Declan Keane

Singleton vaginal breech delivery at term: still a safe option.

OBJECTIVE: To examine the obstetric and perinatal outcome of pregnancies with singleton breech presentation at term when selection for vaginal delivery was based on clear prelabor and intrapartum criteria. METHODS: The outcomes of all pregnancies with a breech presentation after 37 weeks of gestation were retrospectively reviewed from January 1997 to June 2000. Criteria for prelabor cesarean or trial of vaginal breech delivery included type of breech, estimated fetal weight (more than 3,800 g), maternal preference, and gestation more than 41 weeks. An intrapartum protocol excluded induction and oxytocin augmentation of labor, combined with a low threshold for cesarean delivery for dystocic labor; an experienced obstetrician was in attendance during labor and delivery. RESULTS: Of 641 women, 343 (54%) underwent prelabor cesarean, and 298 (46%) had a trial of vaginal delivery, of whom 146 (49%) delivered vaginally. Significantly fewer nulliparas (58 of 158, 37%) than multiparas (88 of 140, 63%; P < .001) achieved vaginal delivery after trial of labor. Significantly more infants weighing more than 3,800 g were selected for prelabor (87 of 343, 25%) and intrapartum (31 of 152, 20%) cesarean than delivered vaginally (15 of 146, 10%). Two neonates (0.7%) had Apgar scores of less than 7 at 5 minutes; both were neurologically normal at 6 weeks. There were no nonanomalous perinatal deaths and no cases of significant trauma or neurological dysfunction; 3 infants delivered vaginally died due to lethal anomalies. CONCLUSION: Safe vaginal breech delivery at term can be achieved with strict selection criteria, adherence to a careful intrapartum protocol, and with an experienced obstetrician in attendance. Our protocol effectively selects larger infants for cesarean delivery. LEVEL OF EVIDENCE: II-2

Effect of fetal sex on labour and delivery: retrospective review

The association of fetal sex with pregnancy induced hypertension and pre-eclampsia, the interaction between sex and risk factors for fetal growth restriction, and the increased likelihood of second stage arrest with male sex have all been studied.1–3 However, a Medline search (1966 to August 2002) using the search terms fetal gender, fetal sex, labour, delivery, and childbirth found no studies on the effect of fetal sex itself on labour outcomes and events. We set out to determine the effect of fetal sex on birth weight, duration of labour, mode of delivery, and birth outcome. In the National Maternity Hospital, Dublin, where the study took place, labour and delivery are actively managed according to a standard protocol.4 We obtained data from the delivery ward database …

Levator ani injury in primiparous women with forceps delivery for fetal distress, forceps for second stage arrest, and spontaneous delivery

To compare levator ani muscle injury rates in primiparous women who had a forceps delivery owing to fetal distress with women delivered by forceps for second stage arrest; and to compare these injury rates with a historical control group of women who delivered spontaneously.

Active management of labour revisited: the first 1000 primiparous labours in 2000

This was a prospective observational study in a tertiary referral obstetric unit in Dublin to ascertain the delivery outcome in the first 1000 nulliparous women in 2000. The initial diagnosis of labour was confirmed in the first 1000 consecutive nulliparous women in spontaneous labour with cephalic presentation at term. All patients underwent active management of labour. Active management included strict criteria for the diagnosis of labour, early amniotomy, 2-hourly vaginal examinations, oxytocin augmentation where progress of labour was slow and the presence of a companion (personal nurse) in labour. Epidural analgesia was freely available. Mode of delivery, duration of labour, analgesia usage and maternal and perinatal complications were the main outcome measures. All patients presented with painful uterine contractions, 75% with show in addition, and 36% had spontaneous rupture of membranes on admission. Eighty per cent presented with a cervical dilatation of h 2 cm; 72.2% had epidural for pain relief. In 81.8% of cases electronic fetal monitoring was used to monitor the baby. Oxytocin was used in 51.8% to augment labour and a further 6.4% required its use for the first time in the second stage of labour. Fetal blood sampling was performed in 20.8%. The spontaneous vaginal delivery rate was 71.8%, 4.2% were delivered by caesarean section and the operative vaginal delivery rate was 24%. The incidence of prolonged labour (labour duration >12 hours) was 4.3%. Postpartum haemorrhage occurred in 3.8% of mothers and 1.6% of babies were admitted to the special care baby unit. Our study suggests that active management of labour is associated with a low incidence of prolonged labour and a low caesarean section rate.

Brominated and fluorinated organic pollutants in the breast milk of first-time Irish mothers: is there a relationship to levels in food?

Brominated flame retardants – polybrominated diphenyl ethers (PBDEs), polybrominated biphenyls (PBBs), hexabromocyclododecane (HBCD) and others – have been measured in 11 pooled breast milk samples from 109 first-time mothers in Ireland. Additionally, the study has measured levels of polybrominated dibenzo-p-dioxins and furans (PBDD/Fs), mixed halogenated dioxins (PXCC/Fs) and biphenyls (PXBs), polychlorinated naphthalenes (PCNs) and perfluoroalkylated substances (PFAS) in these samples. The mean sum of 19 PBDEs including BDE-209 was 4.85 ng g−1 fat, which is comparable with that found in other European countries. BDE-47, BDE-153, BDE-209, BDE-99 and BDE-100 were found at the highest concentrations. The only PBBs detected consistently were BB-77, BB-126 and BB-153, with highest concentrations being found for BB-153 (mean = 0.13 ng g−1 fat). The mean sum of HBCD enantiomers was 3.52 ng g−1 fat, with α-HBCD representing over 70% of the total. Of the other brominated flame retardants – tetrabromobisphenol-A (TBBP-A), hexabromobenzene (HBB), decabromodiphenylethane (DBDPE) and bis(2,4,6-tribromophenoxyethane) (BTBPE) – examined, only TBBP-A was detected above the limit of detection (LOD), in two of the 11 pools analysed. All measured PBDF congeners were observed (at 0.02–0.91 pg g−1 fat), but 2,3,7,8-tetrabromo-dibenzodioxin (TeBDD) was the only PBDD detected, with a mean concentration of 0.09 pg g−1 fat. The occurrence of the mixed chlorinated/brominated dibenzodioxins, dibenzofurans and biphenyls, 2-B-3,7,8-CDD, 2,3-B-7,8-CDF, 4-B-2,3,7,8-CDF, PXB 105, PXB 118, PXB 126 and PCB 156 in breast milk in the current study may indicate that levels of these contaminants are increasing in the environment. Polychlorinated naphthalenes were detected in all samples, but not perfluorooctane sulfonate (PFOS) and other PFAS. The pattern of occurrence of these brominated and fluorinated persistent organic pollutants (POPs) in Irish breast milk shows a general relationship to their occurrence in food, as reported in a number of surveillance studies carried out by the Food Safety Authority of Ireland.

Polychlorinated dibenzo-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs) and polychlorinated biphenyls (PCBs) in breast milk of first-time Irish mothers: impact of the 2008 dioxin incident in Ireland.

The 2008 dioxin incident in Ireland resulted in elevated concentrations of polychlorinated dibenzo-p-dioxins (PCDDs), dibenzofurans (PCDFs) and polychlorinated biphenyls (PCBs) in Irish pork and pork products, due to the consumption of contaminated animal feed by pigs. In order to investigate any resulting impact on the Irish population, these contaminants were measured in pooled breast milk samples from 109 first-time mothers, collected in 2010. A comparison of the results with similar data from 2002 revealed generally lower concentrations of PCDD/Fs and dioxin-like PCBs in the 2010 samples, confirming the declining trend reported by many authors. Contaminant concentration levels for both 2002 and 2010 were generally slightly lower than those reported internationally, with a mean combined PCDD/F and PCB WHO-TEQ of 9.66pgg(-1)fat, for an overall pooled sample of milk from 2010. An apparent slight increase in PCDFs was observed between 2002 and 2010 (from 2.73pg WHO-TEQ g(-1)fat to 3.21pg WHO-TEQ g(-1)fat), with the main contributory congener being 2,3,4,7,8-PentaCDF. While it cannot be totally discounted that the slight increase in 2,3,4,7,8-PentaCDF and in the overall PCDF WHO-TEQ in breast milk could be attributable to consumption of Irish pork during the 2008 incident, we consider that it is more likely that this was due to other factors, including the predominantly urban/industrial sampling locations for the 2010 samples, compared to 2002.

The role of investigations for term stillbirths.

The aim of the study was to document the role of laboratory investigations for unexpected stillbirths at term. It was a retrospective casenote review of 75 unexpected stillbirths at term from 1995 to 1999, at the National Maternity Hospital, Dublin, Republic of Ireland. Investigations performed included blood tests, chromosomal analysis, autopsy and placental histology. Perinatal autopsy was the most informative investigation with positive findings in 49% of cases. There were positive placental findings in 37% of cases. Six of the 26 cases showed abnormal karyotyping. Of the blood tests performed, the Kleihauer – Betke test was most informative, revealing a feto-maternal haemorrhage in 8% of cases and anticardiolipin antibodies were positive in 4% of cases. FBC, TORCH and glycosylated Hb were negative in all 75 patients. Despite thorough investigations 32 of cases (43%) remained unexplained.

Pheochromocytoma, sickle cell disease and pregnancy: a case report

Pheochromocytomas are rare catecholamine-secreting tumors with a 2–4% maternal morbidity rate and a fetal loss rate of 11%. Sickle cell disease is also associated with increased maternal and fetal mortality. We report the first case of a primigravid woman with both conditions and a successful pregnancy outcome.

Early and late preterm delivery rates - a comparison of differing tocolytic policies in a single urban population.

Objective: Preterm delivery results in neonatal morbidity and mortality. We set out to estimate the difference in rates of preterm delivery in two institutions, serving a single population, with differing policies regarding use of tocolytic drugs for the prevention of preterm delivery. Study design: A retrospective study comparing preterm delivery rates between 2002 and 2007 in two large tertiary hospitals serving a single urban population with similar risk factor profile located less than 2 miles from each other. During the study period Hospital A routinely used tocolytic therapy, Hospital B operates a policy of never using any tocolytic drugs. Rates of delivery prior to 26, 30, 34 and 37 weeks were compared for each hospital. Results: During the study period there were 90,843 deliveries between the two hospitals. The overall rates of preterm delivery at less than 37 weeks gestation were comparable with 6.62% (2794/42,232) in Hospital A and 6.15% (2989/48,611) in Hospital B (p = 0.99). There was no significant difference in the numbers delivering at less than 34 weeks, 995/42,232 (2.36%) versus 1134/48,611 (2.33%), p = 0.59, less than 30 weeks, 403/42,232 (0.95%) versus 429/48,611 (0.88%), p = 0.87 or prior to 26 weeks, 126/42,232 (0.29%) versus 121/48,611 (0.25%), p= 0.08. Conclusion: In this large population routine use of tocolytic drugs in the treatment of threatened preterm labor does not alter rates of early or late preterm delivery. While this study is limited by its retrospective nature, it calls into question the practice of tocolysis.

Solvent–detergent plasma as replacement therapy in a pregnant patient with factor V deficiency

This case illustrates the successful treatment of factor V deficiency in pregnancy using solvent-detergent plasma.