The effect of time intervals on neonatal outcome in elective cesarean delivery at term under regional anesthesia

Objectives

To measure 3 intervals of time—induction of regional anesthesia to delivery (I-D), initial skin incision to delivery (S-D), and uterine incision to delivery (U-D)—in elective cesareans and to evaluate the impact of the duration of these 3 components on short-term neonatal outcome.

Methods

We reviewed retrospective data on the duration of the components from the computerized database of the obstetrics operation room at the Sheba Medical Center, Tel Aviv, Israel, and from the medical records of term neonates.

Results

Sufficient data were available in 933 cases. The parameters associated with longer time to delivery at any stage were epidural rather than spinal anesthesia, maternal diabetes, previous cesarean delivery, antihypertensive treatment, higher birth weight (3456 g and 3285 g for U-D interval longer than 2 minutes and U-D interval up to 2 minutes, respectively; P = 0.02), and male fetus. The duration of the I-D, S-D, and U-D intervals had no significant impact on any of the measured neonatal parameters.

Conclusion

With regard to neonatal wellbeing, obstetricians have a relatively large safety margin in the time taken for inducing regional anesthesia and making the first and uterine incisions.     

Effect of the interval between onset of sustained fetal bradycardia and cesarean delivery on long-term neonatal neurologic prognosis

Objective

To examine the effect of the interval between onset of sustained fetal bradycardia and cesarean delivery on long-term neonatal neurologic prognosis.

Method

A retrospective observational case-series performed with patients who had sudden-onset and sustained (< 100 beats per minute) fetal bradycardia during labor. Fetal heart rate was monitored closely until cesarean delivery. The effect of the interval between the onset of bradycardia and delivery on neonatal neurologic prognosis was examined.

Results

Among 2267 deliveries in 2002-2003 at Kitasato University Hospital, 19 pregnancies met the inclusion criteria. Episodes of fetal bradycardia were due to umbilical cord prolapse (n = 5), placental abruption (n = 4), uterine rupture (n = 3), maternal respiratory failure (n = 1), and other causes (n = 6). Mean onset of fetal bradycardia to delivery interval (BDI) was 20.5 ± 8.9 minutes. Mean decision-to-cesarean delivery interval was 11.4 ± 3.9 minutes. BDI was negatively correlated with umbilical arterial pH at delivery. There were 3 postnatal deaths. Neurologic assessment at the age of 2 years revealed that 15 of 16 children were neurologically normal. When the BDI was less than 25 minutes, all term pregnancies led to normal neonatal neurologic development.

Conclusion

In the event of sustained intrapartum fetal bradycardia, delivery by emergency cesarean within 25 minutes improved long-term neonatal neurologic outcome.     

Postpartum urinary retention after vaginal delivery

Objective

To determine the incidence of covert and overt postpartum urinary retention (PUR) after vaginal delivery and to determine obstetric variables contributing to PUR.

Methods

In a cross-sectional study, women who delivered vaginally underwent a transabdominal ultrasound scan for estimation of postvoid residual bladder volume and diagnosis of PUR. Patient data, including age, obstetric history, mode of delivery, and duration of labor, were compared between women with and those without PUR.

Results

Of the 771 participants recruited, 84 (10. 9%) had PUR: 82 (10.6%) with covert PUR and 2 (0.3%) with overt PUR. Women with instrumental delivery were more prone to develop PUR (P = 0.03), with an odds ratio (OR) of 1.194 (95% confidence interval [CI], 0.56-1.90). A duration of labor of more than 700 minutes was a good predictor of PUR. The area under the receiver operating characteristic (ROC) curve was 0.634 (95% CI, 0.567-0.702; P < 0.001), with an OR of 1.003 (95% CI, 1.001-1.004).

Conclusion

Covert retention of urine was significantly associated with parturients who had an instrumental delivery and a duration of labor of more than 700 minutes.     

Urodynamic findings in women with pelvic organ prolapse and obstructive voiding symptoms

Objective

To determine whether obstructive voiding symptoms in women with advanced pelvic organ prolapse (POP) were associated with objective bladder outflow tract obstruction.

Methods

We reviewed preoperative data from patients with advanced POP who underwent surgical correction at the Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel, between December 1, 2005, and November 30, 2007. Obstructive voiding symptoms were recorded from Pelvic Floor Distress Inventory-20 questionnaires.

Results

Of the 81 women aged 44-80 years who were included in the study, 40 (49.4%) reported incomplete bladder emptying preoperatively. There was no significant difference between these women and asymptomatic women in terms of demographic and clinical parameters such as age, parity, and stage of prolapse. Furthermore, there was no significant difference with regard to postvoid residual bladder volume (52.8 ± 65.8 vs 41.6 ± 41.2 mL), maximal (23.8 ± 11 vs 21.9 ± 9.6 mL/second) and average (10.3 ± 6.2 vs 9.3 ± 4 mL/second) urinary flow velocities, prevalence of increased postvoid residual volume (10.0% vs 4.8%), or obstructive urinary flow (17.5% vs 7.3%).

Conclusion

Almost half of all women with advanced POP experienced incomplete bladder emptying; however, this symptom did not correlate with objective urodynamic bladder outflow tract obstruction.     

Effect of combined spinal-epidural analgesia versus epidural analgesia on labor and delivery duration

Objective

To determine whether combined spinal-epidural analgesia (CSEA) can decrease the known epidural effect of lengthening delivery.

Methods

Between April and May 2010, 144 women undergoing childbirth in hospital with epidural pain relief were randomized to receive either low-dose epidural analgesia (LEA) or CSEA. The spinal component included 2.5 mg of bupivacaine, 25 μg of fentanyl, and 200 μg of morphine. The epidural component of the CSEA procedure was started once pain returned. The primary outcome was total labor duration measured from the time of initiation of labor analgesia to delivery.

Results

The difference in duration between LEA (n = 72) and CSEA (n = 72) was 5 minutes for labor (P = 0.82), 2 minutes for delivery (P = 0.60), and 7 minutes for total labor duration (P = 0.75). The combined group used less levobupivacaine (P < 0.001) and had lower sensory blockade at the dermatomal level (P = 0.037). Women in the CSEA group had a higher incidence of pruritus (P = 0.002) and lightheadedness (P = 0.02) during labor; and a higher incidence of pruritus (P = 0.002), nausea-vomiting (P = 0.026), and drowsiness (P = 0.003) in the postpartum period.

Conclusion

As compared with LEA, CSEA did not shorten the duration of labor length; however, it did reduce levobupivacaine consumption and motor weakness.     

Levator ani injury in primiparous women with forceps delivery for fetal distress, forceps for second stage arrest, and spontaneous delivery

Objective

To compare levator ani muscle injury rates in primiparous women who had a forceps delivery owing to fetal distress with women delivered by forceps for second stage arrest; and to compare these injury rates with a historical control group of women who delivered spontaneously.

Methods

Primiparous women who delivered by forceps were recruited retrospectively into 2 groups: forceps for fetal distress with short second stage (25 ± 11 minutes; n = 19); and forceps delivery for second stage arrest (137 ± 26 minutes; n = 19). MR images of the levator ani muscles were compared with a historical control group of women from a previous study who had delivered spontaneously (n = 129).

Results

Major defect rates were: 42% for forceps and short second stage; 63% for forceps and second stage arrest; and 6% for spontaneous delivery. The odds ratios for major injury were: 11.0 for forceps and short second stage compared with spontaneous delivery; 25.9 for forceps and second stage arrest compared with spontaneous delivery; and 2.3 for forceps and second stage arrest compared with short second stage (P = 0.07).

Conclusion

Women delivered by forceps have a higher rate of levator ani injury compared with spontaneous delivery controls; the difference between the forceps groups did not reach significance.     

Implementation of the Zambia Electronic Perinatal Record System for comprehensive prenatal and delivery care

Objective

To characterize prenatal and delivery care in an urban African setting.

Methods

The Zambia Electronic Perinatal Record System (ZEPRS) was implemented to record demographic characteristics, past medical and obstetric history, prenatal care, and delivery and newborn care for pregnant women across 25 facilities in the Lusaka public health sector.

Results

From June 1, 2007, to January 31, 2010, 115 552 pregnant women had prenatal and delivery information recorded in ZEPRS. Median gestation age at first prenatal visit was 23 weeks (interquartile range [IQR] 19-26). Syphilis screening was documented in 95 663 (83%) pregnancies: 2449 (2.6%) women tested positive, of whom 1589 (64.9%) were treated appropriately. 111 108 (96%) women agreed to HIV testing, of whom 22% were diagnosed with HIV. Overall, 112 813 (98%) of recorded pregnancies resulted in a live birth, and 2739 (2%) in a stillbirth. The median gestational age was 38 weeks (IQR 35-40) at delivery; the median birth weight of newborns was 3000 g (IQR 2700-3300 g).

Conclusion

The results demonstrate the feasibility of using a comprehensive electronic medical record in an urban African setting, and highlight its important role in ongoing efforts to improve clinical care.     

Adverse effects of combined spinal-epidural versus traditional epidural analgesia during labor

Objective

To compare two neuraxial block techniques during labor for maternal and fetal effects.

Methods

Women in labor at term with cephalic singleton fetuses were randomized (nonblinded) to receive either labor epidural (EPI) or combined spinal-epidural (CSE) analgesia. Primary outcome was prolonged deceleration (PD) of fetal heart rate. Outcomes also included hypotension, mode of delivery, and efficacy of analgesia by visual analog pain scale (VAPS) before and after block placement.

Results

Randomization occurred in 127 patients: 63 received EPI, 64 received CSE. There was no difference in the rate of PD in the EPI group compared with the CSE group (3.2% vs 6.2% respectively; P = 0.43, RR 2.0; 95% CI 0.4-9.3), rate of cesarean delivery, or mean epidural duration. VAPS ratings were significantly lower in the CSE group.

Conclusions

There were no differences in the rate of PD or other adverse outcomes. Hypotension occurred more frequently with CSE during labor at term. The study supports both EPI and CSE during labor as safe and effective techniques for neuraxial analgesia.     

Manometric evaluation of anal sphincter function after vaginal and cesarean delivery

Objective

To compare anal sphincter function following spontaneous vaginal delivery and cesarean delivery, and assess the association of perineal length and sphincter injury with each delivery mode.

Method

Perineal length was measured and anal manometric measurements were performed in 120 primigravidas before and after delivery.

Results

Mean values for maximum anal resting and squeeze pressures were significantly lower after delivery irrespective of the mode of delivery, but there was a positive correlation between postpartum maximum anal resting pressure and perineal length (r = 0.24, P < 0.01).

Conclusion

Anal sphincter function was disturbed after both vaginal and cesarean delivery, a finding weakened by the fact that almost half of the cesareans were performed for cephalopelvic disproportion identified during labor.     

Uterine massage to reduce postpartum hemorrhage after vaginal delivery

Objective

To determine the effectiveness of sustained uterine massage started before delivery of the placenta in reducing postpartum hemorrhage.

Methods

A randomized controlled trial conducted in Egypt and South Africa between September 2006 and February 2009. A total of 1964 pregnant women were randomly allocated to 1 of 3 treatment groups: intramuscular oxytocin, sustained uterine massage, or both treatments. Blood loss within 30 minutes of delivery was recorded.

Results

The incidence of blood loss of 300 mL or more within 30 minutes of delivery was significantly higher in the massage group than in the massage plus oxytocin (RR 1.88; 95% CI, 1.29-2.74 in Assiut, and RR 1.3; 95% CI, 1.00-1.68 in SA) and the oxytocin only group (RR 1.7; 95% CI, 1.11-2.61 in Assiut, and RR 2.24; 95% CI, 1.54-3.27 in SA). In both centers, use of additional uterotonics was significantly higher in the uterine massage group compared with the other 2 groups.

Conclusion

Uterine massage was less effective than oxytocin for reducing blood loss after delivery. When oxytocin was used, there was no additional benefit from uterine massage. The effectiveness of uterine massage in the absence of oxytocin was not studied. ACTRN: 12609000372280.     

Meperidine versus valethamate bromide in shortening the duration of active labor

Objective

To compare the efficacy and safety of meperidine hydrochloride and valethamate bromide against placebo in shortening the duration of active labor.

Method

We randomly assigned 160 nulliparous women with a singleton pregnancy at term who needed induction of labor to one of 3 treatments: 50 mg of meperidine (n = 53), 16 mg of valethamate bromide (n = 53), or a normal saline solution as placebo (n = 54). All medications were given by slow intravenous infusion. Labor duration was the main outcome measure.

Results

The intervals between infusion and complete cervical dilation and between infusion and delivery were significantly reduced (P < 0.001 and P < 0.01) in the meperidine group (103.0 ± 64.5 minutes and 119.8 ± 70.2 minutes), in contrast to the placebo group (173.9 ± 74.8 minutes and 192.2 ± 82.8 minutes). However, differences were not significant between the 2 treatment groups (139.6 ± 63.1 minutes and 160.6 ± 71.9 minutes), or between the valethamate bromide and the placebo group.

Conclusion

Meperidine, but not valethamate bromide, significantly shortened the duration of active labor in nulliparous women with a singleton pregnancy at term.     

A noninvasive evaluation of autonomic nervous system dysfunction in women with an overactive bladder

Objective

To verify the hypothesis that a connection exists between overactive bladder (OAB) syndrome and a bladder-specific dysfunction of the autonomic nervous system (ANS).

Method

An electrocardiogram recorded heartbeat cycles from the onset of urinary urgency to 5 minutes after voiding in 33 women with an overactive bladder and 176 controls. Power spectral density (PSD) analysis allowed to quantify heart rate variability (HRV), which is in relation to ANS function. Three-dimensional spectrograms and multiscale entropy graphs were used to display HRV values.

Results

The differences between patients and controls were all significant in the time and frequency domains of HRV (P < 0.05), which suggests disturbances in bladder-specific ANS activity in women with OAB.

Conclusion

By quantifying HRV data, PSD analysis provides a simple, noninvasive method of assessing disturbances in ANS activity and monitoring treatment in women with OAB. It can also be used to evaluate other neuronal conditions.     

Pregnancy outcome in patients treated with cervical conization for cervical intraepithelial neoplasia

Objective

To examine the causal contribution of conization to premature delivery.

Methods

This was a retrospective, case-control, multicenter study of women who underwent conization in 5 hospitals in the Basque Country (Spain) from 1998 to 2007. Three study groups were established: group A, post-conization infant deliveries; control group B, pre-conization infant deliveries; and control group C, infant deliveries without conization.

Results

Comparing group A with group C, there was a higher rate of preterm delivery before 35 weeks (5.3% versus 1.6%), a lower mean birth weight (3156.2 g versus 3328.5 g), and a greater prevalence of infants under 2500 g (10.6% versus 3.7%). There were no significant differences between group A and group B: preterm delivery before 35 weeks (5.3% versus 4.8%), mean birth weight (3156.2 g versus 3119.4 g), and prevalence of infants under 2500 g (10.6% versus 10.6%).

Conclusion

Pregnancy in women post-conization was associated with a risk of preterm delivery. However, there were no significant differences between women who underwent conization before and those who underwent conization after delivery. Cervical conization does not necessarily increase the risk of preterm delivery in subsequent pregnancy. Conization should be considered an indicator of such risk because it is associated with pregnancy complications arising from socio-epidemiologic factors present in women requiring conization that are also present in women who have premature delivery.     

Effects of visceral peritoneal closure on scar formation at cesarean delivery

Objective

To determine the effect of closure or non-closure of the visceral peritoneum at cesarean delivery on uterine scar formation assessed at repeat cesarean delivery.

Methods

Women undergoing initial cesarean delivery were allocated into 2 groups: group 1 underwent visceral peritoneal closure, while in group 2 the visceral peritoneum was not closed. At repeat cesarean delivery 4 specimens from the initial uterine scar were collected and assessed by light microscopy and scanning electron microscopy.

Results

In group 1, 57% of women had adhesions compared with 20.6% in group 2 (P < 0.05). Light microscopy revealed reactive mesothelial hyperplasia (51.8% vs 13.7%), submesothelial fibrosis (48.1% vs 6.8%), and neoangiogenesis of mesothelial stroma (44.4% vs 12%) in group 1 and group 2 patients, respectively (P < 0.05). Scanning electron microscopy showed more patients with pericytes on the surface of microvessels in group 1 compared with group 2 (26.3 ± 1.4 vs 11.5 ± 1.1 patients; P < 0.05).

Conclusion

Closure of the visceral peritoneum at cesarean delivery may produce an inflammatory reaction and adhesions, evidenced by reactive and regenerative mesothelial hyperplasia and submesothelial fibrosis.     

A pilot randomized controlled trial of controlled cord traction to reduce postpartum blood loss

Objective

To evaluate whether controlled cord traction (CCT) for management of the third stage of labor reduced postpartum blood loss compared with a “hands-off” management protocol.

Methods

Women with imminent vaginal delivery were randomly assigned to either a CCT group or a hands-off group. The women received prophylactic oxytocin. The primary outcome was blood loss during the third stage of labor.

Results

In total, 103 women were allocated to the CCT group and 101 were allocated to the hands-off group. Median blood loss in the CCT group and the hands-off group was 282.0 mL and 310.2 mL, respectively. The difference in blood loss (- 28.2 mL) was not significant (95% confidence interval, - 92.3 to 35.9; P = 0.126). Blood collection in the hands-off group took 1.2 minutes longer than in the CCT group, which may have contributed to this difference.

Conclusion

CCT may reduce postpartum blood loss. The present findings support conducting a large trial to determine whether CCT can prevent postpartum hemorrhage.     

Rectally administered misoprostol versus intravenous oxytocin infusion during cesarean delivery to reduce intraoperative and postoperative blood loss

Objective

To compare the efficacy of rectally administered misoprostol with intravenous oxytocin infusion in preventing uterine atony and blood loss during cesarean delivery.

Methods

In this prospective, randomized, double-blind trial, 200 women undergoing cesarean delivery who did not have risk factors for postpartum hemorrhage were randomly allocated to receive either 800 µg of rectal misoprostol at the time of peritoneal incision or an intravenous infusion of oxytocin after delivery of the neonate. Primary outcome measures were estimated amount of intraoperative and postoperative (8 hours) blood loss and changes in hemoglobin levels 24 hours after delivery.

Results

A total of 96 and 94 women were analyzed in the misoprostol and oxytocin groups, respectively. Intraoperative and postoperative blood loss was significantly lower in the misoprostol group than in the oxytocin group (503 vs 592 mL, P = 0.003 and 74 vs 114 mL, P = 0.045, respectively). The incidence of shivering was higher in the misoprostol group (8.3% vs 1.1%, P = 0.018; RR 7.83; 95% confidence interval, 0.99-61.42).

Conclusion

Rectal misoprostol appears to be an effective alternative to intravenous oxytocin in preventing blood loss for routine use during cesarean delivery. Clinical Trials Registration: CTRI/2009/091/000075.     

Bilateral uterine artery ligation plus B-Lynch procedure for atonic postpartum hemorrhage with placenta accreta

Objective

To assess the effectiveness of bilateral uterine artery ligation followed by B-Lynch compression suturing in women with atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta.

Method

This protocol was followed in 26 women undergoing cesarean delivery for placenta accreta.

Results

Two women died from disseminated intravascular coagulopathy. In the remaining 24 women, placental remnants completely disappeared within 8 months and ovulation resumed after a mean ± SD of 51.6 ± 3.2 days. Moreover, 18 women (75%) became pregnant within 12 months.

Conclusion

Atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta can be safely controlled by bilateral uterine artery ligation followed by B-Lynch compression suturing in women who desire to remain fertile.     

Second- and third-trimester management of medical termination of pregnancy and fetal death in utero after prior caesarean section

Objectives

To evaluate the results and risks of a protocol for second- and third-trimester termination of pregnancy after prior caesarean section.

Study design

This is a retrospective study, conducted in a level 3 (university hospital) maternity unit between January 2001 and September 2008. 67 women with a history of caesarean section underwent second- and third-trimester termination of pregnancy. The protocol was administration of 600 mg mifepristone the first day and application of laminaria tents the second day. One the third day, 48 h after mifepristone, two 200 μg tablets of misoprostol were given orally every 3 h until delivery. Epidural analgesia was performed routinely. Complications analysed were uterine rupture, labour lasting over 12 h, and bleeding requiring blood transfusion.

Results

Delivery was vaginal in 64 cases (95.5%), a median 4 h 20 min (P25: 3 h 5 min, P75: 7 h 7 min) after administration of misoprostol (median number of tablets 2; P25: 2, P75: 4). The median number of tablets of misoprostol was significantly higher for termination of pregnancy than for fetal death in utero (4 vs. 2; p = 0.002). The rate of uterine rupture was 4.8% [95% CI: 1.2-14.2]. Bleeding during delivery requiring a transfusion occurred in 2 cases (3.0%; 95% CI: 0.5-11.3).

Conclusion

A high rate of vaginal delivery was achieved at low doses of misoprostol, with a short median induction-to-delivery interval, and a rate of uterine rupture higher than that observed during attempted vaginal delivery at term in a caesarean scar pregnancy. The rate of severe bleeding during delivery was low.     

A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Nigeria

Objective

To determine whether the non-pneumatic anti-shock garment (NASG) can improve maternal outcome.

Methods

Women were enrolled in a pre-intervention phase (n = 83) and an intervention phase (n = 86) at a referral facility in Katsina, Nigeria, from November 2006 to November 2007. Entry criteria were obstetric hemorrhage (≥ 750 mL) and a clinical sign of shock (systolic blood pressure < 100 mm Hg or pulse > 100 beats per minute). To determine differences in demographics, condition on study entry, treatment, and outcome, t tests and χ² tests were used. Relative risk (RR) and 95% confidence interval (CI) were estimated for the primary outcome, mortality.

Results

Mean measured blood loss in the intervention phase was 73.5 ±93.9 mL, compared with 340.4 ± 248.2 mL pre-intervention (P < 0.001). Maternal mortality was lower in the intervention phase than in the pre-intervention phase (7 [8.1%]) vs 21 [25.3%]) (RR 0.32; 95% CI, 0.14-0.72).

Conclusion

The NASG showed potential for reducing blood loss and maternal mortality caused by obstetric hemorrhage-related shock.