Femur fracture during abdominal breech delivery

BACKGROUND: While vaginal breech delivery, although rare, can cause femur fracture, abdominal breech delivery is not expected to cause it. CASE: A 2,490-g female infant was delivered at term by elective cesarean section for breech presentation. She sustained a fracture of the femur shaft. A simple splinting led to a complete healing of the fracture without sequelae. CONCLUSION: Although abdominal breech delivery reduces the risk of birth trauma, we must be aware that femur fracture can occur regardless of the mode of delivery.     

Bilateral femur fracture in a newborn: an extreme complication of cesarean delivery

Introduction  Bilateral femoral fracture due to birth trauma which is extremely rare, can occur during cesarean section. Material and methods  This case represents a newborn delivered by cesarean section for breech presentation who sustained bilateral subtrochanteric fracture of the femur. Result  The newborn was treated with immobilization in pelvipedal cast. Conclusion  It has been concluded that performing accurate delivery technique and immediate evaluation–orthopedic consultation of the newborn in the presence of forced obstetrical maneuver are important.     

Attitudes towards mode of delivery and cesarean on demand in Turkey.

OBJECTIVE: To assess the attitudes of healthcare providers and the public in Turkey towards mode of delivery and cesarean delivery on demand. METHODS: A written questionnaire was given to female healthcare providers and women from the general public, and their answers were analyzed. RESULTS: A total of 329 female healthcare providers and 347 women from the public group completed the survey. In response, 48.1% of healthcare providers and 69.6% of the public group chose vaginal delivery as the preferred mode of delivery (P<0.001). Some 45.3% of healthcare providers and 20.6% of the public group had undergone a cesarean delivery without any medical indications (P<0.001). In addition, 37.8% of healthcare providers and 36.2% of the public group believed that women should have the right to a cesarean delivery on demand. CONCLUSIONS: In the two groups studied the preference for cesarean delivery is higher in Turkish healthcare providers than in the public population. In both groups the attitude towards cesarean delivery on demand is high.     

Neonatal clavicle fracture in cesarean delivery: incidence and risk factors

Background: Neonatal clavicle fracture in cesarean delivery is rare and has not been extensively studied.

Methods: We performed a retrospective review of cesarean deliveries with neonatal clavicle fracture during a 12-year period. Maternal and neonatal factors as well as surgical factors related to cesarean delivery for the fracture were determined and compared to the control group to analyze their significance.

Results: Among a total 89?367 deliveries during the study period, 36 286 babies were born via cesarean section. Nineteen cases of clavicle fractures in cesarean section were identified (0.05% of total live births via cesarean section). In the analysis of maternal and neonatal risk factors, birthweight, birthweight ≥?4000 g and maternal age were significantly associated with clavicle fracture in cesarean section. However, clavicle fractures were not correlated with the selected surgical factors such as indication for cesarean section, skin incision to delivery time and incision type of skin and uterus. Logistic regression analysis showed that birthweight was the major risk factor for clavicle fracture.

Conclusion: Clavicle fractures complicated 0.05% of cesarean deliveries. The main risk factor related to a clavicle fracture in cesarean section was the birthweight of an infant. As reported in previous studies associated with vaginal delivery, clavicle fracture is considered to be an unavoidable event and may not be eliminated, even in cesarean delivery.     

Comparison of "instrument-associated" and "spontaneous" obstetric depressed skull fractures in a cohort of 68 neonates

OBJECTIVE: A depressed skull fracture is an inward buckling of the calvarial bones and is referred to as a "ping-pong" fracture. This study aimed to look at differences between "spontaneous" and "instrument-associated" depressed skull fractures. STUDY DESIGN: This retrospective, case-control analysis included every neonate who was admitted with a depressed skull fracture between 1990 and 2000. Cases after a spontaneous vaginal delivery, elective cesarean delivery, or cesarean delivery that was performed during labor without previous instrument use were classified as "spontaneous" (n = 18 cases). Cases after a delivery in which forceps or a vacuum cup had been used either successfully or unsuccessfully were classified as "instrument-associated" (n = 50 cases). Continuous data were analyzed with 2-tailed unpaired t tests; chi 2 analysis was used for nominal data. A probability value of <.05 was considered statistically significant. RESULTS: Fifty depressed skull fractures were associated with an instrument delivery, and 18 depressed skull fractures were classified as "spontaneous." The only obstetric parameter that differed significantly between the 2 groups was the length of the active phase. Among the 68 neonates, 15 neonates underwent prolonged second stage, forceps or manual head rotation, or forceps use during elective cesarean delivery. All "instrument-associated" cases were caused by forceps application or sequential instrument use; depressed skull fractures never occurred after isolated vacuum extraction. Every type of forceps was involved. Intracranial lesions were significantly more frequent in the instrument-associated group (30% vs 0%; P = .02). Two infants sustained persistent severe motor disabilities. CONCLUSION: Depressed skull fractures occur in the setting of spontaneous and operative deliveries, although the incidence is higher in the latter case. Depressed skull fractures that are associated with instrumental deliveries are significantly more likely to be associated with intracranial lesions. Persistent disabilities are rare.     

Mode of delivery and risk of stillbirth and infant mortality in triplet gestations: United States, 1995 through 1998

OBJECTIVE: The purpose of this study was to estimate the risks of stillbirth and neonatal and infant deaths in triplets, according to mode of delivery. STUDY DESIGN: We used the "matched multiple birth" data file that was comprised of triple births that were delivered in the United States in the years 1995 through 1998. Analyses were restricted to fetuses that were delivered at >/=24 weeks of gestation. Based on the order of the birth of the fetuses within the triplet set, the mode of delivery of triplets was assigned as cesarean-cesarean-cesarean (all cesarean), vaginal-vaginal-vaginal (all vaginal), and vaginal-cesarean-cesarean or vaginal-vaginal-cesarean (other). Associations between mode of delivery and stillbirth, neonatal deaths (within 28 days), and infant deaths (up to 1 year) were expressed as relative risks with 95% confidence intervals and population attributable risks, which were derived from multivariate logistic regression models that were based on the method of generalized estimated equations (with all cesarean deliveries serving as the reference). All analyses were adjusted for several confounding factors. RESULTS: Ninety-five percent of all triplets were delivered by cesarean delivery. Vaginal delivery (all vaginal) was associated with an increased risk for stillbirth (relative risk, 5.70; 95% CI, 3.83, 8.49) and neonatal (relative risk, 2.83; 95% CI, 1.91, 4.19) and infant (relative risk, 2.29; 95% CI, 1.61, 3.25) deaths. The population-attributable risks were 15.9% for neonatal and 12.4% for infant deaths, which implied that these proportions of deaths were potentially avoidable had these triplet fetuses all been delivered by cesarean delivery rather than all fetuses being delivered vaginally. CONCLUSION: Cesarean delivery of all 3 triplet fetuses is associated with the lowest neonatal and infant mortality rate. Vaginal delivery among triplet gestations should be avoided.     

Attitudes of Singapore women toward cesarean and vaginal deliveries.

OBJECTIVES: To assess the attitude, knowledge, and expectations of Asian pregnant women toward cesarean and vaginal deliveries. METHODS: Written questionnaires were given to pregnant women attending the National University Hospital antenatal clinics, and 160 responses were tabulated and analyzed using SPSS software. RESULTS: The participation rate was 65% and 50% of the respondents were Chinese, 20% Indian, 21% Malay, 2% White, and 9.2% Other. The median age was 31 years, and approximately 43% were primiparas. Only 3.7% of them would prefer an elective cesarean delivery, and although 50% had friends or relatives who requested one, only 3% felt that this influenced their preference. The most common reasons for choosing a cesarean delivery were avoiding labor pains and lowering the risk of fetal distress. When asked which modality they would recommend to their friends, only 2% expressed that they would recommend cesarean delivery; however, 71% stated that women should have the right to request a cesarean delivery. Awareness of complications arising from vaginal and cesarean deliveries was generally low and related to the frequency of these complications. There was no significant correlation between demographic characteristics and maternal preference for mode of delivery. CONCLUSIONS: Asian women largely prefer a vaginal delivery, and their attitude toward cesarean delivery on demand is comparable with that of Western women. Cultural or ethnic differences are unlikely to affect maternal preference for cesarean delivery in Singapore women.     

Mode of delivery and problems in subsequent births: a register-based study from Finland

OBJECTIVE: The purpose of this study was to investigate the effects of delivery on problems in subsequent births. STUDY DESIGN: This was a cohort study that used register data for 73,104 mothers who had their first birth from 1987 to 1989 and subsequent births from 1987 to1998. Three analyses were performed: (1) examination of second births by mode of delivery in the first birth, with adjustment for confounders, (2) same parameter, with exclusion of women with persistent problems, and (3) examination of third births for women with a first birth vaginal delivery. RESULTS: More complications and poorer infant outcome were found at later births when the first or second birth was by cesarean delivery than after a first spontaneous vaginal delivery, even when women with persistent problems were excluded. Women with instrument first births had a similar rate of complications in the second birth to women with spontaneous vaginal births, but some infant outcomes were poorer. CONCLUSION: Problems that are subsequent to cesarean delivery are unlikely to be explained entirely by indications for cesarean delivery.     

Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option?

OBJECTIVE: This study was undertaken to compare clinical outcomes in women with 1 versus 2 prior cesarean deliveries who attempt vaginal birth after cesarean delivery (VBAC) and also to compare clinical outcomes of women with 2 prior cesarean deliveries who attempt VBAC or opt for a repeat cesarean delivery. STUDY DESIGN: We performed a secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery from 16 community and tertiary care hospitals were reviewed by trained nurse abstractors. Information on demographics, obstetric history, medical and social history, and the outcomes of the index pregnancy was obtained. Comparisons of obstetric outcomes were made between women with 1 versus 2 prior cesarean deliveries, and also between women with 2 prior cesarean deliveries who opt for VBAC attempt versus elective repeat cesarean delivery. Both bivariate and multivariate techniques were used for these comparisons. RESULTS: The records of 20,175 women with one previous cesarean section and 3,970 with 2 prior cesarean sections were reviewed. The rate of VBAC success was similar in women with a single prior cesarean delivery (75.5%) compared with those with 2 prior cesarean deliveries (74.6%), though the odds of major morbidity were higher in those with 2 prior cesarean deliveries (adjusted odd ratio[OR] = 1.61 95% CI 1.11-2.33). Among women with 2 prior cesarean deliveries, those who opt for a VBAC attempt had higher odds of major complications compared with those who opt for elective repeat cesarean delivery (adjusted OR = 2.26, 95% CI 1.17-4.37). CONCLUSION: The likelihood of major complications is higher with a VBAC attempt in women with 2 prior cesarean deliveries compared with those with a single prior cesarean delivery. In women with 2 prior cesarean deliveries, while major complications are increased in those who attempt VBAC relative to elective repeat cesarean delivery, the absolute risk of major complications remains low.     

Buccal misoprostol to prevent hemorrhage at cesarean delivery: a randomized study

OBJECTIVE: The purpose of this study was to assess the efficacy of buccal misoprostol to decrease uterine atony, hemorrhage, and the need for additional uterotonic agents during cesarean delivery. STUDY DESIGN: Patients who underwent cesarean delivery were assigned randomly to either 200-microg misoprostol or placebo placed in the buccal space. A dilute intravenous oxytocin infusion was given to all patients at delivery of the placenta. The primary outcome variable was the need for additional uterotonic agents. RESULTS: A total of 352 women received random assignments. Demographic and intrapartum characteristics were similar between the groups. More women in the placebo group required 1 additional uterotonic agent (43% vs 26%; P < .01; relative risk, 1.3; 95% CI, 1.10, 1.50). There was not a difference between the groups in the incidence of postpartum hemorrhage or a difference in preoperative and postoperative hemoglobin level. CONCLUSION: Buccal misoprostol reduces the need for additional uterotonic agents during cesarean delivery.     

Factors predictive of failed operative vaginal delivery

OBJECTIVE: The purpose of this study was to determine what factors are independently associated with an increased likelihood of failed operative vaginal delivery. STUDY DESIGN: We conducted a population-based case-control study evaluating maternal, pregnancy, provider, care setting, and fetal factors associated with failed operative vaginal delivery. Subjects were identified using Washington state birth certificates for infants born between 1992 and 2001. Cases (n = 1750) were live-born singletons with both labored cesarean delivery and an operative vaginal delivery ("failure") coded on the birth certificate. Controls (n = 3500), frequency matched by delivery year to the cases, were randomly selected from among singletons undergoing a successful operative vaginal delivery. Odds ratios (OR) and associated 95% CI, estimated with Mantel-Haenszel methods, measured the association between case status and potential risk factors. RESULTS: Failed operative vaginal delivery was associated with increased maternal age, African American race, higher body mass index (BMI), diabetes, polyhydramnios, induction of labor, dysfunctional labor, and prolonged labor. Case compared with control mothers were more likely to deliver a low-birth weight or macrosomic infant. CONCLUSION: Identification of maternal and fetal factors associated with failed operative vaginal delivery may enable providers to better counsel patients, and allow improved planning and allocation of surgical resources.     

Preference toward future mode of delivery: how do antepartum preferences and prior delivery experience contribute?

Objective: Examine postpartum preferences toward future mode of delivery (MOD), considering recent MOD, antepartum preferences, and demographics.

Study design: Prospective cohort study where a survey was distributed in outpatient obstetrics clinics to pregnant women over 18 years at 28 weeks gestation or later. Surveys gathered demographics, obstetric history, and preference toward vaginal delivery (VD) versus cesarean delivery (CD). Women were again surveyed at 6–8 weeks postpartum. Chi-square test compared proportions, and logistic regression controlled for potential confounders.

Results: A total of 299 women returned postpartum surveys and expressed preferences. Comparing women who experienced VD versus CD, the majority who had a VD (92.1%) would choose this again, while only 1.9% preferred CD. Among the CD group, preferences were mixed: 29.4% desired repeat CD, 34.1% preferred VD, and 36.5% were undecided (p?<?0.001). Adjusted odds were 34.4 (95% CI 9.4–126.1) for preferring VD over CD among women who experienced a recent VD, adjusting for parity, age, ethnicity, education, possible depression, and type of provider.

Conclusions: The majority of women preferred VD postpartum. Of the minority who desired CD, antenatal preference for cesarean and prior experience with CD were important factors. This highlights the impact of individual desires and experience, and underscores importance of antenatal counseling.     

Preferences in cesarean delivery surgical technique: a survey of maternal–fetal medicine fellows

Objective: Our goal was to (1) describe self-reported cesarean delivery (CD) surgical techniques of Maternal–Fetal Medicine (MFM) fellows and (2) determine whether preferences were congruent with recommendations using US Preventive Services Task Force (USPSTF) criteria.

Methods: MFM fellows were queried regarding their preferred CD technique via online survey. Preferences were compared to evidence-based recommendations using standard recommendation language and quality of evidence as outlined by the USPSTF. Categorical variables were compared by Chi-square analysis or Fisher’s exact test, with p?Results: Of 233 active MFM fellows in August 2012, 167 completed the survey, resulting in a response rate of 71%. Statistically significant differences of preferences were noted when stratified by year in fellowship (blunt tip needles), gender (thromboprophylaxis, skin incision, fascial extension, uterine closure suture) and geographic region of fellowship (fascial extension, skin closure). CD techniques preferred by MFM fellows were congruent with recommendations designated as high or moderate level of certainty with regard to prophylactic antibiotics, uterine incision extension, uterine atony prevention and placenta removal, while incongruent with regards to pre-operative vaginal preparation and blunt needle preference.

Conclusion: Among MFM fellow respondents, variation exists in preferred CD technique and vis-à-vis evidence-based recommendations.     

Differences in levels of oxidative stress in mothers and neonate: the impact of mode of delivery

Abstract

Objective: To determine there are differences in the production levels of oxygen free radical between mothers and neonates by the mode of delivery, we measured oxygen free radical concentrations in maternal vein and umbilical artery.

Methods: Forty-four women with singleton term pregnancies were prospectively recruited and classified into two groups: those who had a spontaneous uncomplicated vaginal delivery (VD group; n?=?21), and those who had an elective cesarean delivery (CD group; n?=?23). We determined maternal and fetal oxidative stress levels by measuring concentrations of derivatives of reactive oxygen metabolites (d-ROMs) in maternal vein before delivery and on postnatal day 5, and in umbilical artery at delivery. We also measured the pH, partial pressure of oxygen (PaO₂), partial pressure of carbon dioxide (PaCO₂) and base excess (BE) in umbilical artery blood collected at delivery.

Results: The concentrations of d-ROMs in maternal vein on postnatal day 5 were significantly decreased in the VD group, but were significantly increased in the CD group, compared to before delivery. The concentrations of d-ROMs in umbilical artery were significantly higher in the VD group than the CD group. Compared to the CD group, umbilical artery pH tended to be lower (p?=?0.07), and BE significantly lower (p?<?0.005), in the VD group. There were no significant differences in umbilical artery PaO₂ and PaCO₂ between the two groups.

Conclusion: Our findings indicate that those production levels of oxygen free radical in mothers are greater by CD than by VD, while those in neonates are greater by VD than by CD.     

Use of fetal pulse oximetry among high-risk women in labor: a randomized clinical trial

OBJECTIVE: The purpose of this study was to determine the clinical role of fetal pulse oximetry to reduce cesarean delivery for a nonreassuring fetal heart rate tracing. STUDY DESIGN: Singletons > or =28 weeks were randomized to fetal pulse oximetry plus electronic fetal heart rate monitoring (monitoring + fetal pulse oximetry) or monitoring alone. RESULTS: Overall, 360 women in labor were recruited: 150 cases with monitoring+fetal pulse oximetry and 177 cases with monitoring alone were analyzed. Most demographic, obstetric, and neonatal characteristics were similar. Specifically, the gestational age, cervical dilation, and station of the fetal head were not differential factors. In addition, cesarean delivery for nonreassuring fetal heart rate tracing was not different between the group with monitoring+fetal pulse oximetry (29%) and the group with monitoring alone (32%; relative risk, 0.95; 95% CI, 0.75, 1.22). Likewise, cesarean delivery for arrest disorder was similar between the group with monitoring+fetal pulse oximetry (22%) and the group with monitoring alone (23%; relative risk, 1.05; 95% CI, 0.79, 1.44). However, the decision-to-incision time was shorter for the group with monitoring+fetal pulse oximetry (17.8 +/- 8.2 min) than for the group with monitoring alone (27.7 +/- 13.9 min; P < .0001). CONCLUSION: The use of fetal pulse oximetry with electronic fetal heart rate monitoring does not decrease the rate of cesarean delivery, although it does alter the decision-to-incision time.     

双胎妊娠的分娩方式与妊娠结局探讨

目的　探讨双胎妊娠的分娩方式与妊娠结局的关系。方法　将 1995年 1月至 2 0 0 3年 5月 98例双胎妊娠产妇按分娩方式分为阴道分娩组及剖宫产组 ,对其临床资料进行回顾性分析。结果　两组的孕周、产后出血率比较差异无显著性意义 (P >0 0 5 ) ,剖宫产组新生儿体重显著高于阴道分娩组 (P <0 0 1) ,两组第 1胎分娩新生儿窒息率差异无显著性意义 (P >0 0 5 ) ,而第 2胎分娩新生儿窒息率剖宫产组显著低于阴道分娩组(P <0 0 5 )。结论　正确选择双胎妊娠的分娩方式 ,将有助于降低剖宫产率及新生儿窒息率     

Increased intravenous fluid intake and the course of labor in nulliparous women.

OBJECTIVE: To compare the effect of 2 regimens of intravenous fluid therapy on the course of labor. METHODS: In a prospective, randomized, double-blind study of 300 nulliparous pregnant women at term conducted at a teaching hospital, 153 women received 125 mL and 147 received 250 mL of intravenous fluid per hour. The groups were matched and analysis was done using the t, chi(2), and Fisher exact tests. P<0.05 was considered statistically significant. RESULTS: In the group that received intravenous fluid at a rate of 250 mL per hour the mean+/-S.D. duration of labor was significantly shorter (253+/-97 vs. 386+/-110 min; P = 0.0001), the frequency of labor lasting both more than 10h and more than 15 h was statistically lower (4.8% vs. 13.8%; P=0.001 and 0% vs. 4.5%; P=0.02, respectively), and the frequency of oxytocin administration was significantly lower (8.1% vs. 20.4%; P=0.001). There was a trend toward a lower frequency of cesarean deliveries in the 250-mL group (16% vs. 22.8%; P=0.1). CONCLUSION: A greater volume per hour of intravenous fluid than is commonly administered to nulliparous women in active labor is associated with significantly shorter duration of labor and lower frequency of both prolonged labor and oxytocin administration.