Showing papers on "Vaginal delivery published in 2020"

Coronavirus in pregnancy and delivery: rapid review.

Abstract: Objectives There are limited case series reporting the impact on women affected by coronavirus during pregnancy. In women affected by severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), the case fatality rate appears higher in those affected in pregnancy compared with non-pregnant women. We conducted a rapid review to guide health policy and management of women affected by COVID-19 during pregnancy, which was used to develop the Royal College of Obstetricians and Gynaecologists' (RCOG) guidelines on COVID-19 infection in pregnancy. Methods Searches were conducted in PubMed and MedRxiv to identify primary case reports, case series, observational studies and randomized controlled trials describing women affected by coronavirus in pregnancy. Data were extracted from relevant papers. This review has been used to develop guidelines with representatives of the Royal College of Paediatrics and Child Health (RCPCH) and RCOG who provided expert consensus on areas in which data were lacking. Results From 9965 search results in PubMed and 600 in MedRxiv, 21 relevant studies, all of which were case reports or case series, were identified. From reports of 32 women to date affected by COVID-19 in pregnancy, delivering 30 babies (one set of twins, three ongoing pregnancies), seven (22%) were asymptomatic and two (6%) were admitted to the intensive care unit (ICU), one of whom remained on extracorporeal membrane oxygenation. No maternal deaths have been reported to date. Delivery was by Cesarean section in 27 cases and by vaginal delivery in two, and 15 (47%) delivered preterm. There was one stillbirth and one neonatal death. In 25 babies, no cases of vertical transmission were reported; 15 were reported as being tested with reverse transcription polymerase chain reaction after delivery. Case fatality rates for SARS and MERS were 15% and 27%, respectively. SARS was associated with miscarriage or intrauterine death in five cases, and fetal growth restriction was noted in two ongoing pregnancies affected by SARS in the third trimester. Conclusions Serious morbidity occurred in 2/32 women with COVID-19, both of whom required ICU care. Compared with SARS and MERS, COVID-19 appears less lethal, acknowledging the limited number of cases reported to date and that one woman remains in a critical condition. Preterm delivery affected 47% of women hospitalized with COVID-19, which may put considerable pressure on neonatal services if the UK's reasonable worst-case scenario of 80% of the population being affected is realized. Based on this review, RCOG, in consultation with RCPCH, developed guidance for delivery and neonatal care in pregnancies affected by COVID-19, which recommends that delivery mode be determined primarily by obstetric indication and recommends against routine separation of affected mothers and their babies. We hope that this review will be helpful for maternity and neonatal services planning their response to COVID-19. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Maternal and Neonatal Outcomes of Pregnant Women With Coronavirus Disease 2019 (COVID-19) Pneumonia: A Case-Control Study.

Abstract: BACKGROUND: The ongoing pandemic of coronavirus disease 2019 (COVID-19) has caused serious concerns about its potential adverse effects on pregnancy. There are limited data on maternal and neonatal outcomes of pregnant women with COVID-19 pneumonia. METHODS: We conducted a case-control study to compare clinical characteristics and maternal and neonatal outcomes of pregnant women with and without COVID-19 pneumonia. RESULTS: During the period 24 January-29 February 2020, there were 16 pregnant women with confirmed COVID-19 pneumonia and 18 suspected cases who were admitted to labor in the third trimester. Two had vaginal delivery and the rest were cesarean delivery. Few patients presented respiratory symptoms (fever and cough) on admission, but most had typical chest computed tomographic images of COVID-19 pneumonia. Compared to the controls, patients with COVID-19 pneumonia had lower counts of white blood cells (WBCs), neutrophils, C-reactive protein (CRP), and alanine aminotransferase on admission. Increased levels of WBCs, neutrophils, eosinophils, and CRP were found in postpartum blood tests of pneumonia patients. Three (18.8%) of the mothers with confirmed COVID-19 pneumonia and 3 (16.7%) with suspected COVID-19 pneumonia had preterm delivery due to maternal complications, which were significantly higher than in the control group. None experienced respiratory failure during their hospital stay. COVID-19 infection was not found in the newborns, and none developed severe neonatal complications. CONCLUSIONS: Severe maternal and neonatal complications were not observed in pregnant women with COVID-19 pneumonia who had vaginal or cesarean delivery. Mild respiratory symptoms of pregnant women with COVID-19 pneumonia highlight the need of effective screening on admission.

Vaginal delivery report of a healthy neonate born to a convalescent mother with COVID--19.

Abstract: The outbreak of the infection of 2019 novel coronavirus disease (COVID--19) has become a challenging public health threat worldwide. Limited data are available for pregnant women with COVID-19 pneumonia. We report a case of a convalescing pregnant woman diagnosed with COVID-19 infection 37 days before delivery in the third trimester. A live birth without severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was performed successfully via the vagina. The findings from our case indicate that there is no intrauterine transmission in this woman who developed COVID-19 pneumonia in late pregnancy.

COVID-19 vaginal delivery - A case report.

Abstract: The novel coronavirus termed SARS-CoV-2 (COVID-19) is a major public health challenge. Many maternity units around the country are currently considering management protocols for these patients. We report a case from a tertiary Australian hospital describing an uncomplicated vaginal birth in a COVID-19 positive mother. To our knowledge this is also the first case described of a mother with COVID-19 not separated from her infant. Management provided supports the current Royal College of Obstetricians and Gynaecologists and World Health Organization guidelines suggesting that it is possible to consider rooming in post-delivery for COVID-19 positive parents. Encouragement of breastfeeding appears possible and safe when viral precautions are observed.

Maternal and neonatal outcomes of pregnant women with COVID-19 pneumonia: a case-control study

Abstract: Background The ongoing epidemics of coronavirus disease 2019 (COVID-19) have caused serious concerns about its potential adverse effects on pregnancy. There are limited data on maternal and neonatal outcomes of pregnant women with COVID-19 pneumonia. Methods We conducted a case-control study to compare clinical characteristics, maternal and neonatal outcomes of pregnant women with and without COVID-19 pneumonia. Results During January 24 to February 29, 2020, there were sixteen pregnant women with confirmed COVID-19 pneumonia and eighteen suspected cases who were admitted to labor in the third trimester. Two had vaginal delivery and the rest took cesarean section. Few patients presented respiratory symptoms (fever and cough) on admission, but most had typical chest CT images of COVID-19 pneumonia. Compared to the controls, COVID-19 pneumonia patients had lower counts of white blood cells (WBC), neutrophils, C-reactive protein (CRP), and alanine aminotransferase (ALT) on admission. Increased levels of WBC, neutrophils, eosinophils, and CRP were found in postpartum blood tests of pneumonia patients. There were three (18.8%) and two (10.5%) of the mothers with confirmed or suspected COVID-19 pneumonia had preterm delivery due to maternal complications, which were significantly higher than the control group. None experienced respiratory failure during hospital stay. COVID-19 infection was not found in the newborns and none developed severe neonatal complications. Conclusion Severe maternal and neonatal complications were not observed in pregnant women with COVID-19 pneumonia who had vaginal delivery or caesarean section. Mild respiratory symptoms of pregnant women with COVID-19 pneumonia highlight the need of effective screening on admission.

Impact of labor and delivery unit policy modifications on maternal and neonatal outcomes during the coronavirus disease 2019 pandemic.

Abstract: Background: In response to the COVID-19 pandemic, hospitals nationwide have implemented modifications to labor and delivery unit practices designed to protect delivering patients and healthcare providers from infection with SARS-CoV-2. Beginning March 2020, our hospital instituted labor and delivery unit modifications targeting visitor policy, use of personal protective equipment, designation of rooms for triage and delivery of persons suspected or infected with COVID-19, delivery management and newborn care. Little is known about the ramifications of these modifications in terms of maternal and neonatal outcomes. Objective: The objective of this study was to determine whether labor and delivery unit policy modifications we made during the COVID-19 pandemic were associated with differences in outcomes for mothers and newborns. Study Design: We conducted a retrospective cohort study of all deliveries occurring in our hospital between January 1, 2020 and April 30, 2020. Patients who delivered in January and February 2020 before labor and delivery unit modifications were instituted were designated as the pre-implementation group, and those who delivered in March and April 2020 were designated as the post-implementation group. Maternal and neonatal outcomes between the pre-and post-implementation groups were compared. Differences between the two groups were then compared to the same time period in 2019 and 2018 to assess whether any apparent differences were unique to the pandemic year. We hypothesized that maternal and newborn lengths of stay would be shorter in the post-implementation group. Statistical analysis methods included Student's T-tests and Wilcoxon tests for continuous variables and chi square or Fisher's exact tests for categorical variables. Results: Postpartum length of stay was significantly shorter after implementation of labor unit changes related to COVID-19. A postpartum stay of 1 night following vaginal delivery occurred in 48.5% of patients in the post-implementation group compared to 24.9% of the pre-implementation group (p<0.0001). Postoperative length of stay after cesarean delivery of ≤2 nights occurred in 40.9% of patients in the post-implementation group as compared to 11.8% in the pre-implementation group (p<0.0001). Similarly, after vaginal delivery, 49.0% of newborns were discharged home after one night in the post-implementation group compared to 24.9% in the pre-implementation group (p <0.0001). After cesarean delivery, 42.5% of newborns were discharged after ≤2 nights in the post-implementation group compared to 12.5% in the pre-implementation group (p<0.0001). Slight differences in the proportions of earlier discharge between mothers and newborns were due to multiple gestations. There were no differences in cesarean delivery rate, induction of labor, or adverse maternal or neonatal outcomes between the two groups. Conclusion: Labor and delivery unit policy modifications to protect pregnant patients and healthcare providers from COVID-19 demonstrate that maternal and newborn length of stay in the hospital were significantly shorter after delivery without increases in the rate of adverse maternal or neonatal outcomes. In the absence of longer-term adverse outcomes occurring after discharge that are tied to earlier release, our study results may support a review of our discharge protocols once the pandemic subsides to move toward safely shortening maternal and newborn lengths of stay.

Caesarean Delivery and Risk of Chronic Inflammatory Diseases (Inflammatory Bowel Disease, Rheumatoid Arthritis, Coeliac Disease, and Diabetes Mellitus): A Population Based Registry Study of 2,699,479 Births in Denmark During 1973-2016.

Abstract: Background Chronic inflammatory diseases in childhood and early adult life share aetiological factors operating from birth and onwards. In this study, we use data from the national Danish health registers to evaluate the risk of developing four common, immune-mediated hospital-diagnosed childhood chronic inflammatory diseases. Methods A national population-based registry study. Data from the Danish Medical Birth Registry and the Danish National Patient Registry from January 1973 to March 2016 were linked at a personal level to evaluate any potential associations between caesarean section and development of Inflammatory bowel diseases, rheumatoid arthritis, coeliac disease and diabetes mellitus among the offspring. A model adjusted for parental age at birth, decade of birth, gender of child, and parents' chronic inflammatory disease status was used. Results This register-based national cohort study of 2672708 children with information on delivery mode found an increased risk of diabetes, arthritis, coeliac disease, and inflammatory bowel disease for both girls and boys after caesarean section compared with vaginal delivery. The higher risk was present at least 40 years after delivery. In a subgroup analysis, both acute and elective caesarean section was associated with an increased risk of developing a chronic inflammatory disease. Conclusions Being born by caesarean section leads to increased host susceptibility for chronic inflammatory diseases that last for decades. This finding should be further addressed in future studies with the aim to support the development of new strategies for prevention, treatment, and maybe even cure.

Early postpartum discharge during the COVID-19 pandemic.

Abstract: Objectives To report our experience with early postpartum discharge to decrease hospital length of stay among low-risk puerperium patients in a large obstetrical service during the COVID-19 pandemic in New York. Methods Retrospective analysis of all uncomplicated postpartum women in seven obstetrical units within a large health system between December 8th, 2019 and June 20th, 2020. Women were stratified into two groups based on date of delivery in relation to the start of the COVID-19 pandemic in New York (Mid-March 2020); those delivering before or during the COVID-19 pandemic. We compared hospital length of stay, defined as time interval from delivery to discharge in hours, between the two groups and correlated it with the number of COVID-19 admissions to our hospitals. Statistical analysis included use of Wilcoxon rank sum test and Chi-squared test with significance defined as p-value<0.05. Results Of the 11,770 patients included, 5,893 (50.1%) delivered prior to and 5,877 (49.9%) delivered during the COVID-19 pandemic. We detected substantial shortening in postpartum hospital length of stay after vaginal delivery (34 vs. 48 h, p≤0.0001) and cesarean delivery (51 vs. 74 h, p≤0.0001) during the COVID-19 pandemic. Conclusions We report successful implementation of early postpartum discharge for low-risk patients resulting in a significantly shorter hospital stay during the COVID-19 pandemic in New York. The impact of this strategy on resource utilization, patient satisfaction and adverse outcomes requires further study.

Tranexamic acid for treatment of primary postpartum hemorrhage after vaginal delivery: a systematic review and meta-analysis of randomized controlled trials

Abstract: Background: Postpartum hemorrhage (PPH) is responsible for about 25% of maternal deaths worldwide. Antifibrinolytic agents, mainly tranexamic acid (TXA), have been demonstrated to reduce bl...

Maternal childbirth experience in induced and spontaneous labour measured in a visual analog scale and the factors influencing it; a two-year cohort study.

Abstract: Poor maternal childbirth experience plays a role in family planning and subsequent pregnancies. The aim of this study was to compare childbirth experiences in induced and spontaneous labor and to investigate the factors influencing the childbirth experience. This two-year cohort study included all women with term singleton pregnancies in cephalic presentation aiming for vaginal delivery at Helsinki University Hospital between January 2017 and December 2018. Maternal satisfaction in the childbirth experience was measured after delivery using a Visual Analog Scale (VAS) score. A low childbirth experience score was defined as VAS < 5. The characteristics and delivery outcomes of the study population were collected in the hospital database and analyzed by SPSS. A total of 18,396 deliveries were included in the study, of which 28.9% (n = 5322) were induced and 71.1% (n = 13 074) were of spontaneous onset. The total caesarean delivery rate was 9.3% (n = 1727). Overall, 4.5% (n = 819) of the women had a low childbirth experience VAS score. The women who underwent labor induction were less satisfied with their birth experience compared to women with spontaneous onset of labor [7.5% (n = 399) vs. 3.2% (n = 420); p < 0.001]. Poor childbirth experience was associated with primiparity [OR 2.0 (95% CI 1.6–2.4)], labor induction [OR 1.6 (95% CI 1.4–1.9)], caesarean delivery [OR 4.5 (95% CI 3.7–5.5)], operative vaginal delivery [OR 3.3 (95% CI 2.7-4.0)], post-partum hemorrhage [OR 1.3 (95% CI 1.1–1.6)], and maternal infections [OR 1.7 (95% CI 1.3–2.4)]. Poor childbirth experience was associated with labor induction, primiparity, operative delivery, and labor complications, such as post-partum hemorrhage and maternal infections. These results highlight the aspects of care for which patient experience may be improved by additional support and counselling.

Reduced pregnancy and live birth rates after in vitro fertilization in women with previous Caesarean section: a retrospective cohort study.

Abstract: Study question Does a previous Caesarean section affect reproductive outcomes, including live birth, in women after IVF or ICSI? Summary answer A previous Caesarean section impairs live birth rates after IVF or ICSI compared to a previous vaginal delivery. What is known already Rates of Caesarean sections are rising worldwide. Late sequelae of a Caesarean section related to a niche (Caesarean scar defect) include gynaecological symptoms and obstetric complications. A systematic review reported a lower pregnancy rate after a previous Caesarean section (RR 0.91 CI 0.87-0.95) compared to a previous vaginal delivery. So far, studies have been unable to causally differentiate between problems with fertilisation, and the transportation or implantation of an embryo. Studying an IVF population allows us to identify the effect of a previous Caesarean section on the implantation of embryos in relation to a previous vaginal delivery. Study design, size, duration We retrospectively studied the live birth rate in women who had an IVF or ICSI treatment at the IVF Centre, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands, between 2006 and 2016 with one previous delivery. In total, 1317 women were included, of whom 334 had a previous caesarean section and 983 had previously delivered vaginally. Participants/materials, setting, methods All secondary infertile women, with only one previous delivery either by caesarean section or vaginal delivery, were included. If applicable, only the first fresh embryo transfer was included in the analyses. Patients who did not intend to undergo embryo transfer were excluded. The primary outcome was live birth. Multivariate logistic regression analyses were used with adjustment for possible confounders ((i) age; (ii) pre-pregnancy BMI; (iii) pre-pregnancy smoking; (iv) previous fertility treatment; (v) indication for current fertility treatment: (a) tubal, (b) male factor and (c) endometriosis; (vi) embryo quality; and (vii) endometrial thickness), if applicable. Analysis was by intention to treat (ITT). Main results and the role of chance Baseline characteristics of both groups were comparable. Live birth rates were significantly lower in women with a previous caesarean section than in women with a previous vaginal delivery, 15.9% (51/320) versus 23.3% (219/941) (OR 0.63 95% CI 0.45-0.87) in the ITT analyses. The rates were also lower for ongoing pregnancy (20.1 versus 28.1% (OR 0.64 95% CI 0.48-0.87)), clinical pregnancy (25.7 versus 33.8% (OR 0.68 95% CI 0.52-0.90)) and biochemical test (36.2 versus 45.5% (OR 0.68 95% CI 0.53-0.88)). The per protocol analyses showed the same differences (live birth rate OR 0.66 95% CI 0.47-0.93 and clinical pregnancy rate OR 0.72 95% CI 0.54-0.96). Limitations, reasons for caution This study is limited by its retrospective design. Furthermore, 56 (16.3%) cases lacked data regarding delivery outcomes, but these were equally distributed between the two groups. Wider implications of the findings The lower clinical pregnancy rates per embryo transfer indicate that implantation is hampered after a caesarean section. Its relation with a possible niche (caesarean scar defect) in the uterine caesarean scar needs further study. Our results should be discussed with clinicians and patients who consider an elective caesarean section. Study funding/competing interest(s) Not applicable. Trial registration number This study has been registered in the Dutch Trial Register (Ref. No. NL7631 http://www.trialregister.nl).

Prophylactic use of tranexamic acid after vaginal delivery reduces the risk of primary postpartum hemorrhage.

Abstract: Background: Postpartum hemorrhage (PPH) is responsible for about 25% of maternal deaths worldwide. Antifibrinolytic agents, mainly tranexamic acid, have been demonstrated to reduce maternal blood l...

Operative vaginal delivery: a review of four national guidelines.

Abstract: There is a broad range in the rates of operative vaginal deliveries (OVD) worldwide, which reflects the variety of local practice patterns, the number of trained clinicians and the lack of international evidence-based guidelines. The aim of this study was to review and compare the recommendations from published guidelines on OVD. Thus, a descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the American College of Obstetricians and Gynecologists (ACOG) on instrumental vaginal birth was conducted. All the guidelines point out that the use of any instrument should be based on the clinical circumstances and the experience of the operator. The indications, the contraindications, the prerequisites and the classification for OVD are overall very similar in the reviewed guidelines. Further, they all agree that episiotomy should not be performed routinely. The RCOG, the RANZCOG and the SOGC describe some interventions which may promote spontaneous vaginal birth and therefore reduce the need for OVD. They also highlight the importance of adequate postnatal care and counseling. There is no consensus on the actual technique that should be used, including the type of forceps or vacuum cup, the force and duration of traction or the number of detachments allowed. Hence, there is need for international practice protocols, so as to encourage the clinicians to use OVD when indicated, minimize the complications and reduce rates of cesarean delivery.

Stroke in Pregnancy: A Focused Update.

Abstract: Ischemic stroke (IS) and hemorrhagic stroke (HS) can be devastating complications during pregnancy and the puerperium that are thought to occur in approximately 30 in 100,000 pregnancies. In high-risk groups, such as women with preeclampsia, the incidence of both stroke subtypes, combined, is up to 6-fold higher than in pregnant women without these disorders. IS or HS may present in young women with atypical symptoms including headache, seizure, extremity weakness, dizziness, nausea, behavioral changes, and visual symptoms. Obstetric anesthesiologists who recognize these signs and symptoms of pregnancy-related stroke are well positioned to facilitate timely care. Acute stroke of any type is an emergency that should prompt immediate coordination of care between obstetric anesthesiologists, stroke neurologists, high-risk obstetricians, nurses, and neonatologists. Historically, guidelines have not addressed the unique situation of maternal stroke, and pregnant women have been excluded from the large stroke trials. More recently, several publications and professional societies have highlighted that pregnant women suspected of having IS or HS should be evaluated for the same therapies as nonpregnant women. Vaginal delivery is generally preferred unless there are obstetric indications for cesarean delivery. Neuraxial analgesia and anesthesia are frequently safer than general anesthesia for cesarean delivery in the patient with a recent stroke. Potential exceptions include therapeutic anticoagulation or intracranial hypertension with risk of herniation. General anesthesia may be appropriate when cesarean delivery will be combined with intracranial neurosurgery.

Predictor variables in the success of slow-release dinoprostone used for cervical ripening in intrauterine growth restriction pregnancies.

Abstract: Objective This study aims to evaluate the consequences of a trigger by vaginal Dinoprotone on outcome of pregnancies with Intrauterine growth restriction (IUGR). Materials and methods This retrospective study included 161 induced IUGR fetuses (35–39 weeks). Consecutive patients who were evaluated formed the basis of the clinical outcomes. The penalized maximum likelihood estimation (PMLE) method was used instead of traditional logistic regression in order to reduce the risk of overfitting. Results Of the 25,678 deliveries that occurred during the study period, 161 (0.6%) women underwent IUGR delivery; of these, 117 (73%) succeeded and 44 (27%) failed to achieve cervical ripening using the dinoprostone slow-release vaginal insert. Two predictors were associated with dinoprostone vaginal delivery success: Parity (OR:1.4([0.89–2.3]), and Bishop score (OR:1.54[1.23–1.94]). The PMLE model correctly classified 78% participants (c-index: 0.78). Conclusion Basic parameters such as parity and Bishop score can be used to predict successful vaginal birth following dinoprostone slow-release vaginal insert administration.