Showing papers on "Vaginal delivery published in 2017"

Selective versus routine use of episiotomy for vaginal birth

Abstract: Background Some clinicians believe that routine episiotomy, a surgical cut of the vagina and perineum, will prevent serious tears during childbirth. On the other hand, an episiotomy guarantees perineal trauma and sutures. Objectives To assess the effects on mother and baby of a policy of selective episiotomy ('only if needed') compared with a policy of routine episiotomy ('part of routine management') for vaginal births. Search methods We searched Cochrane Pregnancy and Childbirth's Trials Register (14 September 2016) and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing selective versus routine use of episiotomy, irrespective of parity, setting or surgical type of episiotomy. We included trials where either unassisted or assisted vaginal births were intended. Quasi-RCTs, trials using a cross-over design or those published in abstract form only were not eligible for inclusion in this review. Data collection and analysis Two authors independently screened studies, extracted data, and assessed risk of bias. A third author mediated where there was no clear consensus. We observed good practice for data analysis and interpretation where trialists were review authors. We used fixed-effect models unless heterogeneity precluded this, expressed results as risk ratios (RR) and 95% confidence intervals (CI), and assessed the certainty of the evidence using GRADE. Main results This updated review includes 12 studies (6177 women), 11 in women in labour for whom a vaginal birth was intended, and one in women where an assisted birth was anticipated. Two were trials each with more than 1000 women (Argentina and the UK), and the rest were smaller (from Canada, Germany, Spain, Ireland, Malaysia, Pakistan, Columbia and Saudi Arabia). Eight trials included primiparous women only, and four trials were in both primiparous and multiparous women. For risk of bias, allocation was adequately concealed and reported in nine trials; sequence generation random and adequately reported in three trials; blinding of outcomes adequate and reported in one trial, blinding of participants and personnel reported in one trial. For women where an unassisted vaginal birth was anticipated, a policy of selective episiotomy may result in 30% fewer women experiencing severe perineal/vaginal trauma (RR 0.70, 95% CI 0.52 to 0.94; 5375 women; eight RCTs; low-certainty evidence). We do not know if there is a difference for blood loss at delivery (an average of 27 mL less with selective episiotomy, 95% CI from 75 mL less to 20 mL more; two trials, 336 women, very low-certainty evidence). Both selective and routine episiotomy have little or no effect on infants with Apgar score less than seven at five minutes (four trials, no events; 3908 women, moderate-certainty evidence); and there may be little or no difference in perineal infection (RR 0.90, 95% CI 0.45 to 1.82, three trials, 1467 participants, low-certainty evidence). For pain, we do not know if selective episiotomy compared with routine results in fewer women with moderate or severe perineal pain (measured on a visual analogue scale) at three days postpartum (RR 0.71, 95% CI 0.48 to 1.05, one trial, 165 participants, very low-certainty evidence). There is probably little or no difference for long-term (six months or more) dyspareunia (RR1.14, 95% CI 0.84 to 1.53, three trials, 1107 participants, moderate-certainty evidence); and there may be little or no difference for long-term (six months or more) urinary incontinence (average RR 0.98, 95% CI 0.67 to 1.44, three trials, 1107 participants, low-certainty evidence). One trial reported genital prolapse at three years postpartum. There was no clear difference between the two groups (RR 0.30, 95% CI 0.06 to 1.41; 365 women; one trial, low certainty evidence). Other outcomes relating to long-term effects were not reported (urinary fistula, rectal fistula, and faecal incontinence). Subgroup analyses by parity (primiparae versus multiparae) and by surgical method (midline versus mediolateral episiotomy) did not identify any modifying effects. Pain was not well assessed, and women's preferences were not reported. One trial examined selective episiotomy compared with routine episiotomy in women where an operative vaginal delivery was intended in 175 women, and did not show clear difference on severe perineal trauma between the restrictive and routine use of episiotomy, but the analysis was underpowered. Authors' conclusions In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal trauma. Other findings, both in the short or long term, provide no clear evidence that selective episiotomy policies results in harm to mother or baby. The review thus demonstrates that believing that routine episiotomy reduces perineal/vaginal trauma is not justified by current evidence. Further research in women where instrumental delivery is intended may help clarify if routine episiotomy is useful in this particular group. These trials should use better, standardised outcome assessment methods.

The effect of an elective cesarean section on maternal request on peripartum anxiety and depression in women with childbirth fear: a systematic review

Abstract: Background Obstetricians are often reluctant to grant requests for an elective cesarean section (ECS) due to childbirth fear. To date, it is unknown if an ECS on request improves mental well-being in the mother in the peripartum period and if possible beneficial effects on anxiety and depression could outweigh the increased risk of complications associated with a surgical delivery. A systematic review was conducted to explore the effect of ECS on request on peripartum anxiety and depression. Methods We searched on PubMed, PsychoInfo and Embase. Studies were included with primary data on anxiety and/or depression postpartum in women with childbirth fear who had requested an ECS. After full-text evaluation of 65 papers and quality analysis of four papers, three papers were included. Of one paper additional and yet unpublished data were provided. Studies varied in outcome measures, hence no meta-analysis was performed. Results Women who requested an ECS had higher antepartum depression and anxiety levels but no different postpartum depression levels than women who delivered vaginally. One study of good quality examined the effect of vaginal delivery in women preferring ECS: These women had significantly higher symptom levels of post-traumatic stress disorder (PTSD) and depression than women with normal vaginal delivery. Conclusions The prospect of an ECS does not lower antepartum anxiety and/or depression levels in women requesting an ECS. If women resolutely persist in wishing an ECS despite adequate counselling and/or psychiatric treatment, the risk of developing depressive and PTSD symptoms in case of vaginal delivery should be taken into account, and an ECS may be considered as a valid alternative.

Does vaginal delivery mitigate or strengthen the intergenerational association of overweight and obesity? Findings from the Boston Birth Cohort

Abstract: Does vaginal delivery mitigate or strengthen the intergenerational association of overweight and obesity? Findings from the Boston Birth Cohort

Impact of delivery mode on the colostrum microbiota composition

Abstract: Breast milk is a rich nutrient with a temporally dynamic nature In particular, numerous alterations in the nutritional, immunological and microbiological content occur during the transition from colostrum to mature milk The objective of our study was to evaluate the potential impact of delivery mode on the microbiota of colostrum, at both the quantitative and qualitative levels (bacterial abundance and microbiota network) Twenty-nine Italian mothers (15 vaginal deliveries vs 14 Cesarean sections) were enrolled in the study The microbiota of colostrum samples was analyzed by next generation sequencing (Ion Torrent Personal Genome Machine) The colostrum microbiota network associated with Cesarean section and vaginal delivery was evaluated by means of the Auto Contractive Map (AutoCM), a mathematical methodology based on Artificial Neural Network (ANN) architecture Numerous differences between Cesarean section and vaginal delivery colostrum were observed Vaginal delivery colostrum had a significant lower abundance of Pseudomonas spp, Staphylococcus spp and Prevotella spp when compared to Cesarean section colostrum samples Furthermore, the mode of delivery had a strong influence on the microbiota network, as Cesarean section colostrum showed a higher number of bacterial hubs if compared to vaginal delivery, sharing only 5 hubs Interestingly, the colostrum of mothers who had a Cesarean section was richer in environmental bacteria than mothers who underwent vaginal delivery Finally, both Cesarean section and vaginal delivery colostrum contained a greater number of anaerobic bacteria genera The mode of delivery had a large impact on the microbiota composition of colostrum Further studies are needed to better define the meaning of the differences we observed between Cesarean section and vaginal delivery colostrum microbiota

Duration of second stage of labor and instrumental delivery as risk factors for severe perineal lacerations: population-based study.

Abstract: We sought to investigate the impact of the duration of second stage of labor on risk of severe perineal lacerations (third and fourth degree). This population based cohort study was conducted in the Stockholm/Gotland region, Sweden, 2008–2014. Study population included 52 211 primiparous women undergoing vaginal delivery with cephalic presentation at term. Unconditional logistic regression analysis was used to calculate crude and adjusted odds ratios (OR), using 95% confidence intervals (CI). Main exposure was duration of second stage of labor, and main outcome was risks of severe perineal lacerations (third and fourth degree). Risk of severe perineal lacerations increased with duration of second stage of labor. Compared with a second stage of labor of 1 h or less, women with a second stage of more than 2 h had an increased risk (aOR 1.42; 95% CI 1.28–1.58). Compared with non-instrumental vaginal deliveries, the risk was elevated among instrumental vaginal deliveries (aOR 2.24; 95% CI 2.07–2.42). The risk of perineal laceration increased with duration of second stage of labor until less than 3 h in both instrumental and non-instrumental vaginal deliveries, but after 3 h, the ORs did not further increase. After adjustments for potential confounders, macrosomia (birth weight > 4 500 g) and occiput posterior fetal position were risk factors of severe perineal lacerations. The risk of severe perineal laceration increases with duration until the third hour of second stage of labor. Instrumental delivery is the most significant risk factor for severe lacerations, followed by duration of second stage of labor, fetal size and occiput posterior fetal position.

The elevated rate of cesarean section and its contribution to non-communicable chronic diseases in Latin America: the growing involvement of the microbiota

Abstract: The current recommendation of the World Health Organization (WHO) regarding cesarean section (C-section) is that this clinical practice should be carried out only under specific conditions, when the health or life of the mother/newborn dyad is threatened, and that its use should not exceed 10-15% of the total deliveries. However, over the last few decades, the frequency of C-section delivery in medium- and high-income countries has rapidly increased worldwide. This review describes the evolution of this procedure in Latin-American countries, showing that today more than half of newborns in the region are delivered by C-section. Given that C-section delivery is more expensive than vaginal delivery, its use has increased more rapidly in the private than the public sector; nevertheless, the prevalence of C-section deliveries in the public sector is higher than the WHO’s recommendations, and continues to increase, representing a growing challenge for Latin America. Although the medium- and long-term consequences of C-section delivery, as opposed to vaginal delivery, on the infant health are unclear, epidemiological studies suggest that it is associated with higher risk of developing asthma, food allergy, type-1 diabetes and obesity during infancy. These findings are important, as the incidence of these diseases in the Latin American pediatric population is also increasing, particularly obesity. Though the link between these diseases and delivery mode remains controversial, recent studies indicate that the establishment of the gut microbiota is delayed in infants born by C-section during the postnatal period, i.e. during a critical developmental window for the maturation of the newborn's immune system. This delay may favor the subsequent development of inflammatory and metabolic disorders during infancy. Accordingly, from a public health perspective, it is important to slow down and eventually reverse the pattern of increased C-section use in the affected populations.

Pelvic Organ Prolapse

Abstract: Pelvic organ prolapse is the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy). Prevalence increases with age. The cause of prolapse is multifactorial but is primarily associated with pregnancy and vaginal delivery, which lead to direct pelvic floor muscle and connective tissue injury. Hysterectomy, pelvic surgery, and conditions associated with sustained episodes of increased intra-abdominal pressure, including obesity, chronic cough, constipation, and repeated heavy lifting, also contribute to prolapse. Most patients with pelvic organ prolapse are asymptomatic. Symptoms become more bothersome as the bulge protrudes past the vaginal opening. Initial evaluation includes a history and systematic pelvic examination including assessment for urinary incontinence, bladder outlet obstruction, and fecal incontinence. Treatment options include observation, vaginal pessaries, and surgery. Most women can be successfully fit with a vaginal pessary. Available surgical options are reconstructive pelvic surgery with or without mesh augmentation and obliterative surgery.

Effect of transcutaneous electrical nerve stimulation on labour pain relief among primigravida and multigravida mothers

Abstract: Background: TENS by neuro-physiological means seems to help in relieving labour pain. Most of the pregnant women are not aware of the coping strategies for labour pain. As a result they tend to be restless and stress themselves by shouting or screaming due to pain. By using TENS, women in labour can save their energy without stressing themselves and make use of the saved energy for pushing the fetus during the second stage of labour. The objective was to analyze the effect of TENS on relieving labour pain among the postnatal mothers who had used TENS to cope up with the labour pain. Methods: Data collected from 1041 women [Primipara (n=702) and Multipara (n=339)] who used TENS to cope up pain throughout the labour was used for this retrospective study. Results: 88% of women had vaginal delivery and only 12% of women had cesarean section. More than 50% of both primiparous and multiparous women who had normal and vacuum assisted vaginal delivery experienced excellent pain relief using TENS. Almost 40 % of both primiparous and multiparous women who had forceps delivery and lower segment cesarean section experienced excellent pain relief using TENS. Except 2% of women with normal vaginal delivery, none of them stated that there was no relief of pain using TENS. Conclusions: TENS had a very good effect in coping up the labour pain and could be used during the first and second stages of labour.

Intrapartum predictors of maternal levator ani injury

Abstract: Introduction Damage to the pelvic floor during vaginal childbirth is common, and may take the form of levator avulsion or irreversible overdistension of the levator hiatus (microtrauma). Such trauma is a major risk factor for pelvic organ prolapse later in life. In this study we aimed to identify intrapartum risk factors for levator trauma. Material and methods This is a retrospective analysis of data obtained in two perinatal studies on primiparous women. Between 2005 and 2014, 1148 women carrying an uncomplicated singleton pregnancy in the late third trimester were seen for 4D pelvic floor ultrasound and an interview. They were invited for a repeat assessment at three months postpartum. Results Of 1148 women, 871 (76%) returned for assessment at a mean of five months postpartum. The datasets of 844 women were analyzed due to missing data or concurrent pregnancy in 27. In all, 452 (54%) had a normal vaginal delivery, 102 (12%) a vacuum, 55 (6%) a forceps, and 235 (28%) a cesarean section. On multivariate analysis forceps, length of second stage and obstetric anal sphincter tears were significantly associated with levator avulsion. There were no significant predictors identified for irreversible overdistension. Conclusions The use of forceps, a prolonged second stage, and obstetric anal sphincter tears were associated with levator avulsion. There were no associated intrapartum predictors for hiatal overdistension.

Recovery after Nulliparous Birth: A Detailed Analysis of Pain Analgesia and Recovery of Function.

Abstract: Background The majority of parturients in the United States first return for evaluation by their obstetric practitioner 6 weeks after delivery. As such, there is little granular data on the pain experience, analgesic requirements, and functional recovery during the postpartum period. This prospective observational study was performed to evaluate these factors to provide expectations for patients. Methods A total of 213 nulliparous women were enrolled and assessed daily until they completed 3 outcomes: (1) pain resolution; (2) opioid cessation; and (3) self-assessed functional recovery from delivery. The primary endpoint, pain- and opioid-free functional recovery, was the time required to reach all three of the endpoints. Pain burden was assessed as the area under the curve created by plotting the daily numerical pain rating scale against the days required to attain pain resolution. Times to attain study endpoints after cesarean delivery and vaginal delivery were compared using survival analysis. Results After vaginal delivery, days required for pain and opioid-free functional recovery (median [interquartile range (IQR)]) were 19 [11 to 26], for opioid cessation 0 [0 to 2], termination of all analgesic (including nonsteroidal antiinflammatories and acetaminophen) 11 [5 to 17], and pain resolution 14 [7 to 24]. Achievement of these endpoints after cesarean delivery required 27 [19 to 40], 9 [5 to 12], 16 [11 to 24], and 21 [14 to 27] days, respectively. Conclusions There is clinically significant variability between healthy nulliparous parturients in the pain experience, opioid use, and functional recovery after childbirth following vaginal and cesarean delivery. Recovery to predelivery function is similar after vaginal and cesarean delivery, and approximately half of the variance was explained by pain burden.

Reducing obstetric anal sphincter injuries using perineal support: our preliminary experience.

Abstract: Obstetric anal sphincter injuries (OASIs) are associated with significant short-term and long-term morbidity. Over the past decade, there has been a steady rise in the rate of OASIs. There is therefore a compelling need to identify strategies to minimize OASIs. The objective of this study was to determine if perineal support at the time of vaginal delivery can reduce the incidence and severity of OASIs. All labour ward staff including midwives and doctors were invited to train in the technique of perineal support during vaginal delivery. Two experts from Norway conducted workshops with practical hands-on training on pelvic models. The midwives and doctors underwent further training with women in labour, and mandatory training was continued within the department. All midwives and doctors were instructed to support the perineum during both spontaneous and assisted vaginal delivery. From April 2011 to November 2014, 11,135 women underwent vaginal delivery. The OASI rate decreased from 4.7 % to 4.1 % (p = 0.11). There was a significant reduction (0.9 % to 0.3 %, p < 0.001) in 3c third-degree and fourth-degree tears (major OASIs). In a multivariate analysis, perineal support was associated with a significant reduction in the rates of OASIs (23 %; OR 0.77, 95 % CI 0.63 – 0.95, p = 0.01]) and major OASIs (71 %; OR 0.34, 95 % CI 0.17 – 0.69, p = 0.03). This interventional study showed that perineal support during vaginal delivery can reduce the risk of major OASIs. With sustained reinforcement of this intervention programme, we anticipate a further reduction in OASI rates.

Episiotomy - risk factors and outcomes.

Abstract: Objective: To identify risk factors for mediolateral episiotomy, and evaluate the risk of obstetrical anal sphincter injury (OASI) among women with an episiotomy.Methods: A retrospective cohort study of all singletons vaginal deliveries at term between 2007 and 2014. Spontaneous and operative vaginal deliveries were compared separately, as well as nulliparous and multiparous women.Results: Overall, 41,347 women were included in the spontaneous vaginal delivery group: 12,585 (30.4%) nulliparous and 28,762 (69.6%) multiparous women. Risk factors for episiotomy (nulliparous) were maternal age (aOR 0.98), gestational age (GA, aOR 1.07), regional analgesia (RA, aOR 1.18), labor induction (aOR 1.17), meconium (aOR 1.37) and birth weight (BW, aOR 1.04). Episiotomy was associated with PPH (aOR 1.49). Among multiparous, risk factors were maternal age (aOR 1.04), previous vaginal delivery (aOR 0.38), GA (aOR 1.06), RA (aOR 1.22), meconium (aOR 1.22) and BW (aOR 1.05). Episiotomy was associated with 3rd degr...

Defining the Most Appropriate Delivery Mode in Women with Inflammatory Bowel Disease: A Systematic Review.

Abstract: Introduction High cesarean section (CS) rates are observed in patients with inflammatory bowel disease (IBD), but limited data are available to support this decision. We conducted a comprehensive review to evaluate the most appropriate mode of delivery in women with IBD according to disease phenotype and activity, as well as surgical history. Materials and methods We searched MEDLINE (source PubMed) and international conference abstracts, and included all studies that evaluated digestive outcome after delivery in patients with IBD. Results A total of 41 articles or abstracts were screened, and 18 studies were considered in this review, with sample sizes ranging from 4 to 229 patients and follow-up ranging from 2 months to 7.7 years. Pooled CS rates in patients without Perianal Crohn's disease (PCD), healed PCD or active PCD, were 27%, 43%, and 46%, respectively. Regarding the median rate of new PCD (3.0% [IQR, 1.5-11.5] versus 6.5% [0-19.7]) or PCD recurrence (13.5% [3.2-32.7] versus 45% [0-58]), no increase was observed in patients with vaginal delivery compared to CS, but for patients with an active disease, worsening of symptoms was noted in two-thirds of cases. Episiotomy, perianal tears, and instrumental delivery did not influence the incidence of PCD. In patients with ileal pouch anal anastomosis, uncomplicated vaginal delivery seemed to moderately influence pouch function, with no significant difference in terms of overall continence, daytime, or night-time stool frequency, or incontinence. However, these parameters seemed negatively impacted by a complicated vaginal delivery. Conclusions New long-term data from well-designed studies are needed, but our review suggests that systematic CS in patients suffering from IBD should probably be limited to women at risk of perineal tears and obstetric injuries, with an active PCD, or with ileal pouch anal anastomosis.

Childbirth Education Class and Birth Plans Are Associated with a Vaginal Delivery

Abstract: Background To determine whether the mode of delivery was different between women who attended childbirth education (CBE) class, had a birth plan, or both compared with those who did not attend CBE class or have a birth plan. Methods This is a retrospective cross-sectional study of women who delivered singleton gestations > 24 weeks at our institution between August 2011 and June 2014. Based on a self-report at the time of admission for labor, women were stratified into four categories: those who attended a CBE class, those with a birth plan, both, and those with neither CBE or birth plan. The primary outcome was the mode of delivery. Multivariate logistic regression analyses adjusting for clinical covariates were performed. Results In this study, 14,630 deliveries met the inclusion criteria: 31.9 percent of the women attended CBE class, 12.0 percent had a birth plan, and 8.8 percent had both. Women who attended CBE or had a birth plan were older (p < 0.001), more likely to be nulliparous (p < 0.001), had a lower body mass index (p < 0.001), and were less likely to be African-American (p < 0.001). After adjusting for significant covariates, women who participated in either option or both had higher odds of a vaginal delivery (CBE: OR 1.26 [95% CI 1.15–1.39]; birth plan: OR 1.98 [95% CI 1.56–2.51]; and both: OR 1.69 [95% CI 1.46–1.95]) compared with controls. Conclusion Attending CBE class and/or having a birth plan were associated with a vaginal delivery. These findings suggest that patient education and birth preparation may influence the mode of delivery. CBE and birth plans could be used as quality improvement tools to potentially decrease cesarean rates.

Antibiotic prophylaxis for operative vaginal delivery

Abstract: Background Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. Prophylactic antibiotics may be prescribed to prevent these infections. However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear. Objectives To assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum or forceps deliveries, or both. Search methods We searched Cochrane Pregnancy and Childbirth's Trials Register (12 July 2017), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (12 July 2017) and reference lists of retrieved studies. Selection criteria All randomised trials comparing any prophylactic antibiotic regimens with placebo or no treatment in women undergoing vacuum or forceps deliveries were eligible. Participants were all pregnant women without evidence of infections or other indications for antibiotics of any gestational age undergoing vacuum or forceps delivery for any indications. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium) compared with either placebo or no treatment. Data collection and analysis Two review authors assessed trial eligibility and methodological quality. Two review authors extracted the data independently using prepared data extraction forms. Any discrepancies were resolved by discussion and a consensus reached through discussion with all review authors. We assessed methodological quality of the one included trial using the GRADE approach. Main results One trial, involving 393 women undergoing either vacuum or forceps deliveries, was included. The trial compared the antibiotic intravenous cefotetan after cord clamping compared with no treatment. This trial reported only two out of the nine outcomes specified in this review. Seven women in the group given no antibiotics had endomyometritis and none in prophylactic antibiotic group, the risk reduction was 93% (risk ratio (RR) 0.07; 95% confidence interval (CI) 0.00 to 1.21; low-quality evidence). There was no difference in the length of hospital stay between the two groups (mean difference (MD) 0.09 days; 95% CI -0.23 to 0.41; low-quality evidence). Overall, the risk of bias was judged to be unclear. The quality of the evidence using GRADE was low for both endometritis and maternal length of stay. Authors' conclusions One small trial was identified reporting only two outcomes. Evidence from this single trial suggests that antibiotic prophylaxis may lead to little or no difference in endometritis or maternal length of stay. There were no data on any other outcomes to evaluate the impact of antibiotic prophylaxis after operative vaginal delivery. Future research on antibiotic prophylaxis for operative vaginal delivery is needed to conclude whether it is useful for reducing postpartum morbidity.

Prevention and Management of Obstetric Lacerations at Vaginal Delivery

Abstract: After all vaginal deliveries, a thorough exam should be performed to evaluate for lacerations. In classifying lacerations, it is important to note if the perineal body, external anal sphincter, or rectal mucosa are involved. Episiotomy may be useful in specific situations; however, routine use is not indicated [1].

Risk factors for chronic post-traumatic stress disorder development one year after vaginal delivery: a prospective, observational study.

Abstract: Our study aimed to assess the prevalence of post-traumatic stress disorder (PTSD) after childbirth one year after vaginal delivery and to identify characteristics of women and deliveries associated with it. Questionnaires were mailed a year after delivery to 1103 women with prospectively collected delivery and postpartum data, including a question on day 2 assessing their experience of childbirth. PTSD was assessed a year later by the Impact of Event and Traumatic Event Scales; 22 women (4.2%, 95%CI 2.7–6.3%) met the PTSD diagnostic criteria and 30 (5.7%; 95%CI 3.9–8.0%) PTSD profile criteria. Factors associated with higher risk of PTSD profile were previous abortion (aOR 3.6, 95%CI 1.4–9.3), previous postpartum hemorrhage (Aor 5.3, 95%CI 1.3–21.4), and postpartum hemoglobin <9 g/dl (aOR 2.7, 95%CI 1.0–7.5). Among 56 women (10.3%) reporting bad childbirth memories at day 2 postpartum, 11 (21.1%) met PTSD diagnosis and 11 (21.1%) PTSD profile criteria a year later, compared with 11 (2.4%) (P < 0.001) and 18 (3.8%) (P < 0.001), respectively, of the 489 (87.7%) women with good memories. PTSD is not rare at one year after vaginal delivery in a low-risk population. A simple question at day 2 post partum may identify women most at risk of PTSD and help determine if early intervention is needed.

Physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery: a protocol for a mixed-methods prospective cohort study

Abstract: Introduction Pelvic floor disorders (PFDs), including pelvic organ prolapse (POP), stress and urgency urinary incontinence, and faecal incontinence, are common and arise from loss of pelvic support. Although severe disease often does not occur until women become older, pregnancy and childbirth are major risk factors for PFDs, especially POP. We understand little about modifiable factors that impact pelvic floor function recovery after vaginal birth. This National Institutes of Health (NIH)-funded Program Project, ‘Bridging physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery’, uses mixed-methods research to study the influences of intra-abdominal pressure, physical activity, body habitus and muscle fitness on pelvic floor support and symptoms as well as the cultural context in which women experience those changes. Methods and analysis Using quantitative methods, we will evaluate whether pelvic floor support and symptoms 1 year after the first vaginal delivery are affected by biologically plausible factors that may impact muscle, nerve and connective tissue healing during recovery (first 8 weeks postpartum) and strengthening (remainder of the first postpartum year). Using qualitative methods, we will examine cultural aspects of perceptions, explanations of changes in pelvic floor support, and actions taken by Mexican-American and Euro-American primipara, emphasising early changes after childbirth. We will summarise project results in a resource toolkit that will enhance opportunities for dialogue between women, their families and providers, and across lay and medical discourses. We anticipate enrolling up to 1530 nulliparous women into the prospective cohort study during the third trimester, following those who deliver vaginally 1 year postpartum. Participants will be drawn from this cohort to meet the project9s aims. Ethics and dissemination The University of Utah and Intermountain Healthcare Institutional Review Boards approved this study. Data are stored in a secure password-protected database. Papers summarising the primary results and ancillary analyses will be published in peer-reviewed journals.

Mode of Delivery and Asthma at School Age in 9 European Birth Cohorts.

Abstract: Evidence on the association between mode of delivery and asthma at school age is inconclusive. We assessed the associations between specific modes of delivery and asthma in children from 9 European birth cohorts that enrolled participants between 1996 and 2006. Cohort-specific crude and adjusted risk ratios for asthma at ages 5-9 years were calculated using Poisson regression models and pooled. A sensitivity analysis was carried out in children born at term to reduce confounding due to perinatal factors. The study included 67,613 participants. Cohort-specific rates of cesarean delivery varied from 9.4% to 37.5%. Cesarean delivery, as opposed to vaginal delivery, was associated with an increased risk of asthma (adjusted risk ratio (aRR) = 1.22, 95% confidence interval (CI): 1.02, 1.46). Compared with spontaneous vaginal delivery, the adjusted risk ratio was 1.33 (95% CI: 1.02, 1.75) for elective cesarean delivery, 1.07 (95% CI: 0.94, 1.22) for emergency cesarean delivery, and 0.97 (95% CI: 0.84, 1.12) for operative vaginal delivery. In children born at term, the associations were strengthened only for elective cesarean delivery (aRR = 1.49, 95% CI: 1.13, 1.97). The large sample size allowed analysis of the associations between specific modes of delivery and asthma at school age. The increased risk of asthma associated with elective cesarean delivery, especially among children born at term, is relevant in counteracting the increasing use of this procedure, which is often performed without a clear medical indication.

Acupuncture or acupressure for induction of labour

Abstract: Background This is one of a series of reviews of methods of cervical ripening and labour induction. The use of complementary therapies is increasing. Women may look to complementary therapies during pregnancy and childbirth to be used alongside conventional medical practice. Acupuncture involves the insertion of very fine needles into specific points of the body. Acupressure is using the thumbs or fingers to apply pressure to specific points. The limited observational studies to date suggest acupuncture for induction of labour has no known adverse effects to the fetus, and may be effective. However, the evidence regarding the clinical effectiveness of this technique is limited. Objectives To determine, from the best available evidence, the effectiveness and safety of acupuncture and acupressure for third trimester cervical ripening or induction of labour. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2016), PubMed (1966 to 25 November 2016), ProQuest Dissertations & Theses (25 November 2016), CINAHL (25 November 2016), Embase (25 November 2016), the WHO International Clinical Trials Registry Portal (ICTRP) (3 October 2016), and bibliographies of relevant papers. Selection criteria Randomised controlled trials comparing acupuncture or acupressure, used for third trimester cervical ripening or labour induction, with placebo/no treatment or other methods on a predefined list of labour induction methods. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. The quality of the evidence was assessed using GRADE. Main results This updated review includes 22 trials, reporting on 3456 women. The trials using manual or electro-acupuncture were compared with usual care (eight trials, 760 women), sweeping of membranes (one trial, 207 women), or sham controls (seven trials, 729 women). Trials using acupressure were compared with usual care (two trials, 151 women) or sham controls (two trials, 239 women). Many studies had a moderate risk of bias. Overall, few trials reported on primary outcomes. No trial reported vaginal delivery not achieved within 24 hours and uterine hyperstimulation with fetal heart rate (FHR) changes. Serious maternal and neonatal death or morbidity were only reported under acupuncture versus sham control. Acupuncture versus sham control There was no clear difference in caesarean sections between groups (average risk ratio (RR) 0.80, 95% confidence interval (CI) 0.56 to 1.15, eight trials, 789 women; high-quality evidence). There were no reports of maternal death or perinatal death in the one trial that reported this outcome. There was evidence of a benefit from acupuncture in improving cervical readiness for labour (mean difference (MD) 0.40, 95% CI 0.11 to 0.69, one trial, 125 women), as measured by cervical maturity within 24 hours using Bishop's score. There was no evidence of a difference between groups for oxytocin augmentation, epidural analgesia, instrumental vaginal birth, meconium-stained liquor, Apgar score < 7 at five minutes, neonatal intensive care admission, maternal infection, postpartum bleeding greater than 500 mL, time from the trial to time of birth, use of induction methods, length of labour, and spontaneous vaginal birth. Acupuncture versus usual care There was no clear difference in caesarean sections between groups (average RR 0.77, 95% CI 0.51 to 1.17, eight trials, 760 women; low-quality evidence). There was an increase in cervical maturation for the acupuncture (electro) group compared with control (MD 1.30, 95% CI 0.11 to 2.49, one trial, 67 women) and a shorter length of labour (minutes) in the usual care group compared to electro-acupuncture (MD 124.00, 95% CI 37.39 to 210.61, one trial, 67 women). There appeared be a differential effect according to type of acupuncture based on subgroup analysis. Electro-acupuncture appeared to have more of an effect than manual acupuncture for the outcomes caesarean section (CS), and instrumental vaginal and spontaneous vaginal birth. It decreased the rate of CS (average RR 0.54, 95% CI 0.37 to 0.80, 3 trials, 327 women), increased the rate of instrumental vaginal birth (average RR 2.30, 95%CI 1.15 to 4.60, two trials, 271 women), and increased the rate of spontaneous vaginal birth (average RR 2.06, 95% CI 1.20 to 3.56, one trial, 72 women). However, subgroup analyses are observational in nature and so results should be interpreted with caution. There were no clear differences between groups for other outcomes: oxytocin augmentation, use of epidural analgesia, Apgar score < 7 at 5 minutes, neonatal intensive care admission, maternal infection, perineal tear, fetal infection, maternal satisfaction, use of other induction methods, and postpartum bleeding greater than 500 mL. Acupuncture versus sweeping if fetal membranes One trial of acupuncture versus sweeping of fetal membranes showed no clear differences between groups in caesarean sections (RR 0.64, 95% CI 0.34 to 1.22, one trial, 207 women, moderate-quality evidence), need for augmentation, epidural analgesia, instrumental vaginal birth, Apgar score < 7 at 5 minutes, neonatal intensive care admission, and postpartum bleeding greater than 500 mL. Acupressure versus sham control There was no evidence of benefit from acupressure in reducing caesarean sections compared to control (RR, 0.94, 95% CI 0.68 to 1.30, two trials, 239 women, moderate-quality evidence). There was no evidence of a clear benefit in reduced oxytocin augmentation, instrumental vaginal birth, meconium-stained liquor, time from trial intervention to birth of the baby, and spontaneous vaginal birth. Acupressure versus usual care There was no evidence of benefit from acupressure in reducing caesarean sections compared to usual care (RR 1.02, 95% CI 0.68 to 1.53, two trials, 151 women, moderate-quality evidence). There was no evidence of a clear benefit in reduced epidural analgesia, Apgar score < 7 at 5 minutes, admission to neonatal intensive care, time from trial intervention to birth of the baby, use of other induction methods, and spontaneous vaginal birth. Authors' conclusions Overall, there was no clear benefit from acupuncture or acupressure in reducing caesarean section rate. The quality of the evidence varied between low to high. Few trials reported on neonatal morbidity or maternal mortality outcomes. Acupuncture showed some benefit in improving cervical maturity, however, more well-designed trials are needed. Future trials could include clinically relevant safety outcomes.

Perinatal and maternal morbidity and mortality after attempted operative vaginal delivery at midpelvic station.

Abstract: BACKGROUND: Increased use of operative vaginal delivery (i.e., forceps or vacuum application), of which 20% occurs at midpelvic station, has been advocated to reduce the rate of cesarean delivery. We aimed to quantify severe perinatal and maternal morbidity and mortality associated with attempted midpelvic operative vaginal delivery. METHODS: We studied all term singleton deliveries in Canada between 2003 and 2013, by attempted midpelvic operative vaginal or cesarean delivery with labour (with and without prolonged second stage). The primary outcomes were composite severe perinatal morbidity and mortality (e.g., convulsions, assisted ventilation, severe birth trauma and perinatal death), and composite severe maternal morbidity and mortality (e.g., severe postpartum hemorrhage, shock, sepsis, cardiac complications, acute renal failure and death). RESULTS: The study population included 187 234 deliveries. Among women with dystocia and prolonged second stage of labour, midpelvic operative vaginal delivery was associated with higher rates of severe perinatal morbidity and mortality compared with cesarean delivery (forceps, adjusted odds ratio [AOR] 1.81, 95% confidence interval [CI] 1.24 to 2.64; vacuum, AOR 1.81, 95% CI 1.17 to 2.80; sequential instruments, AOR 3.19, 95% CI 1.73 to 5.88), especially with higher rates of severe birth trauma. Rates of severe maternal morbidity and mortality were not significantly different after operative vaginal delivery, although rates of obstetric trauma were higher (forceps, AOR 4.51, 95% CI 4.04 to 5.02; vacuum, AOR 2.70, 95% CI 2.35 to 3.09; sequential instruments, AOR 4.24, 95% CI 3.46 to 5.19). Among women with fetal distress, similar associations were seen for severe birth trauma and obstetric trauma, although vacuum was associated with lower rates of severe maternal morbidity and mortality (AOR 0.52, 95% CI 0.33 to 0.80). Associations tended to be stronger among women without a prolonged second stage. INTERPRETATION: Midpelvic operative vaginal delivery is associated with higher rates of severe birth trauma and obstetric trauma, whereas overall rates of severe perinatal and maternal morbidity and mortality vary by indication and operative instrument.