Rachel E. Liebling

Early maternal and neonatal morbidity associated with operative delivery in second stage of labour: a cohort study

BACKGROUND A frequent dilemma for obstetricians is how to keep morbidity to a minimum when faced with arrested progress at full dilatation of the cervix. Our aim was to examine maternal and neonatal morbidity associated with vaginal instrumental delivery in theatre and caesarean section, at full dilatation. METHODS We did a prospective cohort study of 393 women, who had term, singleton, liveborn, cephalic pregnancies requiring operative delivery in theatre at full dilatation for 1 year. FINDINGS Factors increasing the likelihood of caesarean section included maternal body-mass index greater than 30 (adjusted odds ratio 2.4, 95% CI 1.2-4.9), neonatal birthweight greater than 4.0 kg (2.3, 1.3-3.8), and occipitoposterior position (2.5, 1.6-3.9). Women undergoing caesarean section were more likely to have a major haemorrhage (>1 L; 2.8, 1.1-7.6) and extended hospital stay (>/=6 days; 3.5, 1.6-7.6) than those with vaginal delivery. Babies delivered by caesarean section were more likely to require admission for intensive care (2.6, 1.2-6.0) but less likely to have trauma (0.4, 0.2-0.7) than babies delivered by forceps. Overall neonatal morbidity was low, but a few babies in each group had serious complications (serious trauma, eight vs three; sepsis, six vs 13; and jaundice, ten vs 12 after vaginal delivery and caesarean section, respectively). Major haemorrhage was less likely after delivery by a skilled obstetrician (0.5, 0.3-0.9). INTERPRETATION The data lend support to an aim to deliver women vaginally, unless there are clear signs of cephalopelvic disproportion, and underline the importance of skilled obstetricians supervising complex operative deliveries.

Cohort study of operative delivery in the second stage of labour and standard of obstetric care

Objective To assess the maternal and neonatal morbidity following operative delivery in the second stage of labour in relation to the standard of obstetric care.

Women's views on the impact of operative delivery in the second stage of labour: qualitative interview study

Abstract Objective To obtain the views of women on the impact of operative delivery in the second stage of labour. Design Qualitative interview study. Setting Two urban teaching hospitals in the United Kingdom. Participants Purposive sample of 27 women who had undergone operative delivery in the second stage of labour between January 2000 and January 2002. Key themes Preparation for birth, understandings of the indications for operative delivery, and explanation or debriefing after birth. Results The women felt unprepared for operative delivery and thought that their birth plan or antenatal classes had not catered adequately for this event. They emphasised the importance of maintaining an open mind about the management of labour. They had difficulty understanding the need for operative delivery despite a review by medical and midwifery staff before discharge. Operative delivery had a noticeable impact on womens views about future pregnancy and delivery. Conclusions Women consider postnatal debriefing and medical review important deficiencies in current care. Those who experienced operative delivery in the second stage of labour would welcome the opportunity to have a later review of their intrapartum care, physical recovery, and management of future pregnancies.

Management and outcome of pregnancies with parvovirus B19 infection over seven years in a tertiary fetal medicine unit

Objectives: To determine rates of fetal anaemia and pregnancy outcome in susceptible pregnant women infected with human parvovirus B19 infection in a tertiary fetal medicine department over a 7-year period. Additional features enabling identification of fetuses that progress to severe anaemia were also investigated. Methods: Forty-seven susceptible, pregnant women with confirmed parvovirus infection referred to a regional fetal medicine unit, over a 7-year period (1999–2006), were identified. Where possible maternal serum AFP measurements were obtained from second-trimester serum screening and the presence or absence of echogenic bowel noted. Results: Of the 47 cases, one was excluded. Of the remaining 46 cases, 34 (74%) showed no signs of fetal anaemia and delivered at term. The remaining 12 (26%) showed signs of fetal anaemia. Eight of the 12 developed hydrops and underwent fetal blood sampling and transfusion (median pretransfusion Hb 3.6 g/dl). Seven of the 8 transfused fetuses were thrombocytopenic with a platelet count <150 × 109/l, with 2 fetuses having platelet counts <50 × 109/l. The median gestation age at transfusion was 22 weeks (range 18–27 weeks). The median number of weeks between seroconversion and transfusion was 6 (range 3–12). The signs of anaemia resolved after one transfusion in 5 of the 8 transfused fetuses and they subsequently delivered at term. There were 2 fetal deaths during or shortly after transfusion and one neonatal death following delivery at 28 weeks gestation due to severe pre-eclampsia, 5 days after successful transfusion. Conclusions: Following parvovirus seroconversion, the incidence of significant fetal anaemia requiring transfusion was 17%. Seroconversion after 21 weeks did not result in severe fetal anaemia. Significant anaemia requiring intervention did not occur 12 weeks after maternal seroconversion. We did not demonstrate a correlation with either maternal serum AFP or the presence of fetal echogenic bowel and the development of severe fetal anaemia. Because of the association between fetal anaemia and severe thrombocytopenia, it may be prudent to have compatible platelets available at the time of fetal blood sampling.

Neonatal outcomes of pregnancies affected by haemolytic disease of the foetus and newborn and managed with intrauterine transfusion: a service evaluation

BACKGROUND This study, conducted in the tertiary Foetal Medicine Unit at St Michaels Hospital, Bristol, was designed to obtain information regarding neonatal outcomes of pregnancies affected by haemolytic disease of the foetus and newborn and managed by intrauterine transfusion, and to determine whether a change in intrauterine transfusion protocol in 2004 had improved safety. The new protocol included attendance of two Foetal Medicine Unit consultants, foetal sedation and use of the intrahepatic vein as an alternative route to placental cord insertion if deemed safer. MATERIALS AND METHODS Data for pregnancies affected by haemolytic disease of the foetus and newborn as a result of haemolytic red cell alloimmunisation and managed with intrauterine transfusion at St Michaels Hospital between 1999 and 2009 were retrospectively collected using local databases, and medical note review. RESULTS Overall, 256 relevant intrauterine transfusions were performed. The median number of intrauterine transfusions per pregnancy was two. Ninety-three per cent of the live deliveries had 5-minute APGAR scores ≥9 and 98% were admitted to a Neonatal Intensive Care Unit/Special Care Baby Unit, requiring phototherapy (96%), top-up transfusions (44%: 23.2% immediate, 13.4% late, 7.3% both), and exchange transfusion (37%). An association was found between increased intrauterine transfusion number and reduced phototherapy duration and hospital admission: each additional intrauterine transfusion reduced the duration of phototherapy by 16% (95% CI: 0.72-0.98), and Neonatal Intensive Care Unit/Special Care Baby Unit admission by 44% (95% CI: 0.48-0.66). Following the change in intrauterine transfusion protocol, there was a significant reduction in the number of emergency Caesarean sections occurring directly after an intrauterine transfusion (n =5 vs 0; P =0.02). The foetal loss rate within 48 hours of an intrauterine transfusion was 1.9% per pregnancy, or 0.8% per intrauterine transfusion: no losses occurred under the new protocol (n =3 vs 0; P = NS). DISCUSSION Although the majority of neonates required admission to a Neonatal Intensive Care Unit/Special Care Baby Unit and phototherapy, the medium-term outcomes were positive. Importantly, the safety of the intrauterine transfusion procedure has improved significantly since the change in protocol.

Early Maternal and Neonatal Morbidity Associated With Operative Delivery in Second Stage of Labour: A Cohort Study

Obstetricians frequently must decide the best way of minimizing morbidity when labor arrests at full cervical dilation. This prospective cohort study contrasted maternal and neonatal morbidity when selecting either instrumental vaginal delivery or cesarean delivery. The study group, 393 women, all had a singleton pregnancy at term with cephalic presentation, and all delivered a liveborn infant. Cesarean delivery was performed in 209 instances, and instrumental vaginal delivery succeeded in 184 cases. Roughly one fourth of women had immediate section with no attempt at vaginal delivery. Cesarean delivery was likelier after attempted ventouse delivery than after an attempt at forceps delivery. There were 58 deliveries using forceps alone, 67 ventouse deliveries, and 59 utilizing both methods. Risk factors favoring cesarean delivery included a maternal body mass index greater than 30, a birth weight above 4 kg, an occipitoposterior presentation, and station at the ischial spines. Suspected fetal distress was similarly frequent in the two groups. No women died, and none had thromboembolism. Major bleeding was more frequent with cesarean delivery but less likely if done by a senior rather than a middle-grade trainee. Discharge within 48 hours was likelier after vaginal delivery. Serious maternal injuries included extension of the uterine incision and third-degree vaginal tears. There were no perinatal deaths, but two infants had symptoms of hypoxic-ischemic encephalopathy. Trauma such as facial and scalp bruising was significantly less common after cesarean delivery. Six vaginally delivered infants had brachial plexus injuries. Two infants had intracerebral bleeding when cesarean delivery was performed after failed instrumental delivery. Neonatal trauma was significantly likelier after failed vaginal instrumental delivery than after immediate cesarean delivery but less common than with successful instrumental delivery. This study supports the use of safe instrumental vaginal delivery when labor arrests, given appropriate circumstances such as availability of an operating theater and a skilled obstetrician. This approach is favored over cesarean delivery unless cephalopelvic disproportion is clearly present.