Advancing obstetric and neonatal care in a regional hospital in Ghana via continuous quality improvement

ObjectiveTo reduce maternal and neonatal death at a large regional hospital through the use of quality improvement methodologies.MethodsIn 2007, Kybele and the Ghana Health Service formed a partnership to analyze systems and patient care processes at a regional hospital in Accra, Ghana. A model encompassing continuous assessment, implementation, advocacy, outputs, and outcomes was designed. Key areas for improvement were grouped into “bundles” based on personnel, systems management, and service quality. Primary outcomes included maternal and perinatal mortality, and case fatality rates for hemorrhage and hypertensive disorders. Implementation and outcomes were evaluated tri-annually between 2007 and 2009.ResultsDuring the study period, there was a 34% decrease in maternal mortality despite a 36% increase in patient admission. Case fatality rates for pre-eclampsia and hemorrhage decreased from 3.1% to 1.1% (P < 0.05) and from 14.8% to 1.9% (P < 0.001), respectively. Stillbirths were reduced by 36% (P < 0.05). Overall, the maternal mortality ratio decreased from 496 per 100 000 live births in 2007 to 328 per 100 000 in 2009.ConclusionMaternal and newborn mortality were reduced in a low-resource setting when appropriate models for continuous quality improvement were developed and employed.     

Reduced maternal mortality in Tunisia and voluntary commitment to gender-related concerns

ObjectiveTo estimate the number and causes of maternal deaths in Tunisia from 1999 to 2007, and compare the results with the last report (1993–1994).MethodsData on all deaths of women of reproductive age in the public (1999–2007) and private (2006 only) health sectors were collected and assessed for whether the death was due to pregnancy. Number of live births was provided by the National Institute of Statistics.ResultsMean maternal mortality ratio (MMR) in Tunisia decreased from 68.9 per 100 000 live births in 1993–1994 to 36.3 (95% confidence interval, 27.9–46.5) in 2005–2007 (P < 0.001). Causes of maternal death did not change significantly during the study period (1999–2007): hemorrhage and hypertensive disorders were the main causes. The gap between urbanized and more rural regions observed in 1993–1994 had narrowed, although MMR remained higher in central and western regions than on the east coast.ConclusionThe improvement in MMR can be credited to the voluntary political commitment focused on gender-related concerns that has been made in Tunisia, including access to family planning; legalization of abortion; and creation of the National Board for Family and Population, and the Tunisian Safe Motherhood initiative in 1999.     

Rupture of membranes in case of internal podalic version: a risk for cesarean section on the second twin

ObjectivesTo evaluate if internal version with ruptured membranes is a risk factor of cesarean section for the second twin.Patients and methodsTwo hundred and fifty-nine twins vaginal deliveries after 33 weeks of gestation from 1997 to 2009 in a level 3 maternity. A retrospective case–control study comparing two groups: cases of cesarean section on second twin and five twins vaginal deliveries following the case. Active management of the second twin delivery was performed with a short intertwin delivery.ResultsEleven cesarean sections on the second twin were performed (4.2%). The main indication was failure of internal version. The risk of cesarean section was significantly greater when the internal version was performed with ruptured membranes (OR: 25.4 IC 95% [2.3–275.7] P < 0.003) and when intertwin time delivery interval was increased (8.1 ± 5.1 vs 16.7 ± 6.3, P < 0.001).Discussion and conclusionThe rupture of amniotic membranes before or during the internal podalic version is associated with a risk of failure and cesarean for the second twin. We recommend to perform the internal podalic version with unruptured membranes according to the French recommendations.     

Les naissances des grands prématurés en dehors des maternités de type III sont-elles évitables ? Expérience du réseau Grand Lyon

ObjectiveThe main objective of this study was to calculate the percentage of preterm births before 28 weeks gestational age (weeks GA) outside level-3 maternity wards and determine how many could have been prevented.MethodsThis was an observational, multicenter, retrospective cohort study, which included all the deliveries that occurred between 24 and 27 weeks GA + 6 days in the Greater Lyon perinatal network (France) occurring between first of March 2008 and first of March 2009. In utero transfers (IUTs) and newborn transfers (NBTs) which were carried out outside the network, medical abortions, and foetal deaths in utero were excluded. The duration between patient's arrival in the level 1 and 2 maternity and birth was compared at the 97^th percentile of the mother's transfer time in level-3 maternity. Births that occurred outside of level-3 maternity wards were considered avoidable each time the first duration was more than the second.ResultsDuring the study period, 113 infants were born alive between 24 and 27 weeks GA + 6 days in the network. They were all included in the study. Ninety were born in a level-3 maternity ward and 23 were born in level-1 and 2 maternity wards (20%). There were 35 requests for IUT and 28 were carried out (80%). In 65% of non-level 3 births, no IUT was requested. In 17% of cases, an IUT request could have prevented births in level 1/2 maternity wards. If twin pregnancies had been transferred to a level-3 maternity ward, 26% of non-level 3 births would have been avoided. If all high-risk pregnancies had been transferred to a level-3 maternity ward, 40% of non-level 3 births would have been avoided.Discussion and conclusionAny time a pregnant woman is hospitalized in a type 1/2 maternity ward before 28 weeks GA, doctors should consider an in utero transfer to a level-3 maternity ward. It may be possible to lower the birth-rate of non-level 3 births by a targeted increase in in utero transfers and by transferring high-risk pregnancies to a level-3 maternity ward.     

The Maternal and Newborn Health Registry Study of the Global Network for Women's and Children's Health Research

ObjectiveTo implement a vital statistics registry system to register pregnant women and document birth outcomes in the Global Network for Women's and Children's Health Research sites in Asia, Africa, and Latin America.MethodsThe Global Network sites began a prospective population-based pregnancy registry to identify all pregnant women and record pregnancy outcomes up to 42 days post-delivery in more than 100 defined low-resource geographic areas (clusters). Pregnant women were registered during pregnancy, with 42-day maternal and neonatal follow-up recorded—including care received during the pregnancy and postpartum periods. Recorded outcomes included stillbirth, neonatal mortality, and maternal mortality rates.ResultsIn 2010, 72 848 pregnant women were enrolled and 6-week follow-up was obtained for 97.8%. Across sites, 40.7%, 24.8%, and 34.5% of births occurred in a hospital, health center, and home setting, respectively. The mean neonatal mortality rate was 23 per 1000 live births, ranging from 8.2 to 48.5 per 1000 live births. The mean stillbirth rate ranged from 13.7 to 54.4 per 1000 births.ConclusionThe registry is an ongoing study to assess the impact of interventions and trends regarding pregnancy outcomes and measures of care to inform public health.ClinicalTrial.gov Trial Registration: NCT01073475     

Mortalidad materna en España en el período 1995–1997: resultados de una encuesta hospitalaria

ObjectiveThe Spanish Society of Obstetrics and Gynecology (SSOG) was informed of the need for more exact determination of the maternal mortality rate and its causes in SpainSubjects and methodsA survey in accordance with the European Certificate of maternal death was sent to the Spanish hospitals (SSOG Directory, 1995), to investigate the maternal mortality rate and its causes from 1995?–1997ResultsReplies were received from 69 hospitals, with 363,589 live births from 1995–1997. There were 26 maternal deaths; consequently, the mortality rate was 7.15/100,000 live births. A direct obstetric cause was found in 50% of the deaths and an indirect obstetric cause was found in 42%. Only 7.6% were classified as unknown. According to the data of the National Institute of Statistics, the rate was 2.74/100,000ConclusionsOfficial figures may underestimate the maternal mortality rate by 38%. Death certificates should be modified and a National Committee should be established to study maternal death in collaboration with the National Institute of Statistics     

Midwifery Care in Eight Industrialized Countries: How Does Canadian Midwifery Compare?

ObjectivesMuch has been written about the status of midwifery in developing countries, yet there is limited knowledge and analysis of the role of midwifery in the provision of maternity care in the developed world. The purpose of this study was to better understand how midwifery in Canada compares with midwifery in other developed countries with particular attention to educational preparation, scope of practice, and the contribution of midwives to the overall provision of maternity care.MethodsEight countries were selected on the basis of comparably low maternal mortality rates (defined as < 10/100 000 live births). Document analysis and a survey of key informants were used to develop an understanding of the role of midwifery in the various jurisdictions. We then undertook an analysis of similarities and differences among models.ResultsVariations in models of midwifery exist within and among the countries studied. Midwifery in Canada is most similar to midwifery in the Netherlands and New Zealand with regard to the model of practice, continuity of care, choice of birth place and degree of autonomy.ConclusionMidwifery in Canada is growing, but offers a relatively small contribution to the national provision of maternity services in comparison with other countries. The growth of midwifery in Canada may play a key role in lowering intervention rates and strengthening maternity care as is evidenced in other industrialized nations where midwifery care is an integral part of maternity services.     

Comparison of "push" and "pull" methods for impacted fetal head extraction during cesarean delivery

ObjectiveTo compare maternal and neonatal outcomes associated with the “push” and “pull” methods for impacted fetal head extraction during cesarean delivery.MethodsA prospective study was conducted at Imam Reza Hospital, Kermanshah, Iran, from April 2006 to March 2008. After failed vacuum extraction, women with obstructed labor caused by impacted fetal head were randomly assigned to deliver via the push method (n = 35) or the pull method (n = 37). The outcomes investigated included operation time, operative blood loss, incidence of extension of the uterine incision, and postpartum fever. Data were analyzed using χ² and Student t tests.ResultsMean operative time and incidence of extension of the uterine incision were significantly increased in the group that delivered via the push method (P < 0.001). There were no significant differences in the other maternal and neonatal morbidities between the groups, although there was 1 case of neonatal femoral fracture in the pull group.ConclusionAlthough the pull method may lead to some neonatal complications, it is associated with lower maternal morbidity than the push method when used for impacted fetal head extraction during cesarean delivery.     

Perinatal outcomes associated with subsequent pregnancy among adolescent mothers in Peru

ObjectiveTo assess the perinatal outcomes of a subsequent pregnancy among adolescent mothers living in Peru.MethodsA large hospital-based retrospective cohort study was conducted to evaluate singleton births during a 9-year period (2001–2009). The study population was divided into 3 groups: adolescents aged 15–19 years who had 1 previous parturition (n = 2074), nulliparous adolescents (n = 20 721), and multiparous adults aged 20–29 years (n = 23 129).ResultsNo significant differences were found between multiparous adolescents and the 2 control groups with regard to preterm delivery, perinatal death, and 5-minute Apgar score below 7. Logistic regression analysis showed no significant differences in the rates of cesarean delivery or preterm birth before 34 or 37 weeks. After adjusting for confounding factors, low birth weight (LBW) and small for gestational age (SGA) were more likely to occur during a subsequent pregnancy among adolescent mothers than during the 1st pregnancy among nulliparous adolescents. The odds ratios were 1.38 (95% CI, 1.14–1.67) and 1.27 (95% CI, 1.02–1.56), respectively.ConclusionMultiparous adolescents are more likely to experience LBW or SGA than are nulliparous adolescents. No significant differences in other perinatal outcomes were found among the 3 study groups.     

The effect of maternal hypertension on mortality in infants 22, 29 weeks gestation

ObjectiveTo evaluate the effect of maternal hypertension on mortality risk prior to discharge, in infants 22 + 0 to 29 + 6 weeks gestational age.Study designWe evaluated 88,275 North American infants whose births were recorded in Vermont Oxford Network centers between 2008 and 2011 Infants born between 22 + 0 and 29 + 6 weeks gestational age were evaluated in 2-week gestational age cohorts and followed until death or discharge. Logistic regression was used to adjust for birth weight, antenatal steroid exposure, infant sex, maternal race, inborn/outborn, prenatal care and birth year.Results21,896 infants were born to hypertensive mothers; 13% died prior to Neonatal Intensive Care Unit discharge compared to 20% of the 66,379 infants born to mothers without hypertension. After adjustment, infants had significantly lower mortality compared to preterm infants not born to hypertensive mothers, at all gestational ages examined (22/23: odds ratio (OR) = 0.65 (95% Confidence Interval (CI): 0.55, 0.77; 24/25); OR = 0.77 (95% CI: 0.71, 0.84); 26/27: OR = 0.66 (95% CI: 0.59, 0.74); 28/29: OR = 0.58 (95% CI: 0.51, 0.67). Additionally, births associated with maternal hypertension increase dramatically by gestational age, resulting in a larger proportion of births associated with maternal hypertension at later gestational ages.ConclusionsPreterm birth due to any cause carries significant risk of mortality, especially at the earliest of viable gestational ages. Maternal hypertension independently influences mortality, with lower odds of mortality seen in infants born to hypertensive mothers, after adjustment, and should be taken into consideration as an element in counseling parents.     

Trends in maternal mortality in resident vs. migrant women in Shanghai, China, 2000-2009: a register-based analysis

Although Shanghai has good maternal health indicators, it also has a large in-migrating population, which has made control of maternal mortality a major challenge. This study analyzed maternal mortality and causes of death in pregnant women in Shanghai in the ten years from 2000 to 2009, comparing resident and migrant women. All live births were registered and every maternal death audited. The number of live births rose from 84,898 in 2000 to 187,335 in 2009. The number of migrants increased 4.6 times, while the proportion of live births to migrant women increased from 27% to 55%. There were 262 maternal deaths, 55 in Shanghai residents and 207 in migrant women (78.9% of the total). Most deaths in migrant women were due to illegal delivery. Three policy changes focusing on maternal health greatly reduced deaths: low-cost delivery services were established for migrant women in maternity hospitals, five obstetric emergency care and referral centres were created in general hospitals, and training for health professionals and health education for women were instituted. Maternal mortality in Shanghai decreased steadily from 2000 to 2009, reaching 10 per 100,000 live births in 2009. Among Shanghai permanent residents the ratio was below ten in most of those years, while among migrant women it declined sharply from 58 to 12 per 100,000 live births.     

Understanding and recollection of the risks associated with cesarean delivery during the consent process

ObjectiveTo investigate women's recall of information provided during the consent process for cesarean delivery, specifically the associated risks, 24 hours after the procedure.MethodsA prospective questionnaire-based study was conducted at the Barnet and Chase Farm Hospitals NHS Trust between May 2009 and August 2010. Women who had undergone a cesarean delivery (planned or emergency) completed a self-administered questionnaire 24 hours after delivery. Women who did not recall the risks associated with the procedure (group 1) were compared with those who did recall this information (group 2).ResultsA total of 554 women participated in the study. Group 1 (n = 140) were 4 times more likely to have undergone an emergency cesarean than group 2 (n = 414) (OR 4; 95% CI, 2.5–6.2). Group 2 were more to likely to have higher than secondary level education, 7 times more likely to have understood the explanation of the procedure (OR 6.9; 95% CI, 3.3–14.2), and 9 times more likely to recall that the risks had been explained (OR 9.4; 95% CI, 5.2–17.1). More women in group 1 reported that they would have liked to receive an information leaflet about cesarean delivery at the first prenatal visit.ConclusionOne in 4 women did not recall any risks associated with cesarean delivery shortly after the procedure and this group of women were less likely to understand or recall the details of the consent discussion.     

Effects of parity and mode of delivery on urinary incontinence among postmenopausal women in Taiwan

ObjectiveTo investigate the association between the prevalence of urinary incontinence and parity or mode of delivery among Taiwanese women aged 60 years or older.MethodsBetween July 1999 and December 2000, a nationwide epidemiologic study was conducted in Taiwan among 2410 women selected by a multistage random sampling method. Face-to-face interviews with 1517 women were conducted. The relationship between the prevalence of urinary incontinence and the number of vaginal deliveries or number of cesarean deliveries was assessed by frequency and Pearson χ² test using a significance level of less than 0.05. Logistic regression was used to investigate the significance of dichotomous dependent variables.ResultsDecades ago, most Taiwanese women (1435 of 1511 respondents, 94.97%,) gave birth via vaginal delivery and the rate of cesarean delivery was low (20 of 1513 respondents, 1.32%). Parity (odds ratio [OR], 2.42; 95% confidence interval [CI], 0.87–6.71; P = 0.091), vaginal delivery (OR, 0.76; 95% CI, 0.39–1.47; P = 0.408), and cesarean delivery (OR, 1.47; 95% CI, 0.59–3.70; P = 0.409) did not increase the risk of urinary incontinence.ConclusionThere was no association between urinary incontinence and parity or mode of delivery among Taiwanese postmenopausal women decades after their first delivery.     

Kiwi vacuum extractor versus forceps and spatula: maternal and fetal morbidity evaluation in 169 fetal extractions

AimTo evaluate maternal and fetal complications resulting from the use of the Kiwi^® vacuum extractor and to compare them with those resulting from the use of forceps or spatula.Patients and methodsPatients who had instrumental extraction between November 2006 and April 2007 were included in a unicentric retrospective study. Complications resulting from the use of Kiwi^® vacuum extractor and those of other instruments were compared.ResultsOne hundred and sixty-nine patients where included, 79 had extraction with Kiwi^® vacuum extractor. The two populations (women having extraction with Kiwi^® and woman having extraction with spatula or forceps) were similar in terms of maternal characteristics, progress of labour and delivery. The rate of episiotomies was significantly lower with KIWI^® (73.1% versus 94.4%; P = 0.0001), as well as was postpartum haemorrhage rate (8.9 % versus 18.9%; P = 0.04). No perineal tear of second or third degree occurred with Kiwi^®. Kiwi^® vacuum extractor was associated with a higher rate of shoulder dystocia (12.8% versus 6.7%, NS), but related fetal complication rates were similar in the two groups. The extraction failure rate was significantly higher with Kiwi^® (11.4% versus 4.4%; P = 0.04), but cesarean section rate was similar for the two groups (1.3 % versus 4.4%).Discussion and conclusionThis study is the first comparing complications occurring after extraction with KIWI vacuum extractor to those occurring with other instruments. Although the results are limited by the retrospective nature of the study and the small size of the workforce, our study suggests that Kiwi^® vacuum extractor is associated with a lower rate of maternal complications and a rate of fetal complication similar to other kind of instruments. This instrument should be promoted and taught to younger patricians. Our study also revealed higher failure and shoulder dystocia rates. Larger studies are needed to better evaluate risks factor concerning these two complications in order to optimise the use of Kiwi^® vacuum extractor.     

Incidence of gestational diabetes mellitus in Bahrain from 2002 to 2010

ObjectiveTo determine the incidence and trends of gestational diabetes mellitus (GDM) in Bahrain from 2002 to 2010, and to investigate 2 possible risk factors within the affected population.MethodsIn a retrospective survey, data on maternal body weight and age were collected from women who gave birth in government maternity units in Bahrain and who were screened for GDM during pregnancy using the 2-step approach and criteria of the US Expert Committee on the diagnosis and classification of diabetes.ResultsAmong 49 552 pregnant women, 4982 (10.1%) were diagnosed with gestational diabetes. The Cox–Stuart test for trend analysis suggested that there was an increase in the incidence of gestational diabetes from 7.2% in 2002 to 12.5% in 2010 (P < 0.01). For the period 2006–2010, maternal age, and weight at onset of pregnancy and at time of delivery were positively associated with risk of GDM with an odds ratio (95% confidence interval) of 1.094 (1.081–1.107), 1.081 (1.001–1.104), and 1.027 (1.013–1.040), respectively.ConclusionA combination of increasing maternal weight, maternal age, and incidence of GDM among women in Bahrain indicates a significant future burden on health services.     

Effect of coadministration of dexamethasone with intrathecal morphine on postoperative outcomes after cesarean delivery

ObjectiveTo investigate the effect of intrathecal dexamethasone administered with intrathecal morphine at cesarean delivery on postoperative adverse effects and patient satisfaction.MethodsA triple-blind, randomized, placebo-controlled trial conducted between February 2008 and December 2009 of 120 pregnant women scheduled to undergo cesarean delivery. The patients were randomized into 2 groups: group 1 received 0.2 mg of intrathecal morphine plus 8 mg of intrathecal dexamethasone, while group 2 received 0.2 mg of intrathecal morphine plus 0.9% saline solution (placebo). The occurrence of postoperative nausea and vomiting (PONV), postoperative itching, number of vomiting attacks, and need for antiemetics were recorded in both groups. Overall patient satisfaction was also recorded.ResultsPONV was 3 times less likely to occur in the dexamethasone group than in the placebo group. When vomiting did occur, the number of attacks was lower in the dexamethasone group (23 vs 87 attacks; OR 0.26, 95% CI, 0.18–0.39). Administration of antiemetics was markedly lower in the dexamethasone group (18 vs 49 shots; OR 0.10, 95% CI, 0.04–0.23) and less postoperative itching was experienced (OR 0.39; 95% CI, 0.19–0.81). The dexamethasone group reported significantly higher mean overall satisfaction scores (77 ± 17 vs 51 ± 22; mean difference 26.00; 95% CI, 18.97–33.03).ConclusionIntrathecal administration of dexamethasone with morphine significantly decreased PONV and improved overall patient satisfaction after cesarean delivery.     

The association of maternal and fetal glucose homeostasis with fetal adiposity and birthweight

ObjectiveTo examine the association between maternal and fetal glucose levels and fetal adiposity and infant birthweight.Study designThis is a prospective study of 479 healthy, non-diabetic mother and infant pairs attending the National Maternity Hospital in Ireland. Fasting glucose was measured in early pregnancy (11.8 ± 2.3 weeks). At 28 weeks gestation a repeat fasting glucose was measured and 1 h glucose challenge testing (1 h GCT) was performed. At 34 weeks’ gestation (33 + 5–34 + 5 weeks) fetal growth and fetal anterior abdominal wall width, a marker of fetal adiposity, were measured. At delivery cord glucose was measured and neonatal anthropometry recorded.ResultsThere was a positive correlation between fasting glucose concentration during pregnancy and both infant birthweight and fetal anterior abdominal wall width at 34 weeks gestation. The incidence of macrosomia (birthweight > 4.5 kg) was significantly greater for maternal and cord blood glucose levels in the highest quartile compared to the lowest quartile (20.7% vs. 11.7%, p < 0.05 in the first trimester, 21.3% vs. 7.2%, p < 0.05, at 28 weeks, and 33.3% vs. 10%, p < 0.05, in cord blood). Maternal glucose concentrations at each time point, though not cord glucose, were related to early pregnancy maternal body mass index (r = 0.19, p < 0.001 in first trimester, r = 0.25, p < 0.001 at 28 weeks, r = 0.15, p < 0.01 with 1 h GCT).ConclusionMaternal glucose homeostasis is an important determinant of fetal size. We have shown that even small variations in fasting glucose concentrations can influence fetal growth and adiposity. This effect is seen from the first trimester and maintained until delivery.     

Perinatal complications and cesarean delivery among foreign-born and Australian-born women in Western Australia, 1998-2006

ObjectiveTo determine whether common perinatal complications could explain variation in risk of cesarean among foreign-born and Australian-born women in Western Australia (WA).MethodsComplication prevalence was calculated using the linked records of 208 982 confinements to non-indigenous women in WA between 1998 and 2006. Logistic regression was used to estimate differences in risk of elective cesarean and emergency cesarean compared with vaginal delivery for foreign-born women from different regions.ResultsThe most common complications in emergency cesareans were failure to progress (36.7%) and fetal distress (35.7%). The most common complications in elective cesareans were previous cesarean (56.2%) and malpresentation (16.3%). Women from Sub-Saharan Africa, Southeast Asia, and Southern and Central Asia had an increased risk of emergency cesarean compared with Australian-born women (P < 0.05), whereas women from Oceania, North Africa and the Middle East, and Northeast Asia had a decreased likelihood of elective cesarean compared with Australian-born women (P < 0.05).ConclusionComplication prevalence varied by maternal region of birth. However, variation in these complications does not completely explain differences in mode of delivery among foreign-born and Australian-born women in WA. Sociocultural factors must be considered in future research and when establishing culturally appropriate guidelines for obstetric staff dealing with foreign-born women.     

Puerperal and menstrual bleeding patterns with different types of contraceptive device fitted during elective cesarean delivery

ObjectiveTo evaluate the impact of a copper-containing intrauterine contraceptive device (IUCD) and the levonorgestrel-releasing intrauterine system (IUS) on puerperal and menstrual bleeding when fitted intraoperatively during scheduled elective cesarean.MethodsParticipants were allocated to 3 groups: cesarean with no device inserted; IUCD inserted during cesarean; and IUS inserted during cesarean.ResultsThere was significantly shorter and lighter puerperium in the IUS group (20.2 ± 7.7 days and 3.1 ± 1.6 pads/day) than in the IUCD (33.4 ± 9.5 days and 4.9 ± 2.4 pads/day) and the control (27.0 ± 11.4 days and 4.9 ± 2.3 pads/day) groups (P < 0.012 and P < 0.0001, respectively). At the end of puerperium, mean duration of amenorrhea was significantly longer in the IUS group than in the IUCD and control groups (P < 0.0001). Menstrual periods were longer and heavier in the IUCD group than in the control group but the difference was not significant (P > 0.07). In the IUS group, menstrual periods were significantly shorter and lighter than in the other groups (P < 0.0001).ConclusionIntrauterine system fitting at the time of elective cesarean is associated with significant reductions in the duration and amount of puerperal blood loss, as well as a high incidence of amenorrhea and lighter periods thereafter.     

Use of birth weight threshold for macrosomia to identify fetuses at risk of shoulder dystocia among Chinese populations

ObjectiveTo assess the incidence of macrosomia and the influence of birth weight on shoulder dystocia risk among a cohort of Chinese women.MethodsA retrospective analysis was conducted of 80 953 singleton deliveries recorded at the Prince of Wales Hospital, Hong Kong, between 1995 and 2009. The incidences of macrosomia (birth weight ≥ 4000 g) and shoulder dystocia were assessed by birth weight; risk factors for shoulder dystocia were examined by multiple logistic regression analysis.ResultsThe incidence of macrosomia was 3.4%. The overall incidence of shoulder dystocia was 0.3%; however, the incidence rose with increasing birth weight. The odds ratio (OR) for a birth weight of 4000–4199 g was 22.40, while the OR for a birth weight of 4200 g or above was 76.10. Other independent risk factors for shoulder dystocia included instrumental delivery (OR 12.11), short stature (OR 2.16), maternal diabetes mellitus (OR 1.78), and obesity (OR 1.58).ConclusionAlthough the overall incidences of macrosomia and shoulder dystocia were low, the risk of shoulder dystocia was strongly linked to increasing birth weight. International guidelines for elective cesarean delivery in suspected cases of macrosomia may not, therefore, apply to Chinese women.