Roshni R. Patel

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.

Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial

Objectives To determine the effects of two computer based decision aids on decisional conflict and mode of delivery among pregnant women with a previous caesarean section. Design Randomised trial, conducted from May 2004 to August 2006. Setting Four maternity units in south west England, and Scotland. Participants 742 pregnant women with one previous lower segment caesarean section and delivery expected at ≥37 weeks. Non-English speakers were excluded. Interventions Usual care: standard care given by obstetric and midwifery staff. Information programme: women navigated through descriptions and probabilities of clinical outcomes for mother and baby associated with planned vaginal birth, elective caesarean section, and emergency caesarean section. Decision analysis: mode of delivery was recommended based on utility assessments performed by the woman combined with probabilities of clinical outcomes within a concealed decision tree. Both interventions were delivered via a laptop computer after brief instructions from a researcher. Main outcome measures Total score on decisional conflict scale, and mode of delivery. Results Women in the information programme (adjusted difference −6.2, 95% confidence interval −8.7 to −3.7) and the decision analysis (−4.0, −6.5 to −1.5) groups had reduced decisional conflict compared with women in the usual care group. The rate of vaginal birth was higher for women in the decision analysis group compared with the usual care group (37% v 30%, adjusted odds ratio 1.42, 0.94 to 2.14), but the rates were similar in the information programme and usual care groups. Conclusions Decision aids can help women who have had a previous caesarean section to decide on mode of delivery in a subsequent pregnancy. The decision analysis approach might substantially affect national rates of caesarean section. Trial Registration Current Controlled Trials ISRCTN84367722.

Forceps delivery in modern obstetric practice

This review discusses the specific uses and potential advantages of forceps over other modes of delivery. To enable women to make an informed choice about mode of delivery, obstetricians need to be adequately trained and supervised in the use of forceps Global increases in rates of caesarean section show no sign of abating. The US National Center for Health Statistics reported that deliveries by caesarean section in 2001 had increased to almost a quarter, the highest level since 1989.w1 A similar rate was observed in England, Wales, and Northern Ireland in 2000.1 The greatest increases and variation between institutions are seen among first time mothers with a singleton pregnancy at term and women who have had a previous caesarean section. The American College of Obstetrics and Gynecology has recommended training in instrumental delivery to control and reduce the rates of caesarean section.w2 In the United States the rates of forceps delivery have decreased despite an increase in operative deliveries.w3-w6 In the United Kingdom, the rates of instrumental vaginal delivery range between 10% and 15%1 w7; these have remained fairly constant, although there has been a change in preference of instrument. In the 1980s most instrumental vaginal deliveries were by forceps, but by 2000 this had decreased to under a half. Much of the decline has been attributed to an increasing preference for vacuum extraction or for caesarean section when complex vaginal delivery is anticipated.2 3 w8 Lively discussion in both the medical and the lay press has centred on morbidity associated with operative deliveries, the importance of maternal choice, and best clinical practice.4 w9 w10 Most women still aim for spontaneous vaginal delivery. If complications do arise during labour it should be possible to offer women suitable alternatives and not solely caesarean …

Operative delivery and postnatal depression: a cohort study

Abstract Objectives To assess the association between elective caesarean section and postnatal depression compared with planned vaginal delivery and whether emergency caesarean section or assisted vaginal delivery is associated with postnatal depression compared with spontaneous vaginal delivery. Design Prospective population based cohort study. Setting ALSPAC (the Avon longitudinal study of parents and children). Participants 14 663 women recruited antenatally with a due date between 1 April 1991 and 31 December 1992. Main outcome measure Edinburgh postnatal depression scale score ≥ 13 at eight weeks postnatal on self completed questionnaire. Results Albeit with wide confidence intervals, there was no evidence that elective caesarean section altered the odds of postnatal depression compared with planned vaginal delivery (adjusted odds ratio 1.06, 95% confidence interval 0.66 to 1.70, P = 0.80). Among planned vaginal deliveries there was similarly little evidence of a difference between women who have emergency caesarean section or assisted vaginal delivery and those who have spontaneous vaginal delivery (1.17, 0.77 to 1.79, P = 0.46, and 0.89, 0.68 to 1.18, P = 0.42, respectively). Conclusions There is no reason for women at risk of postnatal depression to be managed differently with regard to mode of delivery. Elective caesarean section does not protect against postnatal depression. Women who plan vaginal delivery and require emergency caesarean section or assisted vaginal delivery can be reassured that there is no reason to believe that they are at increased risk of postnatal depression.

Decision‐making about mode of delivery after previous caesarean section: development and piloting of two computer‐based decision aids

Objective  To develop and pilot two computer‐based decision aids to assist women with decision‐making about mode of delivery after a previous caesarean section (CS), which could then be evaluated in a randomized‐controlled trial.

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.

Is operative delivery associated with postnatal back pain at eight weeks and eight months? A cohort study

Background. Back pain is very common during pregnancy and postnatally, and is a serious cause of morbidity. This research investigates the prevalence of antenatal back pain and the associations between mode of delivery and postnatal back pain at 8 weeks and 8 months. Methods. A prospective population‐based cohort based in Avon, UK. Some 14,663 women were recruited antenatally, due between 1 April 1991 and 31 December 1992. Of these, 12,944 women with singleton, liveborn, term fetuses were included. Self‐reported postal questionnaires were used to assess back pain antenatally and postnatally. The main outcome measures were postnatal back pain at 8 weeks and 8 months. Results. Back pain was very common with a prevalence of 80% at 32 weeks antenatally. Postnatally, back pain affected 68% of women at 8 weeks, and 60% at 8 months. Postnatal back pain was not associated with elective or emergency caesarean section (e.g. adjusted 8 weeks OR: 1.23, 95% CI: 0.89, 1.70, and OR: 0.89, 95% CI: 0.65, 1.22, respectively) nor with assisted versus spontaneous vaginal delivery (OR: 0.99, 95% CI: 0.82, 1.20). Very similar patterns were observed at 8 months. Conclusions. Antenatal and postnatal back pain are common. Elective caesarean section does not protect against postnatal back pain. Neither emergency caesarean section nor assisted vaginal delivery increases the risk of postnatal back pain compared with spontaneous delivery.

Prevalence of hypertensive disorders in a prenatal clinic in Zanzibar

Hypertensive disorders in pregnancy are common and are a leading cause of maternal and perinatal mortality worldwide. The WHO estimates worldwide prevalence to be 3.2% of live births annually (4 million cases); of the 72 000 fatalities, 90% occur in lowincome countries [1]. The present study aimed to calculate the prevalence of pregnancyinduced hypertension (PIH), pre-eclampsia, and eclampsia in a random representative sample of pregnant women undergoing prenatal care at MnaziMmoja Hospital, Stone Town, Zanzibar. The University of London provided ethics approval. Women attending the prenatal clinic between September 3 and October 12, 2007, were interviewed and examined. Verbal consent was obtained via a translator (clinic nurse). Women who had already been referred to a doctor for follow-up of hypertension during their current pregnancy were excluded. All women invited to participate did so. Every patient had their blood pressure measured, and the measurement was repeated if it was equal to or greater than 140/ 90 mmHg. Urine was tested via Uristix (Bayer, Leverkusen, Germany) by the same 2 observers in each case. Prevalence was determined using RCOG definitions [1]. Of the 100 women interviewed, 9 had PIH, 9 had pre-eclampsia (4 mild–moderate, 5 severe), and 2 had eclampsia. No single symptom was experienced by all hypertensive women (Fig. 1). Many symptoms that are common to pre-eclampsia were experienced by nonhypertensive women. Women with mild–moderate pre-eclampsia complained mainly only of a headache. Blurred vision and proteinuria were the most specific symptoms for identifying hypertensive disorders, whereas headache, dizziness, and epigastric pain were the least specific. One in 200 pregnancies in the UK ends in stillbirth, with approximately 3% of such cases caused by pre-eclampsia [2]. The UK Obstetric Surveillance System reported the rate of eclampsia to be 2.7 cases per 10 000 births [3]. The prevalence of eclampsia (2.0%) and severe pre-eclampsia (5.0%) in the present study was 40 and 10 times higher, respectively, than in the UK [1,4]. Kidanto et al. [5] reported the rate of eclampsia to be 5.1% at Muhumbili National Hospital, Tanzania, with a case fatality rate of 7.7%. These results indicate that there are differences in the provision of prenatal care worldwide, which could be addressed by asking about symptoms at each prenatal visit and by training staff to act Fig. 1. Proportion of patients with and those without hypertensive disorders experiencing symptoms or signs.

A case-control study of maternal periconceptual and pregnancy recreational drug use and fetal malformation using hair analysis.

Objective Maternal recreational drug use may be associated with the development of fetal malformations such as gastroschisis, brain and limb defects, the aetiology due to vascular disruption during organogenesis. Using forensic hair analysis we reported evidence of recreational drug use in 18% of women with a fetal gastroschisis. Here we investigate this association in a variety of fetal malformations using the same method. Methods In a multi-centre study, women with normal pregnancies (controls) and those with fetal abnormalities (cases) gave informed consent for hair analysis for recreational drug metabolites using mass spectrometry. Hair samples cut at the root were tested in sections corresponding to 3 month time periods (pre and periconceptual period). Results Women whose fetus had gastroschisis, compared to women with a normal control fetus, were younger (mean age 23.78±SD4.79 years, 18–37 vs 29.79±SD6 years, 18–42, p = 0.00001), were more likely to have evidence of recreational drug use (15, 25.4% vs 21, 13%, OR2.27, 95thCI 1.08–4.78, p = 0.028), and were less likely to report periconceptual folic acid use (31, 53.4% vs 124, 77.5%, OR0.33, 95thCI 0.18–0.63, p = 0.001). Age-matched normal control women were no less likely to test positive for recreational drugs than women whose fetus had gastroschisis. After accounting for all significant factors, only young maternal age remained significantly associated with gastroschisis. Women with a fetus affected by a non-neural tube central nervous system (CNS) anomaly were more likely to test positive for recreational drugs when compared to women whose fetus was normal (7, 35% vs 21, 13%, OR3.59, 95th CI1.20–10.02, p = 0.01). Conclusions We demonstrate a significant association between non neural tube CNS anomalies and recreational drug use in the periconceptual period, first or second trimesters, but we cannot confirm this association with gastroschisis. We confirm the association of gastroschisis with young maternal age.