Method of delivery for the preterm infant

The principal issue concerning the mode of delivery is that while elective caesarean births may reduce the chances of fetal or neonatal death, this method of delivery might also increase maternal morbidity. Six trials with a total of 122 women investigated the effects of a policy of elective caesarean delivery (ECD) versus expectant management for small babies. A meta-analysis of these six trials also included additional unpublished data from several of the authors. Babies in the 'elective' group were less likely to develop respiratory distress syndrome and were more likely to have a low pH after birth. They were also less likely to have neonatal seizures and there were fewer perinatal deaths, although the studies were too small to detect even very large differences. However, there was significantly more serious maternal morbidity. There is insufficient evidence to evaluate a policy of ECD. All trials described major problems in recruitment and no subsequent trials have been identified. Changes in population-based data suggest that ECD of very preterm infants has increased markedly in the last 20 years. Given these changes, it seems unlikely that recruitment for future trials will be any easier than it was in the recent past.     

Outcome of second delivery after prior macrosomic infant in women with normal glucose tolerance

OBJECTIVE: Our aim was to estimate the obstetric outcome of second delivery in women with normal glucose tolerance whose first fetus was macrosomic (fetal weight >/= 4,500 g). METHODS: Primiparas delivering a macrosomic infant during the years 1997-2000 were identified from a hospital computer database, and the obstetric outcome of a second delivery was analyzed up until June 2003. A control group (birth weight 3,000-3,500 g) served for comparison. RESULTS: Among 13,020 first pregnancies, 301 (2.3%) were macrosomic. A similar proportion in the macrosomic group, 156 of 301 (52%), and control group, 171 of 300 (57%), returned for second delivery (P = .252). Compared with controls, first macrosomic deliveries were characterized by higher rates of operative delivery, anal sphincter injury, and shoulder dystocia. At second delivery, 32% of neonates in the macrosomic group and 0.3% in the control group weighed 4,500 g or more (P < .001). More prelabor cesareans were performed in the macrosomic group compared with controls (27 of 156, 17.3%, compared with 8 of 171, 4.7%; P < .001). Among 104 women in the macrosomic group who labored after first vaginal delivery, 99% (103 of 104) delivered vaginally again compared with 44% (11 of 25) who labored after primiparous cesarean delivery (P < .001), which compares with 97% (146 of 150) and 77% (10 of 13), respectively, in the control group. CONCLUSION: Despite a one-third recurrence of macrosomia, first vaginal delivery of a macrosomic infant was associated with a high incidence of second vaginal delivery. Conversely, primiparous macrosomic cesarean delivery conveyed a high risk (56%) for repeat intrapartum cesarean whether macrosomia recurred or not. LEVEL OF EVIDENCE: II-2.     

Cesarean delivery and its impact on the anomalous infant

Although cesarean deliveries frequently are performed for anomalous fetal conditions, available data do not always support a fetal benefit from this delivery management. The literature on cesarean delivery for anomalous infants reports insufficient information on comorbid neonatal conditions, so these complications are unknown in this population of newborns. In a minority of cases, a cesarean delivery is reasonable to prevent dystocia or optimize outcome. Areas for future investigation include prospective, randomized, controlled trials of prelabor cesarean compared with vaginal deliveries for myelomeningocele and anterior abdominal wall defects. The rarity of other lesions likely precludes randomized controlled trials.     

Vaginal delivery for the selected frank breech infant at term

A retrospective analysis of 254 term breech deliveries was done, with term breech presentations managed by a protocol in which cesarean section was done for nonfrank breech presentation, or estimated fetal weight in excess of 4000 g. Patients with frank breech presentation were assigned to one of three groups based on x-ray pelvimetry and estimated fetal weight. Of 70 group 1 patients (adequate pelvis with estimated fetal weight less than 3600 g), 79% had a vaginal delivery. Of 21 group 2 patients (borderline pelvis or estimated fetal weight of 3600 to 4000 g), 67% delivered vaginally. In group 3 (contracted pelvis or estimated fetal weight greater than 4000 g), all patients were delivered by cesarean section. The overall cesarean section rate for frank breech infants was 36%. Apgar scores were not significantly different for infants delivered vaginally or abdominally. The crude perinatal mortality rate was 11.8; the corrected perinatal mortality rate was 0. These findings further substantiate the safety of these criteria in management of term breech presentations.     

Delivery of the macrosomic infant: cesarean section versus vaginal delivery

The macrosomic fetus of a diabetic woman faces increased risk for injury at the time of birth. Cesarean section offers the potential for avoiding trauma to the fetus, but can result in increased morbidity in the mother as compared to vaginal delivery. In this article, the advantages and disadvantages of the 2 routes of delivery for the overgrown fetus of a diabetic mother are discussed. In addition, methods for diagnosing macrosomia by ultrasound are examined, along with the benefits and pitfalls of ultrasonic fetal weight estimation in the setting of diabetes. Finally, management approaches for selecting route of delivery for the macrosomic fetus are described and analyzed.     

Evidence-based delivery room care of the very low birth weight infant

The first hour of a newborn's life is fraught with difficulty. Recommendations regarding the fundamental issues of resuscitation of these infants are developed and disseminated by the International Liaison Committee on Resuscitation and other organizations. However, these recommendations frequently do not address the needs of the very low birth weight infant and do not address some of the nuances that might lead to improved outcome. Improved organization and teamwork as well as improved monitoring and respiratory support can potentially improve the outcome of these infants.     

Intrapartum and delivery room management of the very low birthweight infant

The management of a pregnant woman in premature labor is a challenge. The roles of the perinatologist as well as support people is discussed in this article.     

Acute maternal morbidity following classical cesarean delivery of the preterm infant

The acute maternal morbidity after primary classical and primary low transverse cesarean delivery was compared in preterm gestation. Among 178 patients (77 classical and 101 low transverse), there was no difference in acute maternal morbidity; blood transfusion was used twice as often with the classical operation, but this difference did not reach statistical significance.     

Human milk microbes: Strategies to improve delivery to the infant

Mother's own milk provides personalized nutrition and immune protection to the developing infant. The presence of healthy microbes plays an important role in the infant's gut by programming the microbiota and excluding potential pathogens. This review describes the important components in mother's own milk that contribute to its superiority for infant nutrition and suggest potential strategies to replicate these factors in alternative feedings when sufficient milk is unavailable. Current strategies to supplement, substitute and replicate mother's own milk including microbial restoration, use of unpasteurized donor human milk, probiotics and fortification are discussed. Critical work remains to be done in understanding the human milk microbiome and metabolome and in improving lactation support for mothers of preterm infants. Increasing delivery of mother's own milk and milk components to infants would likely positively impact infant mortality and health worldwide.