Outi Palomäki

Intrapartum cardiotocography -- the dilemma of interpretational variation.

Abstract Objective: To evaluate and compare interobserver variation in interpretation of intrapartum cardiotocograms. Subjects: Fifteen senior (experience >4 years) and 16 junior (experience ≤4 years) obstetricians from 10 delivery units. Design: Thirty-one obstetricians interpreted intrapartum cardiotocographic (CTG) readings from 22 parturients. Methods: Inter-observer agreement in CTG interpretation and decision-making was assessed via proportions of agreement (Pa), with 95% confidence intervals (CI). Main outcome measures: The level of inter-observer agreement was analyzed by calculating Pa values for CTG baseline, variability, early, variable and late decelerations, uterine tonus, power of contractions, hypertonus and clinical decision. Results: In assessments of normal cases the Pa were acceptable or good (0.63–0.82) as regards all CTG interpretation elements except for the power of contractions (0.24), but in assessments of abnormal cases the Pa values were lower (0.18–0.60). As regards clinical decisions, a higher Pa was found in cases without recommendation for intervention (0.63, 95% CI 0.62–0.64) than in cases with such recommendation (0.55, 95% CI 0.54–0.56). The Pa in the abnormal cases was better among senior than among junior obstetricians. Conclusions: Inter-observer variation in interpretation of abnormal CTG readings and recommendations for intervention is relatively wide. To improve reliability, uniform classification and standardized training in CTG interpretation are needed, as well as increased use of computerized CTG.

Selective vaginal breech delivery at term – still an option

Objective. To compare the neonatal outcome between planned vaginal or planned cesarean section (CS) breech delivery and planned vaginal vertex delivery at term with singleton fetuses. Design. A cohort study. Setting. Delivery Unit, Tampere University Hospital, Finland, with 5200 annual deliveries. Population. The term breech deliveries over a period of five years (January 2004 to January 2009), a total of 751 breech deliveries, and 257 vertex controls. Methods. The data were collected from the mothers medical records, including a summary of the newborn. In the case of neonatal health problems, the pediatric records were also examined. Main outcome measures. Maternal and neonatal mortality and morbidity as defined in the Term Breech Trial. Low Apgar scores or umbilical cord pH as secondary end‐points. Results. There was no neonatal mortality. Severe morbidity was rare in all groups, with no differences between groups. The Apgar scores at one minute were lower in the planned vaginal delivery group compared with the other groups, but there was no difference at the age of five minutes. Significantly more infants in the vaginal delivery group had a cord pH < 7.05. There was one maternal death due to a complicated CS in the planned CS group and none in the other groups. Mothers in the planned CS group suffered significantly more often from massive bleeding and needed transfusions. Conclusions. Vaginal delivery remains an acceptable option for breech delivery in selected cases.

A comparative study of the safety of 0.25% levobupivacaine and 0.25% racemic bupivacaine for paracervical block in the first stage of labor

Background.  The objective of the study was to evaluate and compare the safety of levobupivacaine and racemic bupivacaine for paracervical block (PCB) in the first stage of labor after uncomplicated pregnancy.

Clinical and sonographic risk factors and complications of shoulder dystocia - a case-control study with parity and gestational age matched controls

OBJECTIVES To examine the clinical risk factors and complications of shoulder dystocia today and to evaluate ultrasound methods predicting it. STUDY DESIGN Retrospective, matched case-control study at a University Hospital with 5000 annual deliveries. The study population consisted of 152 deliveries complicated by shoulder dystocia over a period of 8.5 years (January 2004-June 2012) and 152 controls matched for gestational age and parity. The data was collected from the medical records of mothers and children and analyzed by conditional logistic regression. Incidences and odds ratios were calculated for risk factors and complications. Antenatal ultrasound data was analyzed when available by conditional logistic regression to test for significant differences between study groups. RESULTS Birthweight (OR 12.1 for ≥4000 g; 95% CI 4.18-35.0) and vacuum extraction (OR 3.98; 95% CI 1.25-12.7) remained the most significant clinical risk factors. Only a trend of an association of pregestational or gestational diabetes was noticed (OR 1.87; 95% CI 0.997-3.495, probability of type II error 51%). Of the complications of shoulder dystocia the incidence of brachial plexus palsies was high (40%). Antenatal ultrasound method based on the difference between abdominal and biparietal diameters had a significant difference between cases and controls. CONCLUSIONS The impact of diabetes as a risk factor has diminished, which may reflect improved screening and treatment. Antenatal ultrasound methods are showing some promise, but the predictive value of ultrasound alone is probably low.

Sonographic diagnosis of postpartum pseudoaneurysms of the uterine artery: A report of 2 cases

Two cases of post‐partum uterine artery pseudoaneurysm are described, 1 after normal vaginal delivery and the other after Caesarean section. Both cases were complicated by heavy bleeding and treated with catheter embolization. A turbulent arterial‐type velocity waveform with high peak velocity and forward end‐diastolic flow was registered in the feeding vessel. The peak blood flow velocity was high in both cases. The resistance index in the uterine artery was lower in the affected side of the uterus. Three‐dimensional angiosonography was used to calculate the volume of the lesion, demonstrate its shape, and identify the feeding vessel.

The risk of metabolic syndrome after gestational diabetes mellitus - a hospital-based cohort study

BackgroundWomen with gestational diabetes mellitus (GDM) are at an increased risk of developing metabolic syndrome (MetS) after delivery. Recently, the prevalence of both GDM and MetS has increased worldwide, in parallel with obesity. We investigated whether the presentation of MetS and its clinical features among women with previous GDM differs from that among those with normal glucose tolerance during pregnancy, and whether excess body weight affects the results.MethodsThis hospital-based study of two cohorts was performed in Kanta-Häme Central Hospital, Finland. 120 women with a history of GDM and 120 women with a history of normal glucose metabolism during pregnancy, all aged between 25 and 46 were enrolled. They all underwent physical examination and had baseline blood samples taken. All 240 women were also included in subgroup analyses to study the effect of excess body weight on the results.ResultsAlthough the groups did not differ in body mass index (BMI; p = 0.069), the risk of developing MetS after pregnancy complicated by GDM was significantly higher than after normal pregnancy, 19 vs. 8 cases (p  =  0.039). Fasting glucose (p < 0.001) and triglyceride levels (p < 0.001) were significantly higher in women affected. In subgroup analysis, cardiovascular risk factors were more common in participants with high BMI than in those with previous gestational diabetes.ConclusionsThe risk of MetS was 2.4-fold higher after GDM than after normal pregnancy. Cardiovascular risk factors were more common in participants with high BMI than in those with previous GDM. Multivariate analysis supported the main findings. Weight control is important in preventing MetS after delivery.

What determines the analgesic effect of paracervical block

Background.  The objective of the study was to evaluate the analgesic effect of paracervical block (PCB) in labor pain relief and to discover the determinants associated with good analgesia.

Neonatal outcomes after the obstetric near-miss events uterine rupture, abnormally invasive placenta and emergency peripartum hysterectomy - prospective data from the 2009-2011 Finnish NOSS study.

Neonatal outcomes after the maternal obstetric near‐miss complications of uterine rupture, abnormally invasive placenta, and emergency peripartum hysterectomy were assessed.

Maternal Experiences of Vaginal Breech Delivery

BACKGROUND The optimal mode of breech birth remains controversial. In Finland, a trial of vaginal delivery is possible if strict selection criteria are met. As clinical practice in managing vaginal breech birth differs from that in normal delivery, the birth experience may also be different. This cohort study compares the childbirth experience between term breech and vertex deliveries. METHODS Intended vaginal term breech births from 2008 to October 2012 were included, and for every breech delivery, a vertex control was selected. The proportions of deliveries ending in a cesarean section and of mothers who had given birth vaginally before were equal in both groups. Three hundred eight mothers were sent the childbirth experience questionnaire and 170 returned it. RESULTS The birth experience does not differ between breech and vertex births, except for aspects with respect to the choice of birthing position. Indications of an even more positive experience were observed in the breech group, with the exception of the choice of analgesia, but these were not statistically significant. Primiparity, emergency cesarean section, infant birth trauma and prolonged hospital stay were identified as risk factors for a negative birth experience. CONCLUSION The birth experience of vaginal breech birth seems to be at least as positive as the vaginal vertex birth experience.

Term twin birth – impact of mode of delivery on outcome

The main aims of this study were to compare maternal and neonatal outcomes in term twin birth according to the planned mode of delivery and to study the effects of chorionicity and inter‐twin delivery time on neonatal outcome.