Significant intraventricular hemorrhage is more likely in very preterm infants born by vaginal delivery: a multi-centre retrospective cohort study

Objectives: The objective of this study is to determine the association between mode of delivery (vaginal delivery [VD] versus cesarean section [CS]) and the rate of significant intraventricular hemorrhage (sIVH) in preterm infants.

Methods: A multicenter retrospective cohort study, based on data collected from the Vermont Oxford Network database. Infants born between 23 and 31⁺⁶ weeks of gestational age between 2001 and 2014 were identified. Exposure was the mode of birth (VD versus CS). Primary outcome was development of sIVH. Data were analyzed using univariate and multivariate statistical methods.

Results: A total of 1575 infants were eligible. Nine hundred and two infants were born by CS and 673 by VD. Univariable analysis showed that infants born vaginally were more likely to have sIVH (p?p?p?=?.010) and have a longer hospital stay (p?=?.006). After adjusting for available confounders, multivariable analysis persistently showed that infants between 23 and 27 weeks born by CS were less likely to develop sIVH [OR 1.61 (1.01–2.58), p?=?.049].

Conclusions: sIVH is less common in very preterm infants (23–27 weeks of gestation) delivered by CS. However, neurodevelopmental risks associated with survival at this early age, as well as increased maternal morbidities must also be considered.     

Medically indicated late preterm delivery and its impact on perinatal morbidity and mortality: a retrospective population-based cohort study

Objective: In the last few decades, attention has been focused on morbidity and mortality associated with late preterm delivery (34–36?+?6/7 weeks), accounting for 60–70% of all preterm births. This study is aimed to determine (1) the prevalence of late preterm deliveries (spontaneous and medically indicated) in our population; and (2) the rate of neonatal morbidity and mortality as well as maternal complications associated with the different phenotypes of late preterm deliveries.

Study design: This retrospective population-based cohort study, included 96,176 women who had 257,182 deliveries, occurred between 1988 and 2011, allocated into three groups: term (n?=?242,286), spontaneous (n?=?10,063), and medically indicated (n?=?4833) late preterm deliveries.

Results: (1) Medically indicated late preterm deliveries were associated with increased maternal morbidity, as well as neonatal morbidity and mortality, in comparison with other study groups (p?Conclusions: (1) Medically indicated late preterm deliveries were independently associated with adverse composite neonatal outcome; and (2) to benefit in term of neonatal outcome from the tool of medically indicated late preterm birth, their proportion should be kept below 35% of all late preterm deliveries, while exceeding this threshold increases the risk of neonatal mortality.     

Perinatal risk factors and mode of delivery associated with mortality in very low birth weight infants

Objective: To investigate the association of perinatal risk factors including delivery mode with mortality in very low birthweight (VLBW) in a tertiary hospital setting.

Methods: Medical records of 241 live-born VLBW infants (≤1500?g) were retrospectively reviewed. Details of maternal, obstetrical, perinatal risk factors and their associations with infant mortality were evaluated.

Results: The overall infant mortality rate was 23.2%. Mortality was significantly higher for infants born at ≤27 gestational weeks and with a birthweight of ≤750?g (p?=?0.000 and p?=?0.000, respectively), showing a steep decrease thereafter. On ROC analysis, a cut off of 26.5 weeks was determined for mortality with a sensitivity of 57.1% and a specificity of 90.3% (area under the curve?=?0.792, 95% CI: 0.719–0.866). On multivariate regression analysis, gestational week at birth, birthweight, antenatal steroid treatment and pathologic Doppler ultrasound findings were found as independent risk factors for mortality.

Conclusions: Gestational week at birth, birthweight and antenatal steroid treatment remain the most important perinatal risk factors for infant mortality in VLBW infants. Mode of delivery does not seem to be associated with mortality when adjusted for other perinatal risk factors.     

Neonatal mortality and morbidity after elective cesarean delivery versus routine expectant management: a decision analysis

A number of competing risks and benefits influence the rates of neonatal morbidity and mortality in elective cesarean delivery versus expectant management. To compare these rates, we developed complex decision trees to model the expected outcomes among hypothetical cohorts of 1,000,000 uncomplicated pregnancies undergoing elective cesarean delivery versus 1,000,000 comparable pregnancies undergoing routine pregnancy management. A separate tree was created for each complication, including neonatal death, respiratory morbidity, intracranial hemorrhage, and brachial plexus injury. We found that neonatal mortality was increased among elective cesarean deliveries, but perinatal mortality was higher with routine expectant management due to fetal deaths. Respiratory morbidity was substantially more common among infants delivered by elective cesarean delivery, whereas intracranial hemorrhage and brachial plexus injury were less common. We conclude that the fetal/neonatal impact of elective cesarean is mixed, but any improvement in perinatal health is likely to be small.     

Breech delivery: Review of a consecutive series of 285 cases

In a consecutive series of 285 breech deliveries (3.2%), the overall perinatal mortality rate was 8.0%, but the corrected perinatal mortality rate was 1.2% (primiparae 1.5% — multiparae 1.0%). The incidence of cesarean operation was 11.9%. Of the factors leading to a cesarean operation, unfavorable sociocultural factors (lack of cooperation, inadequate preparation, etc.) are more important than the classical feto-pelvic disproportion. Emphasis is placed on the liberal use of cesarean section, and on more frequent application of forceps on the aftercoming head (FACH) in vaginal deliveries. In any case, the abdominal route is to be preferred to difficult vaginal deliveries. The role of intrapartum fetal monitoring in case of breech delivery is outlined.     

Twin pregnancy outcomes after increasing rate of vaginal twin delivery: retrospective cohort study in a Hong Kong regional obstetric unit

Objective: To determine any change in adverse neonatal/maternal outcomes after increasing the rate of vaginal twin delivery by comparing vaginal twin delivery and caesarean delivery with our previous cohort study.

Methods: In a retrospective cohort study, all twins booked at a Hong Kong regional obstetrics unit were evaluated during a 3-year period from 1 April 2009 to 31 March 2012.

Results: Out of the 269 sets of twins who eventually delivered in our unit, 68 (25.3%) of them were delivered vaginally, compared to 15.8% in our previous cohort study (p?=?0.02). For those who were suitable for vaginal delivery, significantly more women attempted vaginal delivery: 93/133 (69.9%) versus 47/100 (47%) (p?=?0.0005). The success rate for vaginal delivery and rate of requiring caesarean delivery for the 2nd twin were similar between these two periods. There were significantly more 2nd twins with cord blood pH?<?7.2 when both twins were delivered by vaginal delivery. Otherwise, there was no significant difference between other neonatal/maternal morbidities.

Conclusion: With proper counseling, significantly more women who were suitable for vaginal twin delivery would opt to do so. There was no significant increase in neonatal/maternal morbidities despite the increased rate of vaginal twin delivery.     

Vaginal breech delivery at term and neonatal morbidity and mortality – a population-based cohort study in Sweden

Introduction: The routine to deliver almost all term breech cases by elective cesarean section (CS) has continued to be debated due to the risk of maternal and neonatal complications. The aims of the study were (1) to investigate if mode of delivery impacts on the risk of morbidity and mortality among term infants in breech presentation and (2) to compare the rates of severe neonatal complications and mortality in relation to presentation and mode of delivery.

Methods: This population-based cohort study used data from the Swedish Medical Birth Register. All women (and their newborn infants) with singleton pregnancies who gave birth at term to an infant in breech (n?=?27,357) or cephalic presentation (n?=?837,494) between 2001 and 2012 were included. Births with vacuum extraction and induced labors were excluded, as well as antepartum stillbirths, births with infants diagnosed with congenital malformations and multiple births.

Results: On one hand, the rates of neonatal complications and mortality were higher among infants born in vaginal breech compared to the vaginal cephalic group. On the other hand, after CS, the rates of all neonatal complications under study and neonatal mortality were lower among infants in breech presentation than in those in cephalic presentation. After adjustment for confounders, infants delivered in vaginal breech had 23.8 times higher odds AOR (ratio) for brachial plexus injury, 13.3 times higher odds ratio for Apgar score <7 at 5?min, 6.7 times higher odds of intracranial hemorrhage (ICH), or convulsions and 7.6 higher odds ratio for perinatal mortality than those delivered by elective CS.

Conclusions: Despite a probable selection of women who before-hand were considered at low risk and, therefore, could be recommended vaginal breech delivery, infants delivered in vaginal breech faced substantially increased risks of severe neonatal complications compared with infants in breech presentations delivered by elective CS.

• Key message

• Vaginal breech delivery is associated with increased risk for severe neonatal complications.

     

Bacterial vaginosis in a cohort of Danish pregnant women: prevalence and relationship with preterm delivery, low birthweight and perinatal infections

OBJECTIVE: To determine the prevalence of bacterial vaginosis (BV) in the second trimester of pregnancy in a Danish population using the Schmidt criteria and to examine whether BV was associated with subsequent preterm delivery, low birthweight or perinatal infections. DESIGN: Prospective cohort study. SETTING: Department of Obstetrics and Gynaecology at a University Hospital, Denmark. POPULATION: Three thousand five hundred and forty pregnant women aged 18 years or more. METHODS: A smear from the vagina was obtained from all women, air-dried and stored for subsequent diagnosis of BV. After rehydration with isotonic saline, the smear was examined in a phase-contrast microscope at 400x, and the numbers of lactobacilli morphotypes and small bacterial morphotypes were counted. A score for BV was calculated according to the method described by Schmidt. The outcome of pregnancy from 20 weeks of gestation was examined in the 3262 singleton pregnant women who were included in this study before 20 weeks of gestation. The relationship between BV and adverse outcome of pregnancy was examined by univariate and multivariate analyses. MAIN OUTCOME MEASURES: Prevalence of BV, preterm delivery (<37 weeks), low birthweight (<2500 g), preterm delivery of a low-birthweight infant and clinical chorioamnionitis. RESULTS: The prevalence of BV was 16%, and the rate of preterm delivery was 5.2% in the study population of 3262 singleton pregnant women who were included before 20 weeks of gestation. Mean birthweight was significantly lower in infants of women with BV than in infants of women without BV (3408 versus 3511 g, P < 0.01). Univariate analyses showed that BV was marginally associated with preterm delivery but significantly associated with low birthweight, preterm delivery of a low birthweight infant, indicated preterm delivery and clinical chorioamnionitis. Multivariate analyses, which adjusted for previous miscarriage, previous preterm delivery, previous conisation, smoking, gestational diabetes, fetal death and preterm premature rupture of membranes, showed that BV was significantly associated with low birthweight (OR 1.95, 95% CI 1.3-2.9), preterm delivery of a low-birthweight infant (OR 2.5, 95% CI 1.6-3.9), indicated preterm delivery (OR 2.4, 95% CI 1.4-4.1) and clinical chorioamnionitis (OR 2.7, 95% CI 1.4-5.1). CONCLUSIONS: The prevalence of BV determined using the Schmidt criteria in the early second trimester of pregnancy was similar to that found in similar studies. The presence of BV before 20 weeks of gestation was an independent risk factor for delivery of an infant with low birthweight, preterm delivery of a low-birthweight infant, indicated preterm delivery and clinical chorioamnionitis.     

Delivery of the low birthweight and the very low birthweight breech: cesarean section or vaginal delivery?

We studied neonatal survival rates, APGAR scores, and length of hospital stay in 199 singleton breeches weighing 1000-2500 grams at birth. We found that in the birthweight range of 1000-1750 grams, breeches who were delivered by cesarean section had a significantly higher survival rate (74%) than those who were delivered vaginally (36%, p less than 0.01), however, in the birthweight range of 1751-2500 grams, there was no significant difference in the survival rates between breeches delivered abdominally and those delivered vaginally. The 1-minute and the 5-minute APGAR scores and the length of the hospital stay were not significantly different between the abdominal and the vaginal delivery groups in either birthweight range. The data indicate that the very low birthweight breech (less than or equal to 1750 grams) may benefit from a prophylactic cesarean section.     

Mode of delivery in the preterm gestation and maternal and neonatal outcome

Objective.?To determine if the mode of delivery in preterm gestations is associated with changes in maternal and neonatal outcome.

Methods.?A retrospective cohort study that included all singleton deliveries occurring after spontaneous onset of labour between 25?+?0 and 32?+?6 weeks of gestation. Cases of early preterm delivery were identified from clinical records and classified according to the mode of delivery. The following outcomes were derived for each case and compared between caesarean and vaginal deliveries: perinatal death, cranial findings compatible with haemorrhage or white matter disease in the neonate, new-onset of maternal severe anaemia or pyrexia.

Results.?From 1990 to 2007, 109 cases of spontaneous preterm labour were retrospectively selected, including 50 (45.8%) caesarean sections and 59 (54.2%) vaginal deliveries. Perinatal death occurred in 10 infants (9.1%), whereas among survivors abnormal cerebral findings were detected in 20, including 6 cases with haemorrhage, 12 with white matter findings and 2 with both. At multiple logistic regression, a birthweight lower than 1100?g was the only predictor of all adverse outcomes, whereas male sex increased the risk of white matter findings. Caesarean section compared to vaginal delivery conferred a higher risk of maternal complications (23/50 or 46% vs. 6/59 or 10.2%; OR: 11.9, CI 95%: 4.2–333; p?<?0.0005).

Conclusions.?In severely premature infants born after spontaneous onset of labour, the risk of adverse perinatal outcome does not seem to depend upon the mode of delivery, whereas the risk of maternal complications is significantly increased after Caesarean section.     

Preterm outcome table (POT): a simple tool to aid counselling parents of very preterm infants

BACKGROUND: Outcome figures published in scientific journals are often cumbersome and difficult to understand by parents during counselling before or immediately after a very premature birth. AIM: To provide simplified up-to-date outcome information in a table for ease of counselling. METHODS: Regional perinatal mortality rates for very premature births (23-31 weeks gestation) and incidence of significant neonatal events for those admitted to neonatal intensive care units (NICU) were obtained from the NSW Midwives Data Collection, ACT Maternal and Perinatal Data Collection and the NSW and ACT NICUS Data Collection for 2000 and 2001. Neurodevelopmental outcome was obtained for the same cohort at 2-3 years of age, corrected for prematurity. The percentage outcomes were rounded off to the closest conservative multiple of 5 for each data point in a table. RESULTS: The preterm outcome table (POT) for each gestational week was constructed from a total of 2315 births. Of these, 401 (17.3%) were reported as stillborn and were predominantly of 23 to 25 weeks gestation. Of those admitted to NICU, hospital survival rates were 30, 50, 65, 75, 80, 90 and > 95% for 23, 24, 25, 26, 27, 28-29 and 30-31 weeks, respectively. Neurodevelopmental outcome was available for 470 (75%) children, of whom 15% had a moderate to severe functional disability at 2-3 years of age, corrected for prematurity. Simplified data on survival to discharge and outcome were tabulated. CONCLUSION: POT appears simple and easy to use but also provides realistic data to assist clinicians in the counselling process.     

Perinatal outcomes according to the mode of delivery in women with a triplet pregnancy in The Netherlands

Objective: In women with a triplet pregnancy, there is debate on the preferred mode of delivery. We performed a nationwide cohort study to assess the impact of mode of delivery on perinatal outcome in women with a triplet pregnancy.

Methods: Nationwide cohort study on women with a triplet pregnancy who delivered between 26?+?0 and 40?+?0 weeks of gestation in the years 1999–2008. We compared perinatal outcomes according to the intended mode of delivery and the actual mode of delivery. Outcome measures were perinatal mortality and neonatal morbidity. Perinatal outcomes were analyzed taking into account the dependency between the children of the same triplet pregnancy (“any mortality” and “any morbidity”) and were also analyzed separately per child.

Results: We identified 386 women with a triplet pregnancy in the study period. Mean gestational age at delivery was 33.1 weeks (SD 2.5 weeks; range 26.0–40.0 weeks). Perinatal mortality was 2.3% for women with a planned caesarean section and 2.4% in women with a planned vaginal delivery (aOR 0.37; 95% confidence interval (CI) 0.09–1.5) and neonatal morbidity was 26.0% versus 36.0%, (aOR 0.88; 95% CI 0.51–1.4) respectively. In the subgroup analyses according to gestational age and in the analysis of perinatal outcomes per child separately, there were also no large differences in perinatal outcomes. The same applied for perinatal outcomes according to the actual mode of delivery.

Conclusion: In this large cohort study among women with a triplet pregnancy, caesarean delivery is not associated with reduced perinatal mortality and morbidity.     

Risk of preterm delivery in singletons conceived by in vitro fertilization

To evaluate the preterm delivery and other obstetrics complications similar in singleton pregnancies achieved through IVF compared to spontaneous pregnancies. Retrospective case-control study included 1663 women with singleton pregnancies following IVF-ICSI (study group) and 3326 women with singleton spontaneous pregnancies (control group) who delivered between January 2015 and January 2018 at the Peking University Third Hospital. The control group matched 1:2 by age, BMI, parity, and gravidity. Maternal outcomes included preterm delivery and complications. There was significantly higher incidence of gestational diabetes, hypertensive disorders, and placenta previa in IVF-ICSI pregnancies versus controls (p?<?.05). IVF-ICSI resulted in significantly higher rate of preterm birth than in spontaneous pregnancies (p?<?.05) and the difference remained significant for deliveries that occurred before 28, 32, and 34?weeks gestation (p?<?.05). Multivariate logistic regression analysis revealed that female-factor infertility, hypertensive disorder, placenta previa, and PROM were significant prognostic factors associated with increased risk of prematurity. IVF-ICSI is associated with increased risk of obstetric complications including preterm delivery in singleton pregnancies. Female-factor infertility is an independent prognostic factor for preterm birth. This information is important for patient counseling and helps to refine the recommendation to optimize maternal health before embarking on fertility treatments.     

Management and outcome challenges in newborns with gastroschisis: A 6-year retrospective French study

Objective: To identify the gestational age (GA) at which risk of mortality and severe outcome was minimized comparing preterm delivery and expectant management.

Methods: Retrospective study performed between 2009 and 2014 of newborns with gastroschisis in three large French level III neonatal intensive care units. Each department followed two distinct strategies: elective delivery at 35 weeks’ GA and a delayed approach.

Results: We included 69 gastroschisis cases. The lengths of stay lasting more than 60 days were significantly greater in the planned delivery group than in the expectant approach group (18/30 (60%) vs. 8/39 (20.5%), p?=?0.001). Gastroschisis cases receiving antenatal corticoids during the last two weeks of gestation required significantly less surgeries during their initial stay (p?=?0.003) as well as shorter parenteral feedings (p?=?0.002). A multivariate logistic regression showed that a GA of less than 36 weeks’ GA was is a pejorative factor for a stay above 60 days, regardless of whether it was a simple or complex gastroschisis, (OR=?3.8; p?=?0.021). A complex gastroschisis was a risk factor for significantly longer parenteral feedings, regardless of the center where patient is treated (Beta = ?0.3, p?=?0.035).

Conclusions: Future research should focus on decisions about delivery timing by incorporating risk of neonatal morbidity.     

Influence of time of delivery on risk of adverse neonatal outcome in different size of delivery units: a retrospective cohort study in Finland

Purpose: To evaluate the impact of time of birth on adverse neonatal outcome in singleton term hospital births.

Materials and methods: Medical Birth Register Data in Finland from 2005 to 2009. Study population was all hospital births (n?=?263,901), excluding multiple pregnancies, preterm births <37 weeks, major congenital anomalies or birth defects, and antepartum stillbirths. Main outcome measures were either 1-minute Apgar score 0–3, 5-minute Apgar score 0–6, or umbilical artery pH <7.00, and intrapartum and early neonatal mortality. We calculated risk ratios (ARRs) adjusted for maternal age and parity, and 95% confidence intervals (CIs) to indicate the probability of adverse neonatal outcome outside of office hours in normal vaginal delivery, in vaginal breech delivery, in instrumental vaginal delivery, and in elective and nonelective cesarean sections. We analyzed different size-categories of maternity hospitals and different on-call arrangements.

Results: Instrumental vaginal delivery had increased risk for mortality (ARR 3.31, 95%CI; 1.01–10.82) outside office hours. Regardless of hospital volume and on-call arrangement, the risk for low Apgar score or low umbilical artery pH was higher outside office hours (ARR 1.23, 95%CI; 1.15–1.30). Intrapartum and early neonatal mortality increased only in large, nonuniversity hospitals outside office hours (ARR 1.51, 95%CI; 1.07–2.14).

Conclusions: Compared to office hours, babies born outside office hours are in higher risk for adverse outcome. Demonstration of more detailed circadian effects on adverse neonatal outcomes in different subgroups requires larger data.