Correcting occiput posterior position during labor: the role of maternal positions

Occipito-posterior presentation represents 10 to 34% of cephalic presentations in early labor. Spontaneous rotation during labor to occipito-anterior mode occurs in most cases, but 5 to 8% of fetuses will persist in posterior position for the expulsive phase of delivery. Previous research has shown that this presentation carries an increased risk of unusually long labor, maternal and fetal exhaustion, instrument-assisted delivery, severe perineal injury, and cesarean section. The diagnosis of posterior variety is usually made quite late at the end of dilation. Several researchers have reported the benefits of determining presentation during labor by transabdominal ultrasonography. Some obstetrical techniques to correct these presentations at complete dilation have also been described. In the case of diagnosis of posterior variety, the usual attitude is expectant management. Postural techniques to promote physiological labor and delivery have been documented in the literature. De Gasquet has described a very precise technique to facilitate fetal rotation, but its effectiveness has never been assessed scientifically. A Cochrane review on the topic has shown that similar positions are well accepted by women and reduce back pain. On the other hand, the sample size of included studies appeared inadequate to assess their interest for use in childbirth, in general, and for adverse outcomes associated with posterior presentation varieties in particular. Attempts to correct the fetal malposition during the expansion phase would allow to reduce adverse outcomes during the expulsive phase of delivery. Further research is necessary to assess the efficacity of specific maternal positions during labor for the correction of fetal posterior presentation.     

Neonatal clavicle fracture in cesarean delivery: incidence and risk factors

Background: Neonatal clavicle fracture in cesarean delivery is rare and has not been extensively studied.

Methods: We performed a retrospective review of cesarean deliveries with neonatal clavicle fracture during a 12-year period. Maternal and neonatal factors as well as surgical factors related to cesarean delivery for the fracture were determined and compared to the control group to analyze their significance.

Results: Among a total 89?367 deliveries during the study period, 36 286 babies were born via cesarean section. Nineteen cases of clavicle fractures in cesarean section were identified (0.05% of total live births via cesarean section). In the analysis of maternal and neonatal risk factors, birthweight, birthweight ≥?4000 g and maternal age were significantly associated with clavicle fracture in cesarean section. However, clavicle fractures were not correlated with the selected surgical factors such as indication for cesarean section, skin incision to delivery time and incision type of skin and uterus. Logistic regression analysis showed that birthweight was the major risk factor for clavicle fracture.

Conclusion: Clavicle fractures complicated 0.05% of cesarean deliveries. The main risk factor related to a clavicle fracture in cesarean section was the birthweight of an infant. As reported in previous studies associated with vaginal delivery, clavicle fracture is considered to be an unavoidable event and may not be eliminated, even in cesarean delivery.     

Occipital posterior and occipital transverse positions: reappraisal of the obstetric risks

Malpositions in labour in a vertex-presenting fetus are known to be associated with increased risks of operative delivery A retrospective analysis of all deliveries over 4 years in a university teaching obstetric unit was performed using the available obstetric database. All cases of live births with cephalic presenting babies after 36 completed gestational weeks were analysed, and included 17,533 out of 20,533 total deliveries over the study period. The study group included those cases with occipital posterior and transverse positions, based on the documentation of the position of the vertex at the time of delivery, or at the last clinical examination before obstetric intervention, while occipital anterior cases constituted the control group. The overall incidence of malpositions was 14%, and operative delivery rate in the study group was 82.5% versus 20.7% in the control group. After excluding cases of operative delivery for non-mechanical indications, such as fetal distress, the adjusted odds ratio for the malposition group was 9.8 (95% CI 8.91-10.8) for total assisted delivery and 30.2 (95% CI 25.6-35.5) for Caesarean section compared to the occipital anterior group. Malpositions are definitely associated with a marked increase in the risk of operative delivery including Caesarean section. Labour complicated by malposition should be considered high risk, and should warrant due preparation for obstetric intervention.     

Operative vaginal delivery in case of persistent occiput posterior position after manual rotation failure: a 6-month follow-up on pelvic floor function

Purpose

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.

Methods

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.

Results

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.

Conclusions

OP operative deliveries are associated with significant perineal morbidity and pelvic floor dysfunction at 6 months postpartum.

     

Fetal growth restriction: risk factors for unplanned primary cesarean delivery

Objective: The purpose of this study was to identify risk factors before or during labor to predict primary cesarean delivery for non-reassuring fetal heart tracing in cases of fetal growth restriction (FGR) undergoing a trial of labor.

Study design: We reviewed charts of all patients with singleton, non-anomalous fetuses found to have FGR and delivered from January 2008 to December 2012. Characteristics of patients delivered by cesarean were compared to those who had delivered vaginally.

Results: Two hundred and twenty-two patients were delivered with FGR. Fifty-nine patients were excluded due to cesarean delivery prior to labor. Of the remaining 153 patients, 84% delivered vaginally and 16% underwent cesarean delivery. Of the 131 patients who underwent induction, 83% delivered vaginally. Rates of cesarean were higher for primigravity, oligohydramnios and prostaglandin use. However, logistic regression showed that oligohydramnios (odds ratio [OR]: 3.98; CI: 1.35–11.76) and prostaglandin use (OR: 3.67; CI: 1.07–12.60) were significantly associated with cesarean delivery.

Conclusions: The rate of vaginal delivery is high in cases of FGR undergoing a trial of labor. We recommend that these patients undergo a trial of labor. Patients with oligohydramnios and those requiring prostaglandins for cervical ripening should be counseled regarding a significantly higher risk of cesarean delivery.     

Management of persistent occiput posterior position: a substantial role of instrumental rotation in the setting of failed manual rotation

Introduction: To compare the maternal and neonatal outcomes associated with Instrumental Rotation (IR) to operative vaginal delivery in occiput posterior (OP) position with Thierry’s spatulas (TS), in the setting of failed manual rotation (MR).

Study design: We led a prospective observational cohort study in a tertiary referral hospital in Toulouse, France. All women presenting in labor with persistent OP position at full cervical dilatation and who delivered vaginally after failed MR and with IR or OP assisted delivery were included from January 2014 to December 2015.

The main outcomes measured were maternal morbidity parameters including episiotomy rate, incidence and severity of perineal lacerations, perineal hematomas and postpartum hemorrhage. Severe perineal tears corresponded to third and fourth degree lacerations. Fetal morbidity outcomes comprised neonatal Apgar scores, acidemia, fetal injuries, birth trauma and neonatal intensive care unit admissions.

Results: Among 9762 women, 910 (9.3%) presented with persistent OP position at full cervical dilatation and 222 deliveries were enrolled. Of 111 attempted IR, 97 were successful (87.4%). The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.8% vs. 12.6%; p?Conclusion: Our results support the use of IR in order to reduce perineal morbidity associated with OP assisted delivery, in the setting of a failed manual rotation.     

Endomyometritis after cesarean delivery in the era of antibiotic prophylaxis: incidence and risk factors

Purpose: To identify the rate of postpartum endomyometritis (PPE) after cesarean delivery (CD) in the era of antibiotic prophylaxis and determine risk factors.

Methods: A single institution retrospective study was performed in women undergoing CD. Data regarding obstetrical and surgical variables were collected. Diagnosis of PPE was made clinically.

Results: Among 2419 patients, the rate of PPE was 1.6% (n?=?38) and was associated with lower age (27.0 versus 31.0; p?p?p?=?.0081). There was no difference in PPE for cefazolin 2?g versus 1?g (OR: 1.91; p?=?.17) or 3?g versus 1?g (OR: 3.69; p?=?.29), gentamicin/clindamycin versus cefazolin (OR: 5.60; p?p?=?.001), sexually transmitted infection during the pregnancy (OR: 4.197; p?=?.02) or blood transfusion (OR: 9.50; p?Conclusions: While the overall rate of PPE was low, several risk factors were identified. Preoperative diagnosis of chorioamnionitits is associated with a higher rate of PPE. Further studies are needed to identify optimal regimens for antimicrobial prophylaxis in women undergoing CD.     

Cesarean delivery for fetal distress: rate and risk factors

The objective of this article was to review the recent English language literature on cesarean delivery for fetal distress to determine its incidence, diagnostic tests, and the contributing factors to this obstetric complications. A PubMed search (1990-2000) with items of "cesarean, fetal distress," "cesarean, non-reassuring fetal heart rate," "cesarean, neonatal acidosis," and "cesarean, umbilical arterial pH," was undertaken. Reports, letters to the editor, focus on anomalous fetuses, and papers not specifically focused on this topic were excluded. Of the 392 articles that the search yielded, 169 met the inclusion criteria. Based on 37 reports with more than 1,000 patients each, the overall risk of prompt cesarean delivery for fetal concern was 3.1% (43,340 of 13,989,74). The risk exceeded 20% in patients with moderate/severe asthma, severe hypothyroidism, severe preeclampsia, and postterm or fetal growth restricted fetuses with abnormal Doppler studies. Use of likelihood ratios suggests that Doppler of the umbilical artery is a superior diagnostic test to amniotic fluid index in identifying parturients at risk for cesarean for non-reassuring fetal heart rate tracing. Although several risk factors increase the need for cesarean delivery for fetal distress, in general, most are unpreventable. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to estimate the incidence of cesarean delivery for non-reassuring fetal heart rate tracing, outline potential diagnostic tests that are useful for the detection of fetal distress, and summarize medical and obstetric conditions that place patients at risk for cesarean delivery for fetal distress.     

Emergency cesarean delivery in induction of labor: an evaluation of risk factors

BACKGROUND: Induction of labor has been associated with an increased risk of emergency cesarean delivery. Knowledge of factors that influence the risk of cesarean delivery in women with induced labor is limited. METHODS: We performed a case-control study, nested within a population-based cohort of women with induced labor at term during 1991-1996 in Uppsala County, Sweden. Cases were women delivered with emergency cesarean delivery, and controls were women vaginally delivered (n = 193, respectively). Using logistic regression, analyses were performed. Odds ratio (OR) with 95% confidence intervals (CI) was used as a measure of relative risk. RESULTS: Women with a previous cesarean delivery had high risks of cesarean delivery (adjusted OR = 10.10, 95% CI = 3.30-30.92). The risk of cesarean delivery was also increased among nulliparous (adjusted OR = 4.92, 95% CI = 2.81-8.61), short (adjusted OR = 2.20, 95% CI = 1.06-4.59), and obese women (adjusted OR = 2.03, 95% CI = 1.07-3.84). A cervix dilatation less than 1.5 cm doubled the risk of cesarean delivery (adjusted OR = 2.26, 95% CI = 1.09-4.66). Mother's age, epidural analgesia, oxytocin augmentation, gestational age, and birthweight were not significantly associated with risks of cesarean delivery. CONCLUSIONS: Women with a previous cesarean delivery, nulliparous, short, and obese women with induced labor are at high risk of a cesarean delivery. When there is a need to deliver a woman with a previous cesarean section or a nulliparous woman with other risk factors for cesarean delivery, it may be prudent to consider an elective cesarean section.     

Maternal pre-pregnancy overweight status and obesity as risk factors for cesarean delivery

Objective.?To determine the extent to which, if at all, maternal pre-pregnancy adiposity and other anthropometric factors are related to risk of cesarean delivery.

Methods.?This hospital-based prospective cohort study included 738 nulliparous women who initiated prenatal care prior to 16 weeks gestation. Participants provided information about their pre-pregnancy weight and height and other sociodemographic and reproductive covariates. Labor and delivery characteristics were obtained from maternal and infant medical records. Risk ratios (RR) and 95% CI were estimated by fitting generalized linear models.

Results.?The proportion of cesarean deliveries in this population was 26%. Women who were overweight (BMI 25.00–29.99?kg/m²) were twice as likely to deliver their infants by cesarean section as lean women (BMI <?20.00?kg/m²) (RR?=?2.09; 95% CI 1.27–3.42). Obese women (BMI ??30.00?kg/m²) experienced a three-fold increase in risk of cesarean delivery when compared with this referent group (RR?=?3.05; 95% CI 1.80–5.18). The joint association between maternal pre-pregnancy overweight status and short stature was additive. When compared with tall (height ??1.63?m), lean women, short (?<?1.63?m), overweight (BMI ??25.00?kg/m²) women were nearly three times as likely to have a cesarean delivery (RR?=?2.79; 95% CI 1.72–4.52).

Conclusion.?Our findings suggest that nulliparous women who are overweight or obese prior to pregnancy, and particularly those who are also short, have an increased risk of delivering their infants by cesarean section.     

Male fetuses and the risk of cesarean delivery

OBJECTIVE: To assess the reported increased rate of cesarean sections in women carrying male fetuses. STUDY DESIGN: A retrospective analysis of all deliveries in 2001 was performed. All singleton deliveries were enrolled. We compared fetal sex distribution in cesarean ased risk of cesarean sections performed for various indications. The study had 80% power to detect a explained by different parturient difference in the cesarean section rate in women carrying male and female fetuses. RESULTS: The overall cesarean section rate was similar in women with male or female fetuses, 19.7% and 19.1%, respectively. This lack of association was also found in specific subgroups of cesarean indications: non-reassuring fetal heart rate pattern, fetal distress, nonprogressive labor, elective cesarean, suspected macrosomia, abnormal lie and severe preeclampsia. CONCLUSION: In contrast with previous investigators, we did not find an increased risk of cesarean section in women carrying male fetuses.