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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]

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]

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]

Linked article: This is a mini commentary on Giacchino et al., pp. 856–864 in this issue. To view this article visit https://doi.org/10.1111/1471-0528.17402. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion To evaluate the accuracy of combined models of maternal biophysical factors, ultrasound, and biochemical markers for predicting stillbirths.A retrospective cohort study of pregnant women undergoing first‐trimester pre‐eclampsia screening at 11–13 gestational weeks was conducted. Maternal characteristics and history, mean arterial pressure (MAP) measurement, uterine artery pulsatility index (UtA‐PI) ultrasound, maternal ophthalmic peak ratio Doppler, and placental growth factor (PlGF) serum were collected during the visit. Stillbirth was classified as placental dysfunction‐related when it occurred with pre‐eclampsia or birth weight <10th percentile. Combined prediction models were developed from significant variables in stillbirths, placental dysfunction‐related, and controls. We used the area under the receiver‐operating‐characteristics curve (AUC), sensitivity, and specificity based on a specific cutoff to evaluate the model's predictive performance by measuring the capacity to distinguish between stillbirths and live births.There were 13 (0.79%) cases of stillbirth in 1643 women included in the analysis. The combination of maternal factors, MAP, UtA‐PI, and PlGF, significantly contributed to the prediction of stillbirth. This model was a good predictor for all (including controls) types of stillbirth (AUC 0.879, 95% CI: 0.799–0.959, sensitivity of 99.3%, specificity of 38.5%), and an excellent predictor for placental dysfunction‐related stillbirth (AUC 0.984, 95% CI: 0.960–1.000, sensitivity of 98.5, specificity of 85.7).Screening at 11–13 weeks' gestation by combining maternal factors, MAP, UtA‐PI, and PlGF, can predict a high proportion of stillbirths. Our model has good accuracy for predicting stillbirths, predominantly placental dysfunction‐related stillbirths. [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]

Key content: Learning objectives: 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. 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]

• Senior trainees still require confidence and training in complex operative birth. • A new practical course significantly increases trainees' confidence levels. • There remains barriers to maintaining skills, especially with Kielland's forceps. To assess the utility of Art & Craft – a new, hands-on course on Advanced Rotational Techniques and safe Caesarean biRth at Advanced/Full dilation Training aimed at senior Obstetrics trainees. The aims were to assess whether it improved confidence and skills in rotational vaginal birth, impacted fetal head at caesarean, and ultrasound for fetal position. With ethical approval, pre- and post- course questionnaires and post- course interviews of attendees were conducted. A pre course questionnaire was emailed 1 week before the course. Attendees were asked to rate their confidence levels in performing vaginal examination and ultrasound assessment of fetal position, rotational ventouse, manual rotation, Kielland's rotational forceps, and disimpaction of the fetal head during second stage caesarean on a scale of 1 to 5. 1 = not confident at all and 5 = very confident. A post-course questionnaire with the same questions was emailed 3 days after. p values for differences in scores were calculated using the Wilcoxon signed rank test using Stata/MP 18 software. 32 trainees attended the course. 28 questionnaires were available for analysis. The majority 39 % were middle grade (ST3-ST5) level. Initial confidence was very low for rotational forceps (median 1/5). After attending the course and practical stations, respondents' confidence levels increased significantly (p < 0.05) across all domains; vaginal examination from 4 to 5, ultrasound for fetal position, rotational ventouse, and manual rotation from 3 to 5, disimpaction from 4 to 4.5, and Kielland's rotational forceps from 1 to 4. Nine participated in post course interviews, which were thematically analysed. Participants expressed that the course gave them the opportunity to ask specific questions from experts to improve their confidence. A barrier to learning new methods was highlighted in that it is difficult to receive practical training in Kielland's, resulting in low confidence. A practical, hands-on course on complex operative birth significantly increases trainee confidence levels in vaginal examination, ultrasound for fetal position, disimpaction, and techniques for rotational vaginal birth. The evaluation highlights that continued education and practise is required, even when trainees are senior. Evaluation of clinical outcomes after training is needed; and planned. [ABSTRACT FROM AUTHOR]

Environmental factors in the operating room during cesarean sections are likely important for both women/birthing people and their babies but there is currently a lack of rigorous literature about their evaluation. The principal aim of this study was to systematically examine studies published on the physical environment in the obstetrical operating room during c-sections and its impact on mother and neonate outcomes. The secondary objective was to identify the sensors used to investigate the operating room environment during cesarean sections. In this literature review, we searched MEDLINE a database using the following keywords: Cesarean section AND (operating room environment OR Noise OR Music OR Video recording OR Light level OR Gentle OR Temperature OR Motion Data). Eligible studies had to be published in English or French within the past 10 years and had to investigate the operating room environment during cesarean sections in women. For each study we reported which aspects of the physical environment were investigated in the OR (i.e., noise, music, movement, light or temperature) and the involved sensors. Of a total of 105 studies screened, we selected 8 articles from title and abstract in PubMed. This small number shows that the field is poorly investigated. The most evaluated environment factors to date are operating room noise and temperature, and the presence of music. Few studies used advanced sensors in the operating room to evaluate environmental factors in a more nuanced and complete way. Two studies concern the sound level, four concern music, one concerns temperature and one analyzed the number of entrances/exits into the OR. No study analyzed light level or more fine-grained movement data. Main findings include increase of noise and motion at specific time-points, for example during delivery or anaesthesia; the positive impact of music on parents and staff alike; and that a warmer theatre is better for babies but more uncomfortable for surgeons. [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: Caesarean section (CS) is widely perceived as protective against obstetric brachial plexus injury (BPI), but few studies acknowledge the factors associated with such injury. The objectives of this study were therefore to aggregate cases of BPI after CS, and to illuminate risk factors for BPI. Methods: Pubmed Central, EMBASE and MEDLINE databases were searched using free text: ("brachial plexus injury" or "brachial plexus injuries" or "brachial plexus palsy" or "brachial plexus palsies" or "Erb's palsy" or "Erb's palsies" or "brachial plexus birth injury" or "brachial plexus birth palsy") and ("caesarean" or "cesarean" or "Zavanelli" or "cesarian" or "caesarian" or "shoulder dystocia"). Studies with clinical details of BPI after CS were included. Studies were assessed using the National Institutes for Healthy Study Quality Assessment Tool for Case Series, Cohort and Case-Control Studies. Main results: 39 studies were eligible. 299 infants sustained BPI after CS. 53% of cases with BPI after CS had risk factors for likely challenging handling/manipulation of the fetus prior to delivery, in the presence of considerable maternal or fetal concerns, and/or in the presence of poor access due to obesity or adhesions. Conclusions: In the presence of factors that would predispose to a challenging delivery, it is difficult to justify that BPI could occur due to in-utero, antepartum events alone. Surgeons should exercise care when operating on women with these risk factors. [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]

Background: Magnetic resonance imaging (MRI) provides excellent soft tissue visualisation which may be useful in late pregnancy to predict labour outcome and maternal/neonatal birth trauma. Objective: To study if MRI in late pregnancy can predict maternal and neonatal outcomes of labour and birth. Methods: Systematic review of studies that performed MRI in late pregnancy or immediately postpartum. Studies were included if they imaged maternal pelvic or neonatal structures and assessed birth outcome. Meta-analysis was not performed due to the heterogeneity of studies. Results: Eighteen studies were selected. Twelve studies explored the value of MRI pelvimetry measurement and its utility to predict cephalopelvic disproportion (CPD) and vaginal breech birth. Four explored cervical imaging in predicting time interval to birth. Two imaged women in active labour and assessed mouldability of the fetal skull. No marker of CPD had both high sensitivity and specificity for predicting labour outcome. The fetal pelvic index yielded sensitivities between 59 and 60%, and specificities between 34 to 64%. Similarly, although the sensitivity of the cephalopelvic disproportion index in predicting labour outcome was high (85%), specificity was only 56%. In women with breech presentation, MRI was demonstrated to reduce the rates of emergency caesarean section from 35 to 19%, and allowed better selection of vaginal breech birth. Live birth studies showed that the fetal head undergoes a substantial degree of moulding and deformation during cephalic vaginal birth, which is not considered during pelvimetry. There are conflicting studies on the role of MRI in cervical imaging and predicting time interval to birth. Conclusion: MRI is a promising imaging modality to assess aspects of CPD, yet no current marker of CPD accurately predicts labour outcome. With advances in MRI, it is hoped that novel methods can be developed to better identify individuals at risk of obstructed or pathological labour. Its role in exploring fetal head moulding as a marker of CPD should be further explored. [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]