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Key content: The perinatal period confers an elevated risk of both relapses and new onset of mental illness. Suboptimal treatment can have a profound impact on maternal mortality and morbidity, neonatal outcomes and longer term child development.Most psychotropic medication can be used safely in pregnancy, with some notable exceptions.While decisions on the use of psychotropic medications in pregnancy are often complex and should be multidisciplinary, it is imperative that obstetricians and gynaecologists familiarise themselves with current literature to provide evidence‐based counselling and care.Existing guidelines on the use of psychotropic medication are largely aimed at psychiatrists, and to date there has been a lack of concise, digestible information with a focus on core knowledge for obstetricians and gynaecologists.We summarise existing evidence on the use of antidepressants, antipsychotics, mood stabilisers and sedatives in the perinatal period. For each drug class we describe the teratogenicity, impact on pregnancy, breastfeeding and the newborn. Learning objectives: To be familiar with common psychotropic medication used in pregnancy and the postpartum period.To understand key evidence on the safety profile of psychiatric medication in the perinatal period and apply this to individualised counselling. [ABSTRACT FROM AUTHOR]

Objective: To create a sensorised surgical glove that can accurately identify obstetric anal sphincter injury to facilitate timely repair, reduce complications and aid training. Design: Proof‐of‐concept. Setting: Laboratory. Sample: Pig models. Methods: Flexible triboelectric pressure/force sensors were mounted onto the fingertips of a routine surgical glove. The sensors produce a current when rubbed on materials of different characteristics which can be analysed. A per rectum examination was performed on the intact sphincter of pig cadavers, analogous to routine examination for obstetric anal sphincter injuries postpartum. An anal sphincter defect was created by cutting through the vaginal mucosa and into the external anal sphincter using a scalpel. The sphincter was then re‐examined. Data and signals were interpreted. Main Outcome Measures: Sensitivity and specificity of the glove in detecting anal sphincter injury. Results: In all, 200 examinations were performed. The sensors detected anal sphincter injuries in a pig model with sensitivities between 98% and 100% and a specificity of 100%. The current produced when examining an intact sphincter and sphincter with a defect was significantly different (p < 0.001). Conclusion: In this preliminary study, the sensorised glove accurately detected anal sphincter injury in a pig model. Future plans include its clinical translation, starting with an in‐human study on postpartum women, to determine whether it can accurately detect different types of obstetric anal sphincter injury in vivo. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of maternal Coronavirus disease 2019 (COVID‐19) infection on placental histopathological findings in an unselected population and evaluate the potential effect on the fetus, including the possibility of vertical transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Design: Retrospective cohort comparative study of placental histopathological findings in patients with COVID‐19, compared with controls. Setting: During the COVID‐19 pandemic, placentas were studied from women at University College Hospital London who reported and/or tested positive for COVID‐19. Population: Of 10 508 deliveries, 369 (3.5%) women had COVID‐19 during pregnancy, with placental histopathology available for 244 women. Methods: Retrospective review of maternal and neonatal characteristics, where placental analysis had been performed. This was compared with available, previously published, histopathological findings from placentas of unselected women. Main outcome measures: Frequency of placental histopathological findings and relevant clinical outcomes. Results: Histological abnormalities were reported in 117 of 244 (47.95%) cases, with the most common diagnosis being ascending maternal genital tract infection. There was no statistically significant difference in the frequency of most abnormalities compared with controls. There were four cases of COVID‐19 placentitis (1.52%, 95% CI 0.04%–3.00%) and one possible congenital infection, with placental findings of acute maternal genital tract infection. The rate of fetal vascular malperfusion (FVM), at 4.5%, was higher compared with controls (p = 0.00044). Conclusions: In most cases, placentas from pregnant women infected with SARS‐CoV‐2 virus do not show a significantly increased frequency of pathology. Evidence for transplacental transmission of SARS‐CoV‐2 is lacking from this cohort. There is a need for further study into the association between FVM, infection and diabetes. [ABSTRACT FROM AUTHOR]

Background: A core outcome set could address inconsistent outcome reporting and improve evidence for stillbirth care research, which have been identified as an important research priority. Objectives: To identify outcomes and outcome measurement instruments reported by studies evaluating interventions after the diagnosis of a stillbirth. Search strategy: Amed, BNI, CINAHL, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO, and WHO ICTRP from 1998 to August 2021. Selection criteria: Randomised and non‐randomised comparative or non‐comparative studies reporting a stillbirth care intervention. Data collection and analysis: Interventions, outcomes reported, definitions and outcome measurement tools were extracted. Main results: Forty randomised and 200 non‐randomised studies were included. Fifty‐eight different interventions were reported, labour and birth care (52 studies), hospital bereavement care (28 studies), clinical investigations (116 studies), care in a multiple pregnancy (2 studies), psychosocial support (28 studies) and care in a subsequent pregnancy (14 studies). A total of 391 unique outcomes were reported and organised into 14 outcome domains: labour and birth; postpartum; delivery of care; investigations; multiple pregnancy; mental health; emotional functioning; grief and bereavement; social functioning; relationship; whole person; subsequent pregnancy; subsequent children and siblings and economic. A total of 242 outcome measurement instruments were used, with 0–22 tools per outcome. Conclusions: Heterogeneity in outcome reporting, outcome definition and measurement tools in care after stillbirth exists. Considerable research gaps on specific intervention types in stillbirth care were identified. A core outcome set is needed to standardise outcome collection and reporting for stillbirth care research. [ABSTRACT FROM AUTHOR]

To explore the association between abnormal uterine artery Dopplers (combined PI > 2.5) - with normal PAPP-A - and adverse obstetric/neonatal outcomes. This was a retrospective cohort study of 800 patients between 1 March 2019 − 23 November 2021 in a tertiary UK hospital, where it is routine to measure uterine artery Dopplers of all pregnancies during their anomaly scans. 400 nulliparous women/birthing people with complete data were included. 400 nulliparous controls scanned in the same time frame (1.5 years) with normal PAPP-A and uterine artery Dopplers were matched for age and BMI. Outcomes included: mode of birth, postpartum complications, birth weight/centile, Apgar score, gestational age at delivery, neonatal unit admission, and clinical neonatal hypoglycemia. Multivariable analysis was used. Compared to controls, pregnancies with abnormal uterine artery Dopplers and normal PAPP-A were at increased risk of induction (46.5% vs 35.5%, p =.042), cesarean section (46.0% vs 38.0%, p =.002), emergency cesarean section (35.0% vs 26.5%, p =.009), and pre-eclampsia 5.8% vs 2.5%, p =.021). Their babies were more likely to be admitted to the neonatal unit – mostly for prematurity (15.3% vs 6.3%, p =.0004), hypoglycemia (4.0% vs 1.0%, p =.007), be small for gestational age (26.5% vs 11.5%, p =.0001), had intrauterine growth restriction (10.8% vs 1.3%, p =.0001), and be born prematurely (10.0% vs 3.5%, p =.002). Routine measurement of uterine artery Dopplers increased the detection rate of small for gestational age fetuses by 15.1%. Over half of the babies admitted with neonatal hypoglycemia in pregnancies with abnormal uterine artery Dopplers had an unexplained cause. Pregnancies with abnormal uterine Dopplers are not only at increased risk of pre-eclampsia and small for gestational age fetuses/intrauterine growth restriction, but are also at increased risk of emergency cesarean section and adverse neonatal outcomes. The increased incidence of neonatal hypoglycemia is likely driven to some degree by prematurity and placental complications, but possibly also by undiagnosed glucose dysmetabolism. This may warrant routine measurement of uterine artery Dopplers in all pregnancies (regardless of risk), where feasible, to aid antenatal management and counseling. What are the novel findings of this work? Pregnancies with abnormal uterine artery Dopplers at the time of the anomaly scan and normal PAPP-A are at increased risk of having pre-eclampsia, small for gestational age fetuses, emergency cesarean, neonatal unit admission (including but not limited to prematurity), and neonatal hypoglycemia. What are the clinical implications of this work? Due to the significantly increased risk of adverse maternal and neonatal outcomes in first time mothers with increased uterine artery Dopplers despite normal PAPP-A, ultrasound assessment of placental function should be offered to all during their anomaly scans, subject to resources, to aid antenatal management and counseling. Further research is needed into undiagnosed diabetes. [ABSTRACT FROM AUTHOR]

Women with a previous fetal demise have a 2–20 fold increased risk of another stillbirth in a subsequent pregnancy when compared to those who have had a live birth. Despite this, there is limited research regarding the management and outcomes of subsequent pregnancies. This study was conducted to accurately quantify the chances of a woman having a healthy subsequent pregnancy after a pregnancy loss. A retrospective study was conducted at a tertiary-level unit between March 2019 and April 2021. We collected data on all women with a history of previous fetal demise attending a specialized perinatal history clinic and compared the risk of subsequent stillbirth to those with a normal pregnancy outcome. Outcome data included birth outcome, obstetric and medical complications, gestational age and birth weight and mode of delivery. Those who had healthy subsequent pregnancies were compared with those who experienced adverse outcomes. A total of 101 cases were reviewed. Ninety-six women with subsequent pregnancies after a history of fetal demise from 16 weeks were included. Seventy-nine percent of women (n = 76) delivered a baby at term, without complications. Overall, 2.1% had repeat pregnancy losses (n = 2) and 2.1% delivered babies with fetal growth restriction (n = 2). There were no cases of abruption in a subsequent pregnancy. Eighteen neonates were delivered prematurely (18.4%), 15 of these (83.3%) were due to iatrogenic causes and three (16.7%) were spontaneous. In univariable logistic regression analyses, those with adverse outcomes in subsequent pregnancies had greater odds of pre-eclampsia (Odds ratio *(OR) = 3.89, 95% CI = 1.05–14.43, p =.042) and fetal growth restriction (OR = 4.58, 95% CI = 1.41–14.82, p = 0.011) in previous pregnancies compared to those with healthy outcomes. However, in multivariable logistic regression analyses, neither variable had a significant odds ratio (OR = 2.03, 95% CI = 0.44–9.39, p =.366 and OR = 3.42, 95% CI = 0.90 − 13.09, p =.072 for pre-eclampsia and FGR, respectively). Four in five women had a healthy subsequent pregnancy. This is a reassuring figure for women when contemplating another pregnancy, particularly if cared for in a specialist clinic. [ABSTRACT FROM AUTHOR]

In the UK one in 250 pregnancies end in stillbirth. Abnormal placental villous maturation, commonly associated with gestational diabetes, is a risk factor for stillbirth. Histopathology reports of placental distal villous immaturity (DVI) are reported disproportionately in placentas from otherwise unexplained stillbirths in women without formal diagnosis of diabetes but with either clinical characteristics or risk factors for diabetes. This study aims to establish maternal factors associated with DVI in relation to stillbirth. Placental histopathology reports were reviewed for all pregnant women delivering at University College London Hospital between July 2018 to March 2020. Maternal characteristics and birth outcomes of those with DVI were compared to those with other placental lesions or abnormal villous maturation. Of the 752 placental histopathology reports reviewed, 11 (1.5%) were reported as diagnostic of DVI. Eighty cases were sampled for clinical record analysis. All women with DVI had normal PAPP-A (>0.4 MoM), normal uterine artery Doppler studies (UtA-PI) and were normotensive throughout pregnancy. Nearly one in five babies (2/11, 18.5%) with DVI were stillborn and 70% had at least one high glucose test result in pregnancy despite no formal diagnosis of diabetes. These findings suggest that the mechanism underlying stillbirth in DVI likely relates to glucose dysmetabolism, not sufficient for diagnosis using current criteria for gestational diabetes, resulting in placental dysfunction that is not identifiable before the third trimester. Relying on conventional diabetes tests, foetal macrosomia or growth restriction, may not identify all pregnancies at risk of adverse outcomes from glucose dysmetabolism. [ABSTRACT FROM AUTHOR]

Background: Stillbirth, the death of a baby before birth, is associated with significant psychological and social consequences that can be mitigated by respectful and supportive bereavement care. The absence of high‐level evidence to support the broad scope of perinatal bereavement practices means that offering a range of options identified as valued by parents has become an important indicator of care quality. This study aimed to describe bereavement care practices offered to parents across different high‐income and middle‐income countries. Methods: An online survey of parents of stillborn babies was conducted between December 2014 and February 2015. Frequencies of nine practices were compared between high‐income and middle‐income countries. Differences in proportions of reported practices and their associated odds ratios were calculated to compare high‐income and middle‐income countries. Results: Over three thousand parents (3041) with a self‐reported stillbirth in the preceding five years from 40 countries responded. Fifteen countries had atleast 40 responses. Significant differences in the prevalence of offering nine bereavement care practices were reported by women in high‐income countries (HICs) compared with women in middle‐income countries (MICs). All nine practices were reported to occur significantly more frequently by women in HICs, including opportunity to see and hold their baby (OR = 4.8, 95% CI 4.0‐5.9). The widespread occurrence of all nine practices was reported only for The Netherlands. Conclusions: Bereavement care after stillbirth varies between countries. Future research should look at why these differences occur, their impact on parents, and whether differences should be addressed, particularly how to support effective communication, decision‐making, and follow‐up care. [ABSTRACT FROM AUTHOR]

This is particularly pertinent to the complex procedure of rotational vaginal birth, including Kielland forceps. Both non-rotational and rotational instrumental deliveries, including the use of Kielland forceps, are among the techniques taught. Matsubara et al.[1] posed the question if Kielland forceps are for the exclusive use of doctors from the UK following a recent meta-analysis by Giacchino et al.[2] This meta-analysis found that Kielland forceps are safe for the management of malposition of the fetal head in the second stage of labour. [Extracted from the article]

The article discusses leadership enactment in medical emergencies. We draw on video recordings of simulated obstetric emergencies and investigate how senior clinicians 'do being' the leader discursively in the spatiomaterial context of the emergency room. We take an interactional analysis approach, combining conversation analysis and interactional sociolinguistics and look specifically into the ways in which professional roles do interactional control using directives and questions in the material space of the obstetric room. We discuss this interactional performance in relation to the clinical performance of the teams. Our analysis shows that leadership in medical emergencies is multimodally achieved; professionals draw on discursive strategies, the affordances of material space, body and gaze orientation, which build on each other and converge in indexing leadership. Our findings highlight the situated nature of negotiating responsibility, illustrating that leadership in our context is claimed, projected and resisted discursively. We provide a typology of the functions of questions in the emergency encounter, and close the article by foregrounding the implications of our study and providing directions for further research. [ABSTRACT FROM AUTHOR]

Objective To assess whether the implementation of an intrapartum training package (PROMPT (PRactical Obstetric Multi-Professional Training)) across a health service reduced the proportion of term babies born with Apgar score <7 at 5 min (<75mins). Design Stepped-wedge cluster randomised controlled trial. Setting Twelve randomised maternity units with ≥900 births/year in Scotland. Three additional units were included in a supplementary analysis to assess the effect across Scotland. The intervention commenced in March 2014 with follow- up until September 2016. Intervention The PROMPT training package (Second edition), with subsequent unit- level implementation of PROMPT courses for all maternity staff. Main outcome measures The primary outcome was the proportion of term babies with Apgar<75mins. Results 87 204 eligible births (99.2% with an Apgar score), of which 1291 infants had an Apgar<75mins were delivered in the 12 randomised maternity units. Two units did not implement the intervention. The overall Apgar<75mins rate observed in the 12 randomised units was 1.49%, increasing from 1.32% preintervention to 1.59% postintervention. Once adjusted for a secular time trend, the 'intention- to-treat' analysis indicated a moderate but non- significant reduction in the rate of term babies with an Apgar scores <75mins following PROMPT training (OR=0.79 95%CI(0.63 to 1.01)). However, some units implemented the intervention earlier than their allocated step, whereas others delayed the intervention. The content and authenticity of the implemented intervention varied widely at unit level. When the actual date of implementation of the intervention in each unit was considered in the analysis, there was no evidence of improvement (OR=1.01 (0.84 to 1.22)). No intervention effect was detected by broadening the analysis to include all 15 large Scottish maternity units. Units with a history of higher rates of Apgar<75mins maintained higher Apgar rates during the study (OR=2.09 (1.28 to 3.41)) compared with units with pre- study rates aligned to the national rate. Conclusions PROMPT training, as implemented, had no effect on the rate of Apgar <75mins in Scotland during the study period. Local implementation at scale was found to be more difficult than anticipated. Further research is required to understand why the positive effects observed in other single- unit studies have not been replicated in Scottish maternity units, and how units can be best supported to locally implement the intervention authentically and effectively. [ABSTRACT FROM AUTHOR]

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 < .001), die before discharge (p < .001), have a composite poor outcome (death, sIVH or PVL), need oxygen therapy at 36-week corrected gestation (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. [ABSTRACT FROM AUTHOR]