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Uterine contractions during labor and engagement of the fetus in the birth canal can compress the fetal head. Its impact on the fetus is unclear and still controversial. In this integrative physiological review, we highlight evidence that decelerations are uncommonly associated with fetal head compression. Next, the fetus has an impressive ability to adapt to increased intracranial pressure through activation of the intracranial baroreflex, such that fetal cerebral perfusion is well-maintained during labor, except in the setting of prolonged systemic hypoxemia leading to secondary cardiovascular compromise. Thus, when it occurs, fetal head compression is not necessarily benign but does not seem to be a common contributor to intrapartum decelerations. Finally, the intracranial baroreflex and the peripheral chemoreflex (the response to acute hypoxemia) have overlapping efferent effects. We propose the hypothesis that these reflexes may work synergistically to promote fetal adaptation to labor.

Introduction: High fetal head station has been associated with prolonged labor and delivery outcomes. Although clinical assessment of fetal head station is both subjective and unreliable, women with prolonged labor are subjected to multiple digital vaginal examinations. The use of ultrasound has been proposed to aid in the management of labor since 1990s. Ultrasound examination is more accurate and reproducible than clinical examination in the diagnosis of fetal head station and in the prediction of arrest of labor. Ultrasound examination can, to some extent, distinguish those women destined for spontaneous vaginal delivery and those destined for operative delivery and may predict the outcome of instrumental vaginal delivery. Such a technique has the potential to reduce the frequency of intrusive internal examinations and associated infection and could be useful in allowing the assessment of women in whom digital VE is traumatic or contra-indicated. Intrapartum ultrasound not only provides objective and quantitative data in labor, but also helps to make more reliable clinical decisions aiming to improve obstetric outcomes of both the mother and fetus as a supplementary tool for active management. Aim of the work: This study aims at assessing the value of intrapartum transperineal ultrasonography as a quantitative and objective tool in the evaluation of progress of labor and prediction of mode of delivery. Subjects: This study was a prospective observational study conducted on 600 primiparous women in active first stage of labor admitted to Kasr Al Ainy maternity hospital from January 2017 to June 2018. The studied population was divided into two groups. Group A of 300 women with normal progress of labor and group B of 300 women with prolonged 1st stage of labor. Methods: Fetal head station(FHS) was assessed clinically by digital vaginal examination (dVE) and sonographically by transperineal ultrasound measurement of head perineal distance (HPD) and angle of progression (AOP). Intrapartum care of the patient continued as normal based only on digital vaginal examinations using the modified WHO partogram. (1). Statistical analysis was targeted towards assessing the potential of the intrapartum ultrasonography in the evaluation of progress of labor and prediction of mode of delivery. Results: All studied parameters for assessment of FHS (dVE, HPD, and AOP) significantly corelated with each other and with both progress of labor and mode of delivery with P value (

Background Various manoeuvres such as McRoberts position, suprapubic pressure, rotational methods, posterior arm extraction and all-four position (HELPERR) have been proposed for relieving shoulder dystocia with variable success. Posterior axillary sling method using a rubber catheter was proposed in 2009 but has not been widely used. We modified this method using ribbon gauzes and a long right-angle forceps and report a successful case. Case presentation A 44 years old parity one Chinese woman with a history of a caesarean delivery and poorly controlled type 2 diabetes mellitus was admitted to the Accident and Emergency Department for advanced stage of labour at term. Upon arrival, intrauterine fetal demise was diagnosed with severe asynclitism causing obstruction at the perineum. Episiotomy resulted in birth of the fetal head. The fetal posterior right shoulder, however, remained very high up in the pelvis and HELPERR methods failed to extract the shoulders. We then tied two long ribbon gauzes together, and guided its knot to the anterior aspect of the posterior axilla. By using a long right-angle forceps (24 cm long) to grasp the knot on the posterior side of the axilla and pulling it through, a sling was formed. Traction was then applied through the sling to simultaneously pull and rotate the posterior shoulder. A stillbirth of 3488 g was finally extracted. Conclusions We modified the sling method by using two ribbon gauzes, tied together and a right-angle forceps with several advantages. Compared to a rubber catheter, ribbon gauze with a knot can be easily held between the fingers for easy guidance past the fetal axilla. It is also thin, non-elastic and stiff enough to ensure a good grip for traction. The long and slim design of the right-angle forceps makes it easy to pass through a narrow space and reach the axilla high up in the pelvis. We emphasize simultaneous traction and rotation, so that the shoulders are delivered through the wider oblique pelvic outlet dimension.

A male neonate is born at 38 weeks’ gestation via elective cesarean section to a 28-year-old gravida 4, para 3 woman. The neonate’s parents are first-degree cousins without a significant family history. The maternal history is unremarkable. She received antenatal care at a polyclinic and the scan obtained at approximately 24 weeks’ gestation is normal. She presented to the emergency department at 36 weeks’ gestation with a history of decreased fetal movement and was later admitted to the labor and delivery unit for evaluation. The maternal laboratory findings are as follows: hepatitis B, negative; group B Streptococcus , negative; blood type, O positive; antibodies, negative. Bedside ultrasonography shows macrocephaly with a large calcified central intracranial heterogeneous mass of peculiar vascularity measuring 7.74 × 6.55 × 8.37 cm3 in the midline supratentorial region, replacing brain tissue with thinning of the brain parenchyma. The infratentorial structure is normal and no other fetal abnormalities are seen (Fig 1). The mother refused fetal magnetic resonance imaging (MRI). Figure 1. Antenatal ultrasonography of the fetal head showing macrocephaly, with a head circumference of 39.73 cm (yellow arrow) and a large irregular calcified central intracranial heterogeneous mass (red stars) with peculiar vascularity (green arrow). At delivery, the neonate’s Apgar scores are 7 and 9 at 1 and 5 minutes, respectively. His vital signs are stable (temperature, 98°F [36.7°C]; heart rate, 150 beats/min; respiratory rate, 60 breaths/min; blood pressure, 66/41 mm Hg; oxygen saturation, 94%), but an initial newborn examination reveals macrocephaly with separated sutures, sunset eyes, skin peeling over the head, and no other obvious dysmorphic features (Fig 2). Figure 2. Macrocephaly with sunken eyes (anteroposterior/lateral view). The infant’s birthweight is 4,130 g (88th percentile), length 56 cm (99th percentile), and head circumference 48 …

Background: Fetal head “attitude” (relationship of fetal head to spine) in the first stage of labor may have a substantial impact on labor outcome. The diagnosis of fetal head deflexion traditionally is based on digital examination in labor. Objectives: To quantify the degree of fetal head deflection via the use of Ultrasound during the first stage of labor, and the relationship with the course and outcome of labor. Patients and methods: This was a prospective study conducted at Sayed Galal Hospital, Al-Azhar University from June 2019 to December 2019. Nonconsecutive series of women with uncomplicated singleton pregnancies at term gestation (37 weeks or more) were submitted to trans-abdominal ultrasound during the first stage of labor. Fetal position was occipito-anterior, and the angle between the fetal occiput and the cervical spine (the occiput-spine angle) was sonographically obtained on the sagittal plane. The measurements of the occipito-spine-angle were performed offline by an operator who was blinded to the labor outcome. The intra- and inter observer reproducibility and the correlation between the occipito-spine angle and the mode of delivery were evaluated. Results: A total of 400 pregnant women were recruited, 350 of which underwent a spontaneous vaginal delivery, and 50 were submitted to cesarean delivery. The mean value of the occipito-spine angle measured in the active phase of the first stage was 126° ± 2.79° (SD). The occipito-spine angle was significantly narrower in women who underwent CS delivery due to labor arrest. A larger occipito-spine angle (i.e. >126°) showed to be significantly associated with a shorter duration of labor. Conclusion: Fetuses with smaller occipito-spine angle (

Background:Rupture is an injury to the perineum caused by natural tissue damage due to pressure on the fetal head or shoulders during delivery. Postpartum infection (puerpuralis) is an infection of the genitalia after childbirth, which is characterized by an increase in temperature to 38ºC or more for 2 days in the first 10 days after delivery, excluding the first 24 hours. Postpartum infection includes all inflammation caused by entry of germs. or bacteria into the genital tract at the time of delivery and postpartum. Objective:The specific purpose of this study was to describe the level of knowledge of the mother about the prevention of perineal wound infection at the Kristina Clinic in 2021. This study used Non Probability Technique Sampling which is the total sampling method. The samples in this study were all postpartum mothers, both those who experienced rupture and those who did not at Kristina Clinic 2021, as many as 20 people. The research was conducted by distributing questionnaires to all postpartum mothers. The results: obtained based on the knowledge of postpartum mothers about the prevention of perineal wound infection based on education, it can be seen from the majority of respondents having good knowledge with 11 people (55.0%) and the minority having knowledge less with the number of 7 people (35.0%). Conclusion: It is hoped that midwives will be able to conduct postnatal visits for 6 weeks in order to monitor the healing process of perineal wounds in patients to avoid infection of perineal wounds and provide education on how to prevent perineal wound infections and the signs and dangers of perineal wounds.

In the prospective multicenter Genesis study, we developed a prediction model for Cesarean delivery (CD) in term nulliparous women. The objective of this secondary analysis was to determine whether the Genesis model has the potential to predict maternal and neonatal morbidity associated with vaginal delivery.The national prospective Genesis trial recruited 2,336 nulliparous women with a vertex presentation between 39 + 0- and 40 + 6-weeks' gestation from seven tertiary centers. The prediction model used five parameters to assess the risk of CD: maternal age, maternal height, body mass index, fetal head circumference and fetal abdominal circumference. Simple and multiple logistic regression analyses were used to develop the Genesis model. The risk score calculated using this model were correlated with maternal and neonatal morbidity in women who delivered vaginally: postpartum hemorrhage (PPH), obstetric anal sphincter injury (OASI), shoulder dystocia, one- and five-minute Apgar score ≤ 7, neonatal intensive care (NICU) admission, cephalohematoma, fetal laceration, nerve palsy and fractures. The morbidities associated with spontaneous vaginal delivery were compared with those associated with operative vaginal delivery (OVD). The likelihood ratios for composite morbidity and the morbidity associated with OVD based on the Genesis risk scores were also calculated.A total of 1,845 (79%) nulliparous women had a vaginal delivery. A trend of increasing intervention and morbidity was observed with increasing Genesis risk score, including OVD (p 0.001), PPH (p 0.008), NICU admission (p 0.001), low Apgar score at one-minute (p 0.001) and OASI (p = 0.009). The morbidity associated with OVD was significantly higher compared to spontaneous vaginal delivery, including NICU admission (p 0.001), PPH (p = 0.022), birth injury (p 0.001), shoulder dystocia (p = 0.002) and Apgar score of7 at one-minute (p 0.001). The positive likelihood ratios for composite outcomes (where the OVD was excluded) increases with increasing risk score from 1.005 at risk score of 5% to 2.507 for risk score of50%.In women who ultimately achieved a vaginal birth, we have shown more maternal and neonatal morbidity in the setting of a Genesis nomogram-determined high-risk score for intrapartum CD. Therefore, the Genesis prediction tool also has the potential to predict a more morbid vaginal delivery.

Background McRoberts' maneuver, turning the woman's thighs up in the supine position, has become the dominant method for resolving shoulder dystocia (defined as failure to deliver the fetal shoulder(s) with gentle downward traction on the fetal head, requiring additional obstetric maneuvers to effect delivery). Another method that is less commonly used is the Gaskin maneuver, which was first described by the midwife Ina May Gaskin, who learned of it from traditional midwives in Central America, and involves turning women to the hands-and-knees position. One retrospective observational study reported an 84% higher resolution of shoulder dystocia and less injury to the baby with the use of the hands-and-knees position as the first approach to resolving shoulder dystocia. The hands-and-knees position was reported to result in a wider pelvic diameter than the supine position and hence facilitate rotation of the baby and delivery, so it is possibly to resolving shoulder dystocia. The purpose of this study is to explore whether applying the Gaskin maneuver as the first approach for resolving cases of shoulder dystocia is a safer and better method than applying the McRoberts' maneuver first. Methods A time series cohort study was conducted in Laiwu Maternal and Child Health Hospital in Shandong, China over a seven -year period. Between January 2011 and July 2013 all women receiving traditional support at delivery were enrolled as a control group. During this time period, when shoulder dystocia was suspected, McRoberts’ maneuver (MR) was the most commonly employed first maneuver as described in the HELPERR mnemonics. Between October 2013 and December 2017, a change of practice was implemented for all vaginal births at the site, whereby midwives were instructed to use the Gaskin maneuver (i.e., moving the mother onto hands-and-knees position) as the first protocol if shoulder dystocia was suspected. Patients in this group were assigned to the experimental group. The neonatal outcomes including birth asphyxia and baby injury in both groups were recorded and analyzed. Results The injuries in the control group included 14 clavicular fractures, and one permanent brachial plexus injury, three temporary arm movement disorders that resolved within 7 days and those cases were not calculated as baby injury cases (the same in experimental group). In the experimental group, 58 cases of shoulder dystocia were reported, with one case of clavicular fracture, three temporary arm movement disorders that resolved within 3 days, and no permanent brachial plexus injuries. The rate of baby injury in the control group [14.6% (15/103)] was higher than that in the experimental group [1.7% (1/58)], and this difference was statistically significant [ χ 2 ​= ​6.834, P ​= ​0.009; OR ​= ​1.150 (1.055–1.254)]. Multiple logistic regression analysis showed that using the McRoberts' maneuver as the first approach in cases of shoulder dystocia [OR ​= ​19.609 (1.620–273.430)], the mother's employment status [OR ​= ​1.909 (1.118–3.262)], and intravenous dripping of oxytocin [OR ​= ​5.969 (1.391–25.605)] are risk factors for baby injury. There was no difference in neonate Apgar score between the two groups, and no baby died in either group. Conclusions Resolving shoulder dystocia by turning to the Gaskin maneuver as the first approach reduces the incidence of baby injury. This method should be recommended in clinical practice for better neonate outcomes.