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PubMedDate not supplied

Obstetric fistula: a preventable tragedy.

Obstetric fistula disables millions of women and girls in developing countries, primarily in sub-Saharan Africa and South Asia. The United Nations Population Fund (UNFPA) recently launched a global campaign to end fistula, labeling this condition a preventable and treatable tragedy. Obstetric fistula overwhelmingly results from obstructed labor, which occurs in cases of cephalopelvic disproportion and malpresentation. Cephalopelvic disproportion often complicates deliveries in young, primiparous women of low gynecologic age. Social factors, including young age at marriage and malnutrition of girl children, can also contribute to cephalopelvic disproportion. These social etiologies must be addressed by prevention campaigns. Direct prevention of fistula can occur during delivery when skilled providers identify women and girls at risk for obstetric fistula and link them with innovative interventions, such as Fistula Prevention Centers, through which they can more readily access emergency obstetric care, and by setting strict time limits for laboring at home without progress. Community-based programs, such as the Tostan program in West Africa, use social education to prevent fistula. Moreover, effective surgical techniques for fistula repair are available in some settings and should be expanded to reach those in need. Midwives can play a key role in the prevention and treatment of this tragic obstetric complication.

Adolescent↗
PubMed1997

Pelvimetry by magnetic resonance imaging as a diagnostic tool to evaluate dystocia.

OBJECTIVE: To test the clinical value of magnetic resonance imaging (MRI) pelvimetry for the diagnosis of cephalopelvic disproportion. METHODS: All deliveries from January 1993 through December 1994 were reviewed to identify 42 nulliparas at term with vertex presentation and cesarean delivery due to dystocia. Complete data were available for 41 women, and subjects were divided into the following two subgroups, according to clinical data: "cephalopelvic disproportion" (n = 28) and "failure to progress" (n = 13). Ten nulliparous women with uncomplicated vaginal delivery served as controls. Pelvimetry data from postpartum MRI were correlated with fetal and neonatal dimensions to evaluate various criteria for the diagnosis of cephalopelvic disproportion. RESULTS: Comparing both the fetal head volume derived from antepartum ultrasound assessment and the neonatal head volume (postpartum measurement) with maternal pelvic capacity determined by MRI, cephalopelvic disproportion (head volume exceeding pelvic capacity) indicated that 25 and 27, respectively, of the 28 women had been clinically diagnosed correctly with cephalopelvic disproportion, corresponding to sensitivities of 89% and 96%, respectively. Fetal head volume was not larger than pelvic capacity in any of the women in the control group. In seven of the 13 women diagnosed as "failure to progress," the fetal head volume exceeded the pelvic capacity. CONCLUSION: A fetal head volume estimate exceeding MRI-measured pelvic capacity is a frequent finding in nulliparas with cesarean birth due to cephalopelvic disproportion. An appropriate prospective study to determine the benefits of an antepartum diagnosis of cephalopelvic disproportion in high-risk nulliparas is warranted.

Adult↗
PubMed1988

Diagnostic criteria and the management of dystocia.

Cephalopelvic disproportion has been identified as making an important contribution to the rising cesarean birth rate. O'Driscoll and colleagues in Dublin, Ireland, have suggested replacement of cephalopelvic disproportion by the term dystocia for failure of labor to progress and have defined two major subcategories: (1) true cephalopelvic disproportion, and (2) inefficient uterine action. A chart audit of reported indications for cesarean birth in a family practice residency population was done, and patients were classified using the O'Driscoll et al diagnostic criteria for dystocia. When reclassified, the percentage of cesarean births in this population for true cephalopelvic disproportion did not differ significantly from that reported from Dublin (6.1 as compared with 8.8), while the percentage done for inefficient uterine action was significantly greater (35.4 as compared with 4.2). This finding suggests there is a set of labors amenable to a management strategy that could result in a decrease in the cesarean birth rates if efficient uterine action is assured with adequate use of oxytocin.

Adult↗
PubMed2002

MR imaging pelvimetry: a useful adjunct in the treatment of women at risk for dystocia?

OBJECTIVE: The objective of this study was to test the clinical value of MR imaging for diagnosing cephalopelvic disproportion and for predicting labor outcome in women at risk for dystocia. SUBJECTS AND METHODS: Antepartum fetal sonography and maternal MR imaging pelvimetry measurements were performed at term in 38 pregnant women at risk for dystocia with a single fetus in cephalic presentation. Various methods used to diagnose cephalopelvic disproportion were evaluated in a blinded manner for their accuracy to predict both the presence of cephalopelvic disproportion and the mode of delivery (vaginal vs cesarean). RESULTS: None of the methods tested yielded both high sensitivity (15-100%) and high specificity (24-92%) for determining the presence of cephalopelvic disproportion and high levels of accuracy for predicting labor outcome (overall predictability, 50-74%). CONCLUSION: To achieve increased reliability of MR imaging pelvimetry in the diagnosis and treatment of dystocia and in predicting labor outcome, new methods assessing fetal-pelvic compatibility, including measurements of the pelvic outlet and the shape and configuration of the pelvis, need to be established and prospectively tested before firm recommendations for clinical use can be made.

Adult↗
PubMedDate not supplied

[Methods, techniques and assessment criteria in obstetric pelvimetry].

Size and shape of the bony pelvis are important factors determining the progress of labor and delivery. Clinical evaluation of the pelvis and sonographic examination of the fetal size are important tools for the planning of labor and in most cases allow to diagnose cephalopelvic disproportion. Pelvimetry by computed tomography (CT) and by magnetic resonance imaging (MRI) are exact and simple techniques with low or absent ionizing radiation. These new techniques offer distinct advantages over conventional X-ray pelvimetry. However, the value of the measurements of the pelvic dimensions in predicting labor outcome and in the diagnosis of cephalopelvic disproportion remains limited. Only if the pelvimetric data are combined with data on fetal dimensions obtained by ultrasound or by postpartum measurements, the efficacy of the examination in predicting the success of labor and identifying the presence or absence of cephalopelvic disproportion is increased. This combination therefore may confirm the diagnosis of cephalopelvic disproportion after operative delivery, which is important with respect to subsequent deliveries. Furthermore this method could play and important role in selecting patients with term breech presentation for possible vaginal delivery.

Cesarean Section↗
PubMedDate not supplied

[Indications and justification of cesarean sections at the Instituto Mexicano del Seguro Social].

OBJECTIVE: In view of the high frequency rates of cesarean section at the Instituto Mexicano del Seguro Social (IMSS), we carried out a study to know main causes and its justification. MATERIAL AND METHOD: Retrospective study in a randomized national sample of clinical records in 3,232 cesarean cases between June 1997 and June 1999. RESULTS: The most frequent indications were cephalopelvic disproportion (29.6%), one previous section (20.9%), acute fetal distress (14.1%), iterative section (11.9%), and premature rupture of amniotic membranes (10.7%). In cephalopelvic disproportion cases, mean weight of newborns was 3,430 g., 70.6% of patients had irregular uterine contractility, and 21.7% received oxytocin; 78.2% had integrity of membranes and 4 cm or less in cervical dilation. In previous section and cephalopelvic disproportion the mean weight of newborns was 3,425 g; 81.7% did not have regular contractility and, 4.8 received oxytocin. In sections due to acute fetal distress, 94.9% had an Apgar in 8 or more at 5 minutes after delivery. CONCLUSION: The cesarean indications at the IMSS were similar to those are informed most to date in Mexico and throughout the world, but we did not find justification most of cases in this study.

Adult↗
PubMed1987

Symphysiotomy as an alternative to cesarean section.

The author compares the value of symphysiotomy to cesarean section in the management of cephalopelvic disproportion. He outlines the history of the procedure and reviews the literature on the subject. He then presents results of 54 symphysiotomies performed from 1976 to 1983 in two rural hospitals in the southwestern highlands of Tanzania, together with the outcome of subsequent labor in 25 other women with a history of previous symphysiotomy. The risk of maternal mortality after symphysiotomy is lower than after cesarean section when performed for cephalopelvic disproportion. Although different in nature, maternal morbidity after both operations is equally common. In contrast with findings reported in the literature, a history of previous symphysiotomy still constitutes a high obstetrical risk. The author concludes that symphysiotomy has a place in the management of cephalopelvic disproportion.

Africa↗
PubMed2003

[Study on the occurrence of cesarean section (CS) and factors related to CS in China].

OBJECTIVE: To find out the occurrence of cesarean section (CS) and to probe the factors associated with CS. METHODS: Women with CS as "case group" and women without CS as "control group" were chosen in a case-control study. RESULTS: Among 14 071 childbirth women, 6 421 had CS (case group) with the occurrence rate of 45.6% and 7 650 (54.4%) had normal delivery (control group). In comparison with the control group, the CS group had following several higher rates [with significant differences between case group and control group (P < 0.01)]: well-educated (78.9% vs 69.5%), white collar jobs (38.0% vs 32.3%), urban residents (79.1% vs 70.6%), high monthly income (>/= 500 Yuan) (81.0% vs 70.6%), of older age (>/= 25 years) (73.3% vs 63.0%), heavier baby weight (> 4 000 gram) (8.3% vs 2.9%), male babies (53.9% vs 51.4%), BMI of mother (> 24) (8.8% vs 4.8%), cephalopelvic disproportion (21.1% vs 0.9%), intrauterine asphysia (20.3% vs 6.7%), abnormality of force of labor (4.2% vs 2.7%), prolonged labor (2.9% vs 1.0%) and placenta previa (1.4% vs 0.4%). Our study also indicated that the higher the educational level was, the higher the rate of CS appeared; and the older the pregnant women was, the higher the rate of CS was. In CS group, over 70% primipara were over 24 years, and over 20% primipara had cephalopelvic disproportion and over 20% had intrauterine asphysia in CS group. CONCLUSIONS: At present, the occurrence rate of cesarean section was rather high (45.6%) in China. The high rate of CS was more likely to associate not only with abnormal physiological/medical factors (eg. cephalopelvic disproportion, intrauterine asphysia, abnormality of force of labor, and prolonged labour, etc.), but also with some demographic factors as education, occupation, income and age, etc. It is necessary to take measures to reduce the unnecessary CS in China.

Adult↗
PubMed1988

Vaginal birth after cesarean section for arrest of labor: is success determined by maximum cervical dilatation during the prior labor?

The charts of 229 patients who attempted a vaginal birth after a cesarean section were reviewed. A total of 103 patients had a prior cesarean section for either failure to progress or cephalopelvic disproportion. On the basis of the maximum cervical dilatation in the prior labor, the patients were categorized into three groups: 0 to 5 cm, 6 to 9 cm, and 10 cm. The success rates for vaginal delivery of 61%, 80%, and 69%, respectively, were not significantly different among groups (p = 0.31). When arrest of labor was not the indication for primary cesarean section, 78% of the patients were subsequently delivered of their infants vaginally. This was not significantly different from the 70% overall success rate achieved by the group with failure to progress or cephalopelvic disproportion (p = 0.17). Similarly, when the success rate for a trial of labor was plotted against neonatal birth weight, the trends were comparable in the groups with and without failure to progress or cephalopelvic disproportion. These data suggest that patients with a prior cesarean section for arrest of labor are good candidates for a trial of labor and that the cervical dilatation previously reached does not determine the likelihood of success.

Birth Weight↗
PubMed1994

Antenatal screening: its use in assessing obstetric risk factors in Zimbabwe.

STUDY OBJECTIVE: To assess the predictive utility of obstetric risk factors for identifying before the onset of labour those women at high risk of obstetric complications in a developing world setting, where home deliveries predominate and emergency transport is scarce. DESIGN: Risk factors derived from two population based, case-control studies (one of cephalopelvic disproportion and one of post partum haemorrhage), carried out in Zimbabwe were used to construct weighted and unweighted scores, a variety of screening algorithms, and sets of probabilities estimated from logistic regression models. These screening tests were evaluated for sensitivity, specificity, positive predictive value, and "cost" (the proportion of the population testing positive). Each complication was evaluated separately and the two were then pooled. PARTICIPANTS: All were Harare residents with singleton, vertex deliveries and spontaneous onset of labour. A total of 201 experienced cephalopelvic disproportion, 150 had post partum haemorrhage, and 299 had normal, unassisted deliveries. MEASUREMENTS AND MAIN RESULTS: Largely because of the very low incidence of the two complications studied (1% or less), positive predictive values were low (less than 7%). Holding "cost" constant at 10%, a screening test for cephalopelvic disproportion could predict 42.3% of cases compared with only 35.0% of those with post partum haemorrhage. Weighted scores had little advantage over unweighted ones, and probabilities from the logistic regression models did not differentiate cases from controls very well. CONCLUSIONS: With simple algorithms based on maternal height, parity, and obstetric history, more than one third of women at risk for potentially fatal complications could be identified at relatively small cost to themselves or the health care system.

Adult↗
PubMed1998

The effects of carbohydrate restriction in patients with diet-controlled gestational diabetes.

OBJECTIVE: To determine the effect of carbohydrate restriction on perinatal outcome in patients with diet-controlled gestational diabetes mellitus (GDM). METHODS: Women with diet-controlled GDM were divided non-randomly into two groups based on their dietary carbohydrate content: those with low dietary carbohydrate content (below 42%) and those with high dietary carbohydrate content (exceeding 45%). Subjects kept dietary accounts and were followed with daily fasting and postprandial glucose assessments. Subjects also were tested daily for urinary ketones. Glycosylated hemoglobin, mean fasting and postprandial glucose values, incidence of macrosomia and large for gestational age (LGA) infants, cesarean deliveries for cephalopelvic disproportion and macrosomia, and need for insulin therapy were compared between the groups. RESULTS: The two groups were identical in terms of demographic characteristics. Significant reductions in the postprandial glucose values were seen among subjects in the low-carbohydrate group (P < .04). Fewer subjects in the low-carbohydrate group required the addition of insulin for glucose control (P < .047; relative risk [RR] 0.14; 95% confidence interval [CI] 0.02, 1.00). The incidence of LGA infants was significantly lower in the low-carbohydrate group (P < .035; RR 0.22; 95% CI 0.05, 0.91). Subjects in the low carbohydrate group also had a lower rate of cesarean deliveries for cephalopelvic disproportion and macrosomia (P < .037; RR 0.15; 95% CI 0.04, 0.94). CONCLUSION: Carbohydrate restriction in patients with diet-controlled GDM results in improved glycemic control, less need for insulin therapy, a decrease in the incidence LGA infants, and a decrease in cesarean deliveries for cephalopelvic disproportion and macrosomia.

Adult↗
PubMed1988

Postcesarean section plasma fibronectin levels.

Decreases in plasma fibronectin levels following surgery and subsequent to trauma and sepsis have been previously reported. There have been no reports, however, regarding plasma fibronectin levels following cesarean section. Plasma fibronectin levels were followed for 3 days postpartum in 49 patients including cesarean section control patients, patients with cephalopelvic disproportion, pregnancy-induced hypertension, and endometritis. Cesarean section and cephalopelvic disproportion were not associated with a change in postpartum fibronectin levels. Pregnancy-induced hypertension and endometritis did show a significant increase (p less than 0.05) in plasma fibronectin levels. These levels are probably not decreased because of the large fibronectin pool in these otherwise healthy women.

Cesarean Section↗
PubMed1980

Changing primary cesarean section patterns at a private hospital.

The primary cesarean section patterns for a two-year premonitoring period, 1967 and 1968, and a two-year postmonitoring period, 1977 and 1978, were determined and compared at a private hospital. The frequency of cesarean section deliveries increased from 5.0% to 14.6% during those times. Cephalopelvic disproportion as an indication for cesarean section was more common than the combined total of breech presentation and fetal distress. Cephalopelvic disproportion increased as a diagnosis from 0.8% to 4.1% (5 X ) of deliveries; breech presentation, from 0.4% to 2% (5 X ); and fetal distress from 0.1% to 0.8% (8 X ). A changing patient population was identified as one contributing factor to the rising cesarean section rate. Allowing patients an adequate trial of labor with or without oxytocin stimulation, applying strict criteria for attempting a vaginal breech delivery and utilizing fetal scalp blood sampling with abnormal fetal heart rate tracings are suggested ways to decrease the cesarean section rate without compromising perinatal morbidity and mortality.

Adult↗