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Objectives: To investigate the association and the potential value of prelabour fetal heart rate short‐term variability (STV) determined by computerised cardiotocography (cCTG) and maternal and fetal Doppler in predicting labour outcomes. Design: Prospective cohort study. Setting: The Prince of Wales Hospital, a tertiary maternity unit, in Hong Kong SAR. Population: Women with a term singleton pregnancy in latent phase of labour or before labour induction were recruited during May 2019–November 2021. Methods: Prelabour ultrasonographic assessment of fetal growth, Doppler velocimetry and prelabour cCTG monitoring including Dawes–Redman CTG analysis were registered shortly before induction of labour or during the latent phase of spontaneous labour. Main outcome measures: Umbilical cord arterial pH, emergency delivery due to pathological CTG during labour and neonatal intensive care unit (NICU)/special care baby unit (SCBU) admission. Results: Of the 470 pregnant women invited to participate in the study, 440 women provided informed consent and a total of 400 participants were included for further analysis. Thirty‐four (8.5%) participants underwent emergency delivery for pathological CTG during labour. A total of 6 (1.50%) and 148 (37.00%) newborns required NICU and SCBU admission, respectively. Middle cerebral artery pulsatility index (MCA‐PI) and MCA‐PI z‐score were significantly lower in pregnancies that required emergency delivery for pathological CTG during labour compared with those that did not (1.23 [1.07–1.40] versus 1.40 [1.22–1.64], p = 0.002; and 0.55 ± 1.07 vs. 0.12 ± 1.06), p = 0.049]. This study demonstrated a weakly positive correlation between umbilical cord arterial pH and prelabour log10 STV (r = 0.107, p = 0.035) and the regression analyses revealed that the contributing factors for umbilical cord arterial pH were smoking (p = 0.006) and prelabour log10 STV (p = 0.025). Conclusions: In pregnant women admitted in latent phase of labour or for induction of labour at term, prelabour cCTG STV had a weakly positive association with umbilical cord arterial pH but was not predictive of emergency delivery due to pathological CTG during labour. [ABSTRACT FROM AUTHOR]

Objective: Deceleration area (DA) and capacity (DC) of the fetal heart rate can help predict risk of intrapartum fetal compromise. However, their predictive value in higher risk pregnancies is unclear. We investigated whether they can predict the onset of hypotension during brief hypoxaemia repeated at a rate consistent with early labour in fetal sheep with pre‐existing hypoxaemia. Design: Prospective, controlled study. Setting: Laboratory. Sample Chronically instrumented, unanaesthetised near‐term fetal sheep. Methods One‐minute complete umbilical cord occlusions (UCOs) were performed every 5 minutes in fetal sheep with baseline paO2 <17 mmHg (hypoxaemic, n = 8) and >17 mmHg (normoxic, n = 11) for 4 hours or until arterial pressure fell <20 mmHg. Main outcome measures: DA, DC and arterial pressure. Results: Normoxic fetuses showed effective cardiovascular adaptation without hypotension and mild acidaemia (lowest arterial pressure 40.7 ± 2.8 mmHg, pH 7.35 ± 0.03). Hypoxaemic fetuses developed hypotension (lowest arterial pressure 20.8 ± 1.9 mmHg, P < 0.001) and acidaemia (final pH 7.07 ± 0.05). In hypoxaemic fetuses, decelerations showed faster falls in FHR over the first 40 seconds of UCOs but the final deceleration depth was not different to normoxic fetuses. DC was modestly higher in hypoxaemic fetuses during the penultimate (P = 0.04) and final (P = 0.012) 20 minutes of UCOs. DA was not different between groups. Conclusion: Chronically hypoxaemic fetuses had early onset of cardiovascular compromise during labour‐like brief repeated UCOs. DA was unable to identify developing hypotension in this setting, while DC only showed modest differences between groups. These findings highlight that DA and DC thresholds need to be adjusted for antenatal risk factors, potentially limiting their clinical utility. [ABSTRACT FROM AUTHOR]

55 women (34.16%) had preterm labour, 68 (42.2%) had an emergency caesarean section, 25 (15.5%) had an operative vaginal birth and 25 (15.5%) had a spontaneous vaginal delivery (included 1 vaginal birth after caesarean section). B Method: b Data was analysed for the changes in rates of total births, induction of labour (IOL) and Caesarean section (CS), from a tertiary maternity unit over the last eleven years (2012- 2022). In the nulliparous CRB group, the average time from labour induction to delivery was 25.8 h. 31 women had normal vaginal delivery (NVD) with average costs of S$4244.00, 6 women required assisted vaginal delivery (AVD) with mean costs of S$4467.00 and 35 women required caesarean section (CS) with costs of S$6890.95. OP.0032 OptiBreech versus standard care for breech presentation at term: A pilot trial Shawn Walker 1,2; Emma Spillane 3; Kate Stringer 4; Lauren Trepte 2; Siân Davies 1; Jane... 1 King's College London, London, UK; 2 West Middlesex Hospital, Isleworth, UK; 3 Kingston Hos... B Background: b OptiBreech Care is a care pathway for breech presentation at term, including where chosen, vaginal breech birth (VBB) attended by professionals with advanced training. [Extracted from the article]

Objective: To investigate maternal lactate concentrations in labour and the puerperium. Design: Reference study. Setting: Tertiary obstetric unit. Population: 1279 pregnant women with good perinatal outcomes at term. Methods: Electronic patient records were searched for women who had lactate measured on the day of delivery or in the following 24 hours, but who were subsequently found to have a very low likelihood of sepsis, based on their outcomes. Main outcome measures: The normative distribution of lactate and C‐reactive protein (CRP), differences according to the mode of birth, and the proportion of results above the commonly used cut‐offs (≥2 and ≥4 mmol/l). Results: Lactate varied between 0.4–5.4 mmol/l (median 1.8 mmol/l, interquartile range [IQR] 1.3–2.5). It was higher in women who had vaginal deliveries than caesarean sections (median 1.9 vs. 1.6 mmol/l, pdiff < 0.001), demonstrating the association with labour (particularly active pushing in the second stage). In contrast, CRP was more elevated in women who had caesarean sections (median 71.8 mg/l) than those who had vaginal deliveries (33.4 mg/l, pdiff < 0.001). In total, 40.8% had a lactate ≥2 mmol/l, but 95.3% were <4 mmol/l. Conclusions: Lactate in labour and the puerperium is commonly elevated above the levels expected in healthy pregnant or non‐pregnant women. There is a paucity of evidence to support using lactate or CRP to make decisions about antibiotics around the time of delivery but, as lactate is rarely higher than 4 mmol/l, this upper limit may still represent a useful severity marker for the investigation and management of sepsis in labour. [ABSTRACT FROM AUTHOR]

Increased fetal heart rate variability (FHRV) in intrapartum cardiotocographic recording has been variably defined and poorly understood, limiting its clinical utility. Both preclinical (animal) and clinical (human) evidence support that increased FHRV is observed in the early stage of intrapartum fetal hypoxaemia but can also be observed in a subset of fetuses during the preterminal stage of repeated hypoxaemia. This review of available evidence provides data and expert opinion on the pathophysiology of increased FHRV, its clinical significance and a stepwise approach regarding the management of this pattern, and propose recommendations for standardisation of related terminology. Increased fetal heart rate variability is parasympathetic‐mediated and is caused by acutely deteriorating placental function. [ABSTRACT FROM AUTHOR]

Despite higher strength of uterine contractions among obese parturients, they reach the active stage of labour less often than leaner ones. Linked article: This article is commented on by Mikko Tarvonen, pp. 1798 in this issue. To view this minicommentary visit https://doi.org/10.1111/1471-0528.17153 [ABSTRACT FROM AUTHOR]

Objective: To assess the current status of caesarean delivery (CD) in China, propose reference CD rates for China overall, and by regions, investigate the main indications for CDs and identify possible areas for safe reduction. Design: A multicentre cross‐sectional study. Setting: A total of 94 hospitals across 23 provinces in China. Population: A total of 73 977 randomly selected deliveries. Methods: We used a modified Robson classification to characterise CDs in subgroups and by regions, and the World Health Organization (WHO) C‐Model to calculate reference CD rates. Main outcome measures: CD rates in China. Results: In 2015–2016, the overall CD rate in China was 38.9% (95% CI 38.6–39.3%). Considering the obstetric characteristics of the population, the multivariable model‐based reference CD rate was estimated at 28.5% (95% CI 28.3–28.8%). Accordingly, an absolute reduction of 10.4% (or 26.7% relative reduction) may be considered. The CD rate varied substantially by region. Previous CD was the most common indication in all regions, accounting for 38.2% of all CDs, followed by maternal request (9.8%), labour dystocia (8.3%), fetal distress (7.7%) and malpresentation (7.6%). Overall, 12.7% of women had prelabour CDs, contributing to 32.8% of the total CDs. Conclusions: Nearly 39% of births were delivered by caesarean in China but a reduction of this rate by a quarter may be considered attainable. Repeat CD contributed more than one‐third of the total CDs. Given the large variation in maternal characteristics, region‐specific or even hospital‐specific reference CD rates are needed for precision management of CD. The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%. The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%. Linked article This article is commented on by M Varner, p. 148 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16953. [ABSTRACT FROM AUTHOR]

Objective: To assess whether delivery mode and duration of labour in a first labour of spontaneous onset is associated with gestational length, delivery mode and neonatal outcome in the subsequent pregnancy. Study design: Retrospective analysis of prospectively collected data. Setting: 15 Maternity units in North West London (1988–2000). Population: 30 840 women with spontaneous onset of labour in pregnancy 1 and a subsequent birth reported in the same database. Methods: Assessment of outcomes by mode of delivery in pregnancy 1, restricting the analysis to the difference in the gestational length between pregnancy 1 and 2. Main outcome measures: Gestational length, mode of delivery and neonatal unit admission in pregnancy 2. Results: Caesarean section (CS) in the first or second stage of labour in pregnancy 1 was associated with pregnancy 2 being a median of 5 and 8 days shorter and a preterm birth rate of 6.0% and 10.1%, respectively, whereas following a normal or instrumental vaginal birth in pregnancy 1, the median duration was similar, with preterm delivery rates of 4.5% and 3.9%. In all, 56.2% of women with a CS in pregnancy 1 had a repeat CS and 12.5% of their babies were admitted to a neonatal unit, compared with 5.3% of women with vaginal birth. Longer labours were associated with shorter gestations in pregnancy 2. Conclusions: Compared with vaginal birth, an emergency CS in the first‐term pregnancy is associated with a shorter gestational length, increased rate of repeat CS and increased risk of NNU admission in the next pregnancy. An emergency caesarean section in the first‐term pregnancy affects the duration and outcome of the next pregnancy. An emergency caesarean section in the first‐term pregnancy affects the duration and outcome of the next pregnancy. [ABSTRACT FROM AUTHOR]

B Results b 160 deliveries were included, 43% delivered by OVD in theatre and 57% delivered by CS. 48% of all CS having no attempted OVD before. 1978 The risk of preterm delivery following caesarean section at full dilation B Windrim, C SP 1,2 sp ; McEvoy, A SP 1 sp ; Corcoran, S SP 1,2 sp b SP 1 sp National Maternity Hospital, Dublin, Ireland; SP 2 sp University College Dublin, Dublin, Ireland B Objective b Caesarean delivery rates continue to rise worldwide with an increasing proportion occurring at full dilation (FDCS). 2289 Labour management: active phase versus latent phase at the time of admission B Shah, J SP 1,2 sp ; Shah, S SP 2 sp b SP 1 sp Sheth L.G. Hospital, Ahmadabad, India; SP 2 sp SBKS MI & RC, Vadodara, India B Objective b To study the patients in both active and latent phase of labour at the time of admission, who are left for spontaneous delivery and in whom induction of labour is done and correlate the same with mode of delivery and fetal outcome. B Conclusions b The change in induction procedures has significantly improved the proportion of complex deliveries occurring in-hours and improved the proportion of total caesarean sections occurring in-hours, despite an overall fall in the caesarean section rate. This work suggests that pregnancies progressing past 42 + 0 weeks gestation lead to a high rate of adverse outcomes and induction of labour guidelines should aim for delivery prior to 42 + 0. 1435 Ultrasound-guided transversus abdominis plane block for post-cesarean analgesia: a double-bli... B Shields Pimentel, R; Galbo, P; Rachel Ponce, A; Rose Taladro, M b Cebu Doctors' University Hospital, Cebu City, Philippines B Objective b To determine the analgesic efficacy of the ultrasound-guided TAP block for post-cesarean analgesia versus placebo. [Extracted from the article]

Objective: To determine the risk of spontaneous and medically indicated preterm birth associated with mode of birth in previous term‐born pregnancy. Design: Retrospective cohort study. Setting: Two UK maternity units. Population or sample: A total of 16 340 women with first two consecutive singleton births and the first birth at term. Methods: Retrospective cohort study using routinely collected clinical data. Main outcome measures: Incidence of spontaneous preterm birth and medically indicated preterm birth at less than 37 weeks of gestation after term birth, in relation to mode of birth in first pregnancy. Subgroup analysis on cervical dilatation at the time of first caesarean birth. Results: Compared with vaginal birth, emergency caesarean birth at full dilatation was associated with an increase in spontaneous preterm birth (2.3% vaginal birth versus 4.5% full dilatation caesarean; adjusted odds ratio [aOR] 3.29, 95% CI 2.02–5.13, P < 0.001). Elective caesarean, emergency caesarean at <4 cm dilatation, and emergency caesarean at 4–9 cm dilatation were associated with increased medically indicated preterm birth (0.8% vaginal births versus 1.9% elective caesarean, 3.3% <4 cm caesarean, 1.3% 4–9 cm caesarean; aOR 2.30, 95% CI 1.19–4.15, P = 0.009; aOR 4.68, 95% CI 2.98–7.24, P < 0.001; and aOR 2.43, 95% CI 1.43–4.00, P = 0.001, respectively). Conclusions: Term caesarean in the first stage of labour or performed prelabour is associated with medically indicated preterm birth. Term caesarean in the second stage of labour is associated with spontaneous preterm birth. Caesarean in the second stage of labour is associated with spontaneous preterm birth. Caesarean in the second stage of labour is associated with spontaneous preterm birth. [ABSTRACT FROM AUTHOR]

Objective: To compare neonatal outcomes of women with a body mass index (BMI) of ≥35 kg/m2 who underwent a trial of labour with those of women who underwent a planned primary caesarean section (CS). Design: A retrospective cohort study of births between April 2012 and March 2014. Setting: A provincial database: Better Outcomes Registry & Network (BORN) Ontario, Canada. Population: A cohort of 8752 women with a BMI of ≥35 kg/m2 who had a singleton birth at 38–42 weeks of gestation. Methods: Neonatal outcomes were compared between women who underwent a trial of labour (with either a successful vaginal birth or intrapartum CS) and those who underwent a planned CS. Main outcome measure: A composite of any of the following outcomes: intrapartum neonatal death, neonatal intensive care unit admission, 5‐minute Apgar score of <7 or umbilical artery pH of <7.1. Results: During the study period, 8433 (96.4%) women had a trial of labour and 319 (3.6%) had a planned CS. Intrapartum CS was performed in 1644 (19.5%) cases. There was no association between planned mode of delivery and the primary outcome (aOR 0.80, 95% CI 0.59–1.07). The primary outcome was lower among women who had a successful trial of labour (aOR 0.67, 95% CI 0.50–0.91) and was higher among women who had a failed trial of labour (aOR 1.74, 95% CI 1.21–2.48), compared with women who underwent a planned CS. Conclusions: In women with a BMI of ≥35 kg/m2 at a gestational age of 38–42 weeks, neonatal outcomes are comparable between planned vaginal delivery and planned CS, although a failed trial of labour is at risk of adverse neonatal outcome. Neonatal outcomes are not affected by planned mode of delivery in women who are obese, with a BMI of ≥35 kg/m2. Neonatal outcomes are not affected by planned mode of delivery in women with obesity BMI ≥35 kg/m2. [ABSTRACT FROM AUTHOR]

In their recent commentary, Hofmeyr et al. anticipate that departure from the familiar partograph 'may provoke anxiety and even antipathy among healthcare professionals'.1 We agree that change is urgently needed to reach beyond the coexistence of "too little, too late" and "too much, too soon" care during childbirth.2 In particular, we applaud the World Health Organization (WHO) for their underlying Better Outcomes in Labour Difficulty (BOLD) project, which has revealed the urgency of delaying the onset of the active phase of the first stage of labour from 3-4 cm of cervical dilatation to at least 5 cm.3 We do agree that the previously premature designation was 'a major iatrogenic cause of apparent poor labour progress and unnecessary interventions', which has contributed to the epidemic of caesarean sections in many countries globally.1 For the Labour Care Guide (LCG) to catalyse change, we urge the WHO to consider three major concerns, relevant for labour practice, before any further LCG implementation. World Health Organization partograph in management of labour. As the LCG stands now, the new "partograph" may work in private practice with one-to-one care, a birth companion present and pain relief available. [Extracted from the article]

Objectives: To test whether providing psychological self-help materials would significantly lower the incidence of post-traumatic stress disorder (PTSD) at 6-12 weeks postnatally.Design: Open-label randomised controlled trial, with blinded outcome assessment.Setting: Community midwifery services in two National Health Service (NHS) trusts in the North West.Sample: A cohort of 2419 women receiving normal NHS postnatal care.Methods: Midwives screened women for traumatic birth experience; 678 women who screened positively (28.1%) were randomly allocated to self-help with usual care (n = 336) or to usual care alone (n = 342). The self-help materials were a leaflet and online film designed to prevent the development of PTSD after trauma exposure through explaining how to manage early psychological responses.Main Outcome Measure: The primary outcome was a composite of diagnostic and subdiagnostic PTSD at 6-12 weeks postnatally using the gold-standard Clinician-Administered PTSD Scale (CAPS-5) interview.Results: Of the 678 women correctly randomised plus the nine women randomised in error, 478 (70.5%) were followed up. Diagnostic or subdiagnostic PTSD rates at follow-up did not differ between groups who received self-help (26.7%, 65/243) or usual care alone (26.2%, 64/244) (intention-to-treat analysis: RR 1.02, 95% CI 0.68-1.53). Findings remained consistent in the per-protocol analysis (RR 1.04, 95% CI 0.85-1.27). Women viewed the materials very positively. There were no adverse effects. Health economic micro-costing indicated implementation would be very low cost.Conclusions: Many women experience a traumatic birth and risk developing PTSD, but self-help strategies without professional support are insufficient and should not be routinely introduced.Tweetable Abstract: Self-help information alone does not reduce the number of women developing PTSD after a traumatic childbirth. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to establish rotational thromboelastometry (ROTEM® ) baseline parameters in labouring women at term gestation. The secondary aim was to compare these reference ranges with those from previous studies on labouring women and from the manufacturer.Design: A prospective, observational study.Setting: Tertiary referral hospital.Participants: Healthy women in labour.Methods: Ethics approval was granted for an opt-out recruitment approach. ROTEM® testing was performed in labouring women at term gestation. Women with any condition affecting coagulation were excluded. ROTEM® Delta reference ranges were derived by calculating the 2.5% and 97.5% centiles for INTEM/EXTEM/FIBTEM parameters including amplitude at 5 minutes (A5), coagulation time (CT) and maximum clot firmness (MCF).Main Outcome Measures: ROTEM® parameters were measured in labouring women before delivery. The following tests were performed: FIBTEM, EXTEM and INTEM.Results: One hundred and twenty-one women met the inclusion criteria, with a mean (± SD) age of 29.6 ± 5.4 years and median (interquartile range) gestation of 39.4 weeks (37.4-40.4 weeks). Seventy-five (62.0%) women were nulliparous and 71 (58.7%) delivered vaginally. The median and interquartile ranges for selected ROTEM® parameters were: FIBTEM A5, 21 mm (IQR 18-23 mm); EXTEM A5, 55 mm (52-58 mm); and EXTEM CT, 52 seconds (48-56 seconds).Conclusions: The FIBTEM/EXTEM/INTEM amplitudes were higher than the manufacturer's reference ranges for non-obstetric patients. The FIBTEM MCF upper and lower limits were higher and the EXTEM/INTEM CT was shorter and narrower in range. This study provides reference ranges for ROTEM® values in healthy labouring women at term gestation with uncomplicated pregnancies.Tweetable Abstract: This is the first study to report on ROTEM® reference ranges with over 120 healthy labouring women of normal weight at term gestation. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether a history of spontaneous early-term birth (37+0 -38+6  weeks of gestation) in the previous singleton pregnancy is a risk factor for preterm birth (PTB) in a subsequent twin pregnancy.Design: Retrospective cohort study.Settings: Two French university hospitals (2006-2016).Population: All women who delivered twins from 24+0  weeks after a preceding singleton pregnancy birth at 37+0 to 41+6  weeks.Methods: Multivariate logistic regression analysis of association between twin PTB and a previous spontaneous singleton early-term birth.Main Outcome Measures: Twin PTB rate before 37, 34 and 32 weeks of gestation.Results: Among 618 twin pregnancies, 270 were born preterm, 92 of them with a preceding spontaneous singleton early-term birth. The univariate analysis showed a significantly higher risk of twin PTB before 37, 34 and 32 weeks among those 92 women compared with those with a full- or late-term birth in their previous singleton pregnancy. This association remained significant after logistic regression (odds ratio [OR] between 2.42 and 3.88). The secondary analysis, restricted to the twin pregnancies with spontaneous PTB found similar results, with a risk of PTB before 37, 34 and 32 weeks significantly higher among women with a previous spontaneous singleton early-term birth, including after logistic regression analysis (OR between 3.51 and 3.56).Conclusion: A preceding spontaneous singleton early-term birth is a strong and easily identified risk factor for PTB in twin pregnancies.Tweetable Abstract: Spontaneous 'early-term' birth of a singleton is a significant risk factor for future preterm births in twin pregnancies. [ABSTRACT FROM AUTHOR]

Objective: To assess the maternal characteristics and causes associated with refractory postpartum haemorrhage (PPH).Design: Secondary analysis of the WHO CHAMPION trial data.Setting: Twenty-three hospitals in ten countries.Population: Women from the CHAMPION trial who received uterotonics as first-line treatment of PPH.Methods: We assessed the association between sociodemographic, pregnancy and childbirth factors and refractory PPH, and compared the causes of PPH between women with refractory PPH and women responsive to first-line PPH treatment.Main Outcome Measures: Maternal characteristics; causes of PPH.Results: Women with labour induced or augmented with uterotonics (adjusted odds ratio [aOR] 1.35; 95% CI 1.07-1.72), with episiotomy or tears requiring suturing (aOR 1.82; 95% CI 1.34-2.48) and who had babies with birthweights ≥3500 g (aOR 1.33; 95% CI 1.04-1.69) showed significantly higher odds of refractory PPH compared with the reference categories in the multivariate analysis adjusted by centre and trial arm. While atony was the sole PPH cause in 53.2% (116/218) of the women in the responsive PPH group, it accounted for only 31.5% (45/143) of the causes in the refractory PPH group. Conversely, tears were the sole cause in 12.8% (28/218) and 28% (40/143) of the responsive PPH and refractory PPH groups, respectively. Placental problems were the sole cause in 11 and 5.6% in the responsive and refractory PPH groups, respectively.Conclusion: Women with refractory PPH showed a different pattern of maternal characteristics and PPH causes compared with those with first-line treatment responsive PPH.Tweetable Abstract: Women with refractory postpartum haemorrhage are different from those with first-line treatment responsive PPH. [ABSTRACT FROM AUTHOR]

Objective: To compare clinical outcomes following induction of labour (IOL) using a balloon catheter and going home, versus prostaglandin (PG) as an inpatient.Design: Randomised controlled trial.Setting: Eight Australian maternity hospitals.Population: Women with uncomplicated term singleton pregnancies undergoing IOL for low-risk indications including post-term, advanced maternal age and 'social' reasons.Methods: Between September 2015 and October 2018, 347 women were randomised to a balloon outpatient group and 348 to a PG inpatient group. The PG group received Dinoprostone, either 2 mg gel or 10 mg controlled-release tape. The balloon group had a double-balloon catheter inserted and went home.Main Outcome Measures: The primary outcome was a composite neonatal measure comprising nursery admission, intubation/cardiac compressions, acidaemia, hypoxic ischaemic encephalopathy, seizure, infection, pulmonary hypertension, stillbirth or death. Clinical and process outcomes are reported.Results: There were no statistically significant differences in the primary outcome comparing balloon with PG (18.6% versus 25.8%; relative risk = 0.77, 95% CI 0.51-1.02; P = 0.070), cord arterial pH <7.10 (3.5% versus 9.2%; P = 0.072), nursery admissions (12.6% versus 15.5%; P = 0.379), neonatal antibiotic use (12.1% versus 17.6%; P = 0.103), or mode of birth. Nulliparous women in the balloon group had lower rates of the primary outcome (20.4% versus 31.0%;P = 0.032); Parous women were less likely to have an unassisted vaginal birth (77.6% versus 92.3%; P = 0.045).Conclusions: Balloon catheters may be a superior method of cervical priming for nulliparous women, whereas this may not be the case for parous women. It is feasible that nulliparous women go home after commencing balloon catheter IOL, and the likelihood of adverse outcomes is low.Tweetable Abstract: Multicentre trial shows outpatient induction using balloon catheter is safe and feasible for nulliparous women. [ABSTRACT FROM AUTHOR]

Background: There are questions about the use of the 'one-centimetre per hour rule' as a valid benchmark for assessing the adequacy of labour progress.Objectives: To determine the accuracy of the alert (1-cm/hour) and action lines of the cervicograph in the partograph to predict adverse birth outcomes among women in first stage of labour.Search Strategy: PubMed, EMBASE, CINAHL, POPLINE, Global Health Library, and reference lists of eligible studies.Selection Criteria: Observational studies and other study designs reporting data on the correlation between the alert line status of women in labour and the occurrence of adverse birth outcomes.Data Collection and Analysis: Two reviewers at a time independently identified eligible studies and independently abstracted data including population characteristics and maternal and perinatal outcomes.Main Results: Thirteen studies in which 20 471 women participated were included in the review. The percentage of women crossing the alert line varied from 8 to 76% for all maternal or perinatal outcomes. No study showed a robust diagnostic test accuracy profile for any of the selected outcomes.Conclusions: This systematic review does not support the use of the cervical dilatation over time (at a threshold of 1 cm/h during active first stage) to identify women at risk of adverse birth outcomes.Tweetable Abstract: Alert line of partograph does not identify women at risk of adverse birth outcomes. [ABSTRACT FROM AUTHOR]

Objective: To assess intrapartum/neonatal mortality and morbidity risk in infants born at 37 weeks of gestation compared with infants born at 39–41 weeks of gestation. Design: Nationwide cohort study. Setting: The Netherlands. Population: A total of 755 198 women delivering at term of a singleton without congenital malformations during 2010–14. Methods: We used data from the national perinatal registry (PERINED). Analysis was performed with logistic regression and stratification for the way labour started and type of care. Main outcome measures: Intrapartum or neonatal mortality up to 28 days and adverse neonatal outcome (neonatal mortality, 5‐minute Apgar <7, and/or neonatal intensive care unit admission). Results: At 37 weeks of gestation intrapartum/neonatal mortality was 1.10‰ compared with 0.59‰ at 39–41 weeks (P < 0.0001). Adjusted odds ratio (aOR) for 37 weeks compared with 39–41 weeks was 1.84 (95% CI) 1.39–2.44). Adverse neonatal outcome at 37 weeks was 21.4‰ compared with 12.04‰ at 39–41 weeks (P < 0.0001) with an aOR 1.63 (95% CI 1.53–1.74). Spontaneous start of labour at 37 weeks of gestation was significantly associated with increased intrapartum/neonatal mortality with an aOR of 2.20 (95% CI 1.56–3.10), in both primary (midwifery‐led) care and specialist care. Neither induction of labour nor planned caesarean section showed increased intrapartum/neonatal mortality risk. Conclusions: Birth at 37 weeks of gestation is independently associated with a higher frequency of clinically relevant adverse perinatal outcomes than birth at 39–41 weeks. In particular, spontaneous start of labour at 37 weeks of gestation doubles the risk for intrapartum/neonatal mortality. Extra fetal monitoring is warranted. Birth at 37 weeks of gestation gives markedly higher intrapartum/neonatal mortality risk than at 39–41 weeks, especially with spontaneous start of labour. Tweetable abstract Birth at 37 weeks of gestation gives markedly higher intrapartum/neonatal mortality risk than at 39–41 weeks, especially with spontaneous start of labour. [ABSTRACT FROM AUTHOR]

Objective: To investigate the relation between vaginal microbiota composition and outcome of rescue cervical cerclage.Design: Prospective observational study.Setting: Queen Charlotte's and Chelsea Hospital, London.Population: Twenty singleton pregnancies undergoing a rescue cervical cerclage.Methods: Vaginal microbiota composition was analysed in women presenting with a dilated cervix and exposed fetal membranes before and 10 days following rescue cervical cerclage and was correlated with clinical outcomes.Main Outcome Measures: Composition of vaginal bacteria was characterised by culture-independent next generation sequencing. Successful cerclage was defined as that resulting in the birth of a neonate discharged from hospital without morbidity. Unsuccessful cerclage was defined as procedures culminating in miscarriage, intrauterine death, neonatal death or significant neonatal morbidity.Results: Reduced Lactobacillus spp. relative abundance was observed in 40% of cases prior to rescue cerclage compared with 10% of gestation age-matched controls (8/20, 40% versus 3/30, 10%, P = 0.017). Gardnerella vaginalis was over-represented in women presenting with symptoms (3/7, 43% versus 0/13, 0%, P = 0.03, linear discriminant analysis, LDA (log 10) and cases culminating in miscarriage (3/6, 50% versus 0/14, 0%, P = 0.017). In the majority of cases (10/14, 71%) bacterial composition was unchanged following cerclage insertion and perioperative interventions.Conclusions: Reduced relative abundance of Lactobacillus spp. is associated with premature cervical dilation, whereas high levels of G. vaginalis are associated with unsuccessful rescue cerclage cases. The insertion of a rescue cerclage does not affect the underlying bacterial composition in the majority of cases.Tweetable Abstract: Preterm cervical dilatation associates with reduced Lactobacillus spp. Presence of Gardnerella vaginalis predicts rescue cerclage failure. [ABSTRACT FROM AUTHOR]

Objective: To investigate the association of chorioamnionitis and its duration with adverse maternal outcomes by mode of delivery.Design: A retrospective cohort study.Setting: Data from the Consortium on Safe Labor Study in the USA (2002-2008).Population: Singleton deliveries at ≥23 weeks of gestation (221 274 assessed deliveries, 62 331 by caesarean section).Methods: The association of chorioamnionitis, and secondarily the duration of chorioamnionitis estimated from intrapartum antibiotic use, with adverse maternal outcomes was analysed using logistic regression with generalised estimating equations, adjusting for age, parity, race, pregestational diabetes, chronic hypertension, gestational age at delivery, study site and delivery year. Analyses were stratified by vaginal versus caesarean delivery.Main Outcome Measures: The composite adverse maternal outcome included: postpartum transfusion, endometritis, wound/perineal infection/separation, venous thromboembolism, hysterectomy, admission to intensive care unit and/or death.Results: Chorioamnionitis was associated with higher odds of the composite adverse maternal outcome with caesarean delivery (adjusted odds ratio 2.31; 95% CI 1.97-2.71); and the association persisted regardless of whether a woman had a trial of labour, preterm delivery or maternal group B streptococcus colonisation. The most common adverse outcomes after caesarean section were postpartum transfusion (56.0%) and wound/perineal infection or endometritis (38.6%). Chorioamnionitis was not associated with adverse maternal outcomes after vaginal delivery. The duration of chorioamnionitis as the exposure did not alter the association between chorioamnionitis and adverse maternal outcomes.Conclusions: Chorioamnionitis, but not the estimated duration, was associated with increased odds of adverse maternal outcomes with caesarean delivery. This finding has implications for care programmes to prevent maternal morbidity after a caesarean section complicated by chorioamnionitis.Tweetable Abstract: Chorioamnionitis, but not its duration, increases the risk of adverse maternal outcomes with caesarean delivery. [ABSTRACT FROM AUTHOR]

The article discusses various issues related to labour and gynecology as of 2019. Topics include a study in Great Britain on the termination of pregnancy using mifepristone followed by misoprostol, the non-clinical interventions recommended by the World Health Organization to reduce unnecessary caesarean sections, the enactment of the Safe Motherhood and Reproductive Health Rights Act to protect women's rights in Nepal.

Background: Controversy exists regarding the optimal mode of delivery for fetuses with open neural tube defects.Objective: To compare neurological outcomes among infants with open neural tube defects who underwent vaginal compared with caesarean delivery.Search Strategy: Electronic databases MEDLINE, EMBASE, Scopus, and Clinicaltrials.gov were searched from inception to November 2017.Selection Criteria: Eligible studies included observational or randomised studies comparing vaginal and caesarean delivery in pregnancies with fetal open neural tube defects who did not undergo prenatal repair.Data Collection and Analysis: Two reviewers independently reviewed abstracts and full-text articles. Outcomes were compared between vaginal and caesarean delivery and prelabour caesarean versus exposure to labour. The primary outcome was motor-anatomic level difference. Secondary outcomes included shunt requirement, sac disruption, meningitis, and ambulation at 2 years. Meta-analysis was performed and mean difference or odds ratios with 95% CI were calculated.Main Results: Of 201 abstracts identified in the primary search, nine studies (672 women) met the eligibility criteria. Comparing vaginal and caesarean delivery, there was no significant difference in motor-anatomic level difference (mean difference -0.10, 95% CI -0.58 to 0.38; I2  = 57%). The vaginal delivery group was less likely to require a shunt or have sac disruption [odds ratio (OR) 0.37, 95% CI 0.14-0.95 and OR 0.46, 95% CI 0.23-0.90, respectively]. Comparisons by prelabour caesarean versus exposure to labour showed no significant difference in motor-anatomic level difference (OR 1.29, 95% CI 0.63-3.21) or ambulation at 2 years (OR 2.13, 95% CI 0.35-13.12).Conclusion: Caesarean delivery was not associated with improved neurological outcomes among fetuses with open neural tube defects.Tweetable Abstract: Available evidence does not support routine caesarean delivery for fetuses with open neural tube defects. [ABSTRACT FROM AUTHOR]

Objective: International comparison of complete uterine rupture.Design: Descriptive multi-country population-based study.Setting: International.Population: International Network of Obstetric Survey Systems (INOSS).Methods: We merged individual data, collected prospectively in nine population-based studies, of women with complete uterine rupture, defined as complete disruption of the uterine muscle and the uterine serosa, regardless of symptoms and rupture of fetal membranes.Main Outcome Measures: Prevalence of complete uterine rupture, regional variation and correlation with rates of caesarean section (CS) and trial of labour after CS (TOLAC). Severe maternal and perinatal morbidity and mortality.Results: We identified 864 complete uterine ruptures in 2 625 017 deliveries. Overall prevalence was 3.3 (95% CI 3.1-3.5) per 10 000 deliveries, 22 (95% CI 21-24) in women with and 0.6 (95% CI 0.5-0.7) in women without previous CS. Prevalence in women with previous CS was negatively correlated with previous CS rate (ρ = -0.917) and positively correlated with TOLAC rate of the background population (ρ = 0.600). Uterine rupture resulted in peripartum hysterectomy in 87 of 864 women (10%, 95% CI 8-12%) and in a perinatal death in 116 of 874 infants (13.3%, 95% CI 11.2-15.7) whose mother had uterine rupture. Overall rate of neonatal asphyxia was 28% in neonates who survived.Conclusions: Higher prevalence of complete uterine ruptures per TOLAC was observed in countries with low previous CS and high TOLAC rates. Rates of hysterectomy and perinatal death are about 10% following complete uterine rupture, but in women undergoing TOLAC the rates are extremely low (only 2.2 and 3.2 per 10 000 TOLACs, respectively.) TWEETABLE ABSTRACT: Prevalence of complete uterine rupture is higher in countries with low previous CS and high TOLAC rates. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of admission cardiotocography (ACTG) versus intermittent auscultation (IA) of the fetal heart (FH) in low-risk pregnancy during assessment for possible labour on caesarean section rates.Design: A parallel multicentre randomised trial.Setting: Three maternity units in the Republic of Ireland.Population: Healthy, low-risk pregnant women, at term and ≥ 18 years old, who provided written informed consent.Methods: Women were randomised to receive IA of the FH or 20 minutes ACTG on admission for possible labour onset, using remote telephone randomisation. Both groups received IA during labour, with conversion to continuous CTG as clinically indicated.Main Outcome Measures: Caesarean section (primary outcome), obstetric interventions (e.g. continuous CTG during labour, fetal blood sampling, augmentation of labour) and neonatal morbidity (e.g. metabolic acidosis, admission to the neonatal intensive care unit, neonatal death).Results: Based on 3034 women (1513 and 1521 randomised to IA and ACTG, respectively), there was no statistical difference between the groups in caesarean section [130 (8.6%) and 105 (6.9%) for IA and ACTG groups, respectively; relative risk (RR) 1.24; 95% CI 0.97-1.58], or in any other outcome except for use of continuous CTG during labour, which was lower in the IA group (RR 0.90, 95% CI 0.86-0.93).Conclusion: Our study demonstrates no differences in obstetric or neonatal outcomes between IA and ACTG for women with possible labour onset, other than an increased risk for continuous CTG in women receiving ACTG.Tweetable Abstract: No differences in outcomes between intermittent auscultation and admission cardiotocography for women with possible labour onset. [ABSTRACT FROM AUTHOR]

Objective: Does planned caesarean compared with planned vaginal birth lower the risk of problematic urinary stress, faecal, or flatal incontinence?Design: Women between 320/7 and 386/7 weeks of gestation with a twin pregnancy were randomised to planned caesarean or planned vaginal birth.Setting: The trial took place at 106 centres in 25 countries.Population: A total of 2305 of the 2804 women enrolled in the study completed questionnaires at 2 years (82.2% follow-up): 1155 in the planned caesarean group and 1150 in the planned vaginal birth group.Methods: A structured self-administered questionnaire completed at 2 years postpartum.Main Outcome Measures: The primary maternal outcome of the Twin Birth Study was problematic urinary stress, or fecal, or flatal incontinence at 2 years RESULTS: Women in the planned caesarean group had lower problematic urinary stress incontinence rates compared with women in the planned vaginal birth group [93/1147 (8.11%) versus 140/1143 (12.25%); odds ratio, 0.63; 95% confidence interval, 0.47-0.83; P = 0.001]. Among those with problematic urinary stress incontinence, quality of life (measured using the Incontinence Impact Questionnaire, IIQ-7) was not different for planned caesarean versus planned vaginal birth groups [mean (SD): 18.4 (21.0) versus 19.1 (21.5); P = 0.82]. There were no differences in problematic faecal or flatal incontinence, or in other maternal outcomes.Conclusions: Among women with a twin pregnancy and no prior history of urinary stress incontinence, a management strategy of planned caesarean compared with planned vaginal birth reduces the risk of problematic urinary stress incontinence at 2 years postpartum. Our findings show that the prevalence but not the severity of urinary stress incontinence was associated with mode of birth.Funding: Canadian Institutes of Health Research (CIHR) (grant no. MCT-63164).Tweetable Abstract: For women with twins, planned caesarean compared with planned vaginal birth is associated with decreased prevalence but not severity of urinary stress incontinence at 2 years. [ABSTRACT FROM AUTHOR]

Objective: To determine the effectiveness and economic impact of two methods for induction of labour in hypertensive women, in low-resource settings.Design: Cost-consequence analysis of a previously reported multicentre, parallel, open-label randomised trial.Setting& Population: A total of 602 women with a live fetus, aged ≥18 years requiring delivery for pre-eclampsia or hypertension, in two public hospitals in Nagpur, India.Methods: We performed a formal economic evaluation alongside the INFORM clinical trial. Women were randomised to receive transcervical Foley catheterisation or oral misoprostol 25 mcg. Healthcare expenditure was calculated using a provider-side microcosting approach.Main Outcome Measures: Rates of vaginal this delivery within 24 hours of induction, healthcare expenditure per completed treatment episode.Results: Induction with oral misoprostol resulted in a (mean difference) $20.6USD reduction in healthcare expenditure [95% CI (-) $123.59 (-) $72.49], and improved achievement of vaginal delivery within 24 hours of induction, mean difference 10% [95% CI (-2 to 17.9%), P = 0.016]. Oxytocin administration time was reduced by 135.3 minutes [95% CI (84.4-186.2 minutes), P < 0.01] and caesarean sections by 9.1% [95% CI (1.1-17%), P = 0.025] for those receiving oral misoprostol. Following probabilistic sensitivity analysis, oral misoprostol was cost-saving in 63% of 5,000 bootstrap replications and achieved superior rates of vaginal delivery, delivery within 24 hours of induction and vaginal delivery within 24 hours of induction in 98.7%, 90.7%, and 99.4% of bootstrap simulations. Based on univariate threshold analysis, the unit price of oral misoprostol 25 mcg could feasibly increase 31-fold from $0.24 to $7.50 per 25 mcg tablet and remain cost-saving.Conclusion: Compared to Foley catheterisation for the induction of high-risk hypertensive women, oral misoprostol improves rates of vaginal delivery within 24 hours of induction and may also reduce costs. Additional research performed in other low-resource settings is required to determine their relative cost-effectiveness.Tweetable Abstract: Oral misoprostol less costly and more effective than Foley catheter for labour induction in hypertension. [ABSTRACT FROM AUTHOR]

The transcription factor nuclear factor kappa B (NFκB) controls the expression of over 400 genes, some of which are associated with reproductive events. During implantation, immune cells accumulate in the maternal-fetal interface; they secrete inflammatory mediators under the control of NFĸB, the level of which also rises. NFĸB is then downregulated to maintain gestation, but its level rises again before birth to manage prostaglandin, cytokine, and chemokine synthesis, and to stimulate uterine contraction. This review summarises the current state of knowledge about NFκB and its role in the molecular regulation of processes related to pregnancy development.Tweetable Abstract: This review examines the current state of knowledge about role of NFκB in the development of pregnancy. [ABSTRACT FROM AUTHOR]

The article focuses on the issues relating to the mistreatment of women during childbirth in Latin America. It mentions the information on the pregnancy complications. It also mentions the laws relating to prevent obstetric violence, women's rights and gender-based violence along with the need to protect the human right to dignified, quality maternity care.

Background: It has been suggested that cervical ripening with a balloon catheter for labour induction can be done in an outpatient setting in low-risk pregnancies. Introduction of such an approach needs to be accompanied with monitoring of potential complications. Therefore the existence and frequency of any associated adverse event during cervical ripening needs to be established.Objective: To assess the complication rate during cervical ripening with balloon induction.Search Strategy: We searched Embase, Medline, Cochrane Collaboration and CINAHL using keywords 'induction of labour', 'cervical ripening', 'balloon catheter', 'Foley balloon', 'transcervical balloon'.Selection Criteria: We included randomized controlled trials and cohort studies containing original data on fetal and maternal morbidity in pregnant women during cervical ripening with a balloon catheter. Only articles for which authors were able to give data for this exact time frame were included.Data Collection and Analysis: Two reviewers assessed independently the eligibility of included studies, extracted data and performed a quality assessment. A meta-analysis was performed to calculate the estimated prevalence of the adverse events.Main Results: In total 26 studies were included reporting on 8292 women. The estimated prevalence of the analysed adverse events in the random effects model was between 0.0 and 0.26%, of which 'pain/discomfort' had the highest prevalence.Conclusion: This study suggests the risk of adverse events during the period between insertion and expulsion of a balloon catheter in cervical ripening to be low. These data facilitate further evaluation and implementation of this procedure in an outpatient setting for low-risk pregnancies.Tweetable Abstract: Balloon catheter for cervical ripening appears to be safe enough to evaluate its use in the outpatient setting. [ABSTRACT FROM AUTHOR]

The authors support the World Health Organization (WHO) model of intrapartum care for a positive childbirth experience and for transforming care of women and babies for improved health and well-being. They discuss the guiding principles for intrapartum care and outline recommended practices for positive childbirth experience. They stress the need for healthcare systems to implement the WHO model of care in accordance with a human rights-based approach. They

Objective: To assess the accuracy of the World Health Organization (WHO) partograph alert line and other candidate predictors in the identification of women at risk of developing severe adverse birth outcomes. Design: A facility‐based, multicentre, prospective cohort study. Setting: Thirteen maternity hospitals located in Nigeria and Uganda. Population: A total of 9995 women with spontaneous onset of labour presenting at cervical dilatation of ≤6 cm or undergoing induction of labour. Methods: Research assistants collected data on sociodemographic, anthropometric, obstetric, and medical characteristics of study participants at hospital admission, multiple assessments during labour, and interventions during labour and childbirth. The alert line and action line, intrapartum monitoring parameters, and customised labour curves were assessed using sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and the J statistic. Outcomes: Severe adverse birth outcomes. Results: The rate of severe adverse birth outcomes was 2.2% (223 women with severe adverse birth outcomes), the rate of augmentation of labour was 35.1% (3506 women), and the caesarean section rate was 13.2% (1323 women). Forty‐nine percent of women in labour crossed the alert line (4163/8489). All reference labour curves had a diagnostic odds ratio ranging from 1.29 to 1.60. The J statistic was less than 10% for all reference curves. Conclusions: Our findings suggest that labour is an extremely variable phenomenon, and the assessment of cervical dilatation over time is a poor predictor of severe adverse birth outcomes. The validity of a partograph alert line based on the ‘one‐centimetre per hour’ rule should be re‐evaluated. Funding: Bill & Melinda Gates Foundation, United States Agency for International Development (USAID), UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), and WHO (A65879). Tweetable abstract: The alert line in check: results from a WHO study. [ABSTRACT FROM AUTHOR]

The authors calls for the need of a paradigm shift in research and prevention of obstetric fistula. They refer to obstructed labor injury complex as one way to describe the impact of obstetric fistula on women's lives. They suggest the use of prolonged urinary catheterization after obstructed labor to reduce the incidence of fistula formation and address concerns about the safety of prolonged catheterization, as well challenges with compliance, catheter management and health system failures.

Background: What constitutes respectful maternity care (RMC) operationally in research and programme implementation is often variable.Objectives: To develop a conceptualisation of RMC.Search Strategy: Key databases, including PubMed, CINAHL, EMBASE, Global Health Library, grey literature, and reference lists of relevant studies.Selection Criteria: Primary qualitative studies focusing on care occurring during labour, childbirth, and/or immediately postpartum in health facilities, without any restrictions on locations or publication date.Data Collection and Analysis: A combined inductive and deductive approach was used to synthesise the data; the GRADE CERQual approach was used to assess the level of confidence in review findings.Main Results: Sixty-seven studies from 32 countries met our inclusion criteria. Twelve domains of RMC were synthesised: being free from harm and mistreatment; maintaining privacy and confidentiality; preserving women's dignity; prospective provision of information and seeking of informed consent; ensuring continuous access to family and community support; enhancing quality of physical environment and resources; providing equitable maternity care; engaging with effective communication; respecting women's choices that strengthen their capabilities to give birth; availability of competent and motivated human resources; provision of efficient and effective care; and continuity of care. Globally, women's perspectives of what constitutes RMC are quite consistent.Conclusions: This review presents an evidence-based typology of RMC in health facilities globally, and demonstrates that the concept is broader than a reduction of disrespectful care or mistreatment of women during childbirth. Innovative approaches should be developed and tested to integrate RMC as a routine component of quality maternal and newborn care programmes.Tweetable Abstract: Understanding respectful maternity care - synthesis of evidence from 67 qualitative studies. [ABSTRACT FROM AUTHOR]

Background: The call for women-centred approaches to reduce labour interventions, particularly primary caesarean section, has renewed an interest in gaining a better understanding of natural labour progression.Objective: To synthesise available data on the cervical dilatation patterns during spontaneous labour of 'low-risk' women with normal perinatal outcomes.Search Strategy: PubMed, EMBASE, CINAHL, POPLINE, Global Health Library, and reference lists of eligible studies.Selection Criteria: Observational studies and other study designs.Data Collection and Analysis: Two authors extracted data on: maternal characteristics; labour interventions; the duration of labour centimetre by centimetre; and the duration of labour from dilatation at admission through to 10 cm. We pooled data across studies using weighted medians and employed the Bootstrap-t method to generate the corresponding confidence bounds.Main Results: Seven observational studies describing labour patterns for 99 971 women met our inclusion criteria. The median time to advance by 1 cm in nulliparous women was longer than 1 hour until a dilatation of 5 cm was reached, with markedly rapid progress after 6 cm. Similar labour progression patterns were observed in parous women. The 95th percentiles for both parity groups suggest that it was not uncommon for some women to reach 10 cm, despite dilatation rates that were much slower than the 1-cm/hour threshold for most part of their first stage of labours.Conclusion: An expectation of a minimum cervical dilatation threshold of 1 cm/hour throughout the first stage of labour is unrealistic for most healthy nulliparous and parous women. Our findings call into question the universal application of clinical standards that are conceptually based on an expectation of linear labour progress in all women.Funding: UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, and the United States Agency for International Development (USAID).Tweetable Abstract: Cervical dilatation threshold of 1 cm/hour throughout labour is unrealistic for most women, regardless of parity. [ABSTRACT FROM AUTHOR]

Objective: To estimate the association between lipoprotein particle concentrations in pregnancy and gestational age at delivery.Design: Prospective cohort study.Setting: The study was conducted in the USA at the University of North Carolina.Population: We assessed 715 women enrolled in the Pregnancy, Infection, and Nutrition study from 2001 to 2005.Methods: Fasting blood was collected at two time points (<20 and 24-29 weeks of gestation). Nuclear magnetic resonance (NMR) quantified lipoprotein particle concentrations [low-density lipoprotein (LDL), high-density lipoprotein (HDL), very-low density lipoprotein (VLDL)] and 10 subclasses of lipoproteins. Concentrations were assessed as continuous measures, with the exception of medium HDL which was classified as any or no detectable level, given its distribution. Cox proportional hazards models estimated hazard ratios (HR) for gestational age at delivery adjusting for covariates.Main Outcome Measures: Gestational age at delivery, preterm birth (<37 weeks of gestation), and spontaneous preterm birth.Results: At <20 weeks of gestation, three lipoproteins were associated with later gestational ages at delivery [large LDLNMR (HR 0.78, 95% CI 0.64-0.96), total VLDLNMR (HR 0.77, 95% CI 0.61-0.98), and small VLDLNMR (HR 0.78, 95% CI 0.62-0.98], whereas large VLDLNMR (HR 1.19, 95% CI 1.01-1.41) was associated with a greater hazard of earlier delivery. At 24-28 weeks of gestation, average VLDLNMR (HR 1.25, 95% CI 1.03-1.51) and a detectable level of medium HDLNMR (HR 1.90, 95% CI 1.19-3.02) were associated with earlier gestational ages at delivery.Conclusion: In this sample of pregnant women, particle concentrations of VLDLNMR , LDLNMR , IDLNMR , and HDLNMR were each independently associated with gestational age at delivery for all deliveries or spontaneous deliveries <37 weeks of gestation. These findings may help formulate hypotheses for future studies of the complex relationship between maternal lipoproteins and preterm birth.Tweetable Abstract: Nuclear magnetic resonance spectroscopy may identify lipoprotein particles associated with preterm delivery. [ABSTRACT FROM AUTHOR]

The article evaluates the efficacy of uterine massage as part of active management of third stage of labour in addition to oxytocin and controlled cord traction after vaginal delivery in preventing postpartum hemorrhage through a meta-analysis of randomized controlled trials. Topics include a list of terms searched from electronic databases used in the study, the seven domains related to risk of bias assessed in each trial and the limited evidence of uterine massage efficacy found by the study.

The article discusses risk factor in Caesarean Delivery (CD) for women having inflammatory and metabolic diseases. It also states the benefits and risk associated with Vaginal seedling. Topics discussed includes Vaginal seedling, Neonatal colonization (NC) and Danish Society of Obstetrics and Gynecology (DSOG).

Objective: To assess the costs of labour induction with oral misoprostol versus Foley catheter.Design: Economic evaluation alongside a randomised controlled trial.Setting: Obstetric departments of six tertiary and 23 secondary care hospitals in the Netherlands.Population: Women with a viable term singleton pregnancy in cephalic presentation, intact membranes, an unfavourable cervix (Bishop score <6) without a previous caesarean section, were randomised for labour induction with oral misoprostol (n = 924) or Foley catheter (n = 921).Methods: We performed economic analysis from a hospital perspective. We estimated direct medical costs associated with healthcare utilisation from randomisation until discharge. The robustness of our findings was evaluated in sensitivity analyses.Main Outcome Measures: Mean costs and differences were calculated per women induced with oral misoprostol or Foley catheter.Results: Mean costs per woman in the oral misoprostol group and Foley catheter group were €4470 versus €4158, respectively [mean difference €312, 95% confidence interval (CI) -€508 to €1063]. Multiple sensitivity analyses did not change these conclusions. However, if cervical ripening for low-risk pregnancies in the Foley catheter group was carried out in an outpatient setting, with admittance to labour ward only at start of active labour, the difference would be €4470 versus €3489, respectively (mean difference €981, 95% CI €225-1817).Conclusions: Oral misoprostol and Foley catheter generate comparable costs. Cervical ripening outside labour ward with a Foley catheter could potentially save almost €1000 per woman.Tweetable Abstract: Oral misoprostol or Foley catheter for induction of labour generates comparable costs. [ABSTRACT FROM AUTHOR]

We agree that viewing ethnic and racial categories as biological determinants of health is inherently racist and runs the risks of perpetuating the very health inequalities that we are trying to address. We eagerly look forward to the development of a tool which will be able to address the complex factors associated with racial and ethnic inequalities, but until it exists, discounting ethnicity in its entirety will continue to perpetuate the stark health disparities that currently exist in our National Health Service. [Extracted from the article]

Objective: To evaluate effect of locally tailored labour management guidelines (PartoMa guidelines) on intrahospital stillbirths and birth asphyxia.Design: Quasi-experimental pre-post study investigating the causal pathway through changes in clinical practice.Setting: Tanzanian low-resource referral hospital, Mnazi Mmoja Hospital.Population: Facility deliveries during baseline (1 October 2014 until 31 January 2015) and the 9th to 12th intervention month (1 October 2015 until 31 January 2016) [corrected].Methods: Birth outcome was extracted from all cases of labouring women during baseline (n = 3690) and intervention months (n = 3087). Background characteristics and quality of care were assessed in quasi-randomly selected subgroups (n = 283 and n = 264, respectively).Main Outcome Measures: Stillbirths and neonates with 5-minute Apgar score ≤5.Results: Stillbirth rate fell from 59 to 39 per 1000 total births (RR 0.66, 95% CI 0.53-0.82), and subanalyses suggest that this was primarily due to reduction in intrahospital stillbirths. Apgar scores between 1 and 5 fell from 52 to 28 per 1000 live births (RR 0.53, 95% CI 0.41-0.69). Median time from last fetal heart assessment till delivery (or fetal death diagnosis) fell from 120 minutes (IQR 60-240) to 74 minutes (IQR 30-130) (Mann-Whitney test for difference, P < 0.01). Oxytocin augmentation declined from 22% to 12% (RR 0.54, 95% CI 0.37-0.81) and timely use improved.Conclusion: Although low human resources and substandard care remain major challenges, PartoMa guidelines were associated with improvements in care, leading to reductions in stillbirths and birth asphyxia. Findings furthermore emphasise the central role of improved fetal surveillance and restricted intrapartum oxytocin use in safety at birth. TWEETABLE ABSTRACT: #PartoMa guidelines aided in reducing stillbirths and birth asphyxia at a Tanzanian low-resource hospital PLAIN LANGUAGE SUMMARY: PartoMa guidelines help birth attendants in Tanzania to save lives Every year, 3 million babies die on the day of birth. The vast majority of these deaths occur in the poorest countries. If their mothers had received better care during birth, most babies would have survived. At Mnazi Mmoja Hospital, an East African referral hospital, the PartoMa study shows that use of locally developed guidelines helps birth attendants to deliver better quality of care, which has led to improved survival at birth. At the hospital studied, resources are scarce. Each birth attendant assists four to six birthing women simultaneously, and many have less than 1 year of professional experience. International guidelines are available, but they are often unachievable and seldom applied. The PartoMa guidelines were developed in close collaboration with the birth attendants and approved by seven international experts. The result is an 8-page pocket booklet providing locally achievable and simple decision support for care during birth. Use of the PartoMa guidelines began in February 2015. As the staff group frequently changes, quarterly seminars are conducted where birth attendants are welcomed after working hours to learn about the guidelines. The guidelines have been positively received, and seminar attendance remains high. Use of the PartoMa guidelines is associated with: A decrease by one-third in stillbirths (59 to 39 per 1000 total births) A nearly halving in the number of babies born in immediate poor medical condition (52 to 28 per 1000 live births) The results presented here derive from a comparison of births before using the PartoMa guidelines and during the 9th-12th month of use. Such a 'before-after' study cannot exclude the possibility of other causes of better survival at birth. However, the improved survival is consistent with improved care during birth, which is in line with the PartoMa guidelines. [ABSTRACT FROM AUTHOR]

Background: In most regions worldwide, caesarean section (CS) rates are increasing. In these settings, new strategies are needed to reduce CS rates.Objectives: To identify, critically appraise and synthesise studies using the Robson classification as a system to categorise and analyse data in clinical audit cycles to reduce CS rates.Search Strategy: Medline, Embase, CINAHL and LILACS were searched from 2001 to 2016.Selection Criteria: Studies reporting use of the Robson classification to categorise and analyse data in clinical audit cycles to reduce CS rates.Data Collection: Data on study design, interventions used, CS rates, and perinatal outcomes were extracted.Results: Of 385 citations, 30 were assessed for full text review and six studies, conducted in Brazil, Chile, Italy and Sweden, were included. All studies measured initial CS rates, provided feedback and monitored performance using the Robson classification. In two studies, the audit cycle consisted exclusively of feedback using the Robson classification; the other four used audit and feedback as part of a multifaceted intervention. Baseline CS rates ranged from 20 to 36.8%; after the intervention, CS rates ranged from 3.1 to 21.2%. No studies were randomised or controlled and all had a high risk of bias.Conclusion: We identified six studies using the Robson classification within clinical audit cycles to reduce CS rates. All six report reductions in CS rates; however, results should be interpreted with caution because of limited methodological quality. Future trials are needed to evaluate the role of the Robson classification within audit cycles aimed at reducing CS rates.Tweetable Abstract: Use of the Robson classification in clinical audit cycles to reduce caesarean rates. [ABSTRACT FROM AUTHOR]

Objectives: Our objective was to describe contemporary practice patterns in the timing of caesarean delivery in relation to cervical dilation, overall and by indication for caesarean. Our secondary objective was to examine how commonly caesarean delivery was performed for labour dystocia at dilations below 4 cm or without the use of oxytocin, overall and between hospitals.Design: Retrospective, population-based cohort study.Setting: Ontario, Alberta, and British Columbia, Canada, 2008-2012.Population: Nulliparous women in labour who delivered term singletons in cephalic position.Methods: Histograms were used to examine the distribution of cervical dilation at time of caesarean delivery, overall and by indication for caesarean. Funnel plots were used to illustrate variation in hospital-level rates of caesarean deliveries for labour dystocia that were performed early (<4 cm dilation) or without the use of oxytocin.Main Outcome Measures: Cervical dilation (in centimetres) at time of caesarean delivery.Results: The population-based cohort comprised 392 025 women, of whom 18.8% had a caesarean delivery. Of first-stage caesareans for labour dystocia in women who entered labour spontaneously, 13.6% (95% CI 12.9, 14.2) had dilations <4 cm [hospital-level inter-quartile range (IQR): 6.2% to 20.0%] and 29.5% (95% CI 28.6, 30.4) did not receive oxytocin to treat their dystocia (hospital-level IQR: 22.1-54.6%).Conclusions: The proportion of caesareans done before 4 cm dilation or without oxytocin varies substantially across hospitals and suggests the need for institutions to review their practices and ensure that management of labour practice guidelines are followed.Tweetable Abstract: Many caesareans for labour dystocia are performed early during labour (<4 cm dilation) or without oxytocin. [ABSTRACT FROM AUTHOR]

Objective: To evaluate complications of pregnancy, including thromboembolism, in women with extensive vascular malformations associated with Klippel-Trénaunay syndrome (KTS).Design: Nationwide cross-sectional study.Setting: Two tertiary expert centres and the Dutch Klippel-Trénaunay patient organisation.Sample: Adult women with KTS.Methods: Patients with KTS were invited to participate in a comprehensive online survey about their obstetric history. Reference data on pregnancy outcomes and complications of non-diseased women were collected from population-based cohorts from the literature.Main Outcome Measures: Prevalence of complications, specifically venous thromboembolism and postpartum haemorrhage.Results: Sixty women completed the survey. Seventeen patients did not conceive, of whom three refrained from pregnancy because of KTS. A total of 97 pregnancies and 86 deliveries were reported in 43 patients. KTS-related symptoms were aggravated during pregnancy in 43% of patients. Deep vein thrombosis was present in 5.8% and pulmonary embolism was present in 2.3% of pregnancies, which was extremely high compared with the reference population (P < 0.0001), with a relative risk of 108.9 (95% confidence interval, 95% CI 46.48-255.03) and 106.2 (95% CI 26.97-418.10), respectively. Severe postpartum haemorrhage (PPH) occurred in 11% of KTS pregnancies, compared with 5.8% of pregnancies in the reference population (relative risk, RR 1.81, 95% CI 0.97-3.37, P = 0.06).Conclusions: Our data suggest that women with KTS have a significant risk of venous thromboembolic events, severe postpartum haemorrhage, and aggravation of KTS symptoms during pregnancy, and in early postpartum period. Obstetricians should counsel patients about these risks in the preconception phase. Antithrombotic prophylaxis should be considered in the obstetric management of patients with KTS.Tweetable Abstract: High risk of complications during pregnancy and labour in women with Klippel-Trénaunay syndrome. [ABSTRACT FROM AUTHOR]

Objective: To investigate the independent impact of prepregnancy obesity on preterm delivery among women without chronic diseases by gestational age, preterm category and parity.Design: A retrospective cohort study.Setting: Data from the Consortium on Safe Labor (CSL) in the USA (2002-08).Population: Singleton deliveries at ≥23 weeks of gestation in the CSL (43 200 nulliparas and 63 129 multiparas) with a prepregnancy body mass index (BMI) ≥18.5 kg/m2 and without chronic diseases.Methods: Association of prepregnancy BMI and the risk of preterm delivery was examined using Poisson regression with normal weight as reference.Main Outcome Measures: Preterm deliveries were categorised by gestational age (extremely, very, moderate to late) and category (spontaneous, indicated, no recorded indication).Results: Relative risk of spontaneous preterm delivery was increased for extremely preterm among obese nulliparas (1.26, 95% CI: 0.94-1.70 for overweight; 1.88, 95% CI: 1.30-2.71 for obese class I; 1.99, 95% CI: 1.32-3.01 for obese class II/III) and decreased for moderate to late preterm delivery among overweight and obese multiparas (0.90, 95% CI: 0.83-0.97 for overweight; 0.87, 95% CI: 0.78-0.97 for obese class I; 0.79, 95% CI: 0.69-0.90 for obese class II/III). Indicated preterm delivery risk was increased with prepregnancy BMI in a dose-response manner for extremely preterm and moderate to late preterm among nulliparas, as it was for moderate to late preterm delivery among multiparas.Conclusions: Prepregnancy BMI was associated with increased risk of preterm delivery even in the absence of chronic diseases, but the association was heterogeneous by preterm categories, gestational age and parity.Tweetable Abstract: Obese nulliparas without chronic disease had higher risk for spontaneous delivery <28 weeks of gestation. [ABSTRACT FROM AUTHOR]

Background: Induction of labour has become an increasingly common procedure. Ripening methods, including mechanical devices and pharmacological agents, improve the success rate of labour induction.Objective: To compare the efficacy and safety of the double-balloon catheter with prostaglandin E2 agents used for labour induction.Search Strategy: We searched electronic sources from MEDLINE, Embase and Web of Science, the Cochrane Library Database of Systematic Reviews, and ClinicalTrials.gov website.Selection Criteria: Only randomised controlled trials comparing the PGE2 agents with the double-balloon catheter for cervical ripening and labour induction in women with unfavourable cervices were included in the analysis.Data Collection and Analysis: The main outcomes included the vaginal delivery rate within 24 hours and risk of caesarean section. We calculated relative risks and mean differences using fixed- and random-effects models.Main Results: Nine studies (1866 patients) were included in this systematic review. Both the double-balloon catheter and PGE2 agents were comparable with regard to rate of caesarean section (RR 0.92; 95% CI 0.79, 1.07), vaginal delivery within 24 hours (RR 0.95; 95% CI 0.78, 1.16) and maternal adverse events, but the risk of excessive uterine activity (RR 10.02; 95% CI 3.99, 25.17) and need for neonatal intensive care unit admissions (RR 1.31; 95% CI 1.01, 1.69) were significantly increased in women who received PGE2 agents.Conclusions: The double-balloon catheter demonstrated greater safety and cost-effectiveness than PGE2 agents for cervical ripening and labour induction. The efficacy profiles of both methods were similar.Tweetable Abstract: Double-balloon catheter versus prostaglandin E2 for cervical ripening and labour induction. [ABSTRACT FROM AUTHOR]

Objective: To distinguish satisfaction with pain relief using remifentanil patient-controlled analgesia (RPCA) compared with epidural analgesia (EA) in low-risk labouring women.Design: Randomised controlled equivalence trial.Setting: Eighteen midwifery practices and six hospitals in the Netherlands.Population: A total of 408 pregnant women at low risk for obstetric complications initially under the care of primary-care midwives.Methods: Women randomised before active labour to receive analgesia with RPCA or EA, if requested.Main Outcome Measures: Primary outcome was satisfaction with pain relief measured hourly using a visual analogue scale and summed as area under the curve (AUC). Secondary outcomes were overall satisfaction with pain relief, pain intensity scores during labour, mode of delivery, and maternal and neonatal outcomes.Results: We randomised 418 women, of whom 409 could be followed for the primary endpoint. Analgesia was received by 46% (94/203) in the remifentanil group and 37% (76/206) in the epidural group. The AUC for satisfaction with pain relief was 32 in the remifentanil group and 31 in the epidural group (mean difference -0.50; 95% CI -6.8 to 5.9). Among women who actually received analgesia, these values were 23 and 35, respectively (mean difference -12; 95% CI -22 to -1.5). Secondary outcomes were comparable.Conclusions: In low-risk labouring women, we could not demonstrate equivalence between a strategy with RPCA to EA with respect to satisfaction with pain relief assessed during the total duration of labour. However, once applied satisfaction was higher in women who received epidural analgesia.Tweetable Abstract: Satisfaction with pain relief is higher in women receiving epidural analgesia compared with Remifentanil PCA. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of maternal low flow oxygen administration during the second stage of labour on umbilical cord artery pH.Design: A randomised controlled trial.Setting: A tertiary teaching hospital in China.Population: Women in the second stage of labour with no complications.Methods: About 443 women were randomly allocated to receive either supplemental oxygen at a flow rate of 2 l/min or a sham supplementation by nasal cannula. Healthcare providers, women and outcome assessors were blinded to allocation.Main Outcome Measures: Umbilical cord artery pH and fetal heart rate (FHR) pattern.Results: Baseline characteristics were similar between the two groups. There were no significant differences between the two groups in the umbilical cord artery pH [median 7.261, interquartile range (IQR) 7.228-7.295 versus 7.266 (IQR 7.232-7.297), P = 0.64], the proportion with pH less than 7.2 [30/219 versus 34/224, P = 0.66, RR (relative risk) 0.9, 95% CI 0.57-1.42], and the proportion with normal FHR pattern (147/219 versus 153/224, P = 0.79, RR 0.98, 95% CI 0.86-1.12). Maternal partial pressure of dissolved oxygen was significantly higher in the oxygen group than in the sham group [median 150.0 mmHg (IQR 142.6-156.7) versus 112.0 (IQR 104.8-118.3), P < 0.001], whereas carbon dioxide was significantly lower in the oxygen group than in the sham group (mean difference -1.1, 95% CI -2.1 to -0.1, P = 0.03).Conclusion: The use of 2 l/min maternal oxygen during the second stage of labour did not adversely affect either the umbilical artery pH or the FHR pattern distribution.Tweetable Abstract: No difference in abnormal fetal acid base or normal heart rate if maternal O2 given, randomised trial finds. [ABSTRACT FROM AUTHOR]