Does Cerclage Prevent Preterm Birth?

Cerclage procedures can be classified according to timing, (elective, urgent, emergent), and anatomic approach (transvaginal and transabdominal). The most current clinical data and the evidence-based recommendations for each type of cerclage procedure are listed.     

Does Maternal Age Predict Multiple Birth,Preterm Delivery or Low Birth Weight in Successful In Vitro Fertilization Pregnancies?

Objective: to describe the influence of maternal age on births associated with in vitro fertilization (IVF), including lower birth weights, delivery prior to 37 weeks gestational age, and multiple birth.Methods: data on IVF pregnancies from 1994 to 1997 was reviewed. This data included infant birth weight, gestational age, occurrence of multiple births, and maternal age.The age of mothers was categorized as less than 30 years, 30 to 34 years, and 35 years or greater.Results: maternal age information was available for 76 percent of the clients. Four hundred and forty-six births were reviewed, of which 306 (49.8%) infants were multiples, 236 (38.4%) infants were less than 2,500 g and 329 (53.8%) were less than 37 weeks gestation. In successful IVF pregnancies, mothers age 35 and over, compared to those under age 30, were slightly less likely to have a multiple birth (26.1 % versus 37.3%, p<0.08 ), less likely to deliver a low birth weight infant (LBW, <2,500 g) (32.4% versus 48.3%, p<0.005), and less likely to deliver at less than 37 weeks (49.6% versus 57.1%, p<0.005). Among singleton deliveries, advanced maternal age was not associated with higher rates of LBW (9.6% versus 13.5%, p = 0.54) or preterm delivery (21.3% versus 13.5%, p = 0.24).Conclusions: these findings indicate that IVF can be performed in older women without concern that infant morbidity is greater than among younger IVF clients.     

Antenatal Corticosteroids in the Management of Preterm Birth: Are We Back Where We Started?

Though the preterm birth rate in the United States has finally begun to decline, preterm birth remains a critical public health problem. The administration of antenatal corticosteroids to improve outcomes after preterm birth is one of the most important interventions in obstetrics. This article summarizes the evidence for antenatal corticosteroid efficacy and safety that has accumulated since Graham Liggins and Ross Howie first introduced this therapy. Although antenatal corticosteroids have proven effective for singleton pregnancies at risk for preterm birth between 26 and 34 weeks’ gestation, questions remain about the utility in specific patient populations such as multiple gestations, very early preterm gestations, and pregnancies complicated by IUGR. In addition, there is still uncertainty about the length of corticosteroid effectiveness and the need for repeat or rescue courses. Though a significant amount of data has accumulated on antenatal corticosteroids over the past 40 years, more information is still needed to refine the use of this therapy and improve outcomes for these at-risk patients.     

The Canadian Perinatal Network: A National Network Focused on Threatened Preterm Birth at 22 to 28 Weeks’ Gestation

ObjectiveThe Canadian Perinatal Network (CPN) maintains an ongoing national database focused on threatened very preterm birth. The objective of the network is to facilitate between-hospital comparisons and other research that will lead to reductions in the burden of illness associated with very preterm birthMethodsWomen were included in the database if they were admitted to a participating tertiary perinatal unit at 22+0 to 28+6 weeks' gestation with one or more conditions most commonly responsible for very preterm birth, including spontaneous preterm labour with contractions, incompetent cervix, prolapsing membranes, preterm prelabour rupture of membranes, gestational hypertension, intrauterine growth restriction, or antepartum hemorrhage. Data were collected by review of maternal and infant charts, entered directly into standardized electronic data forms and uploaded to the CPN via a secure networkResultsBetween 2005 and 2009, the CPN enrolled 2524 women from 14 hospitals including those with preterm labour and contractions (27.4%), short cervix without contractions (16.3%), prolapsing membranes (9.4%), antepartum hemorrhage (26.0%), and preterm prelabour rupture of membranes (23 0%) The mean gestational age at enrolment was 25.9 ± 1.9 weeks and the mean gestation age at delivery was 29.9 ± 5.1 weeks; 57.0% delivered at < 29 weeks and 75.4% at < 34 weeks. Complication rates were high and included serious maternal complications (26 7%), stillbirth (8.2%), neonatal death (16.3%), neonatal intensive care unit admission (60 7%), and serious neonatal morbidity (35 0%)ConclusionThis national dataset contains detailed information about women at risk of very preterm birth. It is available to clinicians and researchers who are working with one or more CPN collaborators and who are interested in studies relating processes of care to maternal or perinatal outcomes.     

Prediction of Preterm Birth in Multiple Pregnancies: Development of a Multivariable Model Including Cervical Length Measurement at 16 to 21 Weeks’ Gestation

ObjectiveTo develop a multivariable prognostic model for the risk of preterm delivery in women with multiple pregnancy that includes cervical length measurement at 16 to 21 weeks’ gestation and other variables.MethodsWe used data from a previous randomized trial. We assessed the association between maternal and pregnancy characteristics including cervical length measurement at 16 to 21 weeks’ gestation and time to delivery using multivariable Cox regression modelling. Performance of the final model was assessed for the outcomes of preterm and very preterm delivery using calibration and discrimination measures.ResultsWe studied 507 women, of whom 270 (53%) delivered < 37 weeks (preterm) and 66 (13%) < 32 weeks (very preterm). Women with cervical length < 30 mm delivered more often preterm (hazard ratio 1.9; 95% CI 0.7 to 4.8). Other independently contributing predictors were previous preterm delivery, monochorionicity, smoking, educational level, and triplet pregnancy. Prediction models for preterm and very preterm delivery had a c-index of 0.68 (95% CI 0.63 to 0.72) and 0.68 (95% CI 0.62 to 0.75), respectively, and showed good calibration.ConclusionIn women with a multiple pregnancy, the risk of preterm delivery can be assessed with a multivariable model incorporating cervical length and other predictors.     

Birth centres: financially viable?

The financial issues for birth centres are: Those that conduct a small number of births--certainly those conducting less than 100 births a year--are unlikely to generate income that covers their costs; In future, all community activity will come under PbR and it will then be much easier to identify how much antenatal and postnatal activity occurs from birth centres and what income should therefore be derived from that activity; Even if a birth centre is financially viable in its own terms, will it make economic sense as part of the entire maternity service? For a freestanding unit, it is clear that in terms of economies of scale, two sites will almost always be more expensive than one; For birth centres to survive, they must be able to demonstrate a sound business case that balances financial affordability with the wider policy agenda. The business case for birth centres has to be made in terms that make sense to the rest of the NHS.     

Classical Cesarean: What Are the Maternal and Infant Risks Compared With Low Transverse Cesarean in Preterm Birth,and Subsequent Uterine Rupture? A Systematic Review and Meta-analysis

ObjectivesClassical cesarean section may be associated with increased short- and long-term risks. The objectives of this study were to review the following systematically: first, the short-term maternal and infant risks with preterm classical compared with low transverse cesarean sections; and second, the risk of spontaneous or early-labour uterine rupture.Data sourcesMedline, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from January 1980 to July 2018.Study selectionA total of 772 studies were independently screened by two reviewers, and 91 full texts were reviewed. The review included nine studies comparing outcomes after preterm classical versus low transverse cesarean section and 15 studies addressing subsequent pregnancy outcomes.Data synthesisOur primary short-term outcomes were maternal death and intensive care unit (ICU) admission. For subsequent pregnancies, our primary outcome was the risk of spontaneous or early-labour uterine rupture. The data were synthesized using random effects, and odds ratios (ORs) and 95% confidence intervals (CIs) were generated. There were no significant differences between preterm classical and low transverse cesarean sections in the odds of maternal death (OR 2.38; 95% CI 0.15–38.07) or ICU admission (adjusted OR 2.38; 95% CI 0.42–13.35). A subgroup from 28 to 31 weeks gestation had increased risks of endometritis, transfusion, and ICU admission with the classical incision. The low vertical incision was associated with a lower odds of organ injury than was the low transverse incision. The incidence of uterine rupture following the classical incision without a trial of labour was 1%.ConclusionPreterm classical cesarean section is not associated with significantly increased risks, but data are scarce. Subsequent uterine rupture risk when not planning a trial of labour is 1%.     

Are Routine Interventions Necessary in Normal Birth?

Routine interventions during labor and birth, such as perineal shaving and enemas before vaginal delivery, continuous intrapartum electronic fetal monitoring (EFM), and episiotomy are prevalent in Taiwan, but they may not always be necessary. Numerous studies investigating these interventions have failed to find absolute benefits for women with uncomplicated and low-risk pregnancies. No evidence-based benefits support routine perineal shaving or enemas during labor for reducing the risk of perineal wound infection or neonatal infection. The use of EFM is associated with an increased rate of operative interventions (vacuum, forceps, cesarean delivery) but does not result in a significant decrease in the incidence of perinatal death or cerebral palsy. Routine episiotomy does not have demonstrable advantages over restrictive episiotomy in the frequency or severity of perineal damage or pelvic relaxation.     

Birth planning--is it beneficial to pregnant women?

The aim of this study was to investigate the experience of birth planning for pregnant women. Research in Australia and overseas has suggested that there are a number of conflicting issues with women's preparation and participation in childbirth. The researcher interviewed forty-two first time mothers in a variety of maternity settings around Victoria to ascertain the importance of birth planning in their approach to childbirth and the ways they went about making their plan and negotiating their needs with health professionals. The data from those interviews demonstrated that the means women used to negotiate their needs for childbirth with health professionals had little influence on their overall pregnancy and birth experience.     

Preterm premature rupture of membranes: is home care acceptable?

Background: Preterm prelabor rupture of membranes is a frequent obstetric condition associated with increased risks of maternal and neonatal morbidity and mortality. Conventional management is in hospital. Outpatient management is an alternative in selected cases; however, the safety of home management has not been established.

Objective: To study the obstetric and neonatal outcomes of women with preterm premature rupture of membranes between 24 and 34 weeks who were managed as outpatient (outpatient care group), compared with those managed in hospital (hospital care group).

Study design: A retrospective cohort study between 1 January 2009 and 31 December 2013 in three French tertiary care centers.

Results: Ninety women were included in the outpatient care group and 324 in the hospital care group. In the outpatient care group, the gestational age at membrane rupture was lower, compared to the hospital care group (28.8 (26.6–30.5) vs. 30.3 (27.6–32.1) weeks; p?p?Conclusion: We observed no major complication related to home care after a period of observation. A randomized study would be necessary to confirm its safety.     

Emotional Responses of Mothers of Late‐Preterm and Term Infants

ObjectiveTo compare the emotional responses of mothers of late‐preterm infants (34 0/7 to 36 6/7 weeks gestation) with those of mothers of full‐term infants.DesignA mixed method comparative study.SettingA southeastern tertiary academic medical center postpartum unit.ParticipantsSixty mothers: 29 mothers of late‐preterm infants and 31 mothers of full‐term infants.MethodsMeasures of maternal emotional distress (four standardized measures of anxiety, postpartum depression, posttraumatic stress symptoms, and worry about infant health) and open‐ended semistructured maternal interviews were conducted in the hospital following birth and by phone at one month postpartum.ResultsMothers of late‐preterm infants experienced significantly greater emotional distress immediately following delivery, and their distress levels continued to be higher at one month postpartum on each of the standardized measures. Mothers of late‐preterm infants also discussed the altered trajectories in their birth and postpartum experiences and feeling unprepared for these unexpected events as a source of ongoing emotional distress.ConclusionMothers of late‐preterm infants have greater emotional distress than mothers of term infants for at least one month after delivery. Our findings suggest that it may not be a single event that leads to different distress levels in mothers of late‐preterm and full‐term infants but rather the interaction of multiple alterations in the labor and delivery process and the poorer‐than‐expected infant health outcomes. In the future, researchers need to examine how and when mothers’ emotional responses change over time and how their responses relate to parenting and infant health and development.     

Birth trauma – risk factors and short-term neonatal outcome

Abstract

Objective: The ability to predict birth trauma (BT) based on the currently recognized risk factors is limited and there is little information regarding the short-term neonatal outcome following BT. We aimed to identify risk factors for BT and to evaluate the effect of BT on short-term neonatal outcome.

Methods: A retrospective, cohort, case–control study of all cases of BT in a single tertiary center (1986–2009). The control group included the two subsequent full-term singleton neonates who did not experienced BT. Short-term neonatal outcome was compared between the groups including Apgar scores, NICU admission, duration of hospitalization and neurologic, respiratory and metabolic morbidity.

Results: Of the 118?280 singleton full-term newborns delivered during the study period, 2874 were diagnosed with BT (24.3/1000). The most frequent types of BT were scalp injuries (63.9%, 15.5/1000) and clavicular fracture (32.1%, 7.7/1000). The following factors were found to be independent risk factors for BT: instrumental delivery (OR 7.5, 95% CI 6.3–8.9), birth weight, delivery during risk hours, parity, maternal age and neonatal head circumference. Cesarean delivery was the only factor protective of BT (OR 0.2, 95% CI 0.2–0.3). Neonates in the study group had a prolonged length of hospital stay (3.3 versus 2.7?d, p?=?0.001), were more likely to be admitted to the NICU (3.9% versus 1.9%, p?<?0.001), and had a higher rate of jaundice (11.9% versus 7.1%, p?<?0.001) and neurological morbidity (4.7% versus 2.3%, p?<?0.001).

Conclusion: Instrumental delivery appears to be responsible for most cases of neonatal BT.