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Objective: To evaluate neonatal outcomes following failed vacuum extraction using the Kiwi OmniCup vacuum device., Methods: We conducted a retrospective study of 288 failed vacuum deliveries using the OmniCup device. The neonatal morbidity was recorded for each delivery., Results: Of the 288 women involved, 82.3% were nulliparous. In 245 cases (85.1%), failed vacuum was followed by successful forceps delivery; failed vacuum and failed forceps was followed by Caesarean section in 5.9%; failed vacuum was followed by spontaneous vaginal delivery in 3.8%; and failed vacuum was followed by Caesarean section in 5.2%. Cephalhematoma was diagnosed in 19.8% of the 288 infants delivered. There were no cases of neonatal intracranial or subgaleal hemorrhage., Conclusion: Although the method of delivery following failed vacuum extraction is controversial, and most national guidelines warn of increased neonatal morbidity with subsequent use of forceps, the low morbidity in this study is reassuring. In our cohort, low forceps delivery (station > 2 cm) following failed vacuum extraction was not associated with serious neonatal morbidity.

Objective: To determine the antecedent factors, morbidity, and mortality associated with disseminated intravascular coagulation (DIC) in a Nova Scotia tertiary maternity hospital over a 30-year period., Methods: Cases of DIC were identified from the Nova Scotia Atlee Perinatal Database for the years 1980 to 2009 and the hospital charts reviewed. The clinical diagnosis of DIC was confirmed or refuted using a combination of the International Society of Thrombosis and Haemostasis scoring system and an obstetrical DIC-severity staging system. The cause of DIC was determined from chart review. Maternal outcomes included massive transfusion (≥ 5 units), hysterectomy, admission to ICU, acute tubular necrosis (ATN) requiring dialysis, and death. Neonatal outcomes included Apgar scores, birth weight, NICU admission, and death. Treatment of DIC was assessed by blood products administered, postpartum hemorrhage management, and laboratory measurements., Results: There were 49 cases of DIC in 151 678 deliveries (3 per 10,000) over the 30 years. Antecedent causes included placental abruption (37%), postpartum hemorrhage or hypovolemia (29%), preeclampsia/HELLP (14%), acute fatty liver (8%), sepsis (6%), and amniotic fluid embolism (6%). The associated maternal morbidity included transfusion ≥ 5 units (59%), hysterectomy (18%), ICU admission (41%), and ATN requiring dialysis (6%). There were three maternal deaths, giving a case fatality rate of 1 in 16. The perinatal outcomes included stillbirth (25%), neonatal death (5%), and NICU admission (72.5%)., Conclusion: Obstetrical DIC is an uncommon condition associated with high maternal and perinatal morbidity and mortality. Prompt recognition and treatment with timely administration of blood products is crucial in the management of this life-threatening disorder.

Objective: To identify potential determinants of perinatal mortality and neonatal morbidity among second twins relative to first twins., Methods: A retrospective cohort design was used to study twin deliveries in Nova Scotia from 1988 to 2002. Monoamniotic or conjoined twins and twin pairs with major congenital anomaly or antepartum fetal death of either twin were excluded. The primary outcome was a composite measure of perinatal mortality and neonatal morbidity, including birth asphyxia, respiratory distress, neonatal trauma, and infection. Risk of adverse outcome of second twins relative to first-born co-twins was determined by matched-pair analysis., Results: Of 1,542 twin pairs, the second twin was at greater risk of composite adverse outcome (relative risk [RR] 1.62, 95% confidence interval [CI] 1.38-1.9) than the first twin. This excess risk was evident independent of presentation, chorionicity, or infant sex but was associated with planned vaginal delivery, birth weight discordance, and prolonged interdelivery interval. Term second twins were less likely to suffer excess morbidity with elective cesarean (RR 1.0, 95% CI 0.14-7.10) than with planned vaginal delivery (RR 3.0, 95% CI 1.47-6.11). The major contributors to neonatal morbidity in the second twin were birth asphyxia at 37 weeks or later and respiratory distress syndrome at less than 37 weeks., Conclusion: The second twin is at greater risk of adverse perinatal outcome than the first twin, independent of presentation, chorionicity, or infant sex. Planned vaginal delivery, birth weight discordance, and prolonged interdelivery interval increase this infant risk. Elective cesarean delivery at term may improve perinatal outcome for the second twin. However, the number of cesarean births required to prevent one case of composite adverse outcome, assuming causality, was 33.

Objective: To estimate whether the incidences of adverse fetal and neonatal outcomes in infants of mothers with preexisting types 1 and 2 diabetes 1) differ from infants of nondiabetic mothers in Nova Scotia (NS); and 2) have changed between 1988 and 2002., Methods: Population-based cohort study using the NS Atlee Perinatal Database, a well-validated source of standardized clinical information., Results: A total of 516 infants of diabetic mothers and 150,589 infants of nondiabetic mothers from singleton pregnancies were studied. Infants of diabetic mothers had significantly higher rates of perinatal mortality (17.4/1,000 compared with 5.9/1,000, relative risk [RR] 3.01, 95% confidence interval [CI] 1.55-5.84), major congenital anomaly (9.1% compared with 3.1%, RR 2.97, 95% CI 2.25-3.90), and large for gestational age birth (LGA, more than 90th percentile weight for gestational age) (45.2% compared with 12.6%, RR 3.59, 95% CI 3.26-3.95) than infants of nondiabetic mothers. In infants of diabetic mothers, there was no improvement in perinatal mortality (23.4/1,000 in 1988-1995 compared with 11.5/1000 in 1996-2002, P = .340), incidence of LGA (48.0% in 1988-1995 compared with 42.3% in 1996-2002, P = .237), or rate of major congenital anomaly (8.2% in 1988-1995 compared with 10.0% in 1996-2002, P = .560). Diabetes remained an independent risk factor for LGA infants and major congenital anomaly after adjusting for possible confounders., Conclusion: Rates of adverse neonatal outcomes are 3-9 times greater in infants of diabetic mothers compared with those of nondiabetic mothers. There were no significant improvements in rates of perinatal mortality, congenital anomaly, or LGA birth in infants of diabetic mothers in 1996-2002 compared with 1988-95.

Objective: To investigate the relationship between prepregnancy obesity and maternal outcomes., Methods: A 15-year, population-based cohort study using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in obese and nonobese women. Prepregnancy weight of 55-75 kg was considered nonobese, and weight greater than 90 kg was considered obese. Obese women were categorized into moderate obesity (90-120 kg) and severe obesity (> 120 kg) groups. Univariate and multivariable logistic regression analysis was performed, and odds ratios (ORs), adjusted ORs, and 95% confidence intervals (CIs) were calculated. P < .05 was considered statistically significant., Results: In 142,404 singleton pregnancies, 10,134 (7.2%) women were identified as obese (moderate obesity 92.3%, severe obesity 7.7%). The proportion of women in the obese categories increased from 3.2% in 1988 to 10.2% in 2002. Moderately obese women had an increased risk of pregnancy-induced hypertension (PIH) (adjusted OR 2.38, 95% CI 2.24-2.52), antepartum venous thromboembolism (adjusted OR 2.17, 95% CI 1.30-3.63), labor induction (adjusted OR 1.94, 95% CI 1.86-2.04), cesarean delivery (adjusted OR 1.60, 95% CI 1.53-1.67), and wound infection (adjusted OR 1.67, 95% CI 1.38-2.00). Severely obese women had an increased risk of PIH (adjusted OR 3.00, 95% CI 2.49-3.62), antepartum venous thromboembolism (adjusted OR 4.13, 95% CI 1.26-13.54), induction of labor (adjusted OR 2.77, 95% CI 2.39-3.21), cesarean delivery (adjusted OR 2.46, 95% CI 2.15-2.81), anesthesia complications (adjusted OR 2.01, 95% CI 1.33-3.06), and wound infection (adjusted OR 4.79, 95% CI 3.30-6.95). This implies that, relative to nonobese women, there was 1 excess case of PIH per 10 moderately obese women and 1 per 7 severely obese women. For antepartum venous thromboembolism, there was 1 excess case per 857 moderately obese women and 1 per 321 severely obese women., Conclusion: Prepregnancy maternal obesity increases the risk of PIH, antepartum venous thromboembolism, labor induction, cesarean delivery, and wound infection.

To estimate maternal and perinatal morbidity associated with caesarean delivery at full cervical dilatation, a population-based cohort study from 1997 to 2002 was used, which included 1623 nullipara with singleton pregnancies at 37-42 weeks of gestation requiring caesarean delivery in labour. Compared to caesarean delivery at less than full dilatation, women undergoing caesarean delivery at full dilatation were more likely to have complications of intraoperative trauma (RR 2.6, P < 0.001) and infants with perinatal asphyxia (RR 1.5, P < 0.05). There was no difference in maternal or perinatal morbidity when duration of the second stage of labour or when failed assisted vaginal delivery was considered.

Objective: To evaluate the effect of hospital closures on critical obstetrical interventions and perinatal outcomes in rural communities in Nova Scotia, Canada., Methods: A population-based cohort study was carried out for the years 1988 to 2002, using data extracted from the Nova Scotia Atlee Perinatal Database. Regions of maternal residence were defined geographically and administratively as Eastern, Northern,Western, and Central. The time periods of 1988 to 1993 and 1996 to 2002 were chosen based on the timing of hospital closures. Changes in rates of several perinatal outcomes were examined by region in relation to the extent of hospital closures experienced by that region., Results: The majority of hospital closures occurred in 1994 to 1995 with the establishment of new health regions, and affected the Western region most profoundly. In comparison with the Central region (relative risk [RR], 0.56; 95% confidence interval [CI], 0.53-0.59), the temporal reduction in the rate of forceps-assisted vaginal delivery was smaller in the Western region (RR, 0.83; 95% CI, 0.76-0.91; P < .001), but greater in the Northern (RR, 0.36; 95% CI, 0.32-0.41; P < .001) and Eastern (RR, 0.26; 95% CI, 0.23-0.30; P < .001) regions. The temporal increase in the rate of breastfeeding at discharge from hospital was smaller in the Northern region (RR, 1.36; 95% CI, 1.29-1.45; P < .001) compared to that in the Central region (RR, 1.55; 95% CI, 1.49-1.61). The decrease in the rate of fetal growth restriction was smaller in the Western (RR, 0.95; 95% CI, 0.87-1.02; P = .002) and Eastern (RR, 0.90; 95% CI, 0.82-0.98; P = .002) regions of residence compared to the Central region (RR, 0.75; 95% CI, 0.71-0.79). There were no significant regional differences in temporal patterns of preterm induction and/or preterm Caesarean delivery, or perinatal mortality., Conclusion: Although trends over time demonstrated some regional differences in obstetrical interventions and perinatal outcomes, our retrospective evaluation did not reveal a consistent relationship between reductions in maternity services associated with hospital closures and systematic, population-level adverse perinatal consequences in Nova Scotia.

Objective: To study the incidence and mortality and morbidity rates of twin-twin transfusion syndrome in a complete population-based cohort in Nova Scotia., Methods: A population-based cohort study of all monochorionic diamniotic twin pregnancies of 20 weeks of gestation or longer born to Nova Scotia (Canada) residents between 1988 and 2000 was examined. The effect of gestational age adjustment and birth weight discordancy of more than 20% on mortality and 1-year survival was studied. Other outcomes studied included birth depression, respiratory distress syndrome, chronic lung disease, interventricular hemorrhage, periventricular leukomalacia, acute renal failure, and congestive heart failure., Results: Of 404 monochorionic-diamniotic twin pregnancies examined, 48 were identified with twin-twin transfusion syndrome. Total mortality rates per pregnancy were significantly greater in the twin-twin transfusion syndrome group than in the remainder of our monochorionic diamniotic population (P < .01). However, when adjusted for gestational age, mortality failed to achieve statistical significance. Similarly, no differences were noted for 1-year survival and other outcomes of liveborn infants after gestational age adjustment. Discordance in birth weight predicted a higher incidence of morbid outcomes per pregnancy, but this effect was lost after gestational age adjustment., Conclusion: Increased morbidity and mortality of twins with twin-twin transfusion syndrome is likely to be due to a higher incidence of preterm birth. Birth weight discordancy was not found to be an independent predictor of mortality after controlling for gestational age and twin-twin transfusion syndrome.

The objective of this study was to determine the rate, origin, maternal and perinatal outcomes, and the associated hospital costs of higher order multiple births in one Canadian province. All higher order multiple pregnancies (triplets and above) in Nova Scotia over a 22-year period (1980 to 2001) were reviewed, and the maternal and perinatal outcomes and hospital costs were compared with singletons and twins in the same hospital population. During the 22-year period, 116,785 infants were delivered, including 3448 twins, 99 triplets, and 16 quadruplets. Of the higher order multiple gestations, 51.4% were conceived through infertility therapy. When compared with mothers of either singletons or twins, mothers of higher order gestations were significantly older, had longer antepartum and postpartum hospital stays, were more likely to have cesarean delivery, preterm labor, preeclampsia, and require intensive care unit admission. Triplets and quadruplets had significantly higher rates of preterm delivery, major anomalies, neonatal intensive care, respiratory distress syndrome, intrauterine growth restriction, serious morbidity, 5-minute Apgar scores < or = 3, and neonatal death than twins or singletons. The estimated hospital costs for this population ranged from 6,750 US dollars for a singleton pregnancy to 278,400 US dollars for a quadruplet pregnancy. Maternal morbidity, perinatal morbidity and mortality, and hospital costs are significantly increased in higher order births compared with both twins and singletons.

Objective: To determine the prevalence of eclampsia and the associated maternal and perinatal outcomes in the province of Nova Scotia., Methods: From the Nova Scotia Atlee Perinatal Database, the population-based rates of preeclampsia, eclampsia, and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome for the period 1988 to 2000 were determined. A retrospective case review was then performed of all women with eclampsia at the tertiary maternity hospital in Halifax, Nova Scotia, Women's Hospital, IWK Health Centre, for the years 1981 to 2000., Results: In the province of Nova Scotia from 1988 to 2000, there were 142,362 births. Thirty-nine women developed eclampsia (0.27/1000). Over this time interval, the prevalence of severe preeclampsia fell from 2.08% to 1.63%, and the diagnosis of HELLP syndrome increased from 0.03% to 0.31%. At the Women's Hospital, IWK Health Centre, between 1981 and 2000, there were 31 cases of eclampsia in 105,651 deliveries (0.29/1000). Sixty-one percent of first convulsions occurred antepartum, 13% occurred intrapartum, and 26% occurred postpartum. Eighty-one percent of women reported prodromal symptoms. Sixty-one percent of the women received anti-hypertensive therapies, 48% received antiepileptic therapies, and 97% received magnesium sulfate. Ten percent of the women had convulsions while on magnesium sulfate therapy. Antepartum eclampsia was associated with increased rates of general anaesthesia (26%) and Caesarean section (79%). There were no maternal deaths, but the rate of major maternal complications was 32%. The perinatal mortality rate was 64 in 1000 deliveries, and the rate of severe perinatal complications was 56%., Conclusion: The incidence of eclampsia in Nova Scotia is 0.27 per 1000 deliveries. Although rare, this condition is associated with significant maternal and perinatal morbidity.