening for labor induction in nulliparous women at term, the vaginal delivery rate on using a dilator and on using a balloon seems to be equivalent. Concerning maternal complications and neonatal outcomes, cervical ripening with hygroscopic dilators in labor induction might be safer. PMID:29272277

Reducing the rate of preterm birth through a simple antenatal screen-and-treat programme: a retrospective cohort study.

PubMed

Kiss, Herbert; Petricevic, Ljubomir; Martina, Simhofer; Husslein, Peter

2010-11-01

To assess whether a simple screen-and-treat strategy in pregnancy, previously tested in a randomised controlled study, also effectively lowers the rate of preterm delivery under real-life conditions. In a retrospective cohort study, data were enrolled of 2986 women with singleton pregnancies presenting for routine antenatal care between 11 and 24 weeks and registering for delivery. Data of 1273 women in the intervention group were collected between 1 September 2004 and 31 August 2005. The data of 1713 women in the control group had been collected 2 years previously. All women were screened for asymptomatic vaginal infection using Gram stain, differentiating between bacterial vaginosis, vaginal candidiasis, trichomoniasis, or combinations of any of the three. Women with infection received standard treatment and follow-up. Prenatal care was the same for women in the intervention and control groups, the only difference being the absence of screening and treating for vaginal infection in the control group. The primary outcome variable was the rate of preterm delivery at less than 37 weeks. Secondary outcome variables were preterm delivery at less than 37 weeks combined with birth weights ≤ 2500 g, ≤ 2000 g, ≤ 1500 g, or ≤ 1000 g. In the intervention group, the rate of preterm birth was significantly lower than in the control group (8.2% vs. 12.1%, p < 0.0001), as was the number of preterm infants with birth weights of 2500 g or below. Also, a significant difference between groups was found for very preterm deliveries, i.e., those occurring before 33 weeks (1.9% vs. 5.4%, p < 0.0001). Integration of a simple screen-and-treatment programme for common vaginal infections into routine antenatal care led to a significant reduction in preterm births in a general population of pregnant women. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

Invasive Obstetric Procedures and Cesarean Sections in Women With Known Herpes Simplex Virus Status During Pregnancy

PubMed Central

Moss, Nicholas J; Laschansky, Ellen; Drolette, Linda; Magaret, Amalia S; Selke, Stacey; Gardella, Carolyn; Wald, Anna

2017-01-01

Abstract Background Neonatal herpes is a potentially devastating infection that results from acquisition of herpes simplex virus (HSV) type 1 or 2 from the maternal genital tract at the time of vaginal delivery. Current guidelines recommend (1) cesarean delivery if maternal genital HSV lesions are present at the time of labor and (2) antiviral suppressive therapy for women with known genital herpes to decrease HSV shedding from the genital tract at the time of vaginal delivery. However, most neonatal infections occur in infants born to women without a history of genital HSV, making current prevention efforts ineffective for this group. Although routine serologic HSV testing of women during pregnancy could identify women at higher risk of intrapartum viral shedding, it is uncertain how this knowledge might impact intrapartum management, and a potential concern is a higher rate of cesarean sections among women known to be HSV-2 seropositive. Methods To assess the effects of prenatal HSV-2 antibody testing, history of genital herpes, and use of suppressive antiviral medication on the intrapartum management of women, we investigated the frequency of invasive obstetric procedures and cesarean deliveries. We conducted a retrospective cohort study of pregnant women delivering at the University of Washington Medical center in Seattle, Washington. We defined the exposure of interest as HSV-2 antibody positivity or known history of genital herpes noted in prenatal records. The primary outcome was intrapartum procedures including fetal scalp electrode, artificial rupture of membranes, intrauterine pressure catheter, or operative vaginal delivery (vacuum or forceps). The secondary outcome was incidence of cesarean birth. Univariate and multivariable logistic regressions were performed. Results From a total of 449 women included in the analysis, 97 (21.6%) were HSV-2 seropositive or had a history of genital herpes (HSV-2/GH). Herpes simplex virus-2/GH women not using suppressive antiviral therapy were less likely to undergo intrapartum procedures than women without HSV-2/GH (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.25–0.95; P = .036), but this relationship was attenuated after adjustment for potential confounders (adjusted OR, 0.69; 95% CI, 0.34–1.41; P = .31). There was no difference in intrapartum procedures for women on suppressive therapy versus women without HSV-2/GH (OR, 1.17; 95% CI, 0.66–2.07; P = .60). Similar proportions of cesarean sections were performed within each group of women: 25% without history of HSV-2/GH, 30% on suppressive treatment, and 28.1% without suppressive treatment (global, P = .73). Conclusions In this single-site study, provider awareness of genital herpes infection either by HSV serotesting or history was associated with fewer invasive obstetric procedures shown to be associated with neonatal herpes, but it was not associated with an increased rate of cesarean birth. PMID:29308404

Balancing the efficacy and safety of misoprostol: a meta-analysis comparing 25 versus 50 micrograms of intravaginal misoprostol for the induction of labour.

PubMed

McMaster, K; Sanchez-Ramos, L; Kaunitz, A M

2015-03-01

The optimal dose of misoprostol for the induction of labour remains uncertain. To compare the efficacy and safety of 25 versus 50 micrograms of intravaginal misoprostol tablets for the induction of labour and cervical ripening. We performed electronic and manual searches to identify relevant randomised trials. The efficacy outcomes assessed were rates of vaginal delivery within 24 hours, delivery within one dose, and oxytocin augmentation, and interval to delivery. The safety outcomes assessed were incidences of tachysystole, hyperstimulation, caesarean delivery, cesarean delivery for non-reassuring fetal heart rate (FHR), operative vaginal delivery, abnormal 5-minute Apgar score, abnormal cord gas values, admission to a neonatal intensive care unit (NICU), and meconium passage. Thirteen studies (1945 women) were included. Relative risk (RR) and 95% confidence intervals (CI) were calculated using fixed-effects and random-effects models. We found that 25 micrograms was less efficacious, with lower rates of delivery after one dose (RR 0.59; 95% CI 0.39-0.88) and vaginal delivery within 24 hours (RR 0.88; 95% CI 0.79-0.96), and with increased rates of oxytocin augmentation (RR 1.54, 95% CI 1.36-1.75). We noted an improved safety profile with 25 micrograms, however, with decreased rates of tachysystole (RR 0.46; 95% CI 0.35-0.61), hyperstimulation (RR 0.5; 95% CI 0.31-0.78), caesarean deliveries for non-reassuring FHR (RR 0.67; 95% CI 0.52-0.87), NICU admissions (RR 0.63; 95% CI 0.4-0.98), and meconium passage (RR 0.65; 95% CI 0.45-0.96). Although 50 micrograms of intravaginal misoprostol may be more efficacious, safety concerns make the 25-microgram dose preferable. © 2014 Royal College of Obstetricians and Gynaecologists.

Effect of probiotics on vaginal health in pregnancy. EFFPRO, a randomized controlled trial.

PubMed

Gille, Christian; Böer, Bettina; Marschal, Matthias; Urschitz, Michael S; Heinecke, Volker; Hund, Verena; Speidel, Sarah; Tarnow, Inge; Mylonas, Ioannis; Franz, Axel; Engel, Corinna; Poets, Christian F

2016-11-01

Preterm delivery is a leading cause of neonatal morbidity and death. It often results from chorioamnionitis, which is a complication of bacterial vaginosis. Probiotics are effective in the treatment of bacterial vaginosis in women who were not pregnant; studies in pregnant woman are missing. The purpose of this study was to evaluate whether an oral probiotic food supplement supports the maintenance or restoration of a normal vaginal microbiota during pregnancy. We conducted a randomized, placebo-controlled, triple-blind, parallel group trial. Oral Lactobacillus rhamnosus GR-1and L reuteri RC-14 (10 9 colony-forming units) or placebo were administered for 8 weeks to women with <12 completed weeks of pregnancy. Participants were enrolled at Tuebingen University Hospital and 10 recruiting gynecologic practices. Vaginal swabs were taken before and after intervention and analyzed according to the Nugent scoring system. Telephone interviews were performed before and after intervention and after delivery. Primary outcome was the proportion of swabs with normal Nugent score (<4) after intervention, compared by Fisher's exact test in an intention-to-treat analysis. Three hundred twenty pregnant women were enrolled. Vaginal swabs were analyzed from 290 women before and 271 women after intervention. The proportion of normal vaginal microbiota decreased from 82.6 to 77.8% in the treatment group and from 79.1 to 74.3% in the placebo group, with no significant difference across groups after intervention (P=.297). Oral probiotics may be suitable for implementation in antenatal care but, as administered here, had no effect on vaginal health during mid gestation. Other application routes or probiotic preparations may be more effective in supporting vaginal microbiota during pregnancy. Copyright © 2016 Elsevier Inc. All rights reserved.

Early elective cesarean delivery before 36 weeks vs late spontaneous delivery in infants with gastroschisis.

PubMed

Hadidi, Ahmed; Subotic, Ulrike; Goeppl, Maximilian; Waag, Karl-L

2008-07-01

The aim of this study is to assess the value of early elective cesarean delivery for patients with gastroschisis in comparison with late spontaneous delivery. Analysis of infants with gastroschisis admitted between 1986 and 2006 at a tertiary care center was performed. The findings were analyzed statistically. Eighty-six patients were involved in the study. This included 15 patients who underwent emergency cesarean delivery (EM CD group) because of fetal distress and/or bowel ischemia. The remaining 71 patients born electively were stratified into 4 groups. The early elective cesarean delivery (ECD) group included 23 patients born by ECD before 36 weeks; late vaginal delivery (LVD) group included 23 patients who had LVD after 36 weeks; 24 patients had LCD after 36 weeks because of delayed diagnosis that resulted in late referral; and 1 patient had early spontaneous vaginal delivery (EVD group) before 36 weeks. The mean time to start oral feeding, incidence of complications, and primary closure were significantly better in the ECD group than in the LVD group. The duration of ventilation and the length of stay were shorter in ECD group, but the difference was not statistically significant. Elective cesarean delivery before 36 weeks allows earlier enteral feeding and is associated with less complications and higher incidence of primary closure (statistically significant).

Short-term complications associated with the use of transvaginal mesh in pelvic floor reconstructive surgery: Results from a multi-institutional prospectively maintained dataset.

PubMed

Caveney, Maxx; Haddad, Devin; Matthews, Catherine; Badlani, Gopal; Mirzazadeh, Majid

2017-11-01

Vaginal reconstructive surgery can be performed with or without mesh. We sought to determine comparative rates of perioperative complications of native tissue versus vaginal mesh repairs for pelvic organ prolapse. Using the National Surgical Quality Improvement Program (NSQIP) database, we concatenated surgical data from vaginal procedures for prolapse repair, including anterior and posterior colporrhaphy, paravaginal defect repair, enterocele repair, and vaginal colpopexy using Current Procedural Terminology (CPT) coding. We stratified this data by the modifier associated with mesh usage at the time of the procedure. We then compared 30-day perioperative outcomes, postoperative complications (bleeding, infection, etc), and readmission rates between women with and without mesh-based repairs. We identified 10 657 vaginal reconstructive procedures without mesh and 959 mesh-based repairs from 2009 through 2013. Patients undergoing mesh repair were more likely to experience at least one complication than native tissue repair (9.28% vs 6.15%, P < 0.001), with the overall complication rate also being higher in the mesh group (11.37% vs 9.39%, P = 0.03). Procedures with mesh had a higher rate of perioperative bleeding requiring transfusion than native tissue repair (2.3% vs 0.49%, P < 0.001), and organ surgical site infection (SSI) (0.52% vs 0.17%, P = 0.02). There were no significant differences in rates of readmission, superficial, or deep SSIs, pneumonia, urinary tract infection, sepsis, or renal failure. The use of vaginal mesh for pelvic organ prolapse repair appears to result in a higher rate of perioperative complications than native tissue repair. Patients undergoing these procedures should be counselled preoperatively concerning these risks. © 2017 Wiley Periodicals, Inc.

Risk Factors for Chorioamnion Infection and Adverse Pregnancy Outcome Among Military Women

DTIC Science & Technology

1996-10-01

have been enrolled to date. Vaginal cultures from 145 of these women have been assessed for Ureaplasma urealyticum colonization and Bacterial Vaginosis...shown that Ureaplasma urealyticum is the single most common microorganism isolated from the chorioamnion of women in spontaneous labor with intact...vaginal U. urealyticum and BV, the 1,272 women 00005 will also undergo culture of placental and amniotic fluid for aerobes, anaerobes, and ureaplasma

Graft and mesh use in vaginal surgery.

PubMed

Rizvi, Raheela Mohsin; Chughtai, Novera Ghayoor

2017-12-01

Pelvic organ prolapse and urinary incontinence are among the most common chronic disorders in women. These are common problems whose pathogenesis remains unclear. As life expectancy increases, significantly greater number of women now present with pelvic organ prolapse and urinary incontinence requiring surgical intervention. Currently, the lifetime risk of undergoing prolapse or continence surgery is one in 11, and up to 30% of patients will require repeat reconstructive surgery and repeat surgery for incontinence in 10%. In an attempt to improve surgical outcomes and to preserve vaginal capacity and coital function, a number of synthetic and biological prostheses have been developed. This review aims to look at the role of graft and mesh in vaginal surgery. We conducted a search for English-language articles published during 1997 to 2016, using MEDLINE, PubMed and United States' National Library of Medicine databases. We reviewed around 50 papers but referenced only 30 for this article. The literature review provided us a new insight regarding safety of mesh. Polypropylene mesh is safe for vaginal surgery if used by experienced surgeons. The safety of mesh becomes compromised in the hands of commercial surgical kit providers. All the new mesh tailored kits should undergo evidence-based trials and then can be safely used worldwide.

Immediate compared with delayed pushing in the second stage of labor: a systematic review and meta-analysis.

PubMed

Tuuli, Methodius G; Frey, Heather A; Odibo, Anthony O; Macones, George A; Cahill, Alison G

2012-09-01

To estimate whether immediate or delayed pushing in the second stage of labor optimizes spontaneous vaginal delivery and other perinatal outcomes. We searched electronic databases MEDLINE and CINHAL through August 2011 without restrictions. The search terms used were MeSH headings, text words, and word variations of the words or phrases labor, laboring down, passive descent, passive second stage, physiologic second stage, spontaneous pushing, pushing, or bearing down. We searched for randomized controlled trials comparing immediate with delayed pushing in the second stage of labor. The primary outcome was spontaneous vaginal delivery. Secondary outcomes were instrumental delivery, cesarean delivery, duration of the second stage, duration of active pushing, and other maternal and neonatal outcomes. Heterogeneity was assessed using the Q test and I2. Pooled relative risks (RRs) and weighted mean differences were calculated using random-effects models. Twelve randomized controlled trials (1,584 immediate and 1,531 delayed pushing) met inclusion criteria. Overall, delayed pushing was associated with an increased rate of spontaneous vaginal delivery compared with immediate pushing (61.5% compared with 56.9%, pooled RR 1.09, 95% confidence interval [CI] 1.03-1.15). This increase was smaller and not statistically significant among high-quality studies (59.0% compared with 54.9%, pooled RR 1.07, 95% CI 0.98-1.26) but larger and statistically significant in lower-quality studies (81.0% compared with 71.0%%, pooled RR 1.13, 95% CI 1.02-1.24). Operative vaginal delivery rates were high in most studies and not significantly different between the two groups (33.7% compared with 37.4%, pooled RR 0.89, 95% CI 0.76-1.06). Delayed pushing was associated with prolongation of the second stage (weighted mean difference 56.92 minutes, 95% CI 42.19-71.64) and shortened duration of active pushing (weighted mean difference -21.98 minutes, 95% CI -31.29 to -12.68). Studies to date suggest there are few clinical differences in outcomes with immediate compared with delayed pushing in the second stage of labor, especially when high-quality studies are pooled. Effects on maternal and neonatal outcomes remain uncertain.

The influence of women’s preferences and actual mode of delivery on post-traumatic stress symptoms following childbirth: a population-based, longitudinal study

PubMed Central

2014-01-01

Background This study aimed to examine whether a mismatch between a woman’s preferred and actual mode of delivery increases the risk of post-traumatic stress symptoms after childbirth. Methods The study sample consisted of 1,700 women scheduled to give birth between 2009 and 2010 at Akershus University Hospital, Norway. Questionnaire data from pregnancy weeks 17 and 32 and from 8 weeks postpartum were used along with data obtained from hospital birth records. Post-traumatic stress symptoms were measured with the Impact of Event Scale. Based on the women’s preferred and actual mode of delivery, four groups were established: Match 1 (no preference for cesarean section, no elective cesarean section, N = 1,493); Match 2 (preference for cesarean section, elective cesarean section, N = 53); Mismatch 1 (no preference for cesarean section, elective cesarean section, N = 42); and Mismatch 2 (preference for cesarean section, no elective cesarean section, N = 112). Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) were conducted to examine whether the level of post-traumatic stress symptoms differed significantly among these four groups. Results Examining differences for all four groups, ANOVA yielded significant overall group differences (F = 11.96, p < 0.001). However, Bonferroni post-hoc tests found significantly higher levels of post-traumatic stress symptoms only in Mismatch 2 compared to Match 1. This difference could be partly explained by a number of risk factors, particularly psychological risk factors such as fear of childbirth, depression, and anxiety. Conclusions The results suggest increased post-traumatic stress symptoms in women who preferred delivery by cesarean section but delivered vaginally compared to women who both preferred vaginal delivery and delivered vaginally. In psychologically vulnerable women, such mismatch may threaten their physical integrity and, in turn, result in post-traumatic stress symptoms. These women, who often fear childbirth, may prefer a cesarean section even though vaginal delivery is usually the best option in the absence of medical indications. To avoid potential trauma, fear of childbirth and maternal requests for a cesarean section should be taken seriously and responded to adequately. PMID:24898436

The influence of women's preferences and actual mode of delivery on post-traumatic stress symptoms following childbirth: a population-based, longitudinal study.

PubMed

Garthus-Niegel, Susan; von Soest, Tilmann; Knoph, Cecilie; Simonsen, Tone Breines; Torgersen, Leila; Eberhard-Gran, Malin

2014-06-05

This study aimed to examine whether a mismatch between a woman's preferred and actual mode of delivery increases the risk of post-traumatic stress symptoms after childbirth. The study sample consisted of 1,700 women scheduled to give birth between 2009 and 2010 at Akershus University Hospital, Norway. Questionnaire data from pregnancy weeks 17 and 32 and from 8 weeks postpartum were used along with data obtained from hospital birth records. Post-traumatic stress symptoms were measured with the Impact of Event Scale. Based on the women's preferred and actual mode of delivery, four groups were established: Match 1 (no preference for cesarean section, no elective cesarean section, N = 1,493); Match 2 (preference for cesarean section, elective cesarean section, N = 53); Mismatch 1 (no preference for cesarean section, elective cesarean section, N = 42); and Mismatch 2 (preference for cesarean section, no elective cesarean section, N = 112). Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) were conducted to examine whether the level of post-traumatic stress symptoms differed significantly among these four groups. Examining differences for all four groups, ANOVA yielded significant overall group differences (F = 11.96, p < 0.001). However, Bonferroni post-hoc tests found significantly higher levels of post-traumatic stress symptoms only in Mismatch 2 compared to Match 1. This difference could be partly explained by a number of risk factors, particularly psychological risk factors such as fear of childbirth, depression, and anxiety. The results suggest increased post-traumatic stress symptoms in women who preferred delivery by cesarean section but delivered vaginally compared to women who both preferred vaginal delivery and delivered vaginally. In psychologically vulnerable women, such mismatch may threaten their physical integrity and, in turn, result in post-traumatic stress symptoms. These women, who often fear childbirth, may prefer a cesarean section even though vaginal delivery is usually the best option in the absence of medical indications. To avoid potential trauma, fear of childbirth and maternal requests for a cesarean section should be taken seriously and responded to adequately.

Counseling on vaginal delivery of contraceptive hormones: implications for women's body knowledge and sexual health.

PubMed

Nappi, Rossella E

2013-12-01

Healthcare providers (HCPs) have an important role in helping women select the contraceptive method that best matches their needs and lifestyle. Recent surveys outline the need of women to be informed about all available choices, including the newest methods (particularly those not requiring daily administration), such as vaginal contraception. The most relevant publications on combined contraceptive vaginal ring are revised in the context of counseling as an opportunity to empower women in term of vaginal health and sexual functioning. HCPs should explain the main characteristics of the combined contraceptive vaginal ring including the anatomical and physiological implications that make the vagina an ideal route of hormonal administration and the basic notions about functional modifications of the vagina during reproductive life. Clinical data on the vaginal ring should be summarized with regard to efficacy, tolerability, pharmacokinetics, cycle control and user acceptability, including recent findings on extra-contraceptive benefits (also compared to other hormonal contraceptives) on the vaginal flora and on sexual function. Vaginal contraception offers various benefits and should always be discussed during contraceptive counseling. An open dialogue about vaginal contraception will also help enhance body knowledge and sexual health.

Progesterone to prevent spontaneous preterm birth

PubMed Central

Romero, Roberto; Yeo, Lami; Chaemsaithong, Piya; Chaiworapongsa, Tinnakorn; Hassan, Sonia

2014-01-01

Summary Preterm birth is the leading cause of perinatal morbidity and mortality worldwide, and its prevention is an important healthcare priority. Preterm parturition is one of the ‘great obstetrical syndromes’ and is caused by multiple etiologies. One of the mechanisms of disease is the untimely decline in progesterone action, which can be manifested by a sonographic short cervix in the midtrimester. The detection of a short cervix in the midtrimester is a powerful risk factor for preterm delivery. Vaginal progesterone can reduce the rate of preterm delivery by 45%, and the rate of neonatal morbidity (admission to neonatal intensive care unit, respiratory distress syndrome, need for mechanical ventilation, etc.). To prevent one case of spontaneous preterm birth <33 weeks of gestation, 12 patients with a short cervix would need to be treated. Vaginal progesterone reduces the rate of spontaneous preterm birth in women with a short cervix both with and without a prior history of preterm birth. In patients with a prior history of preterm birth, vaginal progesterone is as effective as cervical cerclage to prevent preterm delivery. 17α-Hydroxyprogesterone caproate has not been shown to be effective in reducing the rate of spontaneous preterm birth in women with a short cervix. PMID:24315687

Postpartum anal sphincter lacerations in a population with minimal exposure to episiotomy and operative vaginal delivery.

PubMed

Lewis, Cindi; Williams, Alana M; Rogers, Rebecca G

2008-01-01

This case-control study was designed to identify risk factors for anal sphincter lacerations (ASL) in a multicultural population where episiotomies and operative vaginal deliveries are rarely performed. Cases were subjects with ASL delivered between July 1997 and June 2003. Two controls were selected for each case matched for gestational age. Independent variables collected included age, race/ethnicity, parity, tobacco use, medical conditions, episiotomy, operative vaginal delivery, epidural use, and infant weight. One thousand and sixty-six subjects met the inclusion criteria. The risk of ASL increased with increasing maternal age (Odds ratio [OR] 1.09 per year, 95% confidence interval [CI] 1.06, 1.12) and increasing infant weight (OR 1.09 per 100 g, 95% CI 1.06, 1.13). Multiparity was protective (P1 vs P2 OR 0.19, 95% CI 0.13, 0.28, and > or =P3 vs P1 OR 0.04, 95% CI 0.02, 0.11). Hispanic and Native American women were at increased risk for ASL (OR 2.08, 95% CI 1.41, 3.09 and OR 1.92, 95% CI 1.07, 3.45, respectively).

Management of vaginal extrusion after tension-free vaginal tape procedure for urodynamic stress incontinence.

PubMed

Giri, Subhasis K; Sil, Debasri; Narasimhulu, Girish; Flood, Hugh D; Skehan, Mark; Drumm, John

2007-06-01

To report our experience in the management of vaginal extrusion after the tension-free vaginal tape (TVT) procedure for urodynamic stress incontinence. Five patients diagnosed with vaginal extrusion after a TVT procedure performed at our institution were identified. We reviewed the patients' records retrospectively. The interval from TVT placement to diagnosis, presenting symptoms and signs, duration of symptoms, diagnostic test findings, treatment, and postoperative results were recorded. Patients were followed up for at least 12 months. From January 2001 to June 2004, a total of 166 patients underwent the TVT procedure. Of these, 5 patients (3%) were diagnosed with isolated vaginal extrusion 4 to 40 months postoperatively. No cases of urethral or bladder erosion occurred in this series. The symptoms included vaginal discharge, pain, bleeding, and dyspareunia. The eroded margin of the vaginal mucosa was trimmed, mobilized, and closed over the tape with interrupted vertical mattress sutures in a single layer using 2-0 polyglactin 910 to avoid mucosal inversion. All patients remained symptom free without any evidence of defective healing or additional extrusion at a minimal follow-up of 12 months. Primary reclosure of the vaginal mucosa over the TVT tape is an effective first-line treatment option for vaginal extrusion without compromising continence. Patients undergoing the TVT procedure should be adequately counseled about the possibility of this complication and the available treatment options.

Novel approaches to vaginal delivery and safety of microbicides: biopharmaceuticals, nanoparticles, and vaccines.

PubMed

Whaley, Kevin J; Hanes, Justin; Shattock, Robin; Cone, Richard A; Friend, David R

2010-12-01

The HIV-1 epidemic remains unchecked despite existing technology; vaccines and microbicides in development may help reverse the epidemic. Reverse transcriptase inhibitors (RTIs) formulated in gels tenofovir (TFV) and IVRs (dapivirine) are under clinical development. While TFV or similar products may prove successful for HIV-1, alternatives to RTIs may provide additional benefits, e.g., broader STI prevention. Biopharmaceutical agents under development as microbicides include cyanovirin, RANTES analogues, commensals, and Mabs. Cost of manufacturing biopharmaceuticals has been reduced and they can be formulated into tablets, films, and IVRs for vaginal delivery. Nanotechnology offers a novel approach to formulate microbicides potentially leading to uniform epithelial delivery. Delivery through vaginal mucus may be possible by controlling nanoparticle size and surface characteristics. Combining prevention modalities may be the most effective means of preventing STI transmission, importantly, codelivery of microbicides and vaccines has demonstrated. Finally, the safety of microbicide preparations and excipients commonly used can be assessed using a mouse/HSV-2 susceptibility model. Screening of new microbicide candidates and formulation excipients may avoid past issues of enhancing HIV-1 transmission. This article forms part of a special supplement covering several presentations on novel microbicide formulations from the symposium on "Recent Trends in Microbicide Formulations" held on 25 and 26 January 2010, Arlington, VA. Copyright © 2010 Elsevier B.V. All rights reserved.

Longitudinal comparison study of pelvic floor function between women with and without stress urinary incontinence after vaginal delivery.

PubMed

Yoshida, Mikako; Murayama, Ryoko; Haruna, Megumi; Matsuzaki, Masayo; Yoshimura, Kenichi; Murashima, Sachiyo; Kozuma, Shiro

2013-04-01

To compare the pelvic floor function between women with and without stress urinary incontinence after vaginal delivery. Seventeen women (age 35.5 ± 3.5) were prospectively studied at about 6 weeks, 3 months, and 6 months after vaginal delivery. Urinary incontinence was assessed by the International Consultation on Incontinence Questionnaire - Short Form. Pelvic floor function was assessed by antero-posterior diameter of the levator hiatus using transperineal ultrasound. Five of 17 women experienced postpartum stress urinary incontinence. The antero-posterior diameter of the levator hiatus at rest was significantly longer in stress urinary incontinent women than in continent women until 3 months after delivery (p < 0.01), though shortening of the antero-posterior diameter of the levator hiatus was not significantly different between continent women and stress urinary incontinent women. Regardless of urinary incontinence, the antero-posterior diameter of the levator hiatus at rest shortened at 6 months postpartum, compared to 6 weeks postpartum (p < 0.001). The antero-posterior diameter of the levator hiatus during contraction had shortened only in continent women by 6 months postpartum (p = 0.02). The extended pelvic floor may be a cause of stress urinary incontinence in the postpartum period. Therefore, treatment to improve the extended pelvic floor should be developed for the prevention of stress urinary incontinence.

A Violent Birth: Reframing Coerced Procedures During Childbirth as Obstetric Violence.

PubMed

Borges, Maria TR

2018-01-01

In the United States, women are routinely forced to undergo cesarean sections, episiotomies, and the use of forceps, despite their desire to attempt natural vaginal delivery. Yet, the current American legal system does little to provide redress for women coerced to undergo certain medical procedures during childbirth. Courts and physicians alike are prepared to override a woman's choice of childbirth procedure if they believe this choice poses risks to the fetus, and both give little value to the woman's right to bodily autonomy. This Note proposes a solution for addressing the problem of coerced medical procedures during childbirth by importing a framework created in Venezuela and Argentina that characterizes this issue as "obstetric violence." First, this Note contains an overview of the shortcomings of the existing American legal framework to address the problem. Second, it explains the advantages of the obstetric violence framework and argues that its adoption in the United States would address many of the failures of the existing system. And third, this Note introduces a few legislative and litigation strategies that can be used to implement this framework in the United States and briefly addresses some of the challenges these strategies may pose.

Vaginal inserts based on chitosan and carboxymethylcellulose complexes for local delivery of chlorhexidine: preparation, characterization and antimicrobial activity.

PubMed

Bigucci, Federica; Abruzzo, Angela; Vitali, Beatrice; Saladini, Bruno; Cerchiara, Teresa; Gallucci, Maria Caterina; Luppi, Barbara

2015-01-30

The aim of this work was to prepare vaginal inserts based on chitosan/carboxymethylcellulose polyelectrolyte complexes for local delivery of chlorhexidine digluconate. Complexes were prepared with different chitosan/carboxymethylcellulose molar ratios at a pH value close to pKa interval of the polymers and were characterized in terms of physico-chemical properties, complexation yield and drug loading. Then complexes were used to prepare inserts as vaginal dosage forms and their physical handling, morphology, water-uptake ability and drug release properties as well as antimicrobial activity toward Candida albicans and Escherichia coli were evaluated. Results confirmed the ionic interaction between chitosan and carboxymethylcellulose and the influence of the charge amount on the complexation yield. Complexes were characterized by high values of drug loading and showed increasing water-uptake ability with the increase of carboxymethylcellulose amount. The selection of appropriate chitosan/carboxymethylcellulose molar ratios allowed to obtain cone-like shaped solid inserts, easy to handle and able to hydrate releasing the drug over time. Finally, the formulated inserts showed antimicrobial activity against common pathogens responsible for vaginal infections. Copyright © 2014 Elsevier B.V. All rights reserved.

Maternal sepsis: a Scottish population-based case-control study.

PubMed

Acosta, C D; Bhattacharya, S; Tuffnell, D; Kurinczuk, J J; Knight, M

2012-03-01

To describe the risk of maternal sepsis associated with obesity and other understudied risk factors such as operative vaginal delivery. Population-based, case-control study. North NHS region of Scotland. All cases of pregnant, intrapartum and postpartum women with International Classification of Disease-9 codes for sepsis or severe sepsis recorded in the Aberdeen Maternal and Neonatal Databank (AMND) from 1986 to 2009. Four controls per case selected from the AMND were frequency matched on year-of-delivery. Cases and controls were compared; significant variables from univariable regression were adjusted in a multivariable logistic regression model. Dependent variables were uncomplicated sepsis or severe ('near-miss') sepsis. Independent variables were demographic, medical and clinical delivery characteristics. Unadjusted and adjusted odds ratios (OR) with 95% confidence intervals (95% CI) are reported. Controlling for mode of delivery and demographic and clinical factors, obese women had twice the odds of uncomplicated sepsis (OR 2.12; 95% CI 1.14-3.89) compared with women of normal weight. Age <25 years (OR 5.15; 95% CI 2.43-10.90) and operative vaginal delivery (OR 2.20; 95% CI 1.02-4.87) were also significant predictors of sepsis. Known risk factors for maternal sepsis were also significant in this study (OR for uncomplicated and severe sepsis respectively): multiparity (OR 6.29, 12.04), anaemia (OR 3.43, 18.49), labour induction (OR 3.92 severe only), caesarean section (OR 3.23, 13.35), and preterm birth (OR 2.46 uncomplicated only). Obesity, operative vaginal delivery and age <25 years are significant risk factors for sepsis and should be considered in clinical obstetric care. © 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.

Risk factors for retained placenta.

PubMed

Coviello, Elizabeth M; Grantz, Katherine L; Huang, Chun-Chih; Kelly, Tara E; Landy, Helain J

2015-12-01

Retained placenta complicates 2-3% of vaginal deliveries and is a known cause of postpartum hemorrhage. Treatment includes manual or operative placental extraction, potentially increasing risks of hemorrhage, infections, and prolonged hospital stays. We sought to evaluate risk factors for retained placenta, defined as more than 30 minutes between the delivery of the fetus and placenta, in a large US obstetrical cohort. We included singleton, vaginal deliveries ≥24 weeks (n = 91,291) from the Consortium of Safe Labor from 12 US institutions (2002-2008). Multivariable logistic regression analyses estimated the adjusted odds ratios (OR) and 95% confidence intervals (CI) for potential risk factors for retained placenta stratified by parity, adjusting for relevant confounding factors. Characteristics such as stillbirth, maternal age, race, and admission body mass index were examined. Retained placenta complicated 1047 vaginal deliveries (1.12%). Regardless of parity, significant predictors of retained placenta included stillbirth (nulliparous adjusted OR, 5.67; 95% CI, 3.10-10.37; multiparous adjusted OR, 4.56; 95% CI, 2.08-9.94), maternal age ≥30 years, delivery at 24 0/7 to 27 6/7 compared with 34 weeks or later and delivery in a teaching hospital. In nulliparous women, additional risk factors were identified: longer first- or second-stage labor duration, whereas non-Hispanic black compared with non-Hispanic white race was found to be protective. Body mass index was not associated with an increased risk. Multiple risk factors for retained placenta were identified, particularly the strong association with stillbirth. It is plausible that there could be something intrinsic about stillbirth that causes a retained placenta, or perhaps there are shared pathways of certain etiologies of stillbirth and a risk of retained placenta. Copyright © 2015 Elsevier Inc. All rights reserved.

Operative vaginal delivery in case of persistent occiput posterior position after manual rotation failure: a 6-month follow-up on pelvic floor function.

PubMed

Guerby, Paul; Parant, Olivier; Chantalat, Elodie; Vayssiere, Christophe; Vidal, Fabien

2018-07-01

To compare the short- and long-term perineal consequences (at 6 months postpartum) and short-term neonatal consequences of instrumental rotation (IR) to those induced by assisted delivery (AD) in the occiput posterior (OP) position, in case of manual rotation failure. A prospective observational cohort study; tertiary referral hospital including all women presenting with persistent OP position who delivered vaginally after manual rotation failure with attempted IR or AD in OP position from September 2015 to October 2016. Maternal and neonatal outcomes of all attempted IR deliveries were compared with OP operative vaginal deliveries. Main outcomes measured were pelvic floor function at 6 months postpartum including Wexner score for anal incontinence and ICIQ-FLUTS for urinary symptoms. Perineal morbidity comprised severe perineal tears, corresponding to third and fourth degree lacerations. Fetal morbidity parameters comprised low neonatal Apgar scores, acidaemia, major and minor fetal injuries and neonatal intensive care unit admissions. Among 5265 women, 495 presented with persistent OP positions (9.4%) and 111 delivered after manual rotation failure followed by AD delivery: 58 in the IR group and 53 in the AD in OP group. The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.7% vs. 24.5%; p < 0.001) without increasing neonatal morbidity. At 6 months postpartum, AD in OP position was associated with higher rate of anal incontinence (30% vs. 5.5%, p = 0.001) and with more urinary symptoms, dyspareunia and perineal pain. OP operative deliveries are associated with significant perineal morbidity and pelvic floor dysfunction at 6 months postpartum.

Microdose transdermal estrogen therapy for relief of vulvovaginal symptoms in postmenopausal women.

PubMed

Bachmann, Gloria A; Schaefers, Matthias; Uddin, Alkaz; Utian, Wulf H

2009-01-01

The aim of this study was to investigate the effectiveness of microdose transdermal 17beta-estradiol (E2) therapy in postmenopausal women with moderate to severe vulvovaginal symptoms. This report is based on a subset of 121 women who reported most bothersome moderate or severe vulvovaginal symptoms at baseline, from a previous randomized, double-blind, placebo-controlled, multicenter study of 425 healthy, symptomatic, postmenopausal women. Recruits had experienced at least 7 moderate or severe hot flushes daily for at least 1 week or at least 50 moderate or severe hot flushes per week for at least 1 week. Effects on coprimary efficacy variables have been reported previously. Participants received low-dose transdermal E2 plus levonorgestrel (n = 43; nominal delivery 0.023 mg/d E2/0.0075 mg/d levonorgestrel), microdose E2 (n = 42; nominal delivery 0.014 mg/d), or placebo (n = 36) for 12 weeks. Secondary efficacy variables reported herein include mean change from baseline in vaginal pH and vaginal maturation index, the proportion of women with symptoms of vulvar and vaginal atrophy at baseline and week 12, and the proportion of women with moderate-to-severe symptoms of vulvar and vaginal atrophy. Microdose transdermal E2 treatment was associated with a consistent benefit versus placebo in women with vulvovaginal atrophy. There was a statistically significant difference between both E2 versus placebo for changes in vaginal pH and vaginal maturation index. Microdose transdermal E2 offers a useful addition to the therapeutic armamentarium for postmenopausal women in whom vulvovaginal symptoms are particularly troublesome.

Pregnancy complications in HIV-positive women: 11-year data from the Frankfurt HIV Cohort.

PubMed

Reitter, A; Stücker, A U; Linde, R; Königs, C; Knecht, G; Herrmann, E; Schlößer, R; Louwen, F; Haberl, A

2014-10-01

The aim of the study was to assess pregnancy complications in HIV-positive women and changes in the rates of such complications over 11 years in the Frankfurt HIV Cohort. There were 330 pregnancies in HIV-positive women between 1 January 2002 and 31 December 2012. The rate of pregnancy-related complications, such as gestational diabetes mellitus (GDM), pre-eclampsia and preterm delivery, the mode of delivery and obstetric history were analysed. Maternal and neonatal morbidity/mortality as well as HIV mother-to-child transmission (MTCT) were evaluated. In our cohort, GDM was diagnosed in 38 of 330 women (11.4%). Five women (1.5%) developed pre-eclamspia or hypertension. In 16 women (4.8%), premature rupture of membranes (PROM) occurred and 46 women (13.7%) were admitted with preterm contractions. The preterm delivery rate was 36.5% (n = 122), and 26.9% of deliveries (n = 90) were between 34+0 and 36+6 weeks of gestation. Over the observation period, the percentage of women with undetectable HIV viral load (VL) increased significantly (P < 0.001), from 26.1% to 75%, leading to obstetric changes, including an increase in the rate of vaginal deliveries (P < 0.001), from no vaginal births to 50%. The preterm delivery rate decreased significantly (P < 0.001), from 79.2% to 8.3%. There were no significant changes in the rate of GDM, pre-eclampsia, PROM or preterm contractions. In the 11 years of our analysis, there was a significant reduction in the rate of preterm deliveries and an increase in the vaginal delivery rate, possibly reflecting changes in treatment policies in the same period and the availability of more effective antiretroviral therapy options. The rates of complications such as GDM, pre-eclampsia, preterm contractions, PROM and postnatal complications were stable over the 11 years, but were still increased compared with the general population. © 2014 British HIV Association.

Study comparing 3 hour and 24 hour post-operative removal of bladder catheter and vaginal pack following vaginal surgery: a randomised controlled trial.

PubMed

Rajan, Priya; Soundara Raghavan, S; Sharma, Deepak

2017-09-11

Traditional practice after vaginal hysterectomy was to keep the vaginal pack and urinary catheter for 24 hours post operatively. But there were studies that prolonged cathterisation was associated with urinary infection. So this study was conducted to compare the post operative outcome when the urinary catheter and vaginal pack were removed after 3 hours and after 24 hours after surgery. The study was done in the Department of Obstetrics and Gynecology, in a tertiary teaching institute of South India from September 2008 to March 2010. It was a randomised controlled trial involving 200 women undergoing vaginal surgery, who were randomly assigned to 2 groups - catheter and vaginal pack were removed either in 3 h in study group or were removed in 24 h in control group. The outcome of the study were vaginal bleeding, urinary retention, febrile morbidity, and urinary infection. There was no significant difference between the study and control groups with respect to vaginal bleeding (0 and 1%, p = 1), urinary retention (9 and 4%, p = 0.15), febrile morbidity (7 and 4%, p = 0.35), and urinary infection (26% in each group, p = 1.0). Keeping the urinary catheter and vaginal pack for 24 h following vaginal surgery does not offer any additional benefit against removing them after 3 h.

Rehospitalizations and outpatient contacts of mothers and neonates after hospital discharge after vaginal delivery.

PubMed

Meikle, S F; Lyons, E; Hulac, P; Orleans, M

1998-07-01

Our purpose was to determine whether length of hospital stay after vaginal delivery as determined by the discharging physician is associated with rehospitalizations or increased outpatient contacts by mothers and neonates and to assess the impact of home health care visits. An inception cohort study of all rehospitalizations and outpatient contacts of mothers and neonates after vaginal delivery at St. Joseph Hospital, Denver, Colorado, was done from January 1, 1994, to September 30, 1995. All Kaiser Permanente mother-neonate pairs in which the delivery was vaginal (excluding those with multiple gestations or birth weight < 2500 g) were included. Length of initial hospital stay was divided into three time periods: < or = 24 hours, 25 to 48 hours, and > 48 hours. The Colorado Kaiser Permanente Perinatal Database was used to identify perinatal and demographic factors that might have increased health care use. Additional information was sought in administrative databases, bill records, and inpatient charts. Mothers were followed up for 6 weeks and neonates for 28 days after delivery. Home care visits were provided to more than half the mothers and neonates by means of a standardized protocol. The main outcome measures were rehospitalizations and outpatient visits for mothers and neonate, controlling for home care visits. A total of 4323 mother-neonate pairs were identified. For the mothers, a longer initial hospital stay (> 48 hours) was significantly associated with both readmission (P < .01) and increased outpatient care use (P = .01) in the 6-week postpartum period. Thirty-five mothers (.81%) were rehospitalized by 6 weeks. Maternal factors associated with increased outpatient contacts were preeclampsia, preterm delivery, and instrument delivery. Sixty-seven neonates (1.55%) were readmitted to the hospital. Home care visits reduced the need for both readmissions and outpatient visits. For mothers in this cohort a longer initial hospital stay was significantly associated with hospital readmission and increased outpatient care in the postpartum period. Further analysis revealed that mothers with recognized potential and observed problems were rarely discharged in < or = 24 hours. We did not find statistically significant problems among neonates that were related to the length of their initial hospital stay. Those neonates receiving home care were less likely to require hospital readmission and less likely to seek outpatient care. It is unlikely that a single discharge policy will be appropriate for all mothers and neonates.

Influence of the duration of the second stage of labor on the likelihood of obstetric anal sphincter injury.

PubMed

Aiken, Catherine E; Aiken, Abigail R; Prentice, Andrew

2015-03-01

Duration of the second stage of labor has been suggested as an independent risk factor for clinically detectable obstetric anal sphincter injury in low-risk nulliparous women. A retrospective 5-year cohort study was conducted in a UK obstetrics center which included a high-risk delivery unit and a low-risk birthing center. The study included 4,831 nulliparous women with vertex-presenting, single, live-born infants at term, stratified according to spontaneous or instrumental delivery. Binary logistic regression models were used to examine the association between duration of second stage and sphincter injury. Three-hundred twenty-five of 4,831 women (6.7%) sustained sphincter injuries. In spontaneously delivering women, no association between duration of the second stage and the likelihood of sphincter injury was recorded. Factors associated with increased likelihood of sphincter injury included older maternal age, higher birthweight, and Southeast Asian ethnicity. In contrast, for women undergoing instrumental delivery, a longer second stage was associated with an increased sphincter injury risk of 6 percent per 15 minutes in the second stage of labor before delivery. For spontaneous vaginal deliveries, duration of the second stage of labor was not an independent risk factor for obstetric anal sphincter injury. The association between prolonged second stage and sphincter injury for instrumental deliveries is likely explained by the risk posed by the use of the instruments themselves or by delay in initiating instrumental assistance. Attempts to modify the duration of the second stage for prevention of sphincter injuries are unlikely to be beneficial and may be detrimental. © 2014 Wiley Periodicals, Inc.

Factors Associated with Trial of Labour and Mode of Delivery in Robson Group 5: A Select Group of Women With Previous Caesarean Section.

PubMed

Smithies, Mila; Woolcott, Christy G; Brock, Jo-Ann K; Maguire, Bryan; Allen, Victoria M

2018-06-01

To determine the proportion of women in Robson group 5 (RG5) who were eligible for a trial of labour after Caesarean (TOLAC) and, among eligible candidates, identify determinants of having a TOLAC and subsequent vaginal delivery (VD). This population-based cohort study used data derived from the Nova Scotia Atlee Perinatal Database. Deliveries from 1998-2014 to women in RG5 (≥1 previous CS with a singleton term cephalic fetus) were included. Eligibility for a TOLAC was based on SOGC criteria. Multivariable logistic regression was used to identify characteristics independently associated with TOLAC and VD. The characteristics associated with VD were used in a logistic model to predict the theoretical probability of VD in women who did not have a TOLAC. Of the 15 111 deliveries in RG5, 75.3% were by CS. Of the 14 763 eligible women, 5488 (37.2%) had a TOLAC, of which 3739 (68.1%) resulted in VD. Predictors of VD included high area-level income and either a CS without labour or a spontaneous VD in the preceding pregnancy. While mode of previous delivery also predicted TOLAC among eligible women, high area-level income was associated with reduced odds of TOLAC. The probability of VD in women who did not undergo TOLAC was estimated to be 47.1%, and the lowest CS rate attainable in RG5 was estimated at 46.3%. Sociodemographic factors such as income and previous mode of delivery were associated with the rates of TOLAC and subsequent VD in eligible women, and suggest that the Caesarean section rate in RG5 could be safely reduced. Copyright © 2018 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.

Early pregnancy vaginal microbiome trends and preterm birth.

PubMed

Stout, Molly J; Zhou, Yanjiao; Wylie, Kristine M; Tarr, Phillip I; Macones, George A; Tuuli, Methodius G

2017-09-01

Despite decades of attempts to link infectious agents to preterm birth, an exact causative microbe or community of microbes remains elusive. Nonculture 16S ribosomal RNA gene sequencing suggests important racial differences and pregnancy specific changes in the vaginal microbial communities. A recent study examining the association of the vaginal microbiome and preterm birth documented important findings but was performed in a predominantly white cohort. Given the important racial differences in bacterial communities within the vagina as well as persistent racial disparities in preterm birth, it is important to examine cohorts with varied demographic compositions. To characterize vaginal microbial community characteristics in a large, predominantly African-American, longitudinal cohort of pregnant women and test whether particular vaginal microbial community characteristics are associated with the risk for subsequent preterm birth. This is a nested case-control study within a prospective cohort study of women with singleton pregnancies, not on supplemental progesterone, and without cervical cerclage in situ. Serial mid-vaginal swabs were obtained by speculum exam at their routine prenatal visits. Sequencing of the V1V3 region of the 16S rRNA gene was performed on the Roche 454 platform. Alpha diversity community characteristics including richness, Shannon diversity, and evenness as well as beta diversity metrics including Bray Curtis Dissimilarity and specific taxon abundance were compared longitudinally in women who delivered preterm to those who delivered at term. A total of 77 subjects contributed 149 vaginal swabs longitudinally across pregnancy. Participants were predominantly African-American (69%) and had a preterm birth rate of 31%. In subjects with subsequent term delivery, the vaginal microbiome demonstrated stable community richness and Shannon diversity, whereas subjects with subsequent preterm delivery had significantly decreased vaginal richness, diversity, and evenness during pregnancy (P < .01). This change occurred between the first and second trimesters. Within-subject comparisons across pregnancy showed that preterm birth is associated with increased vaginal microbiome instability compared to term birth. No distinct taxa were associated with preterm birth. In a predominantly African-American population, a significant decrease of vaginal microbial community richness and diversity is associated with preterm birth. The timing of this suppression appears early in pregnancy, between the first and second trimesters, suggesting that early gestation may be an ecologically important time for events that ordain subsequent term and preterm birth outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

Quantitative analyses of variability in normal vaginal shape and dimension on MR images

PubMed Central

Luo, Jiajia; Betschart, Cornelia; Ashton-Miller, James A.; DeLancey, John O. L.

2016-01-01

Introduction and hypothesis We present a technique for quantifying inter-individual variability in normal vaginal shape, axis, and dimension, and report findings in healthy women. Methods Eighty women (age: 28~70 years) with normal pelvic organ support underwent supine, multi-planar proton-density MRI. Vaginal width was assessed at five evenly-spaced locations, and vaginal axis, length, and surface area were quantified via ImageJ and MATLAB. Results The mid-sagittal plane angles, relative to the horizontal, of three vaginal axes were 90± 11, 72± 21, and 41± 22° (caudal to cranial, p < 0.001). The mean (± SD) vaginal widths were 17± 5, 24± 4, 30± 7, 41± 9, and 45± 12 mm at the five locations (caudal to cranial, p < 0.001). Mid-sagittal lengths for anterior and posterior vaginal walls were 63± 9 and 98 ± 18 mm respectively. The vaginal surface area was 72 ± 21 cm2 (range: 34 ~ 164 cm2). The coefficient of determination between any demographic variable and any vaginal dimension did not exceed 0.16. Conclusions Large variations in normal vaginal shape, axis, and dimensions were not explained by body size or other demographic variables. This variation has implications for reconstructive surgery, intravaginal and surgical product design, and vaginal drug delivery. PMID:26811115

[Determination of nosocomial infection incidence in mothers and newborns during the early postpartum period].

PubMed

Malavaud, S; Bou-Segonds, E; Berrebi, A; Castagno, R; Assouline, C; Connan, L

2003-04-01

We wished to determine the incidence of nosocomial infections in the mother and the newborn during the early postpartum period. Over a three-month period, the same investigator collected 50 different clinical and microbiological, standardized data related to infectious diseases in parturients and their newborns. Data were collected on 804 deliveries. The overall rate of nosocomial infection was 2.9% (23/804). For vaginal deliveries, the rate was 1.9% (12/615) and for deliveries by Cesarean section, the rate was 5.8% (11/189). Of 745 newborns followed until discharge from hospital, 0.7% (5/745) had a nosocomial infection. These results are in line with previously published rates of nosocomial infections, which varied between 0.2% to 2.3% for vaginal deliveries, 1.6% to 18.9% for Cesarean section, and 0.2 to 4% in newborns. Regular surveys of the incidence or the prevalence of nosocomial infections are necessary to monitor the effectiveness of educational programs, aimed to reduce hospital acquired infections.

Site and incidence of birth canal lacerations from instrumental delivery with mediolateral episiotomy.

PubMed

Chikazawa, Kenro; Ushijima, Junko; Takagi, Kenjiro; Nakamura, Eishin; Samejima, Koki; Kadowaki, Kanako; Horiuchi, Isao

2016-12-01

Instrument-assisted vaginal delivery is a significant risk factor for birth canal lacerations. Although many obstetricians recently are recommending restrictive rather than a routine episiotomy, reports have shown restrictive episiotomy to be associated with more extensive anterior birth canal trauma compared with routine episiotomy. We retrospectively reviewed 110 cases of forceps and vacuum deliveries and investigated the site of birth canal lacerations. Birth canal lacerations were divided into four sites according to direction-anterior, ipsilateral, contralateral, and posterior. The frequency of lacerations were, from most to least, posterior (34%), lateral (21.7%), and anterior (1.9%). Moreover, among the lateral lacerations, they were more frequent in the contralateral side of episiotomy than the ipsilateral side (18.9% vs. 4.7%, p < 0.01). Our results indicate that caution is also needed concerning not only the anterior site, but also the contralateral site of an episiotomy to prevent laceration in an instrument-assisted vaginal delivery. Copyright © 2016. Published by Elsevier B.V.

Predictors of successful external cephalic version and assessment of success for vaginal delivery.

PubMed

Salzer, Liat; Nagar, Ran; Melamed, Nir; Wiznitzer, Arnon; Peled, Yoav; Yogev, Yariv

2015-01-01

To identify predictors of successful external cephalic version (ECV) and to compare delivery outcome between women who had a successful ECV and women with spontaneous vertex presentation. A retrospective cohort study of all women who underwent ECV in a single tertiary medical center between 2007 and 2011. Delivery outcome was compared between women who underwent a trial of vaginal delivery following successful ECV with that of a control group in a 2:1 ratio. Multivariate analysis was used to identify predictors of successful ECV. Overall 287 were eligible for the study group. Of these 130 (45.3%) had a successful ECV. Polyhydramnios was the strongest factor associated with successful ECV (OR=3.1, 95%-CI 1.4-7.2), followed by transverse lie (versus breech presentation, OR=2.6, 95%-CI 1.2-6.7) and a posterior placenta (OR=1.7, 95%-CI 1.1-3.9), while nulliparity was associated with a lower likelihood of successful ECV (OR=0.4, 95%-CI 0.2-0.6). Women who had a successful ECV and underwent a trial of labor were more likely to deliver by operative vaginal delivery (OVD) (OR=1.8, 95%-CI 1.2-3.6), mainly due to a higher rate of prolonged 2nd, but were not at an increased risk for CS (OR=0.9, 95%-CI 0.4-2.4). Counselling to women prior to ECV should address the likelihood of success based on the predicting factors described above, as well as the increased risk for OVD in the case of successful ECV.

Labor and delivery in a patient with hemophilia B.

PubMed

Przkora, R; Euliano, T Y; Roussos-Ross, K; Zumberg, M; Robicsek, S A

2011-07-01

Hemophilia B is a rare X-linked disorder that may cause dramatic bleeding. Women account for only 3.2% of those clinically affected. The X-linked inheritance frequently delays the diagnosis in women and may expose the patient to an increased risk of adverse events. There is limited experience with these patients during labor and delivery. A 28-year-old primiparous woman with hemophilia B (bleeding phenotype) delivered a male infant by an unplanned cesarean delivery under general anesthesia following treatment with factor IX and normalization of her coagulation parameters, guided by thromboelastography. Postpartum vaginal bleeding required transfusion of two units of packed red blood cells. Factor IX supplementation continued for one week. Once diagnosed with hemophilia B, a multidisciplinary approach and advanced antenatal planning can increase the likelihood of a safe delivery. Neuraxial approaches and cesarean delivery are recommended only after normalization of the coagulation profile. The male fetus of a hemophilia A or B patient requires special attention. Operative vaginal delivery and invasive fetal monitoring should be avoided. Thromboelastography is an excellent technique to assess parturients with bleeding disorders or peripartum hemorrhage and may be underused. Copyright © 2011 Elsevier Ltd. All rights reserved.

[Breech presentation and vaginal delivery: evolution of acceptability by obstetricians and patients].

PubMed

Lagrange, E; Ab der Halden, M; Ughetto, S; Boda, C; Accoceberry, M; Neyrat, C; Houlle, C; Vendittelli, F; Laurichesse-Delmas, H; Jacquetin, B; Lémery, D; Gallot, D

2007-09-01

To investigate the influence of obstetrician and patient respectively on mode of delivery in case of breech presentation at term. This retrospective study included all women with a singleton pregnancy in a breech presentation delivered at term in a tertiary care maternity unit from January 1998 to December 2004. Mode of delivery was suggested by a score based on maternal age, parity, obstetrical past history, radiopelvimetry and cephalopelvic confrontation. The obstetrician was free to follow or not the score indication and patient's informed consent was required concerning the mode of delivery. Our main outcome measurements were mode of delivery and neonatal parameters. Two hundred cases were identified. Elective cesarean section increased progressively (from 52% in 1998 to 80% in 2004 [P=0,002]). Neonatal status and proportion of score in favour of vaginal birth remained stable during the study period. The rise in cesarean section rate was mainly due to patient's request (P=0,001) whereas the trend of obstetrician in favour of cesarean did not reach significance (P=0,3). The rise of elective cesarean section for term breech delivery in a maternity unit using a predefinite score is mainly induced by patient's request. This evolution has no effect on neonatal status.

A randomized controlled trial of a new treatment for labor dystocia.

PubMed

Wiberg-Itzel, Eva; Wray, Susan; Åkerud, Helena

2018-09-01

Labor dystocia is an intransigent, high-profile issue in obstetric care. Amniotic fluid lactate (AFL) reflects the uterine metabolic status. High levels associate with subsequent need for operative intervention due to dystocia. In sports medicine, it is known that lactic acid can affect muscular performance and can be decreased by bicarbonate given orally before physical activity. Two hundred dystocic deliveries were included. At the confirmation of dystocia, the AFL-level was analyzed. Deliveries were randomized to an intake of bicarbonate or not. In the "non-bicarbonate-group", stimulation with oxytocin was started immediately. In the "bicarbonate-group", bicarbonate was given; and oxytocin was started 1 hour after the intake. New sampling of AF was performed after 1 hour in both groups. if an oral intake of bicarbonate changes the AFL levels and enhances delivery outcome in dystocic deliveries. Bicarbonate decreases the AFL levels (p < .001). The spontaneous vaginal delivery rate after treatment with bicarbonate was increased (p = .007), without affecting the fetal outcome. An increase of spontaneous vaginal deliveries resulted from bicarbonate ingestion by dystocic women. A decreased level of AFL-level was shown. This simple, low cost treatment has the potential to improve maternal morbidity and satisfaction worldwide.

Comparison of oral dydrogesterone with vaginal progesteronefor luteal support in IUI cycles: a randomized clinical trial.

PubMed

Khosravi, Donya; Taheripanah, Robabeh; Taheripanah, Anahita; Tarighat Monfared, Vahid; Hosseini-Zijoud, Seyed-Mostafa

2015-07-01

The aim of this study, we have compared the advantages of oral dydrogestrone with vaginal progesterone (cyclogest) for luteal support in intrauterine insemination (IUI) cycles. Progesterone supplementation is the first line treatment when luteal phase deficiency (LPD) can reasonably be assumed. This study was conduct to compare the effect of oral dydrogestrone with vaginal Cyclogest on luteal phase support in the IUI cycles. This prospective, randomized, double blind study was performed in a local infertility center from May 2013 to May 2014. It consisted of 150 infertile women younger than35years old undergoing ovarian stimulation for IUI cycles. They underwent ovarian stimulation with oral dydrogesterone (20 mg) as group A and vaginal cyclogest (400 mg) as group B in preparation for the IUI cycles. Clinical pregnancy and abortion rates, mid luteal progesterone (7daysafter IUI) and patient satisfaction were compared between two groups. The mean serum progesterone levels was significantly higher in group A in comparison with group B (p=0.001). Pregnancy rates in group A was not statistically different in comparison with group B (p =0.58). Abortion rate in two groups was not statistically different (p =0.056) although rate of abortion was higher in group B in comparison with A group. Satisfaction rates were significantly higher in group A compared to group B (p<0.001). We concluded that oral dydrogestrone is effective as vaginal progesterone for luteal-phase support in woman undergoing IUI cycles. Moreover, the mean serum progesterone levels and satisfaction rates in dydrogestrone group were higher than cyclogest group.

The prevalence of short cervix between 20 and 24 weeks of gestation and vaginal progesterone for prolonging of gestation.

PubMed

Maerdan, Malipati; Shi, Chunyan; Zhang, Xiaoxiao; Fan, Lixin

2017-07-01

The objective of this study is to understand the prevalence of short cervical length between 20 and 24 weeks gestation in China and to evaluate the efficacy of micronized progesterone for prolonging gestation in nulliparous patients with a short cervix. From May 2010 to May 2015, a total of 25 328 asymptomatic women with singleton pregnancies at Peking University First Hospital had their cervical length routinely measured between 20 and 24 weeks of gestation. A cervical length of 25 mm or less was defined as a shortened cervical length. The therapies prescribed include vaginal micronized progesterone capsules (200 mg each night) or bed rest from 20 to 34 weeks of gestation. The primary outcome was spontaneous delivery before 33 weeks. (1) One hundred fourteen women had a cervical length of ≤25 mm (0.45%). (2) Twenty-nine of which with previous spontaneous preterm delivery or late pregnancy loss had cervical cerclage, the remaining 85 women by the use of vaginal progesterone or simply resting activity restriction to prevent preterm birth. (3) In 85 nulliparous women treated by progesterone or bed rest, progesterone use in cervical length between 10 and 20 mm was associated with a statistically significant reduction in the incidence of preterm birth at <33 weeks of gestation (9.5% versus 45.5%, p = 0.02) compared with bed rest. There were no significant differences in cervical length between 20 and 25 mm in their rates of spontaneous preterm delivery at <33 (5.3% versus 3.2%, p = 0.72), <37 (33.3% versus 54.5%, p = 0.25), or <35 weeks (14.3% versus 45.5, p = 0.06) of gestation between vaginal progesterone and bed rest. The rate of short cervical length was less than expected. Vaginal progesterone is efficacious for the prolonging of gestation in women with a cervical length of 10-20 mm in the mid-trimester for a singleton gestation and nulliparous women. For a cervical length of 20-25 mm in the mid trimester, vaginal progesterone compared with bed rest did not prolong pregnancy.

Chitosan/alginate complexes for vaginal delivery of chlorhexidine digluconate.

PubMed

Abruzzo, A; Bigucci, F; Cerchiara, T; Saladini, B; Gallucci, M C; Cruciani, F; Vitali, B; Luppi, B

2013-01-16

Chitosan/alginate complexes were prepared at different polycation/polyanion molar ratios and freeze-dried vaginal inserts were obtained for chlorhexidine digluconate local delivery in genital infections. Complex yield, FT-IR spectra, and TGA thermograms were studied to confirm the interaction between the two polyions. The influence of different complexes on physical handling, morphology, and drug distribution in the samples were evaluated by friability test, scanning electron microscopy (SEM), and energy dispersive X-ray spectroscopy (EDS), respectively. In vitro water-uptake, mucoadhesion and release tests were performed as well as microbiological tests toward pathogenic vaginal microorganisms. The results showed that the selection of suitable chitosan/alginate molar ratio and drug loading allowed modulate insert ability to hydrate, adhere to the mucosa, and release chlorhexidine digluconate. The insert containing an excess of alginate was found to be the best performing formulation and showed good antimicrobial activity toward the pathogens Candida albicans and Escherichia coli. Copyright © 2012 Elsevier Ltd. All rights reserved.

Pregnancy and childbirth in a patient with multiple sclerosis: A case report of successful management.

PubMed

Wang, Chun-Kai; Lin, Chi-Kang; Wang, Tun-Jun; Wang, Chen-Yu; Hsu, Po-Chao; Su, Her-Young

2018-06-01

Multiple sclerosis (MS) preferentially affects females of reproductive age, making reproduction an important issue for women with MS. An increased incidence of poor labor progress often results in assisted vaginal delivery or a cesarean section. However, with good pre-pregnancy counseling and management, women with MS can conceive and give birth safely. Here, we present a case of pregnancy with MS, which was carried to term uneventfully and ended with unassisted vaginal delivery. A 36-year-old woman was treated for MS for three years before she conceived. Because of her mild clinical presentation, medication was discontinued when her pregnancy was confirmed. Counseling was completed, and she had a smooth pregnancy course and gave birth vaginally at 38 weeks and two days. Based on this case report, women with mild clinical presentation of MS before pregnancy can conceive and carry successfully to term with no or improved disease presentation. Copyright © 2018. Published by Elsevier B.V.

Novel ex vivo protocol using porcine vagina to assess drug permeation from mucoadhesive and colloidal pharmaceutical systems.

PubMed

Pereira, Maíra N; Reis, Thaiene A; Matos, Breno N; Cunha-Filho, Marcílio; Gratieri, Taís; Gelfuso, Guilherme M

2017-10-01

Local treatment of vaginal diseases presents advantages over systemic treatments and the interaction of the drug delivery systems with the biological tissue is a key factor for a successful vaginal topical therapy. Conventional protocols for permeation studies have high variability and fail in distinguishing drug penetration from mucoadhesive or colloidal drug delivery systems from conventional formulations, as tissue interaction is normally under estimated. The protocol presented in this paper is a simplified ex vivo vertical model, in which formulations are placed in hung porcine vaginas with the objective of mimicking a condition closer to the biological circumstance, specifically considering the possible leak from the vaginal canal in the vertical position. The results indicate the proposed method was capable of differentiating formulations performances and histological evaluation showed mucosa structures are preserved during this new assay. Therefore, the ex vivo method can be considered reliable for approaching the physiological situation in comparative studies. Copyright © 2017 Elsevier B.V. All rights reserved.

Intravaginal gene silencing using biodegradable polymer nanoparticles densely loaded with small-interfering RNA

NASA Astrophysics Data System (ADS)

Woodrow, Kim A.; Cu, Yen; Booth, Carmen J.; Saucier-Sawyer, Jennifer K.; Wood, Monica J.; Mark Saltzman, W.

2009-06-01

Vaginal instillation of small-interfering RNA (siRNA) using liposomes has led to silencing of endogenous genes in the genital tract and protection against challenge from infectious disease. Although siRNA lipoplexes are easily formulated, several of the most effective transfection agents available commercially may be toxic to the mucosal epithelia and none are able to provide controlled or sustained release. Here, we demonstrate an alternative approach using nanoparticles composed entirely of FDA-approved materials. To render these materials effective for gene silencing, we developed novel approaches to load them with high amounts of siRNA. A single dose of siRNA-loaded nanoparticles to the mouse female reproductive tract caused efficient and sustained gene silencing. Knockdown of gene expression was observed proximal (in the vaginal lumen) and distal (in the uterine horns) to the site of topical delivery. In addition, nanoparticles penetrated deep into the epithelial tissue. This is the first report demonstrating that biodegradable polymer nanoparticles are effective delivery vehicles for siRNA to the vaginal mucosa.

Development of a liposome microbicide formulation for vaginal delivery of octylglycerol for HIV prevention

PubMed Central

Wang, Lin; Sassi, Alexandra Beumer; Patton, Dorothy; Isaacs, Charles; Moncla, B. J.; Gupta, Phalguni; Rohan, Lisa Cencia

2015-01-01

The feasibility of using a liposome drug delivery system to formulate octylglycerol (OG) as a vaginal microbicide product was explored. A liposome formulation was developed containing 1% OG and phosphatidyl choline in a ratio that demonstrated in vitro activity against Neisseria gonorrhoeae, HSV-1, HSV-2 and HIV-1 while sparing the innate vaginal flora, Lactobacillus. Two conventional gel formulations were prepared for comparison. The OG liposome formulation with the appropriate OG/lipid ratio and dosing level had greater efficacy than either conventional gel formulation and maintained this efficacy for at least 2 months. No toxicity was observed for the liposome formulation in ex vivo testing in a human ectocervical tissue model or in vivo testing in the macaque safety model. Furthermore, minimal toxicity was observed to lactobacilli in vitro or in vivo safety testing. The OG liposome formulation offers a promising microbicide product with efficacy against HSV, HIV and N. gonorrhoeae. PMID:22149387

[Physicopharmaceutical characteristics of ulinastatin vaginal suppositories prepared in a hospital].

PubMed

Satake, Kiyoshi; Nakajima, Takanori; Iwata, Masanori; Fujikake, Yoshio; Kimura, Masayuki

2011-01-01

We studied a locally applied vaginal preparation (vaginal suppositories) of ulinastatin (urinary trypsin inhibitor, UTI), designed to threatened premature delivery and maintain pregnancy. Witepsol S55 was chosen as the basic component of the vaginal suppositories based on the physical pharmaceutical characteristics of three kinds of hard fats. The average particle size of the UTI aqueous injection was approximately 70% as compared with that of the UTI lyophilized product, used as the base material for the preparation of UTI vaginal suppositories. We compared the physical pharmaceutical properties of UTI vaginal suppositories with water contents of 2.5%, 5.0%, and 7.5%, respectively. Preparation strength negatively correlated with the water content. The coefficient of viscosity positively correlated with the water content of the preparation. UTI vaginal suppositories with a water content of 5.0% had the highest average drug release rate on moment analysis. A comprehensive evaluation of the properties of UTI vaginal suppositories, including high strength due to disintegration resistance, the coefficient of viscosity and its influence on local retention, and drug release and its influence on the duration of effect, indicated that a 5.0% UTI aqueous solution for injection combined with Witepsol S55 as the base was the optimal formulation for the hospital preparation of vaginal suppositories.

Ovine multiparity is associated with diminished vaginal muscularis, increased elastic fibres and vaginal wall weakness: implication for pelvic organ prolapse

PubMed Central

Emmerson, Stuart; Young, Natharnia; Rosamilia, Anna; Parkinson, Luke; Edwards, Sharon L.; Vashi, Aditya V.; Davies-Tuck, Miranda; White, Jacinta; Elgass, Kirstin; Lo, Camden; Arkwright, John; Werkmeister, Jerome A.; Gargett, Caroline E.

2017-01-01

Pelvic Organ Prolapse (POP) is a major clinical burden affecting 25% of women, with vaginal delivery a major contributing factor. We hypothesised that increasing parity weakens the vagina by altering the extracellular matrix proteins and smooth muscle thereby leading to POP vulnerability. We used a modified POP-quantification (POP-Q) system and a novel pressure sensor to measure vaginal wall weakness in nulliparous, primiparous and multiparous ewes. These measurements were correlated with histological, biochemical and biomechanical properties of the ovine vagina. Primiparous and multiparous ewes had greater displacement of vaginal tissue compared to nulliparous at points Aa, Ap and Ba and lower pressure sensor measurements at points equivalent to Ap and Ba. Vaginal wall muscularis of multiparous ewes was thinner than nulliparous and had greater elastic fibre content. Collagen content was lower in primiparous than nulliparous ewes, but collagen organisation did not differ. Biomechanically, multiparous vaginal tissue was weaker and less stiff than nulliparous. Parity had a significant impact on the structure and function of the ovine vaginal wall, as the multiparous vaginal wall was weaker and had a thinner muscularis than nulliparous ewes. This correlated with “POP-Q” and pressure sensor measurements showing greater tissue laxity in multiparous compared to nulliparous ewes. PMID:28374826

Vaginal Lactoferrin Modulates PGE2, MMP-9, MMP-2, and TIMP-1 Amniotic Fluid Concentrations

PubMed Central

Maritati, Martina; Gonelli, Arianna; Greco, Pantaleo

2016-01-01

Inflammation plays an important role in pregnancy, and cytokine and matrix metalloproteases (MMPs) imbalance has been associated with premature rupture of membranes and increased risk of preterm delivery. Previous studies have demonstrated that lactoferrin (LF), an iron-binding protein with anti-inflammatory properties, is able to decrease amniotic fluid (AF) levels of IL-6. Therefore, we aimed to evaluate the effect of vaginal LF administration on amniotic fluid PGE2 level and MMP-TIMP system in women undergoing genetic amniocentesis. One hundred and eleven women were randomly divided into controls (n = 57) or treated with LF 4 hours before amniocentesis (n = 54). Amniotic fluid PGE2, active MMP-9 and MMP-2, and TIMP-1 and TIMP-2 concentrations were determined by commercially available assays and the values were normalized by AF creatinine concentration. PGE2, active MMP-9, and its inhibitor TIMP-1 were lower in LF-treated group than in controls (p < 0.01, p < 0.005, and p < 0.001, resp.). Conversely, active MMP-2 (p < 0.0001) and MMP-2/TIMP-2 molar ratio (p < 0.001) were increased, whilst TIMP-2 was unchanged. Our data suggest that LF administration is able to modulate the inflammatory response following amniocentesis, which may counteract cytokine and prostanoid imbalance that leads to abortion. This trial is registered with Clinical Trial number NCT02695563. PMID:27872513

A Lactobacillus-Deficient Vaginal Microbiota Dominates Postpartum Women in Rural Malawi

PubMed Central

2018-01-01

ABSTRACT The bacterial community found in the vagina is an important determinant of a woman's health and disease status. A healthy vaginal microbiota is associated with low species richness and a high proportion of one of a number of different Lactobacillus spp. When disrupted, the resulting abnormal vaginal microbiota is associated with a number of disease states and poor pregnancy outcomes. Studies up until now have concentrated on relatively small numbers of American and European populations that may not capture the full complexity of the community or adequately predict what constitutes a healthy microbiota in all populations. In this study, we sampled and characterized the vaginal microbiota found on vaginal swabs taken postpartum from a cohort of 1,107 women in rural Malawi. We found a population dominated by Gardnerella vaginalis and devoid of the most common vaginal Lactobacillus species, even if the vagina was sampled over a year postpartum. This Lactobacillus-deficient anaerobic community, commonly labeled community state type (CST) 4, could be subdivided into four further communities. A Lactobacillus iners-dominated vaginal microbiota became more common the longer after delivery the vagina was sampled, but G. vaginalis remained the dominant organism. These results outline the difficulty in all-encompassing definitions of what a healthy or abnormal postpartum vaginal microbiota is. Previous identification of community state types and associations among bacterial species, bacterial vaginosis, and adverse birth outcomes may not represent the complex heterogeneity of the microbiota present. (This study has been registered at ClinicalTrials.gov as NCT01239693.) IMPORTANCE A bacterial community in the vaginal tract is dominated by a small number of Lactobacillus species, and when not present there is an increased incidence of inflammatory conditions and adverse birth outcomes. A switch to a vaginal bacterial community lacking in Lactobacillus species is common after pregnancy. In this study, we characterized the postpartum vaginal bacterial community of a large group of women from a resource-poor, undersampled population in rural Malawi. The majority of women were found to have a Lactobacillus-deficient community, and even when sampled a year after delivery the majority of women still did not have Lactobacillus present in their vaginal microbiota. The effect of becoming pregnant again for those who do not revert to a Lactobacillus-dominant community is unknown, and this could suggest that not all Lactobacillus-deficient community structures are adverse. A better understanding of this complex community state type is needed. PMID:29305501

Mode of delivery after successful external cephalic version: a systematic review and meta-analysis.

PubMed

de Hundt, Marcella; Velzel, Joost; de Groot, Christianne J; Mol, Ben W; Kok, Marjolein

2014-06-01

To assess the mode of delivery in women after a successful external cephalic version by performing a systematic review and meta-analysis. We searched MEDLINE, Embase, ClinicalTrials.gov, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library for studies reporting on the mode of delivery in women after successful external cephalic version at term and women with a spontaneous cephalic-presenting fetus. Two reviewers independently selected studies, extracted data, and assessed study quality. The association between mode of delivery and successful external cephalic version was expressed as a common odds ratio with a 95% confidence interval (CI). We identified three cohort studies and eight case-control studies, reporting on 46,641 women. The average cesarean delivery rate for women with a successful external cephalic version was 21%. Women after successful external cephalic version were at increased risk for cesarean delivery for dystocia (odds ratio [OR] 2.2, 95% CI 1.6-3.0), cesarean delivery for fetal distress (OR 2.2, 95% CI 1.6-2.9), and instrumental vaginal delivery (OR 1.4, 95% CI 1.1-1.7). Women who have had a successful external cephalic version for breech presentation are at increased risk for cesarean delivery and instrumental vaginal delivery as compared with women with a spontaneous cephalic presentation. Nevertheless, with a number needed to treat of three, external cephalic version still remains a very efficient procedure to prevent a cesarean delivery.

Temporal and spatial variation of the human microbiota during pregnancy

PubMed Central

DiGiulio, Daniel B.; Callahan, Benjamin J.; McMurdie, Paul J.; Costello, Elizabeth K.; Lyell, Deirdre J.; Robaczewska, Anna; Sun, Christine L.; Goltsman, Daniela S. A.; Wong, Ronald J.; Shaw, Gary; Stevenson, David K.; Holmes, Susan P.; Relman, David A.

2015-01-01

Despite the critical role of the human microbiota in health, our understanding of microbiota compositional dynamics during and after pregnancy is incomplete. We conducted a case-control study of 49 pregnant women, 15 of whom delivered preterm. From 40 of these women, we analyzed bacterial taxonomic composition of 3,767 specimens collected prospectively and weekly during gestation and monthly after delivery from the vagina, distal gut, saliva, and tooth/gum. Linear mixed-effects modeling, medoid-based clustering, and Markov chain modeling were used to analyze community temporal trends, community structure, and vaginal community state transitions. Microbiota community taxonomic composition and diversity remained remarkably stable at all four body sites during pregnancy (P > 0.05 for trends over time). Prevalence of a Lactobacillus-poor vaginal community state type (CST 4) was inversely correlated with gestational age at delivery (P = 0.0039). Risk for preterm birth was more pronounced for subjects with CST 4 accompanied by elevated Gardnerella or Ureaplasma abundances. This finding was validated with a set of 246 vaginal specimens from nine women (four of whom delivered preterm). Most women experienced a postdelivery disturbance in the vaginal community characterized by a decrease in Lactobacillus species and an increase in diverse anaerobes such as Peptoniphilus, Prevotella, and Anaerococcus species. This disturbance was unrelated to gestational age at delivery and persisted for up to 1 y. These findings have important implications for predicting premature labor, a major global health problem, and for understanding the potential impact of a persistent, altered postpartum microbiota on maternal health, including outcomes of pregnancies following short interpregnancy intervals. PMID:26283357

Temporal and spatial variation of the human microbiota during pregnancy.

PubMed

DiGiulio, Daniel B; Callahan, Benjamin J; McMurdie, Paul J; Costello, Elizabeth K; Lyell, Deirdre J; Robaczewska, Anna; Sun, Christine L; Goltsman, Daniela S A; Wong, Ronald J; Shaw, Gary; Stevenson, David K; Holmes, Susan P; Relman, David A

2015-09-01

Despite the critical role of the human microbiota in health, our understanding of microbiota compositional dynamics during and after pregnancy is incomplete. We conducted a case-control study of 49 pregnant women, 15 of whom delivered preterm. From 40 of these women, we analyzed bacterial taxonomic composition of 3,767 specimens collected prospectively and weekly during gestation and monthly after delivery from the vagina, distal gut, saliva, and tooth/gum. Linear mixed-effects modeling, medoid-based clustering, and Markov chain modeling were used to analyze community temporal trends, community structure, and vaginal community state transitions. Microbiota community taxonomic composition and diversity remained remarkably stable at all four body sites during pregnancy (P > 0.05 for trends over time). Prevalence of a Lactobacillus-poor vaginal community state type (CST 4) was inversely correlated with gestational age at delivery (P = 0.0039). Risk for preterm birth was more pronounced for subjects with CST 4 accompanied by elevated Gardnerella or Ureaplasma abundances. This finding was validated with a set of 246 vaginal specimens from nine women (four of whom delivered preterm). Most women experienced a postdelivery disturbance in the vaginal community characterized by a decrease in Lactobacillus species and an increase in diverse anaerobes such as Peptoniphilus, Prevotella, and Anaerococcus species. This disturbance was unrelated to gestational age at delivery and persisted for up to 1 y. These findings have important implications for predicting premature labor, a major global health problem, and for understanding the potential impact of a persistent, altered postpartum microbiota on maternal health, including outcomes of pregnancies following short interpregnancy intervals.

Spray-Dried Thiolated Chitosan-Coated Sodium Alginate Multilayer Microparticles for Vaginal HIV Microbicide Delivery.

PubMed

Meng, Jianing; Agrahari, Vivek; Ezoulin, Miezan J; Purohit, Sudhaunshu S; Zhang, Tao; Molteni, Agostino; Dim, Daniel; Oyler, Nathan A; Youan, Bi-Botti C

2017-05-01

It is hypothesized that novel thiolated chitosan-coated multilayer microparticles (MPs) with enhanced drug loading are more mucoadhesive than uncoated MPs and safe in vivo for vaginal delivery of topical anti-HIV microbicide. Formulation optimization is achieved through a custom experimental design and the alginate (AG) MPs cores are prepared using the spray drying method. The optimal MPs are then coated with the thiolated chitosan (TCS) using a layer-by-layer method. The morphological analysis, in situ drug payload, in vitro drug release profile, and mucoadhesion potential of the MPs are carried out using scanning electron microscopy, solid-state 31 P NMR spectroscopy, UV spectroscopy, fluorescence imaging and periodic acid Schiff method, respectively. The cytotoxicity and preclinical safety of MPs are assessed on human vaginal (VK2/E6E7) and endocervical (End1/E6E7) epithelial cell lines and in female C57BL/6 mice, respectively. The results show that the MPs are successfully formulated with an average diameter ranging from 2 to 3 μm with a drug loading of 7-12% w/w. The drug release profile of these MPs primarily follows the Baker-Lonsdale and Korsmeyer-Peppas models. The MPs exhibit high mucoadhesion (20-50 folds) compared to native AGMPs. The multilayer MPs are noncytotoxic. Histological and immunochemical analysis of the mice genital tract shows neither signs of damage nor inflammatory cell infiltrate. These data highlight the potential use of TCS-coated AG-based multilayer MPs templates for the topical vaginal delivery of anti-HIV/AIDS microbicides.

Predictors of obstetric intervention rates: case-mix, staffing levels and organisational factors of hospital of birth.

PubMed

Joyce, Rachel; Webb, R; Peacock, Janet

2002-11-01

We performed a cross-sectional study of all Thames maternity units, 1994-96, including 540,834 live and stillbirths. In contrast to recent media speculation, no association of caesarean section rates with midwifery staffing levels was found after adjustment for confounders. The only association with staffing was with levels of junior obstetric staffing, which could be a reflection of less experienced management of labour. Caesarean section rates were also associated positively with the levels of delivery beds, which could be a reflection of the closer monitoring of labour that may result from increased bed availability. Both caesarean section and instrumental vaginal delivery rates were associated with epidural rates, which was expected from the literature. Variations in epidural rates were mainly associated with variations in demographic case-mix, due possibly to patient demand. Demographic case-mix was also associated with instrumental vaginal deliveries but not the caesarean section rate.

The relation between height, foot length, pelvic adequacy and mode of delivery.

PubMed

Van Bogaert, L J

1999-02-01

To investigate the value of maternal height and foot length as predictors of pelvic adequacy and to evaluate the influence of body components' proportions on the mode of delivery. Retrospective study of the anthropometry of women having normal vertex deliveries (NVD), caesarean sections (CS) and vaginal birth after caesarean (VBAC). NVD patients were taller, had a longer vertebral column, longer lower limbs and longer feet than CS and than VBAC patients. The anthropometric measurements of VBAC patients yielded values intermediate between CS and NVD patients. The ratios of height to any of the other measured variables (vertebral column, lower limb and foot length) were similar in the three groups indicating that the body proportions were the same. Maternal height and foot length are of limited value as predictors of pelvic (in-)adequacy. The anthropometric features of women delivered by CS only are similar to those of women having a vaginal birth after Caesarean.

Value of bacterial culture of vaginal swabs in diagnosis of vaginal infections.

PubMed

Nenadić, Dane; Pavlović, Miloš D

2015-06-01

Vaginal and cervical swab culture is still very common procedure in our country's everyday practice whereas simple and rapid diagnostic methods have been very rarely used. The aim of this study was to show that the employment of simple and rapid diagnostic tools [vaginal fluid wet mount microscopy (VFWMM), vaginal pH and potassium hydroxide (KOH) test] offers better assessment of vaginal environment than standard microbiologic culture commonly used in Serbia. This prospective study included 505 asymptomatic pregnant women undergoing VFWMM, test with 10% KOH, determination of vaginal pH and standard culture of cervicovaginal swabs. Combining findings from the procedures was used to make diagnoses of bacterial vaginosis (BV) and vaginitis. In addition, the number of polymorphonuclear leukocytes (PMN) was determined in each sample and analyzed along with other findings. Infections with Candida albicans and Trichomonas vaginalis were confirmed or excluded by microscopic examination. In 36 (6%) patients cervicovaginal swab cultures retrieved several aerobes and facultative anaerobes, whereas in 52 (11%) women Candida albicans was isolated. Based on VFWMM findings and clinical criteria 96 (19%) women had BV, 19 (4%) vaginitis, and 72 (14%) candidiasis. Of 115 women with BV and vaginitis, pH 4.5 was found in 5, and of 390 with normal findings 83 (21%) had vaginal pH 4.5. Elevated numbers of PMN were found in 154 (30%) women--in 83 (54%) of them VFWMM was normal. Specificity and sensitivity of KOH test and vaginal pH determination in defining pathological vaginal flora were 95% and 81%, and 79% and 91%, respectively. Cervicovaginal swab culture is expensive but almost non-informative test in clinical practice. The use of simpler and rapid methods as vaginal fluid wet mount microscopy, KOH test and vaginal pH offers better results in diagnosis, and probably in the treatment and prevention of sequels of vaginal infections.

Long-term micturition problems of asymptomatic postpartum urinary retention: a prospective case-control study.

PubMed

Mulder, Femke E M; Hakvoort, Robert A; de Bruin, Jan-Peter; Janszen, Erica W; van der Post, Joris A M; Roovers, Jan-Paul W R

2018-04-01

Covert (asymptomatic) postpartum urinary retention (PUR) is defined as post-void residual volume (PVRV) ≥150 mL. Although often supposed to be a common and harmless phenomenon, no data are available on the potential long-term micturition problems of increased PVRV after vaginal delivery. After the first spontaneous void post-vaginal delivery, PVRV was measured using a portable scanning device. Micturition symptoms were compared using validated questionnaires between women with PVRV < 150 mL and those with PVRV ≥150 mL until 1 year after delivery. Women with PVRV ≥ 150 mL were followed until complete bladder emptying was achieved. Data of 105 patients with PVRV < 150 mL and 119 with PVRV ≥ 150 mL were available for analysis. 75% of all patients included had PVRV ≥ 250 mL. More primiparous patients had PVRV ≥ 150 mL (p < 0.02). 92% of women with PVRV ≥ 150 mL after delivery were able to adequately empty their bladder within 4 days. One year after delivery, no statistically significant differences were found. Covert PUR according to the definition of PVRV ≥ 150 mL, is a common and transient phenomenon that does not result in more lower urinary tract symptoms 1 year after delivery. Although the current definition is not useful in identifying postpartum women with a pathological condition, we suggest that the definition of covert PUR should be change to: "PVRV≥500 mL after the first spontaneous void after (vaginal) delivery." This cut-off value is the value at which some women do need more time to normalise emptying of the bladder. The exact clinical implications of covert PUR need to be further studied in this subcategory of women.

Childbirth Education Class and Birth Plans Are Associated with a Vaginal Delivery.

PubMed

Afshar, Yalda; Wang, Erica T; Mei, Jenny; Esakoff, Tania F; Pisarska, Margareta D; Gregory, Kimberly D

2017-03-01

To determine whether the mode of delivery was different between women who attended childbirth education (CBE) class, had a birth plan, or both compared with those who did not attend CBE class or have a birth plan. This is a retrospective cross-sectional study of women who delivered singleton gestations > 24 weeks at our institution between August 2011 and June 2014. Based on a self-report at the time of admission for labor, women were stratified into four categories: those who attended a CBE class, those with a birth plan, both, and those with neither CBE or birth plan. The primary outcome was the mode of delivery. Multivariate logistic regression analyses adjusting for clinical covariates were performed. In this study, 14,630 deliveries met the inclusion criteria: 31.9 percent of the women attended CBE class, 12.0 percent had a birth plan, and 8.8 percent had both. Women who attended CBE or had a birth plan were older (p < 0.001), more likely to be nulliparous (p < 0.001), had a lower body mass index (p < 0.001), and were less likely to be African-American (p < 0.001). After adjusting for significant covariates, women who participated in either option or both had higher odds of a vaginal delivery (CBE: OR 1.26 [95% CI 1.15-1.39]; birth plan: OR 1.98 [95% CI 1.56-2.51]; and both: OR 1.69 [95% CI 1.46-1.95]) compared with controls. Attending CBE class and/or having a birth plan were associated with a vaginal delivery. These findings suggest that patient education and birth preparation may influence the mode of delivery. CBE and birth plans could be used as quality improvement tools to potentially decrease cesarean rates. © 2016 Wiley Periodicals, Inc.

A randomized trial of Foley balloon induction of labor trial in nulliparas (FIAT-N).

PubMed

Connolly, Katherine A; Kohari, Katherine S; Rekawek, Patricia; Smilen, Brooke S; Miller, Meredith R; Moshier, Erin; Factor, Stephanie H; Stone, Joanne L; Bianco, Angela T

2016-09-01

With an increasing rate of induction of labor, it is important to choose induction methods that are safe and efficient in achieving a vaginal delivery. The optimal method for inducing nulliparous women with an unfavorable cervix is not known. We sought to determine if induction of labor with simultaneous use of oxytocin and Foley balloon vs sequential use of Foley balloon followed by oxytocin decreases the time to delivery in nulliparous women. We conducted a randomized controlled trial of nulliparous women presenting for induction at a single institution from December 2013 through March 2015. After decision for induction was made by their primary provider, women with gestational age ≥24 weeks with a nonanomalous, singleton fetus in vertex presentation with intact membranes were offered participation. Exclusion criteria included history of uterine surgery, unexplained vaginal bleeding, latex allergy, or contraindication to vaginal delivery. Participants were randomized to either simultaneous (oxytocin and Foley balloon) or sequential (oxytocin after expulsion of Foley balloon) induction group. The primary outcome was time from induction to delivery. Secondary outcomes included mode of delivery, estimated blood loss, postpartum hemorrhage, chorioamnionitis, and composite neonatal outcome. Maternal and neonatal outcomes were collected via chart review. Analyses were done on an intention-to-treat basis. A total of 166 patients were enrolled; 82 in the simultaneous and 84 in the sequential group. There were no differences in baseline characteristics in the 2 groups. Patients who received simultaneous oxytocin with insertion of a Foley balloon delivered significantly earlier (15.92 vs 18.87 hours, P = .004) than those in the sequential group. There was no difference in rate of cesarean delivery, estimated blood loss, postpartum hemorrhage, chorioamnionitis, or composite neonatal outcome. Simultaneous use of oxytocin and Foley balloon for induction of labor results in a significantly shorter interval to delivery in nulliparas. Copyright © 2016 Elsevier Inc. All rights reserved.

Repeat cesarean delivery: what indications are recorded in the medical chart?

PubMed

Lydon-Rochelle, Mona T; Gardella, Carolyn; Cárdenas, Vicky; Easterling, Thomas R

2006-03-01

National surveillance estimates reported a troubling 63 percent decline in the rate of vaginal birth after cesarean delivery (VBAC) from 1996 (28.3%) to 2003 (10.6%), with subsequent rising rates of repeat cesarean delivery. The study objective was to examine patterns of documented indications for repeat cesarean delivery in women with and without labor. We conducted a population-based validation study of 19 nonfederal short-stay hospitals in Washington state. Of the 4,541 women who had live births in 2000, 11 percent (n = 493) had repeat cesarean without labor and 3 percent (n = 138) had repeat cesarean with labor. Incidence of medical conditions and pregnancy complications, patterns of documented indications for repeat cesarean delivery, and perioperative complications in relation to repeat cesarean delivery with and without labor were calculated. Of the 493 women who underwent a repeat cesarean delivery without labor, "elective"(36%) and "maternal request"(18%) were the most common indications. Indications for maternal medical conditions (3.0%) were uncommon. Among the 138 women with repeat cesarean delivery with labor, 60.1 percent had failure to progress, 24.6 percent a non-reassuring fetal heart rate, 8.0 percent cephalopelvic disproportion, and 7.2 percent maternal request during labor. Fetal indications were less common (5.8%). Breech, failed vacuum, abruptio placentae, maternal complications, and failed forceps were all indicated less than 5.0 percent. Women's perioperative complications did not vary significantly between women without and with labor. Regardless of a woman's labor status, nearly 10 percent of women with repeat cesarean delivery had no documented indication as to why a cesarean delivery was performed. "Elective" and "maternal request" were common indications among women undergoing repeat cesarean delivery without labor, and nearly 10 percent of women had undocumented indications for repeat cesarean delivery in their medical record. Improvements in standardization of indication nomenclature and documentation of indication are especially important for understanding falling VBAC rates. Future research should examine how clinicians and women anticipate, discuss, and make decisions about childbirth after a previous cesarean delivery within the context of actual antepartum care.

Preparation and characterization of mucoadhesive nanoparticles of poly (methyl vinyl ether-co-maleic anhydride) containing glycyrrhizic acid intended for vaginal administration.

PubMed

Aguilar-Rosas, Irene; Alcalá-Alcalá, Sergio; Llera-Rojas, Viridiana; Ganem-Rondero, Adriana

2015-01-01

Traditional vaginal preparations reside in the vaginal cavity for relatively a short period of time, requiring multiple doses in order to attain the desired therapeutic effect. Therefore, mucoadhesive systems appear to be appropriate to prolong the residence time in the vaginal cavity. In the current study, mucoadhesive nanoparticles based on poly(methyl vinyl ether-co-maleic anhydride) (PVM/MA) intended for vaginal delivery of glycyrrhizic acid (GA) (a drug with well-known antiviral properties) were prepared and characterized. Nanoparticles were generated by a solvent displacement method. Incorporation of GA was performed during nanoprecipitation, followed by adsorption of drug once nanoparticles were formed. The prepared nanoparticles were characterized in terms of size, Z-potential, morphology, drug loading, interaction of GA with PVM/MA (by differential scanning calorimetry) and the in vitro interaction of nanoparticles with pig mucin (at two pH values, 3.6 and 5; with and without GA adsorbed). The preparation method led to nanoparticles of a mean diameter of 198.5 ± 24.3 nm, zeta potential of -44.8 ± 2.8 mV and drug loading of 15.07 ± 0.86 µg/mg polymer. The highest mucin interaction resulted at pH 3.6 for nanoparticles without GA adsorbed. The data obtained suggest the promise of using mucoadhesive nanoparticles of PVM/MA for intravaginal delivery of GA.

Which Factors Contribute to False-Positive, False-Negative, and Invalid Results in Fetal Fibronectin Testing in Women with Symptoms of Preterm Labor?

PubMed

Bruijn, Merel M C; Hermans, Frederik J R; Vis, Jolande Y; Wilms, Femke F; Oudijk, Martijn A; Kwee, Anneke; Porath, Martina M; Oei, Guid; Scheepers, Hubertina C J; Spaanderman, Marc E A; Bloemenkamp, Kitty W M; Haak, Monique C; Bolte, Antoinette C; Vandenbussche, Frank P H A; Woiski, Mallory D; Bax, Caroline J; Cornette, Jérôme M J; Duvekot, Johannes J; Bijvank, Bas W A N I J; van Eyck, Jim; Franssen, Maureen T M; Sollie, Krystyna M; van der Post, Joris A M; Bossuyt, Patrick M M; Kok, Marjolein; Mol, Ben W J; van Baaren, Gert-Jan

2017-02-01

Objective  We assessed the influence of external factors on false-positive, false-negative, and invalid fibronectin results in the prediction of spontaneous delivery within 7 days. Methods  We studied symptomatic women between 24 and 34 weeks' gestational age. We performed uni- and multivariable logistic regression to estimate the effect of external factors (vaginal soap, digital examination, transvaginal sonography, sexual intercourse, vaginal bleeding) on the risk of false-positive, false-negative, and invalid results, using spontaneous delivery within 7 days as the outcome. Results  Out of 708 women, 237 (33%) had a false-positive result; none of the factors showed a significant association. Vaginal bleeding increased the proportion of positive fetal fibronectin (fFN) results, but was significantly associated with a lower risk of false-positive test results (odds ratio [OR], 0.22; 95% confidence intervals [CI], 0.12-0.39). Ten women (1%) had a false-negative result. None of the investigated factors was significantly associated with a significantly higher risk of false-negative results. Twenty-one tests (3%) were invalid; only vaginal bleeding showed a significant association (OR, 4.5; 95% CI, 1.7-12). Conclusion  The effect of external factors on the performance of qualitative fFN testing is limited, with vaginal bleeding as the only factor that reduces its validity. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Assessing the potential of the Woman's Condom for vaginal drug delivery.

PubMed

Kramzer, Lindsay F; Cohen, Jessica; Schubert, Jesse; Dezzutti, Charlene S; Moncla, Bernard J; Friend, David; Rohan, Lisa C

2015-09-01

The Woman's Condom is a new female condom that uses a dissolvable polyvinyl alcohol capsule to simplify vaginal insertion. This preclinical study assessed the feasibility to incorporate an antiviral drug, UC781, into the Woman's Condom capsule, offering a unique drug delivery platform. UC781 capsules were fabricated using methods from the development of the Woman's Condom capsules as well as those used in vaginal film development. Capsules were characterized to evaluate physical/chemical attributes, Lactobacillus compatibility, in vitro safety and bioactivity, and condom compatibility. Two UC781 capsule platforms were assessed. Capsule masses (mg; mean±SD) for platforms 1 and 2 were 116.50±18.22 and 93.80±8.49, respectively. Thicknesses were 0.0034±0.0004 in and 0.0033±0.0004 in. Disintegration times were 11±3 s and 5±1 s. Puncture strengths were 21.72±3.30 N and 4.02±0.83 N. Water content measured 6.98±1.17% and 7.04±1.92%. UC781 content was 0.59±0.05 mg and 0.77±0.11 mg. Both platforms retained in vitro bioactivity and were nontoxic to TZM-bl cells and Lactobacillus. Short-term storage of UC781 capsules with the Woman's Condom pouch did not decrease condom mechanical integrity. UC781 was loaded into a polymeric capsule similar to that of the Woman's Condom product. This study highlights the potential use of the Woman's Condom as a platform for vaginal delivery of drugs relevant to sexual/reproductive health, including those for short- or long-acting HIV prevention. We determined the proof-of-concept feasibility of incorporation of an HIV-preventative microbicide into the Woman's Condom capsule. This study highlights various in vitro physical and chemical evaluations as well as bioactivity and safety assessments necessary for vaginal product development related to female sexual and reproductive health. Copyright © 2015 Elsevier Inc. All rights reserved.

Influence of lactoferrin in preventing preterm delivery: a pilot study.

PubMed

Giunta, Giuliana; Giuffrida, Lorena; Mangano, Katia; Fagone, Paolo; Cianci, Antonio

2012-01-01

Lactoferrin (Lf) is an approximately 80-kDa iron-binding glycoprotein, belonging to the transferrin family, with well-known bacteriostatic and bactericidal properties. It is produced and stored in specific (secondary) neutrophil granules and released during neutrophil activation and degranulation. Nowadays, Lf has a well-known therapeutic indication for combating iron deficiency anemia (IDA) in pregnant women. Studies suggest that Lf plays an important role against cervicovaginal infections by decreasing cytokines levels, such as interleukin (IL)-6, in cervicovaginal fluid. The aim of this preliminary trial was to evaluate the effectiveness of Lf in preventing preterm delivery caused by cervical infections and ripening. From November 2009 to August 2010, 21 pregnant women (26-32 weeks pregnant), aged between 22 and 36 years, suffering from IDA, at risk of preterm delivery, were prospectively enrolled in the study. One group (N=14) received 100 mg of recombinant human lactoferrin (bLf) [corrected] (lattoferrina; AG-pharma) twice a day before meals, for one month. The other group (N=7) received 520 mg of ferrous sulfate (Ferro-Grad; Abbott Laboratories, USA) once a day. The patients underwent transvaginal ultrasound to evaluate cervical length and funneling, and vaginal swabs were used to detect infections and cervicovaginal fluid sample collection to determine IL-6 levels. The results showed a correlation between the oral administration of 200 mg of bLf [corrected] with both the normalization of vaginal flora (vaginal infection disappearance) and the decrease in IL-6 cervicovaginal fluid levels in women at risk of preterm delivery.

Deinfibulation for preventing or treating complications in women living with type III female genital mutilation: A systematic review and meta-analysis.

PubMed

Okusanya, Babasola O; Oduwole, Olabisi; Nwachuku, Nuria; Meremikwu, Martin M

2017-02-01

Deinfibulation is a surgical procedure carried out to re-open the vaginal introitus of women living with type III female genital mutilation (FGM). To assess the impact of deinfibulation on gynecologic or obstetric outcomes by comparing women who were deinfibulated with women with type III FGM or women without FGM. Major databases including CENTRAL, MEDLINE, and Scopus were searched until August 2015. We included nonrandomized studies that compared obstetric outcomes of women with deinfibulation, type III FGM (not deinfibulated during labor), and no FGM. Quality of evidence was determined following the GRADE methodology. Summary measures were calculated using odds ratios at 95% confidence intervals. We found no randomized controlled trials. We included four case-control studies. The quality of evidence was very low. Compared with women with type III FGM at delivery, deinfibulated women had a significant reduction in the risk of having a cesarean delivery or postpartum hemorrhage. Compared with women without FGM, deinfibulated women had a similar risk of episiotomy, cesarean delivery, vaginal lacerations, postpartum hemorrhage, and blood loss at vaginal delivery. The length of second stage of labor, mean maternal hospital stay, and Apgar scores less than 7 were also comparable. Low-quality evidence suggests deinfibulation improves birth outcomes for women with type III FGM. CRD42015024466. © 2017 International Federation of Gynecology and Obstetrics. The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.

Descriptive analysis of childbirth healthcare costs in an area with high levels of immigration in Spain

PubMed Central

2011-01-01

Background The aim of this study was to estimate the cost of childbirth in a teaching hospital in Barcelona, Spain, including the costs of prenatal care, delivery and postnatal care (3 months). Costs were assessed by taking into account maternal origin and delivery type. Methods We performed a cross-sectional study of all deliveries in a teaching hospital to mothers living in its catchment area between October 2006 and September 2007. A process cost analysis based on a full cost accounting system was performed. The main information sources were the primary care program for sexual and reproductive health, and hospital care and costs records. Partial and total costs were compared according to maternal origin and delivery type. A regression model was fit to explain the total cost of the childbirth process as a function of maternal age and origin, prenatal care, delivery type, maternal and neonatal severity, and multiple delivery. Results The average cost of childbirth was 4,328€, with an average of 18.28 contacts between the mother or the newborn and the healthcare facilities. The delivery itself accounted for more than 75% of the overall cost: maternal admission accounted for 57% and neonatal admission for 20%. Prenatal care represented 18% of the overall cost and 75% of overall acts. The average overall cost was 5,815€ for cesarean sections, 4,064€ for vaginal instrumented deliveries and 3,682€ for vaginal non-instrumented deliveries (p < 0.001). The regression model explained 45.5% of the cost variability. The incremental cost of a delivery through cesarean section was 955€ (an increase of 31.9%) compared with an increase of 193€ (6.4%) for an instrumented vaginal delivery. The incremental cost of admitting the newborn to hospital ranged from 420€ (14.0%) to 1,951€ (65.2%) depending on the newborn's severity. Age, origin and prenatal care were not statistically significant or economically relevant. Conclusions Neither immigration nor prenatal care were associated with a substantial difference in costs. The most important predictors of cost were delivery type and neonatal severity. Given the impact of cesarean sections on the overall cost of childbirth, attempts should be made to take into account its higher cost in the decision of performing a cesarean section. PMID:21492486

Descriptive analysis of childbirth healthcare costs in an area with high levels of immigration in Spain.

PubMed

Comas, Mercè; Català, Laura; Sala, Maria; Payà, Antoni; Sala, Assumpció; Del Amo, Elisabeth; Castells, Xavier; Cots, Francesc

2011-04-15

The aim of this study was to estimate the cost of childbirth in a teaching hospital in Barcelona, Spain, including the costs of prenatal care, delivery and postnatal care (3 months). Costs were assessed by taking into account maternal origin and delivery type. We performed a cross-sectional study of all deliveries in a teaching hospital to mothers living in its catchment area between October 2006 and September 2007. A process cost analysis based on a full cost accounting system was performed. The main information sources were the primary care program for sexual and reproductive health, and hospital care and costs records. Partial and total costs were compared according to maternal origin and delivery type. A regression model was fit to explain the total cost of the childbirth process as a function of maternal age and origin, prenatal care, delivery type, maternal and neonatal severity, and multiple delivery. The average cost of childbirth was 4,328€, with an average of 18.28 contacts between the mother or the newborn and the healthcare facilities. The delivery itself accounted for more than 75% of the overall cost: maternal admission accounted for 57% and neonatal admission for 20%. Prenatal care represented 18% of the overall cost and 75% of overall acts. The average overall cost was 5,815€ for cesarean sections, 4,064€ for vaginal instrumented deliveries and 3,682€ for vaginal non-instrumented deliveries (p < 0.001). The regression model explained 45.5% of the cost variability. The incremental cost of a delivery through cesarean section was 955€ (an increase of 31.9%) compared with an increase of 193€ (6.4%) for an instrumented vaginal delivery. The incremental cost of admitting the newborn to hospital ranged from 420€ (14.0%) to 1,951€ (65.2%) depending on the newborn's severity. Age, origin and prenatal care were not statistically significant or economically relevant. Neither immigration nor prenatal care were associated with a substantial difference in costs. The most important predictors of cost were delivery type and neonatal severity. Given the impact of cesarean sections on the overall cost of childbirth, attempts should be made to take into account its higher cost in the decision of performing a cesarean section.

Cesarean section in relation to self-esteem and parenting among new mothers in southwestern Nigeria.

PubMed

Loto, Olabisi Morebise; Adewuya, Abiodun O; Ajenifuja, Olusegun K; Orji, Ernest O; Ayandiran, Emmanuel Olufemi; Owolabi, Alexander T; Ade-Ojo, Idowu Pius

2010-01-01

Maternal psychopathology and self-esteem during childbirth may have an effect on maternal parenting self-efficacy. This study aimed to asses the self-esteem of newly delivered primiparous mothers who had cesarean section (CS) in relation to their parenting self-efficacy. A total of 115 primiparous women who delivered by CS were compared with 97 matched controls who had vaginal delivery during the same period. They completed the Rosenberg self-esteem scale prior to discharge. They also completed the parent-child relationship questionnaire at six weeks postpartum, together with the Rosenberg self-esteem scale. The mean score on the Rosenberg self-esteem scale was significantly lower for the CS group, both prior to discharge (p = 0.006) and at six weeks (p < 0.001), than the vaginal delivery group. The mean score on the parent-child relationship questionnaire was also lower in those who had CS compared with those who had vaginal delivery (p < 0.001, OR 4.71, 95% CI 1.75-14.71). CS in Nigerian women is associated with lowered self-esteem and predicts poor parenting self-efficacy in the postnatal period. Psychological support and techniques to improve self-esteem and parenting should be incorporated into the management of women having CS.

Risk Factors for Uterine Atony/Postpartum Hemorrhage Requiring Treatment after Vaginal Delivery

PubMed Central

Wetta, Luisa A; Szychowski, Jeff M; Seals, Ms. Samantha; Mancuso, Melissa S; Biggio, Joseph R; Tita, Alan TN

2013-01-01

Objective To identify risk factors for uterine atony or hemorrhage. Study Design Secondary analysis of a 3-arm double-blind randomized trial of different dose-regimens of oxytocin to prevent uterine atony after vaginal delivery. The primary outcome was uterine atony or hemorrhage requiring treatment. Twenty-one potential risk factors were evaluated. Logistic regression was used to identify independent risk factors using 2 complementary pre-defined model selection strategies. Results Among 1798 women randomized to 10, 40 or 80U prophylactic oxytocin after vaginal delivery, treated uterine atony occurred in 7%. Hispanic (OR 2.1; 95% CI 1.3–3.4) and non-Hispanic whites (OR 1.6; 95% CI 1.0–2.5), preeclampsia (OR 3.2; 95% CI 2.0–4.9) and chorioamnionitis (OR 2.8; 95% CI 1.6–5.0) were consistent independent risk factors. Other risk factors based on the specified selection strategies were obesity, induction/augmentation of labor, twins, hydramnios, anemia, and arrest of descent. Amnioinfusion appeared to be protective against uterine atony (OR 0.53; 95% CI 0.29–0.98). Conclusion Independent risk factors for uterine atony requiring treatment include Hispanic and non-Hispanic white ethnicity, preeclampsia and chorioamnionitis. PMID:23507549

Dislocation of temporo-mandibular joint - an uncommon circumstance of occurrence: vaginal delivery.

PubMed

El Bouazzaoui, Abderrahim; Labib, Smael; Derkaoui, Ali; Adnane Berdai, Mohammed; Bendadi, Azzeddine; Harandou, Mustapha

2010-06-25

Dislocation of temporo-mandibular joint (TMJ) is an infrequent disease but still spectacular. This disease consists of a permanent, to some extent complete disruption of the temporo-mandibular joint. These dislocations often occur in a context of yawning, and less frequently after a burst of laughing or relatively mild facial trauma (slap, punch on the chin). We report a case of TMJ occurring in an uncommon circumstance: vaginal delivery. A woman aged 24-years with no special past medical history; primipara was admitted in the Department of Maternity of the University Hospital Hassan II of Fez for an imminent delivery of a twin pregnancy. Ten minutes after admission, the patient delivered vaginally with episiotomy. She gave birth to twins weighing 2800 g and 2400 g. During labour, and due to efforts of crying, the patient developed a sudden and immediate loss of function of the temporo-mandibular joint, with difficulty of speaking, the mouth permanently opened and with the chin lowered and thrown forward. The examination found an empty glenoid fossa of the temporo-mandibular joint in both sides. The diagnosis of dislocation of the TMJ was established. A CT scan of facial bones was done, objectifying a bilateral dislocation of TMJ. The reduction of this dislocation was performed in the operating room under sedation.

Intrapartum sacral stress fracture due to pregnancy-related osteoporosis: a case report.

PubMed

Oztürk, Gülcan; Külcü, Duygu Geler; Aydoğ, Ece

2013-01-01

Low back pain (LBP) and hip pain frequently occur during pregnancy and postpartum period. Although pelvic and mechanic lesions of the soft tissues are most responsible for the etiology, sacral fracture is also one of the rare causes. A 32-year-old primigravid patient presented with LBP and right hip pain which started 3 days after vaginal delivery. Although direct radiographic examination was normal, magnetic resonance imaging of the sacrum revealed sacral stress fracture. Lumbar spine and femoral bone mineral density showed osteoporosis as a risk factor. There were no other risk factors such as trauma, excessive weight gain, and strenuous physical activity. It is considered that the patient had sacral fatigue and insufficiency fracture in intrapartum period. The patient's symptoms subsided in 3 months after physical therapy and rest. In conclusion, sacral fractures during pregnancy and postpartum period, especially resulting from childbirth, are very rare. To date, there are two cases in the literature. In cases who even do not have risk factors related to vaginal delivery such as high birth weight infant and the use of forceps, exc., sacral fracture should be considered in the differential diagnosis of LBP and hip pain started soon after child birth. Pregnancy-related osteoporosis may lead to fracture during vaginal delivery.

Pregnancy outcome and obstetric management after vaginal radical trachelectomy.

PubMed

Ma, L-K; Cao, D-Y; Yang, J-X; Liu, J-T; Shen, K; Lang, J-H

2014-10-01

Radical vaginal trachelectomy (VRT) is widely prescribed as a surgical procedure to treat early-stage cervical cancer while preserving fertility. However, the ideal obstetric standard of care for patients who have undergone VRT has not yet been established. Aim of this rerport is to analyze pregnancy outcomes and optimal obstetric management during pregnancy and delivery after vaginal radical trachelectomy (VRT). Forty-six cases of VRT from December 2003 to April 2013 in Peking Union Medical College Hospital were analyzed. The mean age of the patients at the time of VRT was 30.6 years and the mean follow-up time was 39.5 months. Of the 32 patients who attempted to conceive, 12 had 16 successful conceptions. There were two miscarriages and two elective abortions. One case of ectopic pregnancy and one case of second trimester loss occurred in this cohort. Ten cases reached the third trimester. Two patients delivered before 32 weeks, and four before 37 weeks. The total preterm delivery rate was 60%. All ten patients delivered by Cesarean section through a high transverse uterine incision. No uterine rupture or postpartum hemorrhage occurred. There is an increased occurrence of preterm delivery after VRT. Cesarean section after full term pregnancy through a high transverse incision should be considered as a suitable and safe procedure.

Vaginal Repair of Cesarean Section Scar Diverticula that Resulted in Improved Postoperative Menstruation.

PubMed

Zhou, Jieru; Yao, Min; Wang, Husheng; Tan, Weilin; Chen, Pin; Wang, Xipeng

2016-01-01

Owing to the increase in cesarean sections (C-sections) worldwide, long-term complications such as postmenstrual spotting, chronic pelvic pain, and C-section scar ectopic pregnancies have created a new medical era of gynecologic disease. A new type of vaginal repair is evaluated to repair C-section diverticulum (CSD) and rebuild the muscular layer to improve symptoms of abnormal uterine bleeding and decrease the risk of uterine rupture. Retrospective cohort study (Canadian Task Force classification II-2). University hospital. A total of 121 patients with CSD diagnoses by transvaginal ultrasound (TVU) presented with postmenstrual spotting between June 2012 and March 2015. All patients had undergone at least 1 C-section delivery and had no history of postmenstrual spotting before undergoing C-section. Vaginal excision and suture of CSD. The mean duration of menstruation was 14.87 ± 3.46 days preoperatively and decreased to 8.22 ± 2.73 days at 1 month after surgery, 8.89 ± 2.67 days at 3 months after surgery, and 9.02 ± 2.47 days at 6 months after surgery (p < .01). The length, width, depth, and thickness of the remaining muscular layer (TRM) at 1 month, 3 months, and 6 months assessed by TVU also improved significantly after surgery (p < .05). However, postoperative menstruation and imaging data did not differ markedly between 3 months and 6 months, suggesting that follow-up at 3 months represents an adequate endpoint for evaluating the effectiveness of surgery. At 6 months, 80.3% of patients (94 of 117) reached ≤10 days of menstruation. Further study revealed that a TRM at 6 months of ≥8.5 mm measured by TVU (relative risk [RR], 6.418; 95% confidence interval [CI], 1.478-28.443) and an interval between CS and vaginal repair of ≤2.5 years (RR, 12.0; 95% CI, 1.541- 93.454) were good prognostic factors associated with surgery. Vaginal repair of CSD improved the symptoms of postmenstrual spotting and anatomically corrected the scars. An interval between C-section and a surgery of ≤2.5 years was optimal for vaginal repair, and a TRM at 6 months of ≥8.5 mm represented the standard healing of CSD. Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.

Maternal and neonatal morbidity in relation to the instrument used for mid-cavity rotational operative vaginal delivery: a prospective cohort study.

PubMed

Bahl, R; Van de Venne, M; Macleod, M; Strachan, B; Murphy, D J

2013-11-01

To compare the maternal and neonatal morbidity associated with alternative instruments used to perform a mid-cavity rotational delivery. A prospective cohort study. Two university teaching hospitals in Scotland and England. Three hundred and eighty-one nulliparous women who had a mid-cavity rotational operative vaginal delivery. A data collection sheet was completed by the research team following delivery. Postpartum haemorrhage, third- and fourth-degree perineal tears, low cord pH, neonatal trauma, and failed or sequential operative vaginal delivery. One hundred and sixty-three women (42.8%) underwent manual rotation followed by non-rotational forceps delivery, 73 (19.1%) had a rotational vacuum delivery, and 145 (38.1%) delivered with the assistance of rotational (Kielland) forceps. The rates of postpartum haemorrhage were similar when comparing manual rotation with rotational vacuum (adjusted OR 1.42, 95% CI 0.66-3.98), and when comparing manual rotation with Kielland forceps (adjusted OR 1.22, 95% CI 0.71-2.88). The results were comparable for third- and fourth-degree perineal tears (adjusted OR 0.85, 95% CI 0.13-1.89; adjusted OR 0.94, 95% CI 0.39-1.82), low cord pH (adjusted OR 1.76, 95% CI 0.44-6.91; adjusted OR 1.12, 95% CI 0.44-2.83), neonatal trauma (adjusted OR 0.50, 95% CI 0.16-1.55; adjusted OR 3.25, 95% CI 0.65-16.17), and admission to the neonatal intensive care unit (adjusted OR 1.47, 95% CI 0.45-4.81; adjusted OR 1.04, 95% CI 0.49-2.19). The sequential use of instruments was less likely with manual rotation and forceps than with rotational vacuum delivery (0.6 versus 36.9%, OR 0.01, 95% CI 0.002-0.090). Maternal and perinatal outcomes are comparable with Kielland forceps, vacuum extraction, and manual rotation, with few serious adverse outcomes. With appropriate training mid-cavity rotational delivery can be practiced safely, including the use of Kielland forceps. © 2013 RCOG.

Association Between Cesarean Birth and Risk of Obesity in Offspring in Childhood, Adolescence, and Early Adulthood.

PubMed

Yuan, Changzheng; Gaskins, Audrey J; Blaine, Arianna I; Zhang, Cuilin; Gillman, Matthew W; Missmer, Stacey A; Field, Alison E; Chavarro, Jorge E

2016-11-07

Cesarean birth has been associated with higher risk of obesity in offspring, but previous studies have focused primarily on childhood obesity and have been hampered by limited control for confounders. To investigate the association between cesarean birth and risk of obesity in offspring. A prospective cohort study was conducted from September 1, 1996, to December 31, 2012, among participants of the Growing Up Today Study, including 22 068 offspring born to 15 271 women, followed up via questionnaire from ages 9 to 14 through ages 20 to 28 years. Data analysis was conducted from October 10, 2015, to June 14, 2016. Birth by cesarean delivery. Risk of obesity based on International Obesity Task Force or World Health Organization body mass index cutoffs, depending on age. Secondary outcomes included risks of obesity associated with changes in mode of delivery and differences in risk between siblings whose modes of birth were discordant. Of the 22 068 offspring (20 950 white; 9359 male and 12 709 female), 4921 individuals (22.3%) were born by cesarean delivery. The cumulative risk of obesity through the end of follow-up was 13% among all participants. The adjusted risk ratio for obesity among offspring delivered via cesarean birth vs those delivered via vaginal birth was 1.15 (95% CI, 1.06-1.26; P = .002). This association was stronger among women without known indications for cesarean delivery (adjusted risk ratio, 1.30; 95% CI, 1.09-1.54; P = .004). Offspring delivered via vaginal birth among women who had undergone a previous cesarean delivery had a 31% (95% CI, 17%-47%) lower risk of obesity compared with those born to women with repeated cesarean deliveries. In within-family analysis, individuals born by cesarean delivery had 64% (8%-148%) higher odds of obesity than did their siblings born via vaginal delivery. Cesarean birth was associated with offspring obesity after accounting for major confounding factors. Although additional research is needed to clarify the mechanisms underlying this association, clinicians and patients should weigh this risk when considering cesarean delivery in the absence of a clear indication.

Elective Caesarean section on maternal request in Germany: factors affecting decision making concerning mode of delivery.

PubMed

Stützer, Paul Philipp; Berlit, Sebastian; Lis, Stefanie; Schmahl, Christian; Sütterlin, Marc; Tuschy, Benjamin

2017-05-01

To investigate sociopsychological factors of women undergoing a caesarean section on maternal request (CSMR). Twenty-eight women who underwent CSMR and 29 women with vaginal delivery (VD) filled in standardized questionnaires concerning psychological burden (SCL-R 90), fear of childbirth (W-DEQ, STAI), personality structure (HEXACO-Pi-R) and social support (F-SozU) as well as one questionnaire assessing potential factors influencing their mode of delivery. Women with CSMR were older (36.5 ± 5.4 vs. 30.6 ± 5.2 years; p < 0.001) and suffered more from fear of childbirth (W-DEQ 4.3 ± 0.8 vs. 3.7 ± 1.2; p = 0.041), concerns for their child (W-DEQ 2.0 ± 1.5 vs. 1.3 ± 0.7; p = 0.026) and appraised the birth less negative (W-DEQ 2.0 ± 0.7 vs. 2.7 ± 1.1; p = 0.008). The majority of parturients had chosen their preferred mode of delivery before pregnancy (CS 61% vs. VD 82%, p = 0.328). In the decision-making process for the mode of delivery, the advice of the partner (85 and 90%) played an important role. 82% of the women who delivered via CSMR did not regret the decision for this mode of delivery. Women who underwent CS had higher fear of childbirth and appraised the birth less negative. The majority did not regret the decision for the CS and would even choose this mode of delivery for their next pregnancy. Although the partner and the physician seem to be important in the decision process for of the mode of delivery, reasons for the choice for CSMR appear to be multifactorial.

[Optimum approach to delivery for control of premature birth (author's transl)].

PubMed

Nieder, J; Lattorff, E

1980-01-01

Foetal condition and neonatal mortality of 637 prematurely born children with birth weights below 2,501 g were analysed, depending on modes of delivery, such as spontaneous birth, speculum delivery, use of forceps, manual support, and caesarean section. The clinical condition of the newborn, assessed five minutes from parturition by Apgar score 1, was found to depend primarily on birth weight rather than on the mode of delivery. The average Apgar values were lower for less mature newborns. While Apgar scores were worst for newborns after caesarean section delivery, the differences between approaches to delivery could not be statistically secured. Neonatal mortality went up, according to expectation, along with dropping birth weight. The mortality rate of premature births below 1,501 g was not affected by delivery modes. Prophylactic use of Shute forceps and speculum delivery appeared to be superior to spontaneous birth in the medium weight class, between 1,501 g and 2,000 g. Yet, not even here were the differences between clear postnatal mortality rates statistically secured. -Lowest mortality figures were recorded from spontaneous birth in the weight class between 2,001 g and 2,500 g, but significant differences were established only to speculum delivery. Premature newborns after caesarean section had poorer prospects than all variants of vaginal birth, but among the latter premature births from breech presentation were more endangered than others. Decisions as to vaginal, abdominal, spontaneous proprophylactically surgical approaches to premature deliveries should be taken for every individual case and due consideration of many factors.

Development of polylactide and polyethylene vinyl acetate blends for the manufacture of vaginal rings.

PubMed

Mc Conville, Christopher; Major, Ian; Friend, David R; Clark, Meredith R; Woolfson, A David; Malcolm, R Karl

2012-05-01

Vaginal rings are currently being investigated for delivery of HIV microbicides. However, vaginal rings are currently manufactured form hydrophobic polymers such as silicone elastomer and polyethylene vinyl acetate (PEVA), which do not permit release of hydrophilic microbicides such as the nucleotide reverse transcriptase inhibitor tenofovir. Biodegradable polymers such as polylactide (PLA) may help increase release rates by controlling polymer degradation rather than diffusion of the drug through the polymer. However, biodegradable polymers have limited flexibility making them unsuitable for use in the manufacture of vaginal rings. This study demonstrates that by blending PLA and PEVA together it is possible to achieve a blend that has flexibility similar to native PEVA but also allows for the release of tenofovir. Copyright © 2011 Wiley Periodicals, Inc.

Women's autonomy and scheduled cesarean sections in Brazil: a cautionary tale.

PubMed

Potter, Joseph E; Hopkins, Kristine; Faúndes, Anibal; Perpétuo, Ignez

2008-03-01

In Brazil, one-fourth of all women deliver in the private sector, where the rate of cesarean deliveries is extremely high (70%). Most (64%) private sector cesareans are scheduled, although many women would have preferred a vaginal delivery. The question this study addresses is whether childbearing women were induced to accept the procedure by their physicians, and if so, how? Three face-to-face structured interviews were conducted with 1,612 women (519 private sector and 1,093 public sector) early in pregnancy, approximately 1 month before their due date, and approximately 1 month postpartum. For all private sector patients having a scheduled cesarean section, women's self-reported reasons given for programming surgical delivery were classified into three groups according to obstetrical justification. After loss to follow-up (19.2% of private sector and 34.4% of public sector), our final sample included 1,136 women (419 private sector and 717 public sector). Compared with public sector participants in the final sample, on average, private sector participants were older by 3.4 years (28.7 vs 25.3 yr), had 0.4 fewer previous deliveries (0.6 vs 1.0), and had 3.4 more years of education (11.0 vs 7.6 yr). The final samples also differed slightly with respect to preference for vaginal delivery: 72.3 percent among those in the private sector and 79.6 percent in public sector. The cesarean section rate was 72 percent in the private sector and 31 percent in the public sector. Of the women with reports about the timing of the cesarean decision, 64.4 percent had a scheduled cesarean delivery in the private sector compared with 23.7 percent in the public sector. Many cesarean sections were scheduled for an "unjustified" medical reason, especially among women who, during pregnancy, had declared a preference for a vaginal delivery. Among 96 women in this latter group, the reason reported for the procedure was unjustified in 33 cases. On the other hand, more cesarean deliveries were scheduled for "no medical justification," including physician's or the woman's convenience, among women who preferred to deliver by cesarean (35/65). The incidence of real medical reasons for a scheduled cesarean section diagnosed before the onset of labor among private sector patients who had no previous cesarean birth and who wanted a vaginal delivery was 13 percent (31/243). The data suggest that doctors frequently persuaded their patients to accept a scheduled cesarean section for conditions that either did not exist or did not justify this procedure. The problem identified in this paper may extend well beyond Brazil and should be of concern to those with responsibility for ethical behavior in obstetrics.

Predictive value of vaginal IL-6 and TNFα bedside tests repeated until delivery for the prediction of maternal-fetal infection in cases of premature rupture of membranes.

PubMed

Kayem, Gilles; Batteux, Frederic; Girard, Noémie; Schmitz, Thomas; Willaime, Marion; Maillard, Francoise; Jarreau, Pierre Henri; Goffinet, Francois

2017-04-01

Examine the predictive value for maternal-fetal infection of routine bedside tests detecting the proinflammatory cytokines, TNFα and IL-6, in the vaginal secretions of women with premature rupture of the membranes (PROM). This prospective two-center cohort study included all women hospitalized for PROM over a 2-year period. A bedside test assessed IL-6 and TNFα in vaginal secretions. Both centers routinely tested CRP and leukocytes, assaying both in maternal serum, and analyzed vaginal bacterial flora; all samples were repeated twice weekly until delivery. The study included 689 women. In cases of preterm PROM (PPROM) before 37 weeks (n=184), a vaginal sample positive for one or more bacteria was the only marker associated with early neonatal infection (OR 5.6, 95%CI; 2.0-15.7). Its sensitivity was 82% (95%CI; 62-94) and its specificity 56% (95%CI; 47-65). All positive markers of infection were associated with the occurrence of chorioamnionitis. In cases of PROM from 37 weeks onward (n=505), only CRP >5mg/dL was associated with early neonatal infection (OR=8.3, 95%CI; 1.1-65.4) or clinical chorioamnionitis (OR=6.8, 95%CI; 1.5-30.0). The sensitivity of CRP >5mg/dL was 91% (95%CI; 59-100) and its specificity 45% (95%CI; 40-51) for predicting early neonatal infection, and 89% (95%CI; 65-99) and 46% (95%CI; 41-51), respectively, for predicting clinical chorioamnionitis. The association of vaginal cytokines with maternal-fetal infection is weak and thus prevents their use as a good predictor of maternal-fetal infection. CRP and vaginal samples may be useful for identifying a group of women at low risk of infection. Copyright © 2017 Elsevier B.V. All rights reserved.

A large head circumference is more strongly associated with unplanned cesarean or instrumental delivery and neonatal complications than high birthweight.

PubMed

Lipschuetz, Michal; Cohen, Sarah M; Ein-Mor, Eliana; Sapir, Hanna; Hochner-Celnikier, Drorith; Porat, Shay; Amsalem, Hagai; Valsky, Dan V; Ezra, Yossef; Elami-Suzin, Matan; Paltiel, Ora; Yagel, Simcha

2015-12-01

Fetal size impacts on perinatal outcomes. We queried whether the fetal head, as the fetal part interfacing with the birth canal, might impact on obstetric outcomes more than birthweight (BW). We examined associations between neonatal head circumference (HC) and delivery mode and risk of perinatal complications as compared to high BW. This was an electronic medical records-based study of term singleton births (37-42 weeks' gestation) from January 2010 through December 2012 (N = 24,780, 6343 primiparae). We assessed risks of unplanned cesarean or instrumental delivery and maternal and fetal complications in cases with HC or BW ≥95th centile (large HC, high BW) vs those with parameters <95th centile (normal). Newborns were stratified into 4 subgroups: normal HC/normal BW (reference, n = 22,548, primiparae 5862); normal HC/high BW (n = 817, P = 213); large HC/normal BW (n = 878, P = 265); and large HC/high BW (n = 537, P = 103). Multinomial multivariable regression provided adjusted odds ratio (aOR) while controlling for potential confounders. Infants with HC ≥95th centile (n = 1415) were delivered vaginally in 62% of cases, unplanned cesarean delivery 16%, and instrumental delivery 11.2%; 78.4% of infants with HC <95th centile were delivered vaginally, 7.8% unplanned cesarean, and 6.7% instrumental delivery. Odds ratio (OR) for unplanned cesarean was 2.58 (95% confidence interval [CI], 2.22-3.01) and for instrumental delivery OR was 2.13 (95% CI, 1.78-2.54). In contrast, in those with BW ≥95th centile (n = 1354) 80.3% delivered vaginally, 10.2% by unplanned cesarean (OR, 1.2; 95% CI, 1.01-1.44), and 3.4% instrumental delivery (OR, 0.46; 95% CI, 0.34-0.62) compared to infants with BW <95th centile: spontaneous vaginal delivery, 77.3%, unplanned cesarean 8.2%, instrumental 7.1%. Multinomial regression with normal HC/normal BW as reference group showed large HC/normal BW infants were more likely to be delivered by unplanned cesarean (aOR, 3.08; 95% CI, 2.52-3.75) and instrumental delivery (aOR, 3.03; 95% CI, 2.46-3.75). Associations were strengthened in primiparae. Normal HC/high BW was not associated with unplanned cesarean (aOR, 1.18; 95% CI, 0.91-1.54), while large HC/high BW was (aOR, 1.93; 95% CI, 1.47-2.52). Analysis of unplanned cesarean indications showed large HC infants had more failure to progress (27.7% vs 14.1%, P < .001), while smaller HC infants had more fetal distress (23.4% vs 16.9%, P < .05). A large HC is more strongly associated with unplanned cesarean and instrumental delivery than high BW. Prospective studies are needed to test fetal HC as a predictive parameter for prelabor counseling of women with "big babies." Copyright © 2015 Elsevier Inc. All rights reserved.

Association between mode of delivery and astigmatism in preschool children.

PubMed

Liu, Fengyang; Yang, Xubo; Tang, Angcang; Liu, Longqian

2018-03-01

To determine whether mode of delivery has any impact on astigmatism. This case-control study was performed in the Department of Ophthalmology in 2015. Exposure was mode of delivery [vaginal delivery (VD) or caesarean section (CS), which here included both elective and emergency CS]. Outcome was astigmatism (≥2.5 D), which was determined by cycloplegic refraction. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were computed to assess the associations between mode of delivery and astigmatism from logistic regression models. Of the 659 children studied here (341 boys; mean age, 4.37 years), 440 were born by CS and 219 by VD. The incidence of severe astigmatism (≥2.5 D) in the CS and VD groups was 22.06% and 13.24%, respectively. Children delivered by CS had a 77.9% higher risk of severe astigmatism compared with vaginally delivered children (OR = 1.779; 95% CI, 1.121 to 2.824). After dividing CS into elective CS and emergency CS, children delivered by elective CS had an 87.3% increased risk of severe astigmatism (OR = 1.873; 95% CI, 1.157 to 3.032), but children delivered by emergency CS did not differ from vaginally delivered children. In addition, the children whose mothers had histories of breastfeeding had a 44.6% lower risk of severe astigmatism than children whose mother did not breastfeed them (OR = 0.554, 95% CI, 0.335-0.914). Birth by CS, especially elective CS, increases the risk of severe astigmatism (≥2.50 D) in childhood. © 2017 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.