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PubMed2000

Severe perineal lacerations during vaginal delivery: the University of Miami experience.

OBJECTIVE: After childbirth-related third- or fourth-degree perineal lacerations, the estimated incidence of wound disruption, fecal incontinence, or fistula ranges from 1% to 10%. Risk factors associated with severe laceration were analyzed at a single large teaching institution. STUDY DESIGN: This study consisted of an analysis of data from the delivery database of Jackson Memorial Hospital, University of Miami, from 1989 through 1995. Included were vaginal deliveries for which complete information was available on maternal age, parity, ethnicity (white, black, or Hispanic), birth weight, episiotomy versus no episiotomy, type of episiotomy, and delivery (normal spontaneous, vacuum, or forceps). Multiple gestations, cases of shoulder dystocia, cesarean deliveries, patients with a history of cesarean delivery, and babies weighing <500 g at birth were excluded from this study. Both univariate and multivariate analyses were performed with variables such as maternal age, race, birth weight, type of episiotomy if any, and type of vaginal delivery. RESULTS: Among the 71,959 women who were delivered at our institution during the 7-year study period, 50,210 met the inclusion criteria. Through time there had been a decline in the use of episiotomy in general and of midline episiotomy in particular. The annual total number of deliveries also decreased. The episiotomy procedure per se and the type of episiotomy as well as birth weight, assisted vaginal delivery, and older maternal age were identified as independent risk factors associated with third- and fourth-degree perineal lacerations. CONCLUSION: Although episiotomy is an important risk factor for severe lacerations after vaginal delivery, there are other significant independent risk factors, such as maternal age, birth weight, and assisted vaginal delivery, that should be considered in counseling and making decisions regarding delivery modality. Older patients who are being delivered of a first child are at higher risk for severe laceration. Midline episiotomy and assisted vaginal delivery should therefore be avoided in this population whenever possible, especially in the presence of a large baby.

Adult↗
PubMed2005

Cohort study of maternal and neonatal morbidity in relation to use of episiotomy at instrumental vaginal delivery.

OBJECTIVE: The aim of this study was to investigate the maternal and neonatal morbidity related to use of episiotomy for vacuum and forceps deliveries. DESIGN: Retrospective population-based cohort study. SETTING: Dundee, Scotland. POPULATION: Two thousand one hundred and fifty three women who experienced an instrumental vaginal delivery between January 1998 and December 2002. METHODS: Univariate and multivariate logistic regression analyses were performed comparing deliveries with and without the use of episiotomy. MAIN OUTCOME MEASURES: Extensive perineal tears (third and fourth degree) and shoulder dystocia. RESULTS: Two hundred and forty-one (11%) of the 2153 women who underwent instrumental vaginal deliveries did not receive an episiotomy. Vacuum delivery was associated with less use of episiotomy compared with forceps (odds ratio 0.10, 95% CI 0.07-0.14). Extensive perineal tears were more likely with use of episiotomy (7.5%vs 2.5%, adjusted OR 2.92, 95% CI 1.27-6.72) as was neonatal trauma (6.0%vs 1.7%, adjusted OR 2.62, 95% CI 1.05-6.54). Use of episiotomy did not reduce the risk of shoulder dystocia (6.9%vs 4.6%, adjusted OR 1.43, 95% CI 0.74-2.76). The findings were similar for delivery by vacuum and forceps. CONCLUSION: The use of episiotomy increased the risk of extensive perineal tears without a reduction in the risk of shoulder dystocia.

Cohort Studies↗
PubMed2006

Occult anal sphincter injuries--myth or reality?

OBJECTIVES: To establish the true prevalence of clinically recognisable and occult obstetric anal sphincter injuries (OASIS). DESIGN: Prospective interventional study. SETTING: Busy district general hospital. SAMPLE: Two hundred and fifty-four women having their first vaginal delivery over a 12-month period were invited. Two hundred and forty-one (95%) participated and 208 (86%) attended follow up. METHODS: Women had a clinical examination at delivery by the accoucheur and repeated by an experienced research fellow immediately after delivery. All identified OASIS were verified and repaired by the duty specialist registrar or consultant. Endoanal ultrasound was performed immediately postpartum prior to suturing and repeated seven weeks later. MAIN OUTCOME MEASURES: Prevalence of recognised and occult anal sphincter injuries. RESULTS: Fifty-nine (24.5%) women sustained OASIS. The prevalence of OASIS increased significantly from 11% to 24.5% when women were re-examined. Of these, 30 occurred in deliveries by midwives who missed 26 (87%) and 29 following deliveries by doctors who missed 8 (28%) injuries. All clinically apparent OASIS were also identified on endoanal ultrasound. In addition, three (1.2%) women had an occult anal sphincter injury. Two of these occult sphincter injuries were isolated to the internal anal sphincter (IAS) and would not usually be clinically detectable. CONCLUSIONS: OASIS occur more frequently than previously reported. Many remain undiagnosed and are subsequently classified as occult when identified on anal endosonography. Genuine occult injuries are rare. Training in perineal anatomy and recognition of OASIS needs to be enhanced in order to increase detection of OASIS and minimise the risk of consequent anal incontinence.

Anal Canal↗
PubMed1975

Very early termination of pregnancy (menstrual extraction).

Very early termination of pregnancy was performed on 424 women in three London teaching hospitals. Altogether 90% of the women were no more than 14 days overdue, and 67% of these had histological evidence of pregnancy. The procedure differed little in technique or its acceptability to the patient from termination done later in the first trimester. The similar incidence of complications suggested that it is not an alternative to conventional contraception. The response of patients, general practitioners, and referral agencies, however, indicated that there is a definite need in the community for a very early termination service.

Abortion, Induced↗
PubMed1987

Changes in fetal and maternal blood levels of prolactin, cortisol, and cortisone during eutocic and dystocic childbirth.

The changes in blood levels of prolactin, total and free cortisol, and cortisone were studied and compared in 51 mother-infant pairs, 30 with eutocic delivery and 21 with dystocic delivery. Regardless of the type of delivery, the newborn at term showed significantly higher prolactin and cortisone serum levels than their mothers, and significantly lower levels of free and total cortisol. In fetal distress of short duration, free cortisol levels were significantly raised in both the mother and the child, while prolactin and cortisone levels were significantly higher only in the child. In contrast to these observations, serum prolactin and cortisone levels in the mother were not altered by the occurrence of fetal distress. In the newborn at delivery there was a negative correlation between serum prolactin and the Apgar score at 1 min applied to the part of the graph between 8 and 2 Apgar scores. This study illustrates the utility of fetal prolactin measurements in evaluating the stress to which the fetus is subjected.

Adult↗
PubMed1998

[Low birth weight of newborns in industrial region: an analysis of ways of delivery in years 1972-1996].

The problem of prematurity in industrial region has been presented. The rate of prematurity in the time of 1972 to 1996 has been estimated and it equaled 13.2%. The highest rate of these newborn reached 16.7% in 1996. Systematical correlation in falling of perinatal mortality has been observed in time of research. Some attempts to compare the way of delivery and perinatal mortality have been made. It has been found that the frequency of caesarean section has grown significantly in the cases of low birth weight newborn.

Adult↗
PubMed2000

[An unrecognized neonatal emergency: extensive hematoma of the scalp. 5 cases].

BACKGROUND: Subgaleal hemorrhage results from a pericranial effusion of blood subsequent to neonatal trauma. This exceptional situation compared with other pericranial effusion conditions in the neonate may be life-threatening. CASE REPORTS: We report the obstetrical and neonatal data in 5 cases of subgaleal hemorrhage observed in our unit over an 8-year 8-month period. We detail one particularly demonstrative case which illustrates the potentially serious course of certain clinical presentations. DISCUSSION: Subgaleal hemorrhage is a clinical diagnosis. Signs of hemorrhagic shock are associated with hemostasis disorders in the more severe forms of the condition. The main risk factor is instrumental delivery with suction. Careful monitoring is required.

Apgar Score↗
PubMed1999

Revival of non-surgical management of neonatal depressed skull fractures.

The management of depressed skull fractures in the newborn infant can be controversial. We report on a neonate, born by Caesarean section with difficult head extraction, complicated by a parietal depressed fracture. This 'ping-pong' fracture was treated by elevation with an obstetrical vacuum extractor. No complications occurred. The possible treatment modalities for neonatal depressed fractures, being conservative or operative, will be discussed.

Adult↗
PubMed2006

Intrapartum translabial ultrasound (ITU): sonographic landmarks and correlation with successful vacuum extraction.

OBJECTIVE: Having studied intrapartum translabial ultrasound (ITU) to define easily obtainable sonographic criteria during maternal pushing, we used it dynamically immediately before vacuum extraction to determine its use in predicting successful operative vaginal delivery. METHODS: In a pilot study, maternal and fetal landmarks were determined sonographically during maternal pushing from a mid-sagittal translabial insonation using a curved array transducer in women delivering singleton fetuses in cephalic presentation spontaneously. With this transducer placed infrapubically ('infrapubic plane'), easily obtainable landmarks and signs were: (i) the 'infrapubic line', perpendicular to the long axis of the pubic joint and extending dorsally from its inferior margin in a mid-sagittal plane, (ii) the widest fetal head diameter and its movement with regard to the infrapubic line during pushing, and (iii) the 'head direction' with respect to the long axis of the symphysis. A three-dimensional reconstruction from a computed tomographic (CT) dataset of a normal female pelvis was then used to quantify accurately the spatial relationship between the infrapubic line and the anatomical landmarks. Finally, 20 pregnant women in spontaneous term labor with normal singleton fetuses in cephalic presentation and clinical indication for vacuum extraction were studied by ITU immediately before operative vaginal delivery. RESULTS: CT reconstruction demonstrated the infrapubic line to be 3 cm cranial to the parallel interspinous plane. Eleven of the 20 vacuum deliveries with the 'head-up' sign (head pointing ventrally) and objective descent of the fetal head below the infrapubic line, both noted at the height of pushing, resulted in successful ('simple' or 'moderately difficult') operative delivery. Lack of descent or lack of passage below the infrapubic line and horizontal or downward head direction were poor prognostic signs. CONCLUSIONS: ITU provides objective information on the dynamics of the second stage of labor, head station and head direction. ITU may be used to assess the prognosis for operative vaginal delivery.

Adolescent↗
PubMed1989

North Staffordshire/Wigan assisted delivery trial.

In a trial conducted at the North Staffordshire and Billinge Maternity Hospitals (NSMH and BMH) a total of 264 women who required an assisted delivery in the second stage of labour were randomly assigned to be delivered either by Kobayashi silicone cup ventouse or by forceps. A larger proportion (90%) of those assigned to the forceps group were actually delivered by the allocated instrument compared to those in the silicone cup group (73%). However, there was a significantly higher rate of maternal morbidity in terms of perineal trauma and discomfort in the forceps group. No differences in neonatal morbidity were detected.

Adult↗
PubMed1975

Identification of high risk labours by labour nomogram.

The labour stencil representing the expected cervimetric progress of normal labour was used in 741 consecutive spontaneous labours to identify high-risk labours which needed oxytocic stimulation. Uterine contractions were stimulated if progress extended two hours past the nomogram, which resulted in shorter labours, fewer instrumental deliveries and caesarean sections, and babies with higher Apgar scores than in those dysfunctional labours which were not stimulated. According to the protocol used 36% of primigravid and 13% of multigravid labours needed acceleration. The remaining patients did not need any oxytocic interference during the first stage. This selection of patients is important to prevent a major obstetric advance being abused and discredited at a time when the profession and public are questioning the safety of active labour.

Anesthesia, Epidural↗