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Background:  Photochemical tissue bonding (PTB) is a technique for peripheral nerve repair in which a collagenous membrane is bonded around approximated nerve ends. Studies using PTB with cryopreserved human amnion have shown promising results in a rat sciatic nerve transection model including a more rapid and complete return of function, larger axon size, and thicker myelination than suture repair. Commercial collagen membranes, such as dehydrated amnion allograft, are readily available, offer ease of storage, and have no risk of disease transmission or tissue rejection. However, the biomechanical properties of these membranes using PTB are currently unknown in comparison to PTB of cryopreserved human amnion and suture neurorrhaphy., Methods:  Rat sciatic nerves ( n  = 10 per group) were transected and repaired using either suture neurorrhaphy or PTB with one of the following membranes: cryopreserved human amnion, monolayer human amnion allograft (crosslinked and noncrosslinked), trilayer human amnion/chorion allograft (crosslinked and noncrosslinked), or swine submucosa. Repaired nerves were subjected to mechanical testing., Results:  During ultimate stress testing, the repair groups that withstood the greatest strain increases were suture neurorrhaphy (69 ± 14%), PTB with crosslinked trilayer amnion (52 ± 10%), and PTB with cryopreserved human amnion (46 ± 20%), although the differences between these groups were not statistically significant. Neurorrhaphy repairs had a maximum load (0.98 ± 0.30 N) significantly greater than all other repair groups except for noncrosslinked trilayer amnion (0.51 ± 0.27 N). During fatigue testing, all samples repaired with suture, or PTBs with either crosslinked or noncrosslinked trilayer amnion were able to withstand strain increases of at least 50%., Conclusion:  PTB repairs with commercial noncrosslinked amnion allograft membranes can withstand physiological strain and have comparable performance to repairs with human amnion, which has demonstrated efficacy in vivo. These results indicate the need for further testing of these membranes using in vivo animal model repairs., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction: A dura mater substitute in decompressive craniectomies must protect the brain while providing a dissection plane between the cortex and myocutaneous layer. The human amniotic membrane (AM) has anti-inflammatory, wound healing, and differentiation properties. We tested AM properties as a dural substitute by comparing the outcomes to biological ones., Methods: We prospectively collected data on 25 patients who randomly underwent decompressive craniectomy with lyophilized AM patches and 25 in which biological substitutes were utilized between 2015 and 2019. The AM was laid with the epithelial side facing the brain because of the anti-adhesive proprieties, while the chorion facing the myocutaneous flap. We collected data on demographics, neurological status, comorbidities, and surgical outcomes. Additionally, we created a score - dura mimicking score- and reviewed postoperative imaging and pathological specimens., Results: The majority (96%) of AM grafts were integrated into native dura. Thirteen patients scored as excellent and 11 good on our "dura mimicking score", showing tissue integration ability but no cerebral cortex adhesion. The histopathological analysis showed that AM had thick plates of dense fibrous tissue with small reactive vessels, reactive fibroblasts, and lymphocytes infiltrate. The AM group's first outcomes were not different from the biological substitute patients but higher integration rate to the dura and less adhesion to the myocutaneous flap in AM patients., Conclusions: We documented the anti-adhesive, protective, and integrative properties of AM dural substitute patches in patients who underwent decompressive craniectomies, comparing the intraoperative differences and postoperative outcomes to biological dural substitutes., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objectives: To assess short- and long-term outcome in a cohort of fetuses diagnosed with hydrothorax (FHT) which underwent thoracoamniotic shunting in utero, and to examine the antenatal predictors of survival and of survival with normal neurodevelopmental outcome., Methods: This was a retrospective analysis of 132 fetuses that underwent thoracoamniotic shunting at our center between 1991 and 2014. Data were extracted from hospital obstetric and relevant neonatal intensive care and neonatal developmental follow-up databases. Outcomes included survival to discharge and survival with normal neurodevelopmental outcome beyond 18 months. Information on malformations, syndromes and genetic abnormalities were obtained from antenatal, postnatal and pediatric hospital records or by parent report. We compared pregnancy characteristics among those who survived vs non-survivors and among those with normal neurodevelopmental outcome vs those who were abnormal or died. We explored whether there was a trend in survival over the study period., Results: The mean gestational age at diagnosis of FHT was 25.6 weeks. The fetus was hydropic at diagnosis in 61% of cases, 69% had bilateral effusions and 55% had bilateral shunts inserted. Other diagnoses were present in 24% of cases, two-thirds of which were discovered only postnatally. There were 16 intrauterine and 30 neonatal deaths, with a 65% survival rate overall. The mean gestational age at delivery of liveborns was 35.4 (range, 26.9-41.6) weeks, and 88/116 (76%) were preterm (< 37 weeks). Of 87 liveborn at the treatment center, 75% experienced some respiratory and/or cardiovascular morbidity after birth, many with a lengthy hospital stay (mean, 36 (range, 1-249) days). Overall, 84% of survivors were developmentally normal beyond 18 months and outcomes were better when pleural effusions were isolated, 92% of these cases being neurodevelopmentally normal. There was no trend in survival or neurodevelopmental outcome over time. Despite the presence of FHT and neonatal respiratory issues, most (89%) of the 55 survivors with relevant follow-up had no long-term pulmonary complications. Gestational age at delivery was the only factor independently predictive of both survival and survival with normal neurodevelopmental outcome., Conclusions: FHT is associated with other pathologies in a quarter of cases and carries a significant risk of prematurity, mortality and neonatal morbidity. The outcome is good in survivors but is best in isolated cases. Predictors of outcome at diagnosis are poor. Future improvement in diagnostics at time of identification of FHT may help to identify those that would benefit most from thoracoamniotic shunting. © 2020 International Society of Ultrasound in Obstetrics and Gynecology., (© 2020 International Society of Ultrasound in Obstetrics and Gynecology.)

Human amniotic membrane (HAM) has recently been used as an interpositional material to prevent ankylosis or primary re-ankylosis after temporomandibular joint (TMJ) arthroplasty. Here, the authors describe an unusual case of a 32-year-old woman who presented with a noninflammatory degenerative osteoarthritis of the TMJ in which a HAM was placed following a high condylar arthroplasty and discectomy and show the clinicoradiological results. The procedure resulted in total pain relief and significant improvement in jaw movements. On the long-term follow-up computed tomography, complete remodeling of the glenoid fossa with formation of new ectopic bone was observed. While the application of a HAM can be an alternative procedure to prevent ankylosis when performing a discectomy and arthroplasty, this clinical report highlights the possibility that it can induce ectopic bone formation at this location.

Purpose: To describe a new surgical technique, using a human amniotic membrane patch, in two cases of retinal detachment with paravascular retinal breaks over patchy chorioretinal atrophy in pathologic myopia, already underwent pars plana vitrectomy with the internal limiting membrane peeling for myopic foveoschisis., Methods: Surgical technique description with surgical video. A 23-gauge pars plana vitrectomy was performed. A human amniotic membrane patch was implanted under the neuroretina to seal the posterior retinal break. Standard silicone oil tamponade was performed at the end of the surgery. The patients were positioned face down after the operation for the first week. Optical coherence tomography scans were used in the follow-ups., Results: The 2 weeks postoperative optical coherence tomography showed a new tissue growth over the human amniotic membrane patch. The 3 months optical coherence tomography showed the new tissue entirely covering the human amniotic membrane plug. Visual acuity improved from 20/2000 (2 LogMAR) to 20/250 (1.1 LogMAR) 3 months after the operation in both patients. The silicone oil was extracted 2 months after surgery, and no recurrences were observed. The patient's visual acuity remained stable at 20/250 after the silicone oil extraction., Conclusion: In these complex cases, human amniotic membrane transplantation can be a valid option, when internal limiting membrane has already been peeled in previous surgeries, to seal the posterior retinal breaks over high myopic chorioretinal atrophy, with encouraging results.

Introduction: Cesarean birth rates vary widely across hospitals in the United States, even among women who are considered low-risk for the procedure. This variation has been attributed to differences in health care provider practice, but few studies have explored patterns of labor management in relation to cesarean birth., Methods: This was a retrospective observational study of 26,259 nulliparous, term, singleton gestation, vertex presentation births following spontaneous onset of labor. Births occurred from 2002 to 2007 in 11 hospitals in the Consortium on Safe Labor. Generalized linear mixed modeling was used to examine the relationship between intrapartum interventions (amniotomy, epidural analgesia, oxytocin augmentation) used individually and in combination and the outcome of cesarean birth., Results: More than 90% of the women in this low-risk sample received at least one intervention regardless of mode of birth. Epidural analgesia was the most frequently applied intervention, both when used as a single intervention (18.7%) and in combination with other interventions (79.9%). The strongest associations between these interventions and cesarean birth were observed when 2 or 3 interventions were applied during labor. Compared with women who received no interventions, the strongest association was observed among women who received amniotomy-oxytocin augmentation (adjusted odds ratio [aOR], 1.89; 95% CI, 1.36-2.62). The use of all 3 interventions (amniotomy-epidural analgesia-oxytocin augmentation) showed a similar positive association with cesarean birth (aOR 1.83; 95% CI, 1.50-2.21)., Discussion: Findings show that the combined use of amniotomy, epidural analgesia, and oxytocin augmentation is positively associated with cesarean birth. Additional research is needed to examine the timing and sequence of interventions as well as whether a causal relationship exists between combinations of interventions and cesarean birth in low-risk nulliparous women., (© 2019 by the American College of Nurse-Midwives.)

Background: Facial burns have lasting physical and psychological effects on pediatric patients. Proper management to minimize morbidities challenges reconstructive surgeons. New technologies allowed the development of skin substitutes such as amniotic and chorionic membranes, yet the use of these skin dressings and their impact on burn outcomes have not been sufficiently studied to guide practices. The objective of this study is to report on the outcomes of dehydrated amniotic membrane as a biologic skin dressing in pediatric facial burn injury compared to cadaveric allografts., Methods: Retrospective review of data collected from our institutional burn registry from 2012 to 2016. The study population included patients younger than 16 years with facial burns. Patients between 2012 and 2014 received cadaveric allografts, whereas during 2015 to 2016 patients received dehydrated human amniotic/chorionic membrane as standard treatment. Demographic characteristics and outcome measures were compared between the 2 groups., Results: Included 30 patients with a mean age of 3.7 years and with an average total body surface area burn of 6.8% (2%-27%). Mean injury severity scores did not significantly differ between both groups, 1.8 in amniotic group versus 2.3 in cadaveric skin group (P > 0.05). There were 4 complications (3 hypertrophic scars and 1 wound infection) in the cadaveric allografts group versus no complications in the amniotic membrane group (P < 0.05)., Conclusion: Dehydrated amniotic/chorionic membrane wound dressings are a safe alternative to cadaveric allografts in treating pediatric partial thickness facial burns.

The twin birth rate is increasing in the United States. Twin pregnancies can be dichorionic or monochorionic (MC). MC twins account for 20% of twin pregnancies but 30% of all-cause pregnancy-related complications. This article describes the imaging findings that establish chorionicity and amnionicity. Ideally, these are established in the first trimester when accuracy is high, but they can also be determined later in pregnancy. Complications unique to MC twin pregnancy include twin-twin transfusion syndrome, twin anemia polycythemia sequence, twin reversed arterial perfusion sequence, and selective fetal growth restriction. The US features, staging systems, and management of these complications are reviewed, and the consequences of MC twin demise are illustrated. Ongoing surveillance for these conditions starts at 16 weeks gestation. Monoamniotic (MA) twins are a small subset of MC twins. In addition to all of the MC complications, specific MA complications include cord entanglement and conjoined twinning. Radiologists must be able to determine chorionicity and amnionicity and should be aware of potential complications so that patients may be referred to appropriate regional specialized centers. A proposed algorithm for referral to specialized fetal treatment centers is outlined. Online supplemental material is available for this article. © RSNA, 2019.

Rhinophyma is a phenotypic subtype of rosacea affecting the nose. It is characterized by phymatous changes, skin thickening/fibrosis, glandular hyperplasia, and chronic inflammation. Treatment of severe rhinophyma is predominantly surgical excision with closure by secondary intention. Amniotic membrane has been used to promote wound healing, fibrosis, and inflammation. In this case study, the authors present a 63-year-old male with longstanding rhinophyma treated with surgical excision with intraoperative placement of amniotic membrane.

Objectives: To describe and compare placental and amniotic histology in women who underwent a fetoscopic myelomeningocele repair to those who underwent an open hysterotomy myelomeningocele repair. Also, we intended to compare findings from both prenatal repair groups to age-matched control pregnant patients., Methods: Placental and membrane histopathology from 43 prenatally repaired spina bifida cases (17 fetoscopic and 26 open) and 18 healthy controls were retrospectively assessed. Quantitative assessment of histopathology included apoptosis count and maternal and fetal underperfusion scores. Qualitative assessment included the detection of pigmented macrophages and/or signs of placental/amniotic inflammation. Associations between the duration of surgery or the duration of CO 2 insufflation and quantitative histological parameters were tested., Results: Fetoscopic surgery cases did not show significant differences in any of the studied parameters when compared against controls. No differences were detected either when compared with open repaired cases, except for lower proportion of pigmented laden macrophages in the fetoscopic group (11.8% vs 61.5%, P < 0.01). No associations between the duration of surgery or the duration of CO 2 exposure and any of the quantitative histological parameters were detected., Conclusions: These preliminary results support the lack of detrimental effects of the use of heated and humidified CO 2 gas for uterine insufflation to fetal membranes and placenta., (© 2019 John Wiley & Sons, Ltd.)

Background: Congenital pleural effusion is a rare condition with an incidence of approximately one per 15,000 pregnancies. The development of secondary hydrops is a poor prognostic indicator and such cases can be managed with a thoracoamniotic shunt (TAS). Our objective is to describe postnatal outcomes in survivors after TAS placement for congenital pleural effusions., Materials and Methods: A retrospective study of all cases with fetal pleural effusions treated between 2006 and 2016. Patients with dominant unilateral or bilateral pleural effusions complicated by secondary hydrops fetalis received TAS placement. The results are reported as median (range)., Results: A total of 29 patients with pleural effusion with secondary hydrops underwent TAS placement. The gestational age at the initial TAS placement was 27.6 (20.3-36.9) wk. Before delivery, hydrops resolved in 17 (58.6%) patients. The delivery gestational age was 35.7 (25.4-41.0) wk and the overall survival rate was 72.4%. Among the 21 survivors, 19 (90.5%) required admission to the neonatal intensive care unit for 15 (5-64) d. All 21 survivors had postnatal resolution of the pleural effusions. All 21 children were long-term survivors, with a median age of survivorship of 3 y 3 mo (9 mo-7 y 6 mo) at the time of last reported follow-up., Conclusions: Thoracoamniotic shunting in fetuses with a dominant pleural effusion(s) and secondary hydrops resulted in a 72% survival rate. Nearly all survivors required admission to the neonatal intensive care unit. However, a majority did not have significant long-term morbidity., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The number of pregnant women with abnormally invasive placenta (AIP) including clinical relevant placenta increta and percreta has markedly increased with a reported incidence of as high as one in 731, By 2020 in the United States, there will be an estimated 4504 new cases of AIP and 130 AIP-associated maternal deaths annually. The preoperative diagnosis and operative management of AIP is challenging. In a planned cesarean delivery, a vertical lower abdominal skin incision is widely used in order to have enough space to perform a hysterotomy above the cranial edge of the placenta to avoid significant fetal and/or maternal hemorrhage. We have used preoperative drainage of the amniotic fluid after epidural anesthesia and immediately before a planned cesarean delivery through a transverse skin incision in five patients with AIP of the anterior uterine wall. With less uterine volume, exteriorization of the gravid uterus is easily performed through a transverse laparotomy. The combination of amnion drainage, transverse laparotomy and exteriorization of the gravid uterus facilitates identification of the exact site of placental implantation, provides adequate space for performing fundal or high anterior or even posterior uterine wall incisions and to deliver the fetus safely while minimizing the risk of placental separation and subsequent uncontrolled blood loss. Furthermore, this technique provides the chance to leave the untouched placenta in situ or to remove the placenta in toto with a uterine wall segment.

In this study we aimed to examine the effects on wound healing and nerve regeneration of human and rat amniotic membrane wraps around primary epineural anastomosis areas after a peripheral nerve transection injury in rats. We randomized 25 male adult rats with induced peripheral transection injuries into 5 groups (control, transection injury, primary epineural anastomosis [PEA] after injury, PEA with a human amniotic membrane [hAM] wrap, and PEA with a rat amniotic membrane [rAM] wrap groups and treated their injuries accordingly. We took tissue samples from the anastomosis regions, 12 weeks after the experiment, and analyzed them stereologically and ultrastructurally. We performed a statistical analysis with the recovered stereological counts and the measurement data. Our results showed that the use of amniotic membranes for allografts (between same species) instead of xenografts (between different species), along with microsurgery, provides a suitable microenvironment during the healing process with less immunological reaction on the injured site and supports axonal regeneration., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Plastic surgeons have used several methods for the construction of neo-vaginas, including the utilization of penile skin, free skin grafts, small bowel or recto-sigmoid grafts, an amnion graft, and cultured cells., Purpose: The aim of this study is to compare the results of amnion grafts with amnion seeded with autograft fibroblasts., Materials and Methods: Over 8 years, we compared the results of 24 male-to-female transsexual patients retrospectively based on their complications and levels of satisfaction. Sixteen patients in group A received amnion grafts with fibroblasts, and the patients in group B received only amnion grafts without any additional cellular lining. The depths, sizes, secretions, and sensations of the vaginas were evaluated. The patients were monitored for any complications, including over-secretion, stenosis, stricture, fistula formation, infection, and bleeding., Results: The mean age of group A was 28 ± 4 years and group B was 32 ± 3 years. Patients were followed up from 30 months to 8 years, (mean 36 ± 4) after surgery. The depth of the vaginas for group A was 14-16 and 13-16 cm for group B. There was no stenosis in neither group. The diameter of the vaginal opening was 34-38 mm in group A and 33-38 cm in group B. We only had two cases of stricture in the neo-vagina in group B, but no stricture was recorded for group A. All of the patients had good and acceptable sensation in the neo-vagina. Seventy-five percent of patients had sexual experience and of those, 93.7% in group A and 87.5% in group B expressed satisfaction., Conclusion: The creation of a neo-vaginal canal and its lining with allograft amnion and seeded autologous fibroblasts is an effective method for imitating a normal vagina. The size of neo-vagina, secretion, sensation, and orgasm was good and proper. More than 93.7% of patients had satisfaction with sexual intercourse. Amnion seeded with fibroblasts extracted from the patient's own cells will result in a vagina with the proper size and moisture that can eliminate the need for long-term dilatation. The constructed vagina has a two-layer structure and is much more resistant to trauma and laceration. No cases of stenosis or stricture were recorded., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Purpose of the Review: In this article, we explore the origins of intervention of fetal lower urinary tract obstruction, and we specifically discuss the background and recent outcomes of vesicoamniotic shunt placement and fetal cystoscopy. The article seeks to provide a comprehensive overview of the field while bringing the reader quickly up to speed on the pertinent literature and the critical data that are available to guide decision-making regarding intervention., Recent Findings: Appropriate patient selection for fetal intervention remains challenging despite advances in prenatal imaging. Both a randomized controlled trial and multiple systematic reviews show evidence of a perinatal survival benefit following fetal intervention but rates of renal morbidity remain very high. Despite 30 years of research, fetal lower urinary tract obstruction remains a difficulty entity to treat. Intervention may lead to survival, but physicians and caregivers must remain alert for the distinct possibility of long-term renal morbidity in survivors.

Objective: The purpose of this study is to investigate the factors associated with successful amniopatch treatment in patients with iatrogenic preterm premature rupture of membranes (iPPROM) or spontaneous PPROM (sPPROM) before 23 weeks' gestation., Materials and Methods: This cohort study included 28 women who received amniopatch treatment due to iPPROM or sPPROM at 15-23 weeks' gestation. Patients' clinical characteristics before performing the amniopatch, factors associated with the procedure, pregnancy and neonatal outcomes were compared between the iPPROM and sPPROM groups, and also between the successful and failed groups., Results: The amniopatch was successful in 6 of 28 patients (21.4%) with a success rate of 36.4% (4/11) and 11.8% (2/17) in the iPPROM group and sPPROM group (P = 0.174), respectively. The success group had a longer PPROM-to-delivery interval, fewer cases of clinical chorioamnionitis, larger birth weight, and lower neonatal intensive care unit admission rate than the failed group. The success rate of amniopatch procedure was proportional to maximal vertical pocket prior to procedure, which showed statistically significant association (adjusted odds ratio: 3.62, 95% confidence interval: 1.16-11.31, P = 0.027)., Conclusion: The amniopatch treatment success rate was higher in the iPPROM group than the sPPROM group, but was not statistically significant. The neonatal outcome was more favorable when the amniopatch was successful. However, the only predictive factor associated with successful amniopatch was a larger amniotic fluid volume before the procedure., (Copyright © 2017. Published by Elsevier B.V.)

Objective: To investigate the effect of amniotomy on the duration of spontaneous labor., Methods: In the present randomized controlled trial, women in spontaneous labor with singleton pregnancies presenting at a tertiary teaching hospital in South India between August 1, 2014, and October 31, 2015, were randomized in a 1:1 ratio to undergo amniotomy or conservative management. The primary outcome was the duration of labor. Per-protocol analyses were performed and the duration of labor was compared between the groups of patients., Results: There were 144 patients randomized to each group. The median duration of labor was 235 minutes (interquartile range 117-355) in the amniotomy group and 364 minutes (interquartile range 201-580) in the conservative management group (P<0.001)., Conclusion: Amniotomy was associated with a shorter duration of labor in comparison with conservative management in patients with singleton pregnancies experiencing spontaneous labor. Clinical Trials Registry-India: (CTRI) (CTRI/2014/12/005264)., (© 2017 International Federation of Gynecology and Obstetrics.)

Introduction: Although mortality has decreased for fetuses with lower urinary tract obstruction treated with vesicoamniotic shunt (VAS) placement, survivors remain at risk for long-term renal impairment. We tested the association of fetal serum β2-microglobulin (fsβ2M) with postnatal renal function in these patients, hypothesizing that fsβ2M may predict such renal impairment., Materials and Methods: fsβ2M was obtained in patients undergoing VAS placement. The primary outcome was renal function at 3-12 months of life, as assessed by a pediatric nephrologist using medical records. Patients were divided into two groups: (1) 'stable renal function' - probable stable long-term renal function and reasonable growth - and (2) 'loss of renal function' - early loss of renal function and failure to thrive., Results: Nineteen patients with preoperative fsβ2M received a VAS. Of the 14 survivors, those with fsβ2M ≤5.6 mg/l tended to have stable renal function compared to those with fsβ2M >5.6 mg/l [5/6 (83.3%) vs. 2/8 (25.0%), OR = 15.00, 95% CI 0.70-709.89; p = 0.1026]. Eight of 9 patients followed for >12 months of age had outcomes consistent with the initial renal assessments., Discussion: Patients with initial fsβ2M >5.6 mg/l and treated with VAS tended to have poor renal outcomes., (© 2016 S. Karger AG, Basel.)

Objective: To evaluate the association between early amniotomy after ripening with a Foley balloon catheter and duration of labor induction., Methods: In this retrospective matched cohort study, 546 nulliparous women with a singleton viable gestation undergoing cervical ripening with a Foley balloon catheter were compared based on timing of amniotomy after catheter removal: early (defined as artificial rupture of membranes less than 1 hour after Foley removal) compared with no artificial rupture of membranes in the first hour. Women in the early amniotomy group were matched to women in the control group according to health care provider type, cervical examination after Foley removal, and indication for induction in a one-to-one ratio. Bivariable and multivariable analyses were performed to determine whether early amniotomy was associated with vaginal delivery within 24 hours and other adverse maternal and neonatal outcomes. Cox proportional hazard regression was used to compare time intervals from catheter removal to complete dilation and from catheter removal to delivery., Results: In univariable analysis, the frequency of vaginal delivery within 24 hours of Foley placement was higher in women with early amniotomy (42.9% compared with 33.0%, P=.02). The median time intervals from Foley catheter removal to complete dilation (9.0 hours compared with 12.1 hours) and to delivery (10.6 hours compared with 13.8 hours) were also significantly shorter for women who underwent early amniotomy (P<.001 for both). There were no significant differences in any other adverse maternal or neonatal outcomes. In multivariable analysis, early amniotomy remained associated with higher odds of vaginal delivery within 24 hours and shorter times from catheter removal to complete dilation and to delivery., Conclusion: Early amniotomy after Foley balloon catheter removal is associated with shorter duration of labor induction among nulliparous women.

Background and Objective: Colonic anastomotic failure is a dreaded complication, and multiple surgical techniques have failed to eliminate it. Photochemical tissue bonding (PTB) is a method of sealing tissue surfaces by light-activated crosslinking. We evaluated if a human amniotic membrane (HAM), sealed over the anastomotic line by PTB, increases the anastomotic strength., Study Design: Sprague-Dawley rats underwent midline laparotomy followed by surgical transection of the left colon. Animals were randomized to colonic anastomosis by one of the following methods (20 per group): single-layer continuous circumferential suture repair (SR); SR with a HAM wrap attached by suture (SR+ HAM-S); SR with HAM bonded photochemically over the anastomotic site using 532 nm light (SR+ HAM-PTB); approximation of the bowel ends with only three sutures and sealing with HAM-PTB (3+ HAM-PTB). A control group underwent laparotomy alone with no colon resection (NR). Sub-groups (n = 10) were sacrificed at days 3 and 7 post-operatively and adhesions were evaluated. A 6 cm section of colon was then removed and strength of anastomosis evaluated by burst pressure (BP) measurement., Results: A fourfold increase in BP was observed in the SR+ HAM-PTB group compared to suture repair alone (94 ± 3 vs. 25 ± 8 mm Hg, P < 0.0001) at day 3. At day 7 the burst pressures were 165 ± 40 and 145 ± 31 mm Hg (P = 1), respectively. A significant decrease in peri-anastomotic adhesions was observed in the SR+ HAM-PTB group compared to the SR group at both time points (P < 0.001)., Conclusion: Sealing sutured colonic anastomotic lines with HAM-PTB increases the early strength of the repair and reduces peri-anastomotic adhesions. Lasers Surg. Med. 48:530-537, 2016. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Objective: To assess the success rate of vaginal delivery among women with twin pregnancies; the Twin Birth Study has shown that vaginal delivery and caesarean section are equally safe for twin delivery but >40% of the planned vaginal delivery group delivered by caesarean section., Design: A retrospective cohort study., Setting: A tertiary medical centre., Population: A total of 2194 women with twin pregnancies not complicated with very low birthweight., Methods: Planned mode of delivery was documented in the woman's electronic record upon entering the delivery room. Information regarding maternal age at delivery, parity, gestational age, presentation, previous history of caesarean delivery, birthweight and Apgar score was collected from the obstetric electronic charts., Main Outcome Measured: Rate of vaginal twin delivery., Results: Of the 2194 women included, 1311 twin pregnancies had planned caesarean delivery and 883 underwent a trial of labour. Of the 883 women who underwent a trial of labour, the rate of vaginal delivery was 86.9%, whereas the rates of caesarean delivery and combined vaginal-caesarean delivery were 11.1% and 2.0%, respectively. Presentation of second twin, gestational age and maternal age did affect the chances of success. Nulliparity [odds ratio (OR) 2.38, 95% confidence interval (95% CI) 1.4-4.05], Foley induction of labour (OR 2.33, 95% CI 1.38-3.91) and body mass index >30 kg/m(2) (OR 1.76, 95% CI 1.03-3) were independent risk factors for caesarean delivery., Conclusions: The rate of vaginal delivery among women with twin pregnancies who undergo labour can be high, especially in women who laboured spontaneously and have delivered before., Tweetable Abstract: The rate of vaginal delivery of twins can be high, especially in women who have delivered before., (© 2015 Royal College of Obstetricians and Gynaecologists.)

We report the case of a 66 year old female with a supratrigonal vesicovaginal fistula (VVF) that developed after undergoing radical hysterectomy, chemotherapy and pelvic radiation therapy for advanced cervical cancer. VVF repairs in an irradiated field are known to be complicated procedures with significant morbidity and a high rate of failure due to the effect of radiation. Amniotic membranes have been demonstrated to improve healing rates in difficult to heal wounds. To decrease morbidity a minimally invasive robotic procedure was performed and a dehydrated amniotic allograft patch was used to augment tissue healing. The VVF was repaired using the da Vinci Surgical System and the amniotic membrane was used as an interposition patch over the repair. There were no operative or postoperative complications and the patient was discharged home on postoperative day one. A cystogram performed 3 weeks postoperatively demonstrated a healed fistula. Follow-up at 5 months revealed no incontinence. This is the first reported case of a robotic VVF repair performed in an irradiated pelvis and the first use of an amniotic membrane allograft in the repair a VVF.

In our retrospective study we evaluated the efficacy of an improved amniotic membrane (AM) roll-in filling technique (AMR) combined with multilayer amniotic membrane cover to treat corneal perforation and included 46 cornea perforations ≤ 3 mm in diameter treated with AMR and 20% C3F8 mixed gas filling of the anterior chamber. Anterior chamber depth, aqueous leakage, bubble maintenance time, and cornea morphology were monitored after each operation. The mean diameter of corneal perforation was 1.60 ± 0.55 mm (range 0.5-3) and the success rate of the AMR method for corneal perforation reconstruction was 100% after a single operation. Anterior chamber depth was normally reconstructed without AMR break-off, aqueous leak, or other complications. The mean time of the C3F8 gas bubble in the anterior chamber was 8.6 ± 2.0 days (range 4-12). At the last follow-up, all patients' visual acuity was improved to varying degrees. The mean follow-up time was 11.0 ± 5.6 months (range 3-36). The AMR plugging combined with multilayer AM cover is a secure and easy intervention, which led to 100% success in our study. Various perforations ranging from trauma to infection can be treated with AMR, which is especially practical in those countries where donor cornea availability is limited.

Objective: The purpose of this study was to compare 2 inductions of labor protocols., Study Design: Women with live singleton pregnancies at ≥37 + 0 weeks gestation who were booked for prostaglandins 2 (PGE2) vaginal gel induction with a modified Bishop's score of <7 were eligible for inclusion. After an evening dose of PGE2 vaginal gel, women were assigned randomly the next morning into the amniotomy or repeat-PGE2 group. The amniotomy group underwent artificial rupture of membranes (ARM), regardless of modified Bishop's score, and received further PGE2 doses only if ARM was not technically possible. The repeat-PGE2 group received further PGE2 (to a maximum of 3 doses) until a modified Bishop's score ≥7 occurred, when an ARM was performed. In both groups, Syntocinon was commenced once membranes were ruptured. The primary outcome measure was time from commencement of induction until birth., Results: Two hundred forty-five women were assigned randomly into either the amniotomy (n = 121) or repeat-PGE2 group (n = 124). The time for induction of labor-to-birth was >5 hours shorter in the amniotomy group (24.8 vs 30.0 hours; mean difference, 5.2 h; 95% confidence interval, -2.5 to -7.8). Fewer women in the amniotomy group remained undelivered after 24 hours (47.1% vs 67.7%; P < .01). However, the likelihood of an in-hours birth and the length of hospital stay were no different between the groups. There was no difference in the mode of birth or any of the secondary outcomes., Conclusion: After an initial dose of PGE2 vaginal gel, an amniotomy (once technically possible) is associated with a shorter induction of labor-to-birth time compared with the use of repeat doses of PGE2. Administering more PGE2 with the aim of starting contractions or making the cervix "more favorable," appears to have no clinical advantage., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: In our fetal lamb model of lower urinary tract obstruction, a pressure limited shunt preserves bladder function and renal development. This study investigates the effects on pulmonary histology., Methods: We created obstructive uropathy (OU) in 60-day gestation fetal lambs, ligating the urethra and urachus, and delivering them at term (130-145days). We compared pulmonary histology in 4 groups: group A, OU without shunt; group B, pressure limited shunt; group C, non-valved shunt. Shunts were inserted 3weeks post-obstruction. Group D were normal controls., Results: We compared 27 fetuses: 7 fetuses in group A, 4 fetuses in group B, 2 fetuses in group C, and 14 fetuses in group D. There was no significant difference in lung volume in any group. In group A, there were some areas of atelectasis and incomplete alveolar formation histologically. The alveoli in group A lambs lungs had a predominance of type II cells, whereas group B lambs lungs were lined by type I epithelial cells and were essentially indistinguishable from controls., Conclusions: This study suggests that using a pressure-limited vesico-amniotic shunt in OU may preserve the renal tract and the lungs., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Early amniotomy is common in obstetric practice but, its effectiveness has not been proven., Objectives: To determine the effects of early amniotomy on the duration of labour, and other maternal / neonatal outcomes of uncomplicated pregnancies in Enugu, South-east Nigeria., Methods: A randomized controlled study of 214 consenting term pregnant women at the University of Nigeria Teaching Hospital Enugu, Nigeria. Intervention group received amniotomy early in active labour while the control group had their membranes conserved., Results: Mean duration of labour for the amniotomy group (279.4 ± 53.7 minutes) was significantly lower than that of control group (354.4 ± 67.5 minutes), (t = -8.988, p <0.001). Three (3.8%) women in amniotomy group needed oxytocin augmentation as against 21 (19.6%) women in the control group RR = 0.14, (CI 95%: 0.04 - 0.46), NNT = 16. The two groups did not vary with respect to cesarean section rate, newborn Apgar scores, and need for new born special care unit admission., Conclusion: Early amniotomy when compared to fetal membrane conservation reduced the duration of labour and need for oxytocin augmentation among term singleton pregnant women in Enugu, Nigeria. Its routine use in well selected cases may reduce prolonged labour and its complications.

Purpose: Artificial rupture of amniotic membranes (amniotomy) which induces or accelerates labor is the most common obstetrical procedure. There is controversy about the effect of early amniotomy on dystocia and cesarean delivery. The study aim was to determine the effect of early amniotomy on the risk of dystocia and cesarean delivery in nulliparous women., Methods: This randomized controlled clinical trial was conducted on 300 nulliparous women. They were randomly assigned into the experimental (early amniotomy; artificial amniotomy at cervical dilation ≤ 4 cm) and control (routine management) groups (each 150 women). Length of labor, dystocia, cesarean delivery, placental abruption, and umbilical cord prolapse were compared between the groups., Results: Early amniotomy shortened labor duration significantly in experimental group (7.5 ± 0.7 h) compared to control group (9.9 ± 1.0 h) (P < 0.001). Dystocia (6.7 vs. 25.3 %, P < 0.0001), cesarean delivery (11.3 vs. 39.3 %, P < 0.001), and placental abruption (4.7 vs. 13.3 %, P = 0.009) were significantly lower in experimental group compared to the control group. Multiple logistic regression showed that early amniotomy decreased the odds of dystocia 80.6 % (95 % CI 58.6-90.1 %) and the odds of cesarean section 81.7 % (95 % CI 66.2-90.1 %)., Conclusion: Early amniotomy was associated with lower rate of dystocia and cesarean delivery as well as shorter duration of labor.

Objective: To determine whether artificial rupture of membranes (AROM) during active phase of labor augments uterine contractility using Electrical Uterine Myography (EUM)., Study Design: A prospective study of 31 women with term singleton pregnancy during active phase of labor. Using a non-invasive EUM technique, electrical uterine activity was recorded in the 30 min preceding AROM and in the immediate 30 min thereafter. Augmentation was defined as >5% increase in EUM index between the basal and post-AROM states, representing the mean EUM increase of the entire cohort. Low basal uterine contraction was defined as EUM index of less than the entire cohort median result prior AROM (3.5 micro-Watt-Second (mWS))., Results: Mean dilatation in which AROM was preformed was 5.5 ± 1.8 cm. There was a significant increase in mean EUM measurement in the post-AROM compared to the basal state (3.59 ± 0.39 versus 3.42 ± 0.47 mWS, p < 0.001). In multivariate analysis, low BMI and low basal uterine contractions were the only significant predictors for augmentation following AROM (OR 0.69, 95% C.I 0.45-0.97, p = 0.009 and OR 16.03, 95% CI 1.90-134.69, p = 0.003, respectively)., Conclusion: Myometrial electrical activity was significantly enhanced following AROM. Augmentation was mostly pronounced in patients with lower BMI and initial lower basal uterine contraction.

Purpose: Hydrops and pulmonary hypoplasia are associated with significant morbidity and mortality in the setting of a congenital lung lesion or pleural effusion (PE). We reviewed our experience using in utero thoracoamniotic shunts (TA) to manage fetuses with these diagnoses., Methods: A retrospective review of fetuses diagnosed with a congenital lung lesion or pleural effusion who underwent TA shunt placement from 1998-2013 was performed., Results: Ninety-seven shunts were placed in 75 fetuses. Average gestational age (±SD) at shunt placement and birth was 25±3 and 34±5 weeks. Shunt placement resulted in a 55±21% decrease in macrocystic lung lesion volume and complete or partial drainage of the PE in 29% and 71% of fetuses. 69% of fetuses presented with hydrops, which resolved following shunt placement in 83%. Survival was 68%, which correlated with GA at birth, % reduction in lesion size, unilateral pleural effusions, and hydrops resolution. Surviving infants had prolonged NICU courses and often required either surgical resection or tube thoracostomy in the perinatal period., Conclusion: TA shunts provide a therapeutic option for select fetuses with large macrocystic lung lesions or PEs at risk for hydrops and/or pulmonary hypoplasia. Survival following shunting depends on GA at birth, reduction in mass size, and hydrops resolution., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: In our fetal lamb model of lower urinary tract obstruction, a valved shunt preserves bladder function. This study investigates the effects on renal histology., Methods: We created obstructive uropathy (OU) in 60-day gestation fetal lambs, ligating the urethra and urachus, and delivering them at term (130-145days). We compared renal histology in 4 groups: group A-OU without shunt, group B-low-pressure shunt (15-54mmH2O), group C-high-pressure shunt (95-150mmH2O). Shunts were inserted 3weeks post-obstruction. Group D were normal controls., Results: We delivered 32 fetuses from 23 ewes: 13 fetuses in group A (9 survived), 6 fetuses in group B (5 survived), 7 fetuses in group C (5 survived), and 6 fetuses in group D. Histologically, we found renal tubular distention, vacuolated degeneration of tubular epithelial cells in 7 lambs, and cyst formation in 4 lambs in group A. There was renal tubular distention in two lambs, and cyst formation in one lamb in both groups B and C, with vacuolated degeneration of tubular epithelial cells observed in all but 1 lamb in each group., Conclusions: V-A shunting prevents multicystic dysplastic kidney (MCDK). Some lambs have renal tubular distention and vacuolated degeneration of renal tubular epithelial cells., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To compare early induction and expectant management regarding delivery outcomes and the experience of delivery in nulliparous women with prolonged latent phases., Design: Randomized controlled trial., Setting: One delivery unit in a Swedish hospital., Population: Nulliparous women at term experiencing continuous contractions impeding rest (women's report) and exceeding 18 h, a cervical dilation of less than 4 cm, intact membranes and with a singleton fetus in cephalic presentation., Methods: The women were randomly allocated to either early induction (n = 65) or expectant management (n = 64). All participants received medication for therapeutic rest. The early induction group was induced five hours after medication, and the expectant group awaited spontaneous onset of labor. The Wijma Delivery Experience Questionnaire (W-DEQ version B) was filled in after delivery., Main Outcome Measures: The primary outcome was mode of delivery. Secondary outcomes included birth experience, duration of labor, postpartum hemorrhage, and neonatal outcomes., Results: The cesarean section rate was 15 of 65 (23.1%) in the early induction group and 24 of 64 (37.5%) in the expectant group (p = 0.076, OR 2.00, 95% CI 0.93-4.31). No significant differences were shown regarding delivery, neonatal outcomes or birth experience., Conclusions: No significant differences were shown between the two groups in the rate of cesarean sections or the experience of delivery. According to the actual results, the power to detect a difference was only 45%. The cesarean section rate was high in both groups, regardless of intervention., (© 2014 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: Amniotomy (the deliberate rupture of membranes) was described almost two centuries ago and since then has been used both for induction and augmentation of labour - which are common obstetric practices. Trends have shown a rise in the induction rates over the last decade and data suggest that the rate of labour inductions is increasing faster than the rate of pregnancy complications. Recent years have seen the emergence of a variety of other methods of induction of labour but amniotomy combined with oxytocin infusion remains the most commonly used method of augmentation of labour. The newer agents for induction are expensive and in resource-poor settings amniotomy is still the chosen method for both induction and augmentation.As with any invasive procedure amniotomy can lead to infection, ascending from the vagina into the uterine cavity and can contribute significantly to both maternal and neonatal infectious morbidity., Objectives: The objective of this review was to evaluate the prophylactic use of antibiotics versus placebo or no treatment prior to amniotomy on maternal and neonatal infectious morbidity and mortality., Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014), the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov (12 September 2014)., Selection Criteria: Randomised controlled trials or cluster-randomised trials comparing antibiotics prior to amniotomy versus placebo (or no treatment) were eligible for inclusion in this review but none were identified. Quasi-randomised trials or cross-over trials were not eligible for inclusion., Data Collection and Analysis: Two review authors independently assessed one trial report for inclusion. In future updates of this review, two review authors will independently assess risk of bias and carry out data extraction. Data will be checked for accuracy., Main Results: We identified one trial report but this was excluded. No studies met the inclusion criteria for this review., Authors' Conclusions: High-quality trials are needed to justify or refute the routine use of antibiotics at amniotomy for prevention of infection in the mother and infant.Future studies should be conducted, especially in resource-constrained settings where amniotomy is still used as a means of induction of labour, in order to evaluate the routine use of antibiotics at amniotomy in these settings. Future research in this area should include important maternal and infant outcomes listed in this review and also consider cost effectiveness and side effects of antibiotic use, including the emergence of antibiotic-resistant strains.

Primary fetal chylothorax is an uncommon complication, associated with high perinatal morbidity and mortality. In our report, we describe two cases of fetal bilateral primary chylothorax successfully treated with pleuro-amniotic shunting. In both cases, ultrasound scans showed bilateral, hypoechoic fluid in the pleural space without any associated structural malformations and features of infection and aneuploidy Laboratory analysis of pleural fluids revealed 79% and 92% of lymphocytes, respectively confirming chylothorax in both fetuses. In the first case, pleuro-amniotic shunts were successfully inserted at 31 weeks and 6 days of gestation. Ultrasound scan after two weeks showed expansion of the left lung and lack of fluid in both pleural cavities. At 39 weeks of gestation, a 2660 g baby boy was delivered by cesarean section (Apgar score: 9). The child did not require surgical intervention and was discharged home on day 16 of life. In the second case, the insertion of shunts (at 24 weeks and 6 days of gestation) also significantly reduced the amount of the fluid in the pleural cavities, but one shunt had to be surgically removed after birth. At 30 weeks and 2 days of gestation, a cesarean section was performed due to maternal cholestasis. A female weighing 1400 g was delivered (Apgar score: 7). The chest X-ray revealed only a small amount of fluid in the left pleural cavity The infant was discharged on postnatal day 26, in good condition and with body weight of 2150 g. Pleuro-amniotic shunt insertion is a method of choice in the treatment of confirmed primary fetal chylothorax.

Unlabelled: More than 50 percent of preterm neonates below 28 gestational weeks in our institution are delivered by cesarean section (CS)., Aim: To present advantages of less used method of delivery of premature and/or very low birth weight (VLBW) neonates by Amnion Protective Cesarean Section (APCS) when indicated and to review our experience with the method. It can be used in all deliveries by CS with unruptured amniotic membranes, at all gestational ages., Materials and Methods: Including criteria were singleton pregnancies, gestation of 26 to 35 weeks and birth body weight between 700 to 1500 g. According to the criteria, during the studied period 10 neonates were delivered by APCS. We compared the outcomes of APCS neonates with ones delivered by coventional CS who matched them in mentioned criteria., Results: Compared to CS cases, APCS neonates had statistically significant better first minute AS. Stay in NICU was shorter for APCS neonates but not statistically significant. From our experience APCS neonates had clinically better appearance (less bruises and hematomas)., Conclusion: APCS is promising method for delivery of preterm and/or VLBW neonates when indicated, although prospective studies are needed in order to prove its effectiveness compared to conventional CS.

Background: Artificial rupture of membranes (Amniotomy) is a common obstetric intervention. Its rates and indications had been subjected to criticism in medical literature. The current practices recommend to reduce its rate and keep the birthing process as natural as possible., Aim: This observational study aimed to describe the rates and indicators for practice of artificial rupture of membranes (Amniotomy) during normal labor and to determine if any significant differences existed between women who have had one pregnancy (PG) and women who have already delivered two or more children (G2 and above) on this obstetric interventions: artificial rupture of membranes (ARM)., Results: There were no PG participants with ruptured membranes whereas slightly more than half of the G2 and above participants (n = 88) had ruptured membranes. The most frequent cause for ARM was active management of latent phase of labor (PG n = 20 and G2 and above n = 9). Furthermore, slow progress of labor (PG n = 17 and G2 and above n = 7) and concerns with fetal heart rate (PG n = 13 and G2 and above n = 5) had the next highest number of occurrences. Results from the proportions tests revealed that there was one significant difference between gravidity groups on the frequency of APH (p = 0.039). That is, G2 and above participants had amniotomy done for APH (5 of 32 = 15.63%) significantly more often than PG participants (4 of 89 = 4.49%). And although not statistically significant (p = 0.084), there were 21 cases within the PG group where ARM was performed for no specific reason (21 of 89 = 23.6%) compared to three cases within the G2 and above group (3 of 32 = 9.4%)., Conclusions: Although ARM is a commonly performed procedure during labor, there is not much difference between its indications between PG and G2 and above. The only significantly different indication was antepartum hemorrhage which was higher in G2 and above. Amniotomy was also performed without any clear indication in 26.4% of PG and 9.4% of G2 and above. Considering ARM as obstetric intervention efforts should be done to reduce its rates. There is a need for arranging normal labor workshops to revise the indications and reviewing the rates after these workshops to reduce the rates of ARM.

Research shows that artificially rupturing the amniotic sac (amniotomy) can cause umbilical cord prolapse. Amniotomy became a routine part of obstetrical care with the introduction of active management, without evidence of benefit. In the 30 years since active management was introduced, the rate at which amniotomy causes umbilical cord prolapse has not been directly studied. Two controlled studies from Turkey from 2002 and 2006 are the only published studies that provide enough data to extract the rate at which cord prolapse follows amniotomy. They show that 1 cord prolapse results from every 300 amniotomies (0.3%). There is data suggesting amniotomy may also increase neonatal GBS infection, maternal pain and fetal blood loss if placental blood vessels are punctured.

Amniotomy has become a routine part of obstetrical care. It was added along with other procedures adopted 50+ years ago without strong evidence. The scientific data supporting this procedure is poor while there is data suggesting it may increase the frequency of cord prolapse, neonatal GBS infection, pain and fetal blood loss if placental blood vessels are punctured. The incidence of cord prolapse overall reported in the literature ranges from 0% to 0.7%. The rate at which cord prolapse immediately follows amniotomy has not been directly studied but is reported in 4 case controlled studies.

Objective: To review the most current literature in order to provide evidence-based recommendations to obstetrical care providers on induction of labour., Options: Intervention in a pregnancy with induction of labour., Outcomes: Appropriate timing and method of induction, appropriate mode of delivery, and optimal maternal and perinatal outcomes., Evidence: Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library in 2010 using appropriate controlled vocabulary (e.g., labour, induced, labour induction, cervical ripening) and key words (e.g., induce, induction, augmentation). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to the end of 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies., Values: The evidence in this document was rated using criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). SUMMARY STATEMENTS: 1. Prostaglandins E(2) (cervical and vaginal) are effective agents of cervical ripening and induction of labour for an unfavourable cervix. (I) 2. Intravaginal prostaglandins E(2) are preferred to intracervical prostaglandins E(2) because they results in more timely vaginal deliveries. (I).

Fetal bladder rupture is a rare complication occurring due to bladder outlet obstruction, mostly posterior urethral valves. A 26-year-old primigravida presented to us at 27 weeks gestation with an ultrasound report showing gross fetal ascitis and mild oligohydramnios. A repeat scan was performed which showed fetal bladder rupture and urinary ascitis. In conjunction with paediatric surgeon, we performed ultrasound-guided placement of double-ended pigtail catheter connecting the fetal peritoneal cavity with the amniotic cavity at 28 weeks gestation. Ultrasound performed 3 days after the placement of the catheter showed its correct placement. Unfortunately, 1 week after the procedure at 29 weeks gestation, the patient had premature rupture of membranes and later went into labour and delivered vaginally. The neonate could not be revived and expired after few hours of birth due to prematurity-related complications. The placement of the shunt could have probably precipitated preterm rupture of membranes.

Background: Caesarean section rates are over 20% in many developed countries. The main diagnosis contributing to the high rate in nulliparae is dystocia or prolonged labour. The present review assesses the effects of a policy of early amniotomy with early oxytocin administration for the prevention of, or the therapy for, delay in labour progress., Objectives: To estimate the effects of early augmentation with amniotomy and oxytocin for prevention of, or therapy for, delay in labour progress on the caesarean birth rate and on indicators of maternal and neonatal morbidity., Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013), MEDLINE (1966 to 4 July 2013), Embase (1980 to 4 July 2013), CINAHL (1982 to 4 July 2013), MIDIRS (1985 to 4 July 2013) and contacted authors for data from unpublished trials., Selection Criteria: Randomized and quasi-randomized controlled trials that compared oxytocin and amniotomy with expectant management., Data Collection and Analysis: Three review authors extracted data independently. We stratified the analyses into 'Prevention Trials' and 'Therapy Trials' according to the status of the woman at the time of randomization. Participants in the 'Prevention Trials' were unselected women, without slow progress in labour, who were randomized to a policy of early augmentation or to routine care. In 'Treatment Trials' women were eligible if they had an established delay in labour progress., Main Results: For the 2013 update, we identified and excluded one new clinical trial. This updated review includes 14 trials, randomizing a total of 8033 women. The unstratified analysis found early intervention with amniotomy and oxytocin to be associated with a modest reduction in the risk of caesarean section; however, the confidence interval (CI) included the null effect (risk ratio (RR) 0.89; 95% CI 0.79 to 1.01; 14 trials; 8033 women). In prevention trials, early augmentation was associated with a modest reduction in the number of caesarean births (RR 0.87; 95% CI 0.77 to 0.99; 11 trials; 7753). A policy of early amniotomy and early oxytocin was associated with a shortened duration of labour (average mean difference (MD) - 1.28 hours; 95% CI -1.97 to -0.59; eight trials; 4816 women). Sensitivity analyses excluding four trials with a full package of active management did not substantially affect the point estimate for risk of caesarean section (RR 0.87; 95% CI 0.73 to 1.05; 10 trials; 5165 women). We found no other significant effects for the other indicators of maternal or neonatal morbidity., Authors' Conclusions: In prevention trials, early intervention with amniotomy and oxytocin appears to be associated with a modest reduction in the rate of caesarean section over standard care.

Purpose: To model the timing and sequence of intrapartum interventions and to estimate the association with labor length and delivery mode., Methods: A longitudinal multi-center cohort study included data from 3,955 low-risk women who gave birth in hospitals in Lower Saxony, Germany. We analyzed three intrapartum interventions: amniotomy, oxytocin augmentation and epidural analgesia. We divided births into time intervals delineated by these interventions and noted cervical dilation at interval onset. We analyzed the duration of intervals from onset of labor until the first intervention and between intrapartum interventions with Kaplan-Meier's estimate, regarding the three interventions as competing risks. Further, we analyzed the cervical dilation before an intervention by Kaplan-Meier's estimate without censoring., Results: 73.2 % of the included 2,082 nulliparae (n = 1,525) and 59.6 % of the included 1,873 multiparae (n = 1,117) received at least one intervention, while 1,313 women (33.2 %) experienced a normal labor without any of these interventions. The intervals from onset of labor until the first intervention and from the first until the second intervention were significantly shorter in multiparae than in nulliparae. The intervention cascade in nulliparae most often started with epidural analgesia in early labor (n = 579, 27.8 %). Oxytocin augmentation most often followed after a short interval (n = 343, 59.2 %, median 1.57 h). In multiparae, amniotomy was most often the first intervention (n = 629, 33.6 %), and spontaneous birth most often followed (n = 503, 80.0 %). Labor duration and operative deliveries increased as interventions increased., Conclusions: The temporal sequence of intrapartum interventions varied in association with parity, cervical dilation, labor duration and mode of birth.

Objectives: To test the effectiveness and safety of early amniotomy after vaginal misoprostol for the induction of labor., Study Design: A randomized clinical trial that included 320 women with medical or obstetric indication for labor induction. They were randomly assigned into two equal groups, amniotomy group and control group. Each participant received vaginal misoprostol 50 μg every 6 h for induction of labor. In amniotomy group, amniotomy was done in the early active phase of labor while in the control group, the membranes were left to rupture spontaneously or as judged by the senior resident in the duty., Results: More subjects in the amniotomy group achieved vaginal delivery within 24 h than in the control group [117 (73.13 %) vs. 105 (65.63 %)]. Subjects in the amniotomy group reported shorter induction to delivery interval (09.72 ± 4.61 h vs. 13.61 ± 5.61, P = .002), and better neonatal outcome compared to the control group. There were no statistically significant differences between both group with regard to number of doses of misoprostol, need for oxytocin, Cesarean Section indication and maternal side effects., Conclusion: Early amniotomy after vaginal misoprostol for labor induction is associated with higher successful vaginal delivery rate, shorter labor duration and better neonatal outcome.

Background: Intentional artificial rupture of the amniotic membranes during labour, sometimes called amniotomy or 'breaking of the waters', is one of the most commonly performed procedures in modern obstetric and midwifery practice. The primary aim of amniotomy is to speed up contractions and, therefore, shorten the length of labour. However, there are concerns regarding unintended adverse effects on the woman and baby., Objectives: To determine the effectiveness and safety of amniotomy alone for routinely shortening all labours that start spontaneously., Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2013)., Selection Criteria: Randomised controlled trials comparing amniotomy alone versus intention to preserve the membranes. We excluded quasi-randomised trials., Data Collection and Analysis: Two review authors assessed identified studies for inclusion, assessed risk of bias and extracted data. Primary analysis was by intention-to-treat., Main Results: We have included 15 studies in this updated review, involving 5583 women. Amniotomy alone versus intention to preserve the membranes (no amniotomy) for spontaneous labour There was no clear statistically significant difference between women in the amniotomy and control groups in length of the first stage of labour (mean difference (MD) -20.43 minutes, 95% confidence interval (CI) -95.93 to 55.06), caesarean section (risk ratio (RR) 1.27, 95% CI 0.99 to 1.63), maternal satisfaction with childbirth experience (MD -1.10, 95% CI -7.15 to 4.95) or Apgar score less than seven at five minutes (RR 0.53, 95% CI 0.28 to 1.00). There was no consistency between trials regarding the timing of amniotomy during labour in terms of cervical dilatation. Amniotomy alone versus intention to preserve the membranes (no amniotomy) for spontaneous labours that have become prolonged There was no clear statistically significant difference between women in the amniotomy and control group in caesarean section (RR 0.95, 95% CI 0.15 to 6.08), maternal satisfaction with childbirth experience (MD 22.00, 95% CI 2.74 to 41.26) or Apgar score less than seven at five minutes (RR 2.86, 95% CI 0.12 to 66.11)., Authors' Conclusions: On the basis of the findings of this review, we cannot recommend that amniotomy should be introduced routinely as part of standard labour management and care. We recommend that the evidence presented in this review should be made available to women offered an amniotomy and may be useful as a foundation for discussion and any resulting decisions made between women and their caregivers.

Objective: To determine elective induction of labor outcomes in term, low-risk women who delivered in a community teaching hospital., Methods: This is a retrospective cohort study of women admitted from January 1, 2006 to January 31, 2010, for elective induction of labor. A comprehensive search of the perinatal database identified low-risk patients at ≥39 weeks gestation and ≤41 weeks with singleton pregnancies in vertex presentation. Data abstracted from manual chart review included patient demographics, admission cervical examination, and induction method. Outcome measures were delivery method and cesarean indications. Time categories calculated were mean times from induction to delivery, delivery to discharge, and total hospital length-of-stay. Descriptive statistics, frequencies, and percentages were reported using multiple regression analysis, analysis of variance, and effect tests with respective values reported. Data were analyzed using JMP software by SAS Institute Inc., Results: Of the 1,159 women identified, 848 records passed exclusion criteria. Vaginal delivery was accomplished for 694 (81.8 %) of patients. The most common induction agent was oxytocin (73.7 %). Induction of labor with oxytocin and artificial rupture of membranes revealed a statistically significant shorter length of induction with average induction of labor for oxytocin of 11.9 h. Multiparous patients of parity >1 and patients presenting with cervical dilation of 3-4 cm had a statistically significant higher probability of vaginal delivery. Patients induced with a foley bulb or dinoprostone had statistically longer induction times (28.2 and 24.9 h, respectively) and had a statistically significant higher probability of cesarean delivery., Conclusion: Multiparous patients and patients with a favorable cervix (>2 cm) were more likely to have a vaginal delivery and shorter length of induction.