Volume 45, Issue 3 - Highlight: Intrapartum Care

An estimated 276,000 babies die within 4 weeks of birth every year, worldwide, from congenital anomalies. Better quality ultrasound screening can increase the detection of these fetal malformations in the prenatal period. Prenatal counseling for the pregnant woman and her family, regarding the nature of the disease and prognosis is necessary. Options for management in prenatal, perinatal, intrapartum, neonatal, and childhood periods need to be thoroughly discussed, so that the family can make an informed decision. A multidisciplinary approach is usually needed once a decision has been made to optimize fetal outcome, to plan for the timing and location as well as the mode of delivery. In most of the cases, vaginal delivery can be attempted. An elective cesarean delivery should be reserved for maternal concern of dystocia, certain fetal conditions that cesarean delivery will optimize perinatal outcome, or if the parents have a psychosocial determination to have a live-born infant.

Neuraxial labor analgesia can be initiated via combined spinal-epidural (CSE) or stand-alone epidural. Pros and cons of these techniques are outlined in this review. In recent years computer-integrated patient-controlled epidural analgesia (CI-PCEA) and programed intermittent epidural boluses (PIEB) have been developed, adding to continuous infusion and PCEA for the maintenance of neuraxial analgesia. Postdural puncture headache (PDPH) and fever can occur secondary to labor epidural that both have clinical relevance for the care givers. Insights into the mechanism of epidural fever and treatment strategies for PDPH are outlined. Due to the increase in obesity the specific considerations for this patient group are discussed. New data have been presented for remifentanil, an ultra-shortly acting opioid, that is used in obstetric analgesia. Without breaking new data, the use of nitrous oxide especially by midwives has a kind of renaissance, and this will be discussed, too.

Objective: To assess risk factors for adverse perinatal and neonatal outcomes in “well-selected” singleton vaginal breech deliveries at term. Methods: During the time span from January 2008 up to April 2015 a total of 786 singleton term breech deliveries with a planned vaginal delivery were identified in a retrospective observational study at Helsinki University Central Hospital, Finland. The study’s end point was a composite of adverse perinatal and neonatal outcomes. Infants with an adverse outcome were compared to all spontaneous singleton vaginal breech deliveries with normal perinatal and neonatal outcomes. A multivariate logistic regression model was used to analyze associations between adverse neonatal outcomes and several variables. The secondary outcome was the severe morbidity rate according to the criteria of the term breech trial. Results: An adverse neonatal outcome was recorded for 38 (4.8%) infants. According to the study the second delivery stage lasting <40 min [adjusted odds ratio (aOR): 0.34, 95% confidence interval (95% CI): 0.15–0.79] was associated with lower odds and had a protective effect against adverse outcomes. Epidural anesthesia (aOR: 2.88, 95% CI: 1.08–7.70) was associated with higher adverse outcomes. The incidence rate of severe morbidity was 1.3% (10/787). Conclusion: Adverse neonatal outcomes in well-selected breech deliveries are associated with a prolonged second delivery stage lasting >40 min and with epidural anesthesia.

Objective: To compare the outcome of two methods of labor induction and spontaneous onset of labor in breech presentation at term. Material: A retrospective study between 2003 and 2012. We compare obstetric (indication of induction, Bishop score, cesarean rate) and perinatal outcomes (Apgar score, umbilical artery pH, base excess ≤−12 mmol/L, admission to neonatal unit) between prostaglandins and oxytocin. We also compare labor induction versus spontaneous onset of labor. Results: Of the 1684 breech deliveries, we carried out labor induction in 221 cases (76% with prostaglandins, 24% with oxytocin). The prostaglandins group had significantly lower Bishop scores and the time for induction phase was significantly higher. There were no differences in cesarean rate between both methods of induction or spontaneous onset of labor. The prostaglandins group had higher rates of base excess ≤−12 mmol/L. Compared with spontaneous onset of labor in breech presentation, induction had significant lower rates of newborn weight and higher rates of admission to the neonatal unit. Conclusions: Induction of labor in breech presentation at term is a reasonable and effective option after a careful selection of cases. It was not associated with an increase of perinatal morbidity or cesarean rate compared with spontaneous onset of labor.

Aim: Fetal skull molding is important for the adaptation of the head to the birth canal during vaginal delivery. Importantly, the fetal head must rotate around the maternal symphysis pubis. The goals of this analysis were to observe a human birth in real-time using an open magnetic resonance imaging (MRI) scanner and describe the fetal head configuration during expulsion. Methods: Real-time cinematic MRI series (TSE single-shot sequence, TR 1600 ms, TE 150 ms) were acquired from the midsagittal plane of the maternal pelvis during the active second stage of labor at 37 weeks of gestation. Frame-by-frame analyses were performed to measure the frontooccipital diameter (FOD) and distance from the vertex to the base of the fetal skull. Results: During vaginal delivery in an occiput anterior position, the initial FOD was 10.3 cm. When expulsion began, the fetal skull was deformed and elongated, with the FOD increasing to 10.8 cm and 11.2 cm at crowning. In contrast, the distance from the vertex to the base of the skull was reduced from 6.4 cm to 5.6 cm at expulsion. Conclusions: Fetal head molding is the change in the fetal head due to the forces of labor. The biomechanics of this process are poorly understood. Our visualization of the normal mechanism of late second-stage labor shows that MRI technology can for the first time help define the changes in the diameters of the fetal head during active labor.

Purpose: Uterine rupture is a rare but serious event with a median incidence of 0.09%. Previous uterine surgery is the most common risk factor. The aim of our study was to analyze retrospectively women with uterine rupture during labor and to evaluate postulated risk factors such as uterine fundal pressure (UFP). Methods: Twenty thousand one hundred and fifty-two deliveries were analyzed retrospectively. Inclusion criteria were 22 weeks and 0 days–42 weeks and 0 days of gestation, singleton pregnancy and cephalic presentation. Women with primary cesarean section were excluded. A logistic regression analysis adjusting for possible risk factors was conducted and a subgroup analysis of women with unscarred uterus was performed. Results: Twenty-eight cases of uterine rupture were identified (incidence: 0.14%). Uterine rupture was noticed in multipara patients only. In the multivariate analysis among all study patients, only previous cesarean section remained a statistically significant risk factor [adjusted odds ration (adj. OR) 12.52 confidence interval (CI) 95% 5.21–30.09]. In the subgroup analysis among women with unscarred uterus (n=19,415) three risk factors were associated with uterine rupture: UFP (adj. OR 5.22 CI 95% 1.07–25.55), abnormal placentation (adj. OR 20.82 CI 95% 2.48–175.16) and age at delivery >40 years (adj. OR 4.77 CI 95% 1.44–15.85). Conclusions: The main risk factor for uterine rupture in the whole study population is previous uterine surgery. Risk factors in women with unscarred uterus were UFP, abnormal placentation, and age at delivery >40 years. The only factor which can be modified is UFP. We suggest that UFP should be used with caution at least in presence of other supposed risk factors.

Objective: To determine the diagnostic accuracy of fetal scalp lactate sampling (FSLS) and to establish an optimal cut-off value for intrapartum acidosis compared with fetal scalp pH. Methods: A 20-month retrospective cohort study was conducted of all neonates delivered in our institution for whom fetal scalp blood sampling (FSBS) was performed, matching their intrapartum gasometry to their cord gasometry at delivery (n=243). The time taken from the performance of scalp blood sampling to arterial umbilical cord gas acquisition was 45 min at most. Five arterial cord gasometry patterns were set for assessing the predictive ability of both techniques. Subsequent obstetric management for a pathological value was analysed considering the use of both techniques. Results: The optimal cut-off value for FSLS was 4.8 mmol/L: this value has 100% sensitivity and 63% specificity for umbilical arterial cord gas pH≤7.0 and base deficit (BD)≥12 detection, and 100% sensitivity and 64% specificity for umbilical arterial cord gas pH≤7.10 and BD≥12 detection, with a false negative rate of <1.3%, improving fetal scalp pH performance. FSLS showed the best area under the curve (AUC) of 0.86 and 0.84 for both arterial cord gasometry patterns, respectively. Expedite birth following lactate criteria would have been the same as following pH criteria (92 obstetric interventions) with no cases of missed metabolic acidosis. In the cohort, 19.8% of cases were discordant, but no cases of metabolic acidosis were in this group. Conclusions: FSLS improves the detection of metabolic acidosis via fetal scalp pH with an optimal cut-off value of 4.8 mmol/L. FSLS can be used without increasing obstetrical interventions or missing metabolic acidosis.

Objective: Lactate Pro ™ (LP1) is the only lactate meter evaluated for fetal scalp blood sampling (FBS) in intrapartum use. The reference values for this meter are: normal value <4.2 mmol/L, preacidemia 4.2–4.8 mmol/L, and acidemia >4.8 mmol/L. The production of this meter has been discontinued. An updated version, Lactate Pro 2 TM (LP2), has been launched and is shown to be differently calibrated. The aims of the study were to retrieve a conversion equation to convert lactate values in FBS measured with LP2 to an estimated value if using LP1 and to define reference values for clinical management when using LP2. Study design: A cross-sectional study was conducted at a university hospital in Sweden. A total of 113 laboring women with fetal heart rate abnormalities on cardiotocography (CTG) had FBS carried out. Lactate concentration was measured bedside with both LP1 and LP2 from the same blood sample capillary. A linear regression model was constructed to retrieve a conversion equation to convert LP2 values to LP1 values. Results: LP2 measured higher values than LP1 in all analyses. We found that 4.2 mmol/L with LP1 corresponded to 6.4 mmol/L with LP2. Likewise, 4.8 mmol/L with LP1 corresponded to 7.3 mmol/L with LP2. The correlation between the analyses was excellent (Spearman’s rank correlation, r=0.97). Conclusion: We recommend the following guidelines when interpreting lactate concentration in FBS with LP2: <6.4 mmol/L to be interpreted as normal, 6.4–7.3 mmol/L as preacidemia indicating a follow-up FBS within 20–30 min, and >7.3 mmol/L as acidemia indicating intervention.

Objective: The aim of this study was to explore whether linear and non-linear analysis of uterine contraction (UC) signals obtained with external tocodynamometry can predict operative vaginal delivery (OVD). Materials and methods: The last 2 h before delivery (H 1 and H 2 ) of 55 UC recordings acquired with external tocodynamometry in the labour ward of a tertiary care hospital were analysed. Signal processing involved the quantification of UCs/segment (UC N ), and the linear and non-linear indices: Sample Entropy (SampEn) measuring signal irregularity; interval index (II) measuring signal variability, both of which may be associated with uterine muscle fatigue, and high frequency (HF), associated with maternal breathing movements. Thirty-two women had normal deliveries and 23 OVDs. Statistical inference was performed using 95% confidence intervals (95% CIs) for the median, and areas under the receiver operating curves (auROCs), with univariate and bivariate analyses. Results: A significant association was found between maternal body mass index (BMI) and UC signal quality in H 1 , with moderate/poor signal quality being more frequent with higher maternal BMI. There was an overall increase in contraction frequency (UC N ), signal regularity (SampEn), signal variability (II), and maternal breathing (HF) from H 1 to H 2 . The OVD group exhibited significantly higher values of signal irregularity and variability (SampEn and II) in H 1 , and higher contraction frequency (UC N ) and maternal breathing (HF) in H 2 . Modest auROCs were obtained with these indices in the discrimination between normal and OVDs. Conclusions: The results of this exploratory study suggest that analysis of UC signals obtained with tocodynamometry, using linear and non-linear indices associated with muscle fatigue and maternal breathing, identifies significant changes occurring during labour, and differences between normal and OVDs, but their discriminative capacity between the two types of delivery is modest. Further refinement of this analysis is needed before it may be clinically useful.

Introduction: A standardized team-training program for healthcare professionals in obstetric units was developed based on an analysis of common causes for adverse events found in claims registries. The interdisciplinary and inter-professional training concept included both technical and non-technical skill training. Evaluation of the program was carried out in hospitals with respect to the immediate personal learning of participants and also regarding changes in safety culture. Methods: Trainings in n=7 hospitals including n=270 participants was evaluated using questionnaires. These were administered at four points in time to staff from participating obstetric units: (1) 10 days ahead of the training (n=308), (2) on training day before (n=239), (3) right after training (n=248), and (4) 6 months after (n=188) the intervention. Questionnaires included several questions for technical and non-technical skills and the Hospital Survey on Patient Safety (HSOPS). Results: Strong effects were found in the participants’ perception of their own competence regarding technical skills and handling of emergencies. Small effects could be observed in the scales of the HSOPS questionnaire. Most effects differed depending on professional groups and hospitals. Conclusions: Integrated technical and team management training can raise employees’ confidence with complex emergency management skills and processes. Some indications for improvements on the patient safety culture level were detected. Furthermore, differences between professional groups and hospitals were found, indicating the need for more research on contributing factors for patient safety and for the success of crew resource management (CRM) trainings.

Objective: To investigate whether fetal blood circulation is influenced by the maternal supine position. Methods: The inclusion criteria were good health, a singleton pregnancy, maternal age between 18 and 40 years, gestational age between 36 and 40 weeks, and an agreement to participate in the study. Each participant (n=20) was initially asked to adopt the left lateral position for 5 min, while fetal Doppler measurements were taken of the fetal middle cerebral artery (MCA), umbilical artery (UA), and umbilical vein (UV). Subsequently, they were asked to change to the supine position for Doppler measurements at 5 and at 10 min. Results: When a woman remained in the supine position for 5 min, there was a significant reduction in fetal MCA-pulsatility index (PI) (median 1.70 vs. 1.42, P=0.003). This reduction did not persist after 10 min (median 1.70 vs. 1.65 P=1.0). There was no significant difference between the left lateral and the supine position at 5 and at 10 min in terms of UA-PI (0.853 vs. 0.870 vs. 0.858, P=0.850), UV flow (217 vs. 242 vs. 236 mL/min, P=0.263), and normalized UV flow (72.2 vs. 80.8 vs. 78.8 mL/min/kg, P=0.271). Conclusions: Changing maternal position from the left lateral to the supine position caused a reduction in resistance in fetal MCA and no changes in UA or UV indices. However, despite the changes in cerebral circulation which occurred at 5 min by shifting position, they did not remain for 10 min. The changes may be related to reduction in maternal oxygen saturation as there was no decrease in UV blood flow.

Introduction: The objective of this study was to evaluate the underlying causes of neonatal mortality (NNM) in midwife-attended home births and compare them to hospital births attended by a midwife or a physician in the United States (US). Methods: A retrospective cohort study of the Centers for Disease Control (CDC) linked birth/infant death data set (linked files) for 2008 through 2012 of singleton, term (≥37 weeks) births and normal newborn weights (≥2500 grams). Results: Midwife-attended home births had the highest rate of neonatal deaths [122/95,657 neonatal mortality (NNM) 12.75/10,000; relative risk (RR): 3.6, 95% confidence interval (CI) 3–4.4], followed by hospital physician births (8695/14,447,355 NNM 6.02/10,000; RR: 1.7 95% CI 1.6–1.9) and hospital midwife births (480/1,363,199 NNM 3.52/10,000 RR: 1). Among midwife-assisted home births, underlying causes attributed to labor and delivery caused 39.3% (48/122) of neonatal deaths (RR: 13.4; 95% CI 9–19.9) followed by 29.5% due to congenital anomalies (RR: 2.5; 95% CI 1.8–3.6), and 12.3% due to infections (RR: 4.5; 95% CI 2.5–8.1). Comment: There are significantly increased risks of neonatal deaths among midwife-attended home births associated with three underlying causes: labor and delivery issues, infections, and fetal malformations. This analysis of the causes of neonatal death in planned home birth shows that it is consistently riskier for newborns to deliver at home than at the hospital. Physicians, midwives, and other health care providers have a professional responsibility to share information about the clinical benefits and risks of clinical management.

Background: The aim was to evaluate the influence of the new International Association of Diabetes and Pregnancy Study Groups (IADPSG) guidelines for screening of gestational diabetes mellitus (GDM) on GDM prevalence in a cohort from a Swiss tertiary hospital. Methods: This was a retrospective cohort study involving all pregnant women who were screened for GDM between 24 and 28 weeks of gestation. From 2008 until 2010 (period 1), a two-step approach with 1-h 50 g glucose challenge test (GCT) was used, followed by fasting, 1- and 2-h glucose measurements after a 75 g oral glucose tolerance test (OGTT) in case of a positive GCT. From 2010 until 2013 (period 2), all pregnant women were tested with a one-step 75 g OGTT according to new IADPSG guidelines. In both periods, women with risk factors could be screened directly with a 75 g OGTT in early pregnancy. Results: Overall, 647 women were eligible for the study in period 1 and 720 in period 2. The introduction of the IADPSG criteria resulted in an absolute increase of GDM prevalence of 8.5% (3.3% in period 1 to 11.8% in period 2). Conclusions: The adoption of the IADPSG criteria resulted in a considerable increase in GDM diagnosis in our Swiss cohort. Further studies are needed to investigate if the screening is cost effective and if treatment of our additionally diagnosed GDM mothers might improve short-term as well as long-term outcome.

Background: Erythropoietin seems to play an important role in the regulation of fetal hypoxemia. The present prospective study was designed to determine if changes in erythropoietin levels can be found in fetuses with severe early-onset growth restriction and hemodynamic compromise. Methods and results: Erythropoietin, hemoglobin, hematocrit, platelet counts, normoblasts, lacate, arterial and venous blood gasses in the umbilical cord were determined in 42 fetuses with fetal growth restriction (IUGR) with absent (zero-flow) and 26 IUGR fetuses with retrograde end-diastolic flow (reverse-flow) in the umbilical artery. Color Doppler measurements were performed on the middle cerebral artery (PI) and ductus venosus [(S-a)/D and (S-a)/V mean ]. Erythropoietin concentrations were significantly lower in the zero-flow group (median: 128.0 mU/mL; range: 60.3–213 mU/mL) compared with the reverse-flow group (median: 202.5 mU/mL; range: 166–1182 mU/mL). Significant differences in median lactate concentrations were observed between the zero-flow group: 3.28 mmol/L (range; 2.3–4.7 mmol/L), and reverse-flow group: 5.6 mmol/L (range: 3.8–7.5 mmol/L). Fetuses with reverse-flow had significantly lower median platelet counts than fetuses with zero-flow (74 vs. 155/μL) and significantly lower normoblast counts (63 vs. 342/100 WBC). Conclusions: Fetuses with severe IUGR due to chronic placental insufficiency and absent or reversed flow in the umbilical artery show increased erythropoietin levels.

Background: Published data on breast milk feeding in infants suffering from inherited metabolic disorders (IMDs) other than phenylketonuria (PKU) are limited and described outcome is variable. Objective: We aimed to evaluate retrospectively whether breastfeeding and/or breast milk feeding are feasible in infants with IMDs including organic acidemias, fatty acid oxidation disorders, urea cycle disorders, aminoacidopathies or disorders of galactose metabolism. Methods: Data on breastfeeding and breast milk feeding as well as monitoring and neurological outcome were collected retrospectively from our database of patients with the mentioned IMD, who were followed in our metabolic center within the last 10 years. Results: Twenty patients were included in the study, who were either breast fed on demand or received expressed breast milk. All the infants were evaluated clinically and biochemically at 2–4-week intervals, with weight gain as the leading parameter to determine metabolic control. Good metabolic control and adequate neurological development were achieved in all patients but one, who experienced the only metabolic crisis observed within the study period. Conclusion: Breast milk feeding with close clinical and biochemical monitoring is feasible in most IMD and should be considered as it offers nutritional and immunological benefits.

Objective: To determine if there is an increased maternal or neonatal morbidity in overweight and obese patients with a false positive glucose challenge test (GCT). Methods: Patients with a body mass index (BMI) ≥25.0 at registration were included in this prospective 36-month study. The study cohort consisted of patients with a false positive (FP) GCT, with two comparison cohorts: those with a (1) screen negative (SN) GCT result and (2) true positive (TP) GCT result. Risks were reported as odd ratios with 95% confidence intervals, with a P<0.05 considered as significant. Results: There were 60 patients in the FP cohort, 106 in the SN cohort, and 64 in the TP cohort. When the BMI of the FP cohort was compared with either the SN cohort or TP cohort, differences were non-significant (SN 32.3 vs. FP 33.3 kg/m 2 , P=0.067) and (FP 33.3 vs. TP 34.4 kg/m 2 , P=0.303). When comparing the FP cohort to the SN cohort, patients in the FP group had significantly more gestational hypertension and pre-eclampsia. There was a trend towards delivering large for gestational weight infants and an infant ≥4000 g in the FP cohort, but this fell short of reaching statistical significance. When comparing the FP to TP cohorts, rates of gestational hypertension, pre-eclampsia, and infants ≥4000 g were similar; however, neonatal morbidity was increased in the TP group. Conclusions: Overweight and obese patients with a FP glucose challenge screen are more likely to have adverse maternal outcomes. Neonatal morbidity was not increased.