阴道分娩97例初产妇产后尿潴留危险因素临床分析

目的：探讨经阴道分娩产后尿潴留（postpartum urinary retention,PUR）的危险因素,为降低PUR发生率、减少产后并发症提供理论依据。方法：选择天津医科大学宝坻临床学院（我院）2016年1-12月经阴道分娩PUR患者97例为观察组[A组,其中分娩镇痛者83例（A1组）,无分娩镇痛者14例（A2组）],随机选择同期经阴道分娩无尿潴留者88例为对照组[B组,其中分娩镇痛者59例（B1组）,无分娩镇痛者29例（B2组）]。记录2组患者一般信息、妊娠期合并症及妊娠期并发症、产时情况、产后出血情况及新生儿体质量,进行回顾性分析。结果：2组产妇妊娠期合并症及并发症、孕次、胎膜早破、枕左前（LOA）胎位、第三产程时间和新生儿体质量比较,差异无统计学意义（均P＞0.05）。孕周、分娩镇痛、产钳助娩、侧切、第一产程时间、第二产程时间和产后出血比较,差异有统计学意义（均P＜0.05）。发生PUR的危险因素有孕周增大（OR=1.619,95%CI：1.121～2.339）、产钳助娩（OR=4.981,95%CI：2.184～11.361）、产后出血（OR=3.429,95%CI：1.024～11.488）和侧切（OR=2.419,95%CI：1.058～5.531）。PUR危险因素的ROC曲线分析：年龄最佳临界值为26.50岁,孕周最佳临界值为40.36周,新生儿体质量最佳临界值为3 372.50 g,分娩镇痛第一产程最佳临界值为402.50 min,分娩镇痛第二产程最佳临界值为61.50 min,无分娩镇痛第一产程最佳临界值为230.00 min,无分娩镇痛第二产程最佳临界值为34.50 min。结论：对孕周、分娩镇痛、产钳助娩、侧切、第一产程时间、第二产程时间、产后出血诸因素适当干预,可减少PUR的发生。     

Spontaneous versus induced labor after a previous cesarean delivery

OBJECTIVE: To compare maternal and neonatal outcomes in spontaneous versus induced labor after one previous cesarean delivery. METHODS: Women with one previous cesarean delivery who had spontaneous labor between January 1992 and January 2000 were compared with those whose labor was induced. RESULTS: Three thousand seven hundred forty-six patients had a trial of labor (2943 spontaneous, 803 induced). Those induced had more frequent early postpartum hemorrhage (7.3% versus 5.0%; odds ratio [OR] 1.66; 95% confidence interval [CI] 1.18, 2.32), cesarean delivery (37.5% versus 24.2%; OR 1.84; 95% CI 1.51, 2.25), and neonatal intensive care unit (NICU) admission (13.3% versus 9.4%; OR 1.69; 95% CI 1.25, 2.29). There was a trend toward higher uterine rupture rates in those with induced versus spontaneous labor (0.7% versus 0.3%, P =.128) and for patients undergoing dinoprostone (prostaglandin E(2)) induction versus other methods (1.1% versus 0.6%, P =.62), although neither difference achieved statistical significance. CONCLUSION: Induced labor is associated with an increased rate of early postpartum hemorrhage, cesarean delivery, and neonatal ICU admission. The higher rate of uterine rupture in those who had labor induced was not statistically significant.     

The length of the third stage of labor and the risk of postpartum hemorrhage

OBJECTIVE: To estimate whether the length of the third stage of labor is correlated with postpartum hemorrhage. METHODS: In this prospective observational study women delivering vaginally in a tertiary obstetric hospital were assessed for postpartum hemorrhage. All women were actively managed with the administration of oxytocin upon delivery of the anterior shoulder. Blood loss was measured at each delivery in collecting devices, and drapes and sheets were weighed to calculate the blood loss at each vaginal delivery. Postpartum hemorrhage was defined as more than 1,000 mL blood loss or hemodynamic instability related to blood loss requiring a blood transfusion. RESULTS: During a 24-month period there were 6,588 vaginal deliveries in a single tertiary obstetric hospital, and postpartum hemorrhage occurred in 335 of these (5.1%). The median length of the third stage of labor was similar in women having and those not having a postpartum hemorrhage. The risk of postpartum hemorrhage was significant at 10 minutes, odds ratio (OR) 2.1, 95% confidence interval (CI), 1.6-2.6; at 20 minutes, OR 4.3, 95% CI 3.3-5.5; and at 30 minutes OR 6.2, 95% CI 4.6-8.2. The best predictor for postpartum hemorrhage using receiver operating characteristic curves was 18 minutes. CONCLUSION: A third stage of labor longer than 18 minutes is associated with a significant risk of postpartum hemorrhage. After 30 minutes the odds of having postpartum hemorrhage are 6 times higher than before 30 minutes. LEVEL OF EVIDENCE: III.     

产后出血的影响因素分析及预测

目的分析产后出血的相关影响因素,寻找预测产后出血的方法,为预防产后出血提供依据。方法选择2008年6月至2010年12月在哈尔滨医科大学附属第一医院住院分娩发生产后出血的67例患者为研究组,按照1：2的比例以随机数的方式随机抽取院内同期分娩非产后出血患者139例为对照组。采取病例对照研究方法分析产后出血的影响因素,建立多因素logistic模型,并使用ROC曲线评估logistic模型的预测效果。结果产后出血发生率约为1.39%（67/4808）。研究组和对照组产程异常、双胎、宫缩乏力、产道裂伤、胎盘因素（胎盘粘连、胎盘植入、前置胎盘）、血小板减少、职业和会阴切开比较,差异具有统计学意义（P〈0.01）。对所有因素进行多因素logistic回归分析,最终进入最优模型的因素有6个：宫缩乏力、血小板减少、会阴切开、分娩方式、前置胎盘和职业;并且宫缩乏力、血小板减少和前置胎盘是产后出血的危险因素,OR值分别为60.415（95%CI：15.86～230.17）、36.216（95%CI：4.68～280.35）和19.175（95%CI：2.78～132.33）;而分娩方式、职业和会阴切开是保护因素,OR值分别为0.219（95%CI：0.082～0.586）、0.292（95%CI：0.100～0.851）和0.092（95%CI：0.014～0.59）。ROC曲线下面积AUC=0.9049,灵敏度为75.9%,特异度为89.9%。结论产后出血为多因素影响的结果,本研究建立的logistic回归模型可有效地预测产后出血的发生。     

Risk factors for perineal injury during delivery

OBJECTIVE: We sought to identify risk factors for anal sphincter injury during vaginal delivery. STUDY DESIGN: This was a retrospective, case-control study. We reviewed 2078 records of vaginal deliveries within a 2-year period from May 1, 1999, through April 30, 2001. Cases (n = 91) during the study period were defined as parturients who had documentation of greater than a second-degree perineal injury. Control subjects (n = 176), who were identified with the use of a blinded protocol, included women who were delivered vaginally with less than or equal to a second-degree perineal injury. For each patient, we reviewed medical and obstetrics records for the following characteristics: maternal age, race, weight, gestational age, parity, tobacco use, duration of first and second stages of labor, use of oxytocin, use of forceps or vacuum, infant birth weight, epidural use, and episiotomy use. RESULTS: Of the 2078 deliveries that were reviewed, we discovered 91 cases (4.4%) of documented anal sphincter injury. The mean maternal age of our sample was 24.9 +/- 5.9 years). Nearly two thirds (63.2%) were white; 26.7% were black, and 10.1% were of other racial backgrounds. Forceps were used in 51.6% of deliveries that resulted in tears (cases), compared to 8.6% of deliveries without significant tears (control subjects, P <.05). Using cases and control subjects with complete data (cases, 82; control subjects, 144), delivery with forceps was associated with a 10-fold increased risk of perineal injury (odds ratio, 10.8; 95% CI, 5.2-22.3) compared to noninstrumented deliveries. The association was similar after adjustment for age, race, parity, mode of delivery, tobacco use, episiotomy, duration of labor (stages 1 and 2), infant birth weight, epidural, and oxytocin use (odds ratio, 11.9; 95% CI, 4.7-30.4). Nulliparous women were at increased risk for tears (adjusted odds ratio, 10.0; 95% CI, 3.0-33.3) compared with multiparous patients, but parity did not reduce the association between forceps-assisted deliveries and anal sphincter injuries. Increasing fetal weight was also a risk factor in both unadjusted and adjusted analyses. The performance of a midline episiotomy was associated with an increased risk of anal sphincter tear compared with delivery without an episiotomy in the univariate analysis (odds ratio, 4.9; 95% CI, 2.5-9.6), but this association was reduced in the adjusted analysis (odds ratio, 2.5; 95% CI, 1.0-6.0). The increased duration of both the first and second stages of labor increased injury risk in the unadjusted, but not adjusted, analysis. No significant association was observed between case status and the use of oxytocin or epidural anesthesia. Greater, but not significant, increased risk was associated with maternal indications for operative delivery compared with fetal indications. CONCLUSION: Our results are consistent with recent reports that identify forceps delivery and nulliparity as risk factors for recognized anal sphincter injury at the time of vaginal delivery. Further investigation should focus on the determination of whether the association of injury to instrumentation is causal or, in fact, modifiable. Because of the established association between sphincteric muscular damage and anal incontinence, patients should be counseled about the risk of anal sphincter injury when operative vaginal delivery is contemplated. Such patients should be followed closely in the postpartum setting to assess for the development of potential anorectal complaints.     

Prolonged third stage of labor: morbidity and risk factors

Although retained placenta is a major cause of postpartum hemorrhage, there is no general agreement regarding when manual placental extraction is indicated to prevent hemorrhage. We sought to determine the following: 1) what duration of the third stage of labor is abnormal, 2) what duration is associated with complications, and 3) what antecedent conditions are associated with prolonged third stage. We studied 12,979 consecutive, singleton vaginal deliveries over an 11-year period. Third-stage duration had a log-normal distribution, with a geometric mean of 6.8 minutes, a median of 6 minutes, and an interquartile range of 4-10 minutes. A third stage of 30 minutes or longer occurred in 3.3% of the deliveries. The incidence of postpartum hemorrhage, transfusion, and D&C remained constant in third stages less than 30 minutes, then rose progressively, reaching a plateau at 75 minutes. The increase in these complications after 30 minutes was observed with both spontaneously delivered and manually extracted placentas. In a logistic regression analysis, factors significantly associated with prolonged third stage included: preterm delivery (odds ratio 3.81), delivery in a labor bed (odds ratio 2.17), preeclampsia (odds ratio 1.76), augmented labor (odds ratio 1.47), and nulliparity (odds ratio 1.45). Because there was no increase in hemorrhage until the third stage exceeded 30 minutes, we suggest that in the absence of bleeding, manual placental extraction is not indicated until 30 minutes have elapsed.     

多功能气囊腹压带助产仪助产及预防产后出血应用研究

目的 探讨多功能气囊腹压带在助产和预防产后出血中的作用。方法 选择2014年4至9月在广东省妇幼保健院住院的初产、单胎、足月、头位、胎方位正常阴式分娩产妇100例,随机分为2组,第二、三产程中使用多功能气囊腹压带的50例为观察组,未使用的50例为对照组,观察两组产妇及胎儿的分娩结局。结果 观察组平均第二产程时间、胎头拨露至胎头娩出时间、胎盘娩出时间及产后出血量明显较对照组短(P<0.05)。两组产妇会阴侧切率、产后2 h内体征和新生儿Apgar评分、出生时脐血血气分析结果比较,差异无统计学意义(P>0.05)。并且第二产程中观察组产妇在不同囊内压时的体征及胎心变化差异亦无统计学意义(P>0.05)。 结论 多功能气囊腹压带通过严密监测,适时合理调节囊内压力,可安全加快第二、第三产程进展,预防产后出血,促进自然分娩。     

Postpartum stroke: a twenty-year experience

OBJECTIVE: The aim of this study was to characterize the clinical presentation, etiology, and acute and subsequent outcomes of postpartum stroke. STUDY DESIGN: This 20-year, single-center, retrospective review included 20 women without previous neurologic deficit with clinical and neuroimaging diagnoses of postpartum stroke. RESULTS: Eight of 20 women (40%) were delivered abdominally. Conduction anesthesia was induced in 9 of 20 women (45%). Causes of stroke included cerebral infarction (n = 13; 7 venous, 6 arterial), intracerebral hemorrhage (n = 5; 1 cocaine-induced, 1 anatomic malformation), cerebritis (n = 1), and cerebral atrophy (n = 1). The median time at onset of stroke was 8 days post partum (range, 3-35 days). Headache, seizures, visual change, and hemiparesis were the most common presenting findings but were neither specific to the underlying pathologic condition nor predictive of ultimate maternal outcome. There were 2 maternal deaths, both caused by severe intracerebral hemorrhage. Intracerebral hemorrhage was associated with the poorest outcome (2 deaths and 1 residual neurologic deficit). Eight women had residual neurologic deficit. There was no correlation between a trial of labor (P =.4; odds ratio, 0.4; 95% confidence interval, 0.01-6.5) or vaginal versus cesarean mode of delivery (P =.6; odds ratio, 1.3; 95% confidence interval 0.1-16.8) and ultimate neurologic diagnosis (cerebral infarction or intracerebral hemorrhage). However, the incidence of cesarean delivery was greater in the cohort of women with postpartum stroke than in the overall obstetric population (P =.015; odds ratio, 3.2; 95% confidence interval, 1.2-8.5). One of the 20 women received methergine; 1 received bromocriptine. All women were either normotensive or had well-controlled hypertension at postpartum discharge. New-onset hypertension or exacerbation of existing hypertension occurred after the acute neurologic insult; subsequent mean (+/-SD) arterial blood pressure was 128.9 +/- 24.0 mm Hg. CONCLUSION: Postpartum stroke is a multifactorial, uncommon, and nonpreventable complication of pregnancy. There was an association between postpartum stroke and hypertensive disorders of pregnancy and cesarean delivery. However, this study refutes any etiologic association between conduction anesthesia and postpartum stroke.     

Postpartum sphincter rupture and anal incontinence: prospective study with 259 patients

AIMS: Damage to the anal sphincter has been considered as the cause of anal incontinence after childbirth. The aims of the present study were to determine prospectively the incidence of anal incontinence and anal sphincter damage after childbirth, and their relationship with obstetric parameters in France. PATIENTS AND METHODS: We studied 259 consecutive women six weeks before and eight weeks after delivery. They were asked to fill out a questionnaire dealing with faecal and urinary incontinence. Anal endosonography (B&K 7-10 MHz) was then performed. Two independent observers analyzed internal and external anal sphincters. RESULTS: Two hundred and thirty-three women (90%) were assessed, among whom 31 had had a caesarean section. De novo sphincter defects were observed in 19.3% (39 patients) in the postpartum period only after vaginal delivery (202 patients). These disruptions occurred with the same incidence after the first and second childbirth. Independent risk factors (odds ratio; 95% confidence interval) for sphincter defect were forceps (odds ratio 11.9; 4.8-33.3), perineal tears (odds ratio 16.1; 4.4-83.9), episiotomy (odds ratio 6.6; 1.7-34.2), and pauciparity < or = 2 (odds ratio 8.8; 1-78.3), as revealed by multivariate analyses. The overall rate of de novo anal incontinence was 9% (20 patients), and independent risk factors involved forceps (odds ratio 4.5; 1.5-13), perineal tears (odds ratio 3.9; 1.4-10.9), de novo sphincter defect (odds ratio 5.5; 5-15) and prolonged labor (odds ratio 3.4; 1-11). Among the 20 women who had de novo anal incontinence, only 45% (9 patients) had sphincter defects. CONCLUSION: De novo anal incontinence after delivery is multifactorial and anal sphincter defects account only for 50% of them. Primiparous and secundiparous women have the same high-risk factor for sphincter disruption and anal incontinence. Since external anal sphincter disruptions are more frequent than internal anal sphincter damage, surgical repair should be discussed.     

Early and late intraventricular hemorrhage: the role of obstetric factors.

OBJECTIVE: To evaluate the influence of active phase labor and other obstetric factors on the development of periventricular-intraventricular hemorrhage in the neonate. METHODS: A total of 230 infants were studied. Antenatal enrollment was carried out when estimated fetal weight was 1750 g or less. Serial head ultrasound scans were performed to screen for periventricular-intraventricular hemorrhage, with the initial scan performed within minutes of birth. Scan findings and obstetric and neonatal variables collected prospectively at scheduled intervals were analyzed to determine the significant factors that predispose to intraventricular hemorrhage. RESULTS: In 47 infants (20%), intraventricular hemorrhage was detected within 1 hour of birth (early) and in another 49 (21%) at a later age (late). The overall incidence of hemorrhage was similar between vaginal and cesarean deliveries (41 and 44%, respectively). Early hemorrhage was more frequent in vaginal (28%) than cesarean deliveries (11%), whereas late hemorrhage was more frequent in cesarean deliveries. When the role of delivery mode and labor was analyzed by stepwise logistic regression, the odds ratios for development of early intraventricular hemorrhage increased in the following order: cesarean delivery with no labor, cesarean delivery with latent phase labor, vaginal delivery with forceps use, cesarean delivery with active phase labor, and vaginal delivery without forceps use. For late hemorrhage, the odds ratios increased in the following order: vaginal delivery with forceps, vaginal delivery without forceps, cesarean delivery with no labor, cesarean delivery with latent phase labor, and cesarean delivery with active phase labor. CONCLUSIONS: Active phase labor may predispose to early periventricular-intraventricular hemorrhage, but its influence may be attenuated by use of forceps or by abdominal delivery. The protective effect of forceps remains for late periventricular-intraventricular hemorrhage, but abdominal delivery does not seem to protect against late hemorrhage.     

Postpartum symptoms. Episiotomy or tear at vaginal delivery

The influence of episiotomy was evaluated in a quasi-randomized follow-up study. In 193 primiparas with spontaneous vaginal delivery, postpartum perineal pain and insufficiency symptoms and their duration were evaluated by means of a questionnaire, 15-24 months post partum. Information about the birth and any complications was obtained from the medical records. On comparing the 85 primiparas delivered by midwives who had a low episiotomy rate (mean 21%) versus the 61 primiparas delivered by midwives with a medium episiotomy rate (mean 34%) and the 41 delivered by midwives with a high episiotomy rate (mean 70%), no differences were found regarding postpartum perineal pain and insufficiency symptoms. Postpartum perineal pain symptoms were significantly correlated to the duration of the second stage of labor, irrespective of the episiotomy rate of the midwife in charge, or of the use of episiotomy.     

未诊断的产后出血160例临床分析

目的：探讨未诊断的产后出血（undiagnosed postpartum hemorrhage,UDPPH）的发生原因、临床特点、影响因素及预防措施。方法：回顾性分析2013年1月—2017年12月于中国人民解放军第161医院行阴道分娩的产妇1 528例的临床资料,将其分为产后出血（postpartum hemorrhage,PPH）组、UDPPH组和对照组（既无PPH也无UDPPH者）,分析UDPPH的临床特点及影响因素,并与PPH组进行比较。结果：阴道分娩中UDPPH和PPH发生率分别为10.5%和6.1%,UDPPH组和PPH组的产前血红蛋白均低于对照组,孕次、总产程时间、第三产程时间、胎盘滞留发生率、会阴损伤发生率均高于对照组,差异有统计学意义（P＜0.05）,UDPPH组的初产妇比例、会阴侧切发生率均高于对照组,差异有统计学意义（P＜0.05）,而PPH组初产妇比例、会阴侧切发生率与对照组比较差异无统计学意义（P＞0.05）,初产妇比例、会阴侧切发生率是UDPPH不同于PPH的影响因素。结论：UDPPH在阴道分娩产妇中很常见,为降低其发生率,需要加强产后观察、正确评估出血量以及针对其影响因素进行预防。     

Factors associated with hemorrhage in cesarean deliveries

A case-control study was performed to study risk factors for hemorrhage in cesarean deliveries. Hemorrhage was defined by a pre- to post-delivery hematocrit decrease of 10 points or more or by the need for red-cell transfusion. Patients with antenatal bleeding were excluded. Among 3052 cesarean deliveries, hemorrhage occurred in 196 cases (6.4%). Three controls were matched to each case and multiple logistic regression was used to control for covariance among predictor variables. Factors having a significant association with hemorrhage were: general anesthesia (adjusted odds ratio 2.94), amnionitis (odds ratio 2.69), preeclampsia (2.18), protracted active phase of labor (2.40), second-stage arrest (1.90), and Hispanic ethnicity (1.82). After adjustment for these variables, a classic uterine incision had a small but significant association (odds ratio 1.06) with hemorrhage. Previous cesarean, parity, gestational age, and several other factors had no association with hemorrhage. These data allow one to anticipate hemorrhage in patients at risk and may be useful in planning appropriate use of blood bank resources, including antepartum autologous blood donation.     

Decreased anal sphincter lacerations associated with restrictive episiotomy use

OBJECTIVE: To determine whether restrictive episiotomy use was associated with decreases in anal sphincter lacerations and the risk of anal sphincter laceration attributable to episiotomy. STUDY DESIGN: This was a retrospective database study. Rates of episiotomy, anal sphincter laceration (third- or fourth-degree tear), and other confounding variables were compared among vaginal deliveries before (1999) and after (2002) restrictive episiotomy use was implemented at our institution. Logistic regression was used to estimate the odds ratio of anal sphincter laceration that was due to episiotomy and other variables. RESULTS: The episiotomy rate decreased 56% (37% to 17%, P < .001) between 1999 and 2002, whereas the anal sphincter laceration rate decreased 44% (9.7% to 5.4%, P < .001). There were no changes in age, race, nulliparity, prolonged second stage of labor, operative vaginal deliveries, birth weight, or macrosomia, although oxytocin use and epidural use decreased slightly (37% to 31%, P < .001, and 80% to 76%, P = .02, respectively). The adjusted odds ratio of anal sphincter laceration attributable to episiotomy decreased 55%, from 6.5 (95% CI: 3.8, 11.1) to 2.9 (95% CI: 1.7, 5.0), between 1999 and 2002. Conversely, the adjusted odds ratios of anal sphincter laceration attributable to the other independent risk factors all increased or remained the same: operative vaginal delivery, which increased from 4.4 (95% CI: 2.7, 6.9) to 6.3 (95% CI: 3.6 11.1); nulliparity, from 2.9 (95% CI: 1.8, 4.8) to 2.9 (95% CI: 1.4, 5.9); macrosomia, from 1.9 (95% CI: 1.1, 3.4) to 2.6 (95% CI: 1.3, 5.4); and prolonged second stage, from 2.0 (95% CI: 1.3, 3.0) to 2.1 (95% CI: 1.2, 3.7). CONCLUSION: With restrictive episiotomy use, the episiotomy rate, anal sphincter laceration rate, and risk of anal sphincter laceration attributable to episiotomy were all reduced by approximately 50%.     

The clinical research into the application of multifunctional airbag abdominal pressure belt in midwifery and in the prevention of postpartum hemorrhage

Objective: Explore the effect of the multifunctional airbag abdominal pressure belt on midwifery and on the prevention of postpartum hemorrhage.

Methods: Select 363 natural delivery cases of hospitalized primiparae and divide them randomly into two groups. In the observation group, 182 primiparae used the multifunctional airbag abdominal pressure belt during the second and third stages of labor, whereas the control group of 181 did not use the belt. Delivery outcomes of the primiparae and their fetus were then observed.

Results: The average duration for the second stage of labor, from head emergence to delivery, placenta delivery and postpartum hemorrhage were all shorter in the observation group (p?p?>?0.05). No statistical difference was found in primipara signs and no fetal heart rate change of the primiparae under different internal pressures of the belt during the second stage of labor in the observation group (p?>?0.05).

Conclusion: By closely monitoring and appropriately adjusting the internal pressure of the belt, the multifunctional airbag abdominal pressure belt can speed up the second and third stages of labor, prevent postpartum hemorrhage and promote natural delivery.     

Delays in the delivery room of a primary maternity unit: a retrospective analysis of obstetric outcomes

Objective: To compare obstetric outcomes in women undergoing vaginal delivery with or without delay in the 2nd and 3rd stage of labour (SOL). Methods: This is an observational retrospective study including 10,416 full-term vaginal deliveries occurred at a primary obstetric unit. Our sample was divided according to the length of 2nd and 3rd SOL: >2?h vs. ≤2?h; and >1?h vs. ≤1?h, respectively. Obstetric outcomes were compared using univariate and multivariate analysis. Results: A prolonged 2nd SOL was associated with severe perineal tears (odds ratio (OR) = 3.53), episiotomy (OR = 3.25), major post-partum hemorrhage (PPH) (OR = 2.35), operative delivery (OR = 3.54), and Asian ethnicity (OR = 12.12). Likewise, a prolonged 3rd SOL was associated with operative deliveries (OR = 10.49), labor induction (OR = 3.24), non-use of oxytocin after delivery (OR = 12.39), major PPH (OR = 46.95), retained placenta (OR = 3.57) and female fetal gender (OR = 4.07). Conclusions: even at a primary care setting, where there are mostly low-risk pregnancies, a prolonged 2nd and 3rd SOL may occur and lead to poor obstetric outcomes. Our findings raise a very controversial issue about the meaning of “low obstetrics risk”, given the unpredictability of any labor, and the management of complications in the delivery room of primary maternity units.     

Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States

OBJECTIVE: The purpose of this study was to estimate the incidence of urinary and bowel incontinence in relation to anal sphincter laceration in primiparous women and to identify factors that are associated with anal sphincter laceration in a unit that uses primarily midline episiotomy. STUDY DESIGN: From January 1, 1997, to March 30, 2000, 2941 questionnaires concerning pelvic floor function 6 months after delivery were mailed to primiparous women who were delivered vaginally at the University of Michigan Medical Center. Charts were reviewed for 2858 deliveries to assess the use of episiotomy and the degree of perineal trauma, along with demographic and pertinent delivery variables. There were 943 women who completed the urinary function questionnaire and 831 women who completed the bowel function questionnaire. Univariate analysis was performed on all covariates. Multiple logistic regression was used for the analysis of the presence of third- or fourth-degree lacerations as the outcome. RESULTS: Nineteen percent of the women who completed the survey had sustained third- or fourth-degree lacerations during childbirth. The women in the sphincter laceration group were more likely (23.0%) to have bowel incontinence than the women in the control group (13.4%) (P<.05). The incidence of worse bowel control was nearly 10 times higher in women with fourth-degree lacerations (30.8%) compared with women with third-degree lacerations (3.6%, P<.001). Macrosomia (odds ratio, 2.19; 95% CI, 1.61, 2.99), forceps-assisted delivery (odds ratio, 4.75; 95% CI, 3.43, 6.57), and vacuum-assisted delivery (odds ratio, 3.51; 95% CI, 2.64, 4.66) were associated with higher risks of third- and fourth-degree lacerations. Midline episiotomy (odds ratio, 2.24; 95% CI, 1.81, 2.77), but not mediolateral (odds ratio, 0.66; 95% CI, 0.375, 1.19), episiotomy was associated with anal sphincter lacerations. More than one half of the women had new onset of urinary incontinence after delivery and reported several lifestyle modifications to prevent leakage. CONCLUSION: Women with third- and fourth-degree lacerations were more likely to have bowel incontinence than women without anal sphincter lacerations. Fourth-degree lacerations appear to affect anal continence greater than third-degree lacerations.     

Surgical glove perforation in obstetrics

Perforation of surgical gloves places the obstetrician at risk for blood-borne infectious diseases. Seven hundred fifty-four surgical gloves used in vaginal and cesarean deliveries and postpartum tubal ligations were examined for evidence of perforation by the air inflation-water submersion technique. The overall glove perforation rate was 13.3%, with 62% of the perforations remaining unrecognized during the surgical procedure. The majority of perforations occurred on the fingers of the nondominant hand. Multivariate analysis with logistic regression indicated that cesarean delivery (odds ratio 3.52), any vaginal laceration or episiotomy (odds ratio 4.95), and chief resident status (odds ratio 3.00) were the major risk factors for surgical glove perforation. Surgical technique by assistants, especially in complex cases, is as important as that of the primary surgeon in regard to glove perforations.     

Incidence and risk factors for severe perineal laceration after vaginal delivery in Japanese patients

Objective: The aim of this study was to assess the frequency of severe perineal lacerations defined as either third- or fourth-degree lacerations during normal spontaneous vaginal delivery and to evaluate potential risk factors in Japanese patients. Materials and methods: An electronic audit of the perinatal database at the Tama-Nagayama Hospital of Nippon Medical School and Yamaguchi Hospital from 1997 through 2004 was completed. Singleton vaginal vertex deliveries were analyzed for potential risk factors using univariate and multivariate logistic regression analysis. Results: From the database, 7,946 deliveries were identified, with 135 deliveries resulting in severe lacerations (1.7%). In the multivariate logistic regression analysis, severe lacerations were associated significantly with primiparous (odds ratio, 4.36; 95% CI, 2.17–9.57), oxytocin use (odds ratio, 2.19; 95% CI, 1.27–3.73), midline episiotomy (odds ratio, 4.68; 95% CI, 2.09–11.55), forceps-assisted delivery (odds ratio, 7.11; 95% CI, 1.95–20.59), vacuum-assisted delivery (odds ratio, 5.93; 95% CI, 3.38–10.36), and shorter attendant experience (odds ratio, 2.88; 95% CI, 1.12–9.81). Conclusions: The present study demonstrated that operator factors, such as midline episiotomy, oxytocin use, assisted delivery and attendant experience, are independent risk for severe perineal lacerations after vaginal delivery in Japanese patients. The results suggest that midline episiotomy and assisted vaginal delivery, especially forceps-assisted delivery should be avoided in patients who are being delivered of a first child whenever possible.     

Second trimester placental location as a predictor of an adverse pregnancy outcome.

OBJECTIVE: To determine if the second trimester placental location is associated with perinatal outcomes. MATERIALS AND METHODS: Observational study of placental location and the subsequent risk of an adverse pregnancy outcome. Placental location was divided into three categories, low, high lateral and high fundal. RESULTS: There were 3336 pregnancies analyzed in this study. Low implantation sites had a greater risk of preterm labor (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.38 to 2.90, P<0.001), preterm delivery (OR 1.86, 95% CI 1.36 to 2.54, P<0.001), fewer fetuses with macrosomia (OR 0.56, 95% CI 0.38 to 0.83, P=0.010) and reduced risk of postpartum hemorrhage (OR 0.56, 95% CI 0.46 to 0.95, P=0.026). High lateral implantations had a greater risk of low 1-min (OR 1.80, 95% CI 1.11 to 2.93, P=0.017) and 5-min (OR 3.49, 95% CI 1.46 to 8.36, P=0.005) Apgar scores. CONCLUSIONS: Low placental implantation was associated with an increased risk of preterm labor, preterm delivery and a reduced risk of postpartum hemorrhage, and of a macrosomic fetus. High lateral implantation was associated with low Apgar scores.