Rita Sharshiner

Fetal malposition: impact and management.

Fetal malposition, either occiput posterior or transverse (OT), leads to greater risk of cesarean delivery, prolonged labor, and increased perinatal morbidity. Historically, there is a known association between epidural use and malposition that was assumed to be due to the increased discomfort of laboring with a fetus in the occiput posterior position. However, evidence now suggests that the epidural itself may contribute to fetal malposition by impacting the probability of internal rotation. Fetal malposition may be impacted by manual rotation. Manual rotation has been associated with greater rates of delivering in the occiput anterior position and lower rates of cesarean delivery.

Management of fetal malpresentation.

Fetal malpresentation is an important cause of the high cesarean delivery rate in the United States and around the world. This includes breech, face, brow, and compound presentations as well as transverse lie. Risk factors include multiparity, previously affected pregnancy, polyhydramnios, and fetal and uterine anomalies. Appropriate management can reduce the need for cesarean delivery in some cases. This review discusses management options and focuses specifically on external cephalic version and vaginal breech delivery.

Maternal co-morbidities and neonatal outcomes associated with cystic fibrosis*

Abstract Objective: To evaluate maternal co-morbidities and adverse perinatal outcomes associated with cystic fibrosis (CF). Methods: This is a retrospective cohort study of 2 178 954 singleton pregnancies at ≥20 weeks’ gestation with and without CF in the state of California during the years 2005–2008. ICD-9 codes and linked hospital discharge and vital statistics data were utilized. Rates of maternal co-morbidities, fetal congenital anomalies and adverse perinatal outcomes were compared in those with CF and those without. Maternal co-morbidities included gestational hypertension, preeclampsia, gestational diabetes and primary cesarean delivery. Perinatal outcomes included neonatal demise, preterm birth, intrauterine growth restriction, macrosomia, anomaly, fetal demise, asphyxia, respiratory distress syndrome, jaundice, intraventricular hemorrhage, hypoglycemia and necrotizing enterocolitis. Results: The cohort included 2 178 954 pregnancies of which 77 mothers had CF. Mothers with CF were more likely to have pre-gestational diabetes and had higher rates of primary cesarean delivery. Neonates delivered to mothers with CF were more likely to be born preterm and have congenital anomalies but otherwise were not at increased risk for significant neonatal morbidity or mortality when adjusted for gestational age. Conclusion: Mothers with CF are more likely to have pre-gestational diabetes, deliver preterm (<37 weeks gestation) and have a primary cesarean delivery. Infants are more likely to have congenital anomalies. In addition to early diabetic screening and genetic counseling, a detailed fetal anatomy ultrasound should be performed in women with CF.

Effects of Persistent Occiput Posterior Position on Mode of Delivery [256]

OBJECTIVE: To investigate the effect of occiput posterior (OP) fetal presentation on mode of delivery in term births and how this effect is affected by parity and birth weight. METHODS: This is a retrospective cohort study of nonanomalous singleton term pregnancies delivered in California. Exclusion criteria include placenta previa, birth weight less than 2,500 g or more than 5,000 g, and delivery before 37 or beyond 42 weeks of gestation. We compared rates of cesarean delivery in nulliparous and multiparous women further stratified by fetal position and birth weight. RESULTS: The rate of cesarean delivery was significantly increased by OP position in nulliparous women (73.6% OP compared with 25% occiput anterior [OA], P<.001) and in multiparous women (38.7% OP compared with 7.5% OA, P<.001). Overall, OP position had a four times greater likelihood of cesarean delivery. When examining cesarean delivery at varying birth weights, among nulliparous women, the cesarean delivery rate was approximately 60% at 2,500 g in those with fetuses in the OP position and did not reach 60% until 4,500 g in those with the OA position. Among multiparous women, the cesarean delivery rates were lower, but birth weight effect was similar as those women with fetuses in the OP position had a cesarean delivery rate of 30% at 2,500 g and in those with a OA position, a cesarean delivery rate of 30% was not reached until 4,750 g. CONCLUSION: Fetal OP position significantly increases the rate of cesarean delivery in both nulliparous and multiparous women. The effect of OP position appears to be similar to that of a 2,000-g birth weight increase. Further investigation into the effect of OP position and interventions to mitigate this effect are important.