Vaginal Delivery

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William A Grobman - One of the best experts on this subject based on the ideXlab platform.

  • attempted operative Vaginal Delivery vs repeat cesarean in the second stage among women undergoing a trial of labor after cesarean Delivery
    American Journal of Obstetrics and Gynecology, 2017
    Co-Authors: Moeun Son, Archana Roy, William A Grobman
    Abstract:

    Background It is not well-characterized whether attempting operative Vaginal Delivery is a safe and effective alternative among women who undergo a trial of labor after cesarean Delivery who are unable to complete second-stage labor with a spontaneous Vaginal Delivery. Objective The purpose of this study was to compare maternal and neonatal outcomes that are associated with attempted operative Vaginal Delivery with those that are associated with second-stage repeat cesarean Delivery without an operative Vaginal Delivery attempt among women who undergo a trial of labor after cesarean Delivery. Study Design This is a retrospective secondary analysis of data from Cesarean Registry of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Women who underwent a trial of labor after cesarean Delivery who were at least 36 weeks gestation were eligible for analysis if they had a live, singleton, nonanomalous gestation in cephalic presentation and reached second-stage labor (defined as complete cervical dilation) with a fetal station of at least +2. The data for women who had an attempted operative Vaginal Delivery with either forceps or vacuum were compared with those of women who underwent second stage repeat cesarean Delivery without operative Vaginal Delivery attempt. Outcomes of maternal and neonatal complications were compared between groups with bivariable and multivariable analyses. Results Of 1230 women whose cases were eligible for analysis, 945 women (76.8%) had an attempted operative Vaginal Delivery. Of those who underwent attempted operative Vaginal Delivery, 914 women (96.7%) achieved a Vaginal Delivery. Women who attempted operative Vaginal Delivery had a lower mean body mass index (30.4±6.0 vs 31.8±5.9 kg/m 2 ; P =.001) and gestational age (39.5±1.3 vs 39.8±1.2 weeks; P =.012) at Delivery and were more likely to be of non-Hispanic black race (30.0% vs 22.1%; P =.002), to have had a previous Vaginal Delivery (34.9% vs 20.4%; P P P P Conclusion In the setting of a trial of labor after cesarean Delivery in the second stage with a fetal station of at least +2, attempted operative Vaginal Delivery resulted in a Vaginal birth after cesarean Delivery in most women and was not associated with increased adverse maternal and neonatal outcomes but was associated with a reduced frequency of endometritis compared with repeat cesarean Delivery without operative Vaginal Delivery attempt.

  • predictors of shoulder dystocia at the time of operative Vaginal Delivery
    American Journal of Obstetrics and Gynecology, 2016
    Co-Authors: Anna Palatnik, Madeline G Hellendag, Timothy M Janetos, Daniel R Gossett, William A Grobman, Emily S. Miller
    Abstract:

    Background It remains uncertain whether clinical factors known prior to Delivery can predict which women are more likely to experience shoulder dystocia in the setting of operative Vaginal Delivery. Objective We sought to identify whether shoulder dystocia can be accurately predicted among women undergoing an operative Vaginal Delivery. Study Design This was a case-control study of women undergoing a low or outlet operative Vaginal Delivery from 2005 through 2014 in a single tertiary care center. Cases were defined as women who experienced a shoulder dystocia at the time of operative Vaginal Delivery. Controls consisted of women without a shoulder dystocia at the time of operative Vaginal Delivery. Variables previously identified to be associated with shoulder dystocia that could be known prior to Delivery were abstracted from the medical records. Bivariable analyses and multivariable logistic regression were used to identify factors independently associated with shoulder dystocia. A receiver operating characteristic curve was created to evaluate the predictive value of the model for shoulder dystocia. Results Of the 4080 women who met inclusion criteria, shoulder dystocia occurred in 162 (4.0%) women. In bivariable analysis, maternal age, parity, body mass index, diabetes, chorioamnionitis, arrest disorder as an indication for an operative Vaginal Delivery, vacuum use, and estimated fetal weight >4 kg were significantly associated with shoulder dystocia. In multivariable analysis, parity, diabetes, chorioamnionitis, arrest disorder as an indication for operative Vaginal Delivery, vacuum use, and estimated fetal weight >4 kg remained independently associated with shoulder dystocia. The area under the curve for the generated receiver operating characteristic curve was 0.73 (95% confidence interval, 0.69–0.77), demonstrating only a modest ability to predict shoulder dystocia before performing an operative Vaginal Delivery. Conclusion While risk factors for shoulder dystocia at the time of operative Vaginal Delivery can be identified, reliable prediction of shoulder dystocia in this setting cannot be attained.

  • predictors of failed operative Vaginal Delivery in a contemporary obstetric cohort
    Obstetrics & Gynecology, 2016
    Co-Authors: Anna Palatnik, Madeline G Hellendag, Timothy M Janetos, Daniel R Gossett, William A Grobman, Emily S. Miller
    Abstract:

    Objective To identify factors associated with failed operative Vaginal Delivery in contemporary parturients and evaluate whether these factors can be used to accurately predict failed operative Vaginal Delivery. Methods This was a case-control study of women undergoing a trial of operative Vaginal Delivery from a low or outlet station between 2005 and 2014. Women in the case group were defined as women who had an attempted operative Vaginal Delivery but ultimately required cesarean Delivery. Women in the control group were defined as women who delivered Vaginally. Bivariable and multivariable analyses were performed to determine factors that were independently associated with failed operative Vaginal Delivery. A receiver operating characteristic curve was created and area under the curve calculated to estimate the predictive capacity of these associations. Results Of 4,352 women who met inclusion criteria, 2,527 underwent an attempt at operative Vaginal Delivery using forceps and 1,825 using vacuum. Failure occurred in 272 (6.3%). In bivariable analysis, nulliparity, white race, induction of labor, chorioamnionitis, second stage 2 hours or greater, fetal occiput-posterior position, low station at application (compared with outlet), larger estimated fetal weight, and arrest or exhaustion as an indication for operative Vaginal Delivery (compared with a fetal indication) were significantly associated with a failed operative Vaginal Delivery. In multivariable analysis, factors that remained independently associated with operative Vaginal Delivery failure were race-ethnicity, arrest or exhaustion as an indication for operative Vaginal Delivery, occiput-posterior position, and a low pelvic application. The area under the curve for this regression was 0.74 (95% confidence interval 0.69-0.77) demonstrating less than optimal prediction of operative Vaginal Delivery failure. Conclusion Risk factors identified before an operative Vaginal Delivery attempt cannot be used to accurately predict whether an operative Vaginal Delivery attempt will fail.

T G Allenmersh - One of the best experts on this subject based on the ideXlab platform.

  • pelvic connective tissue resilience decreases with Vaginal Delivery menopause and uterine prolapse
    British Journal of Surgery, 2003
    Co-Authors: N Reay H J Jones, J C Healy, L J King, S Saini, S Shousha, T G Allenmersh
    Abstract:

    BACKGROUND: The late onset of pelvic visceral prolapse and incontinence after childbirth injury could be explained by menopause-associated connective tissue weakening. Uterosacral ligament resilience (UsR) was assessed to determine whether it influenced uterine or pelvic floor mobility, or varied with age, Vaginal Delivery, menopause or histological variations in the ligament. METHODS: UsR was measured by tensiometry in ligaments from 85 hysterectomy specimens, and was correlated with the presence of symptomatic uterocervical prolapse, prehysterectomy uterine and anorectal mobility, patient age, history of Vaginal Delivery and menopause. Forty-five of these ligaments were examined for ligament thickness, muscle to collagen ratio, and oestrogen and progesterone receptor density. The results were correlated with UsR. RESULTS: UsR was significantly reduced (P = 0.02) in symptomatic uteroVaginal prolapse, but there was no correlation with either uterocervical or anorectal descent in women without symptomatic prolapse. There was a significant decrease in UsR with Vaginal Delivery (P = 0.003), menopause (P = 0.009) and older age (P = 0.005). The uterosacral ligament was significantly thinner and contained fewer oestrogen and progesterone receptors after menopause, but this did not affect UsR. CONCLUSION: Where pelvic floor muscles are weakened, decreases in pelvic connective tissue resilience related to the menopause may facilitate progression to symptomatic pelvic visceral prolapse.

  • pelvic connective tissue resilience decreases with Vaginal Delivery menopause and uterine prolapse
    British Journal of Surgery, 2003
    Co-Authors: N Reay H J Jones, J C Healy, L J King, S Saini, S Shousha, T G Allenmersh
    Abstract:

    Background: The late onset of pelvic visceral prolapse and incontinence after childbirth injury could be explained by menopause-associated connective tissue weakening. Uterosacral ligament resilience (UsR) was assessed to determine whether it influenced uterine or pelvic floor mobility, or varied with age, Vaginal Delivery, menopause or histological variations in the ligament. Methods: UsR was measured by tensiometry in ligaments from 85 hysterectomy specimens, and was correlated with the presence of symptomatic uterocervical prolapse, prehysterectomy uterine and anorectal mobility, patient age, history of Vaginal Delivery and menopause. Forty-five of these ligaments were examined for ligament thickness, muscle to collagen ratio, and oestrogen and progesterone receptor density. The results were correlated with UsR. Results: UsR was significantly reduced (P = 0·02) in symptomatic uteroVaginal prolapse, but there was no correlation with either uterocervical or anorectal descent in women without symptomatic prolapse. There was a significant decrease in UsR with Vaginal Delivery (P = 0·003), menopause (P = 0·009) and older age (P = 0·005). The uterosacral ligament was significantly thinner and contained fewer oestrogen and progesterone receptors after menopause, but this did not affect UsR. Conclusion: Where pelvic floor muscles are weakened, decreases in pelvic connective tissue resilience related to the menopause may facilitate progression to symptomatic pelvic visceral prolapse. Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Per Olofsson - One of the best experts on this subject based on the ideXlab platform.

  • prospect for Vaginal Delivery of growth restricted fetuses with abnormal umbilical artery blood flow
    Obstetrical & Gynecological Survey, 2004
    Co-Authors: Saemundur Gudmundsson, Per Olofsson
    Abstract:

    Prompt operative Delivery is commonly carried out when intrauterine growth restriction (IUGR) is suspected or there is absent or reversed end-diastolic blood flow velocity in the umbilical artery (UA). When resistance to UA blood flow is only slightly or moderately increased, however, there is no general agreement on when or how to deliver the fetus. The goal in this setting is to avoid exposing the fetus to hypoxia and distress when possible. A trial of Vaginal Delivery would be permissible only if there is a minimal risk of distress in labor. This prospective study evaluated planned Vaginal Delivery in 84 women with singleton term pregnancies if IUGR was suspected. UA Doppler velocimetry was carried out, as well as an oxytocin challenge test (OCT). The test was done at or after 36 weeks gestational age and, if it was negative, a trial of Vaginal Delivery was planned. UA Doppler velocimetry yielded normal findings in 51 cases but abnormal results in 33. In the latter cases, the pulsatility index was increased and forward-diastolic blood flow was maintained. These groups were similar in maternal age, parity, and the delay between the OCT and Delivery. Mean gestational age at Delivery was significant in the abnormal UA blood flow group. In addition, the OCT was positive more often (33% vs. 16%) in this group, and Vaginal Delivery was less frequent (40% vs. 63%). After labor had begun, 68% of women with abnormal UA blood flow and 76% of those with normal flow delivered Vaginally. The Vaginal Delivery rate and transfer to the neonatal intensive-care unit did not differ appreciably in the 2 blood flow groups. Three infants with severely restricted growth had malformations, and 1 died as a result. One infant had meconium aspiration and pneumothorax but eventually was discharged home. Vaginal deliveries were significantly less frequent in the presence of abnormal UA Doppler velocimetry in this study, but when a trial of labor was ultimately done, the rates were similar in women with normal and those with abnormal blood flow patterns. There was no indication that any fetus was exposed to harmful hypoxia or distress. The OCT continues to be useful in some cases for assessing the status of growth-restricted fetuses and those with mild to moderate changes in UA blood flow.

  • prospect for Vaginal Delivery of growth restricted fetuses with abnormal umbilical artery blood flow
    Acta Obstetricia et Gynecologica Scandinavica, 2003
    Co-Authors: Saemundur Gudmundsson, Per Olofsson
    Abstract:

    Background. The best mode of Delivery in cases of intrauterine growth restriction (IUGR) with umbilical artery blood flow changes is not well elucidated. Objective. To evaluate outcome in IUGR with umbilical artery blood flow changes planned for Vaginal Delivery after a negative oxytocin challenge test (OCT). Methods. In 84 term singleton pregnancies with suspected IUGR and no unanimous indication for abdominal Delivery, Doppler velocimetry and OCT were performed. Positive OCT cases were delivered by cesarean section, negative OCT cases planned for Vaginal Delivery. Results. Umbilical artery Doppler velocimetry was normal in 51 cases (normal group) and abnormal in 33 cases (increased pulsatility index with maintained forward diastolic flow). Gestational age at Delivery was shorter ( p = 0.008), positive OCT more common (33% vs. 16%; p = 0.06), and Vaginal Delivery less common (40% vs. 63%; p = 0.04) in the abnormal blood flow group compared with the normal flow group. When in labor, 68% in the abnormal fl...

Emily S. Miller - One of the best experts on this subject based on the ideXlab platform.

  • predictors of shoulder dystocia at the time of operative Vaginal Delivery
    American Journal of Obstetrics and Gynecology, 2016
    Co-Authors: Anna Palatnik, Madeline G Hellendag, Timothy M Janetos, Daniel R Gossett, William A Grobman, Emily S. Miller
    Abstract:

    Background It remains uncertain whether clinical factors known prior to Delivery can predict which women are more likely to experience shoulder dystocia in the setting of operative Vaginal Delivery. Objective We sought to identify whether shoulder dystocia can be accurately predicted among women undergoing an operative Vaginal Delivery. Study Design This was a case-control study of women undergoing a low or outlet operative Vaginal Delivery from 2005 through 2014 in a single tertiary care center. Cases were defined as women who experienced a shoulder dystocia at the time of operative Vaginal Delivery. Controls consisted of women without a shoulder dystocia at the time of operative Vaginal Delivery. Variables previously identified to be associated with shoulder dystocia that could be known prior to Delivery were abstracted from the medical records. Bivariable analyses and multivariable logistic regression were used to identify factors independently associated with shoulder dystocia. A receiver operating characteristic curve was created to evaluate the predictive value of the model for shoulder dystocia. Results Of the 4080 women who met inclusion criteria, shoulder dystocia occurred in 162 (4.0%) women. In bivariable analysis, maternal age, parity, body mass index, diabetes, chorioamnionitis, arrest disorder as an indication for an operative Vaginal Delivery, vacuum use, and estimated fetal weight >4 kg were significantly associated with shoulder dystocia. In multivariable analysis, parity, diabetes, chorioamnionitis, arrest disorder as an indication for operative Vaginal Delivery, vacuum use, and estimated fetal weight >4 kg remained independently associated with shoulder dystocia. The area under the curve for the generated receiver operating characteristic curve was 0.73 (95% confidence interval, 0.69–0.77), demonstrating only a modest ability to predict shoulder dystocia before performing an operative Vaginal Delivery. Conclusion While risk factors for shoulder dystocia at the time of operative Vaginal Delivery can be identified, reliable prediction of shoulder dystocia in this setting cannot be attained.

  • predictors of failed operative Vaginal Delivery in a contemporary obstetric cohort
    Obstetrics & Gynecology, 2016
    Co-Authors: Anna Palatnik, Madeline G Hellendag, Timothy M Janetos, Daniel R Gossett, William A Grobman, Emily S. Miller
    Abstract:

    Objective To identify factors associated with failed operative Vaginal Delivery in contemporary parturients and evaluate whether these factors can be used to accurately predict failed operative Vaginal Delivery. Methods This was a case-control study of women undergoing a trial of operative Vaginal Delivery from a low or outlet station between 2005 and 2014. Women in the case group were defined as women who had an attempted operative Vaginal Delivery but ultimately required cesarean Delivery. Women in the control group were defined as women who delivered Vaginally. Bivariable and multivariable analyses were performed to determine factors that were independently associated with failed operative Vaginal Delivery. A receiver operating characteristic curve was created and area under the curve calculated to estimate the predictive capacity of these associations. Results Of 4,352 women who met inclusion criteria, 2,527 underwent an attempt at operative Vaginal Delivery using forceps and 1,825 using vacuum. Failure occurred in 272 (6.3%). In bivariable analysis, nulliparity, white race, induction of labor, chorioamnionitis, second stage 2 hours or greater, fetal occiput-posterior position, low station at application (compared with outlet), larger estimated fetal weight, and arrest or exhaustion as an indication for operative Vaginal Delivery (compared with a fetal indication) were significantly associated with a failed operative Vaginal Delivery. In multivariable analysis, factors that remained independently associated with operative Vaginal Delivery failure were race-ethnicity, arrest or exhaustion as an indication for operative Vaginal Delivery, occiput-posterior position, and a low pelvic application. The area under the curve for this regression was 0.74 (95% confidence interval 0.69-0.77) demonstrating less than optimal prediction of operative Vaginal Delivery failure. Conclusion Risk factors identified before an operative Vaginal Delivery attempt cannot be used to accurately predict whether an operative Vaginal Delivery attempt will fail.

K.s. Joseph - One of the best experts on this subject based on the ideXlab platform.

  • ecological association between operative Vaginal Delivery and obstetric and birth trauma
    Canadian Medical Association Journal, 2018
    Co-Authors: Giulia M Muraca, Amanda Skoll, Sarka Lisonkova, Yasser Sabr, Rollin Brant, Geoffrey W Cundiff, K.s. Joseph
    Abstract:

    BACKGROUND: Increased use of operative Vaginal Delivery (use of forceps, vacuum or other device) has been recommended to address high rates of cesarean Delivery. We sought to determine the association between rates of operative Vaginal Delivery and obstetric trauma and severe birth trauma. METHODS: We carried out an ecological analysis of term, singleton deliveries in 4 Canadian provinces (2004–2014) using data from the Canadian Institute for Health Information. The primary exposure was mode of Delivery. The primary outcomes were obstetric trauma and severe birth trauma. RESULTS: Data on 1 938 913 deliveries were analyzed. The rate of obstetric trauma was 7.2% in nulliparous women, and 2.2% and 2.7% among parous women without and with a previous cesarean Delivery, respectively, and rates of severe birth trauma were 2.1, 1.7 and 0.7 per 1000, respectively. Each 1% absolute increase in rates of operative Vaginal Delivery was associated with a higher frequency of obstetric trauma among nulliparous women (adjusted rate ratio [ARR] 1.06, 95% confidence interval [CI] 1.05–1.06), parous women without a previous cesarean Delivery (ARR 1.10, 95% CI 1.08–1.13) and parous women with a previous cesarean Delivery (ARR 1.11, 95% CI 1.07–1.16). Operative Vaginal Delivery was associated with more frequent severe birth trauma, but only in nulliparous women (ARR 1.05, 95% CI 1.03–1.07). In nulliparous women, sequential vacuum and forceps instrumentation was associated with the largest increase in obstetric trauma (ARR 1.44, 95% CI 1.35–1.55) and birth trauma (ARR 1.53, 95% CI 1.03–2.27). INTERPRETATION: Increases in population rates of operative Vaginal Delivery are associated with higher population rates of obstetric trauma, and in nulliparous women with severe birth trauma.

  • perinatal and maternal morbidity and mortality among term singletons following midcavity operative Vaginal Delivery versus caesarean Delivery
    British Journal of Obstetrics and Gynaecology, 2018
    Co-Authors: Giulia M Muraca, Amanda Skoll, Sarka Lisonkova, Yasser Sabr, Rollin Brant, Geoffrey W Cundiff, K.s. Joseph
    Abstract:

    Objective To quantify severe perinatal and maternal morbidity/mortality associated with midcavity operative Vaginal Delivery compared with caesarean Delivery. Design Population-based, retrospective cohort study. Setting British Columbia, Canada. Population Term, singleton deliveries (2004–2014) by attempted midcavity operative Vaginal Delivery or caesarean Delivery in the second stage of labour, stratified by indication for operative Delivery (n = 10 901 deliveries; 5057 indicated for dystocia, 5844 for fetal distress). Methods Multinomial propensity scores and mulitvariable log-binomial regression models were used to estimate adjusted rate ratios (ARR) and 95% confidence intervals (95% CI). Main outcome measures Composite severe perinatal morbidity/mortality (e.g. convulsions, severe birth trauma and perinatal death) and severe maternal morbidity (e.g. severe postpartum haemorrhage, shock, sepsis and cardiac complications). Results Among deliveries with dystocia, attempted midcavity operative Vaginal Delivery was associated with higher rates of severe perinatal morbidity/mortality compared with caesarean Delivery (forceps ARR 2.11, 95% CI 1.46–3.07; vacuum ARR 2.71, 95% CI 1.49–3.15; sequential ARR 4.68, 95% CI 3.33–6.58). Rates of severe maternal morbidity/mortality were also higher following midcavity operative Vaginal Delivery (forceps ARR 1.57, 95% CI 1.05–2.36; vacuum ARR 2.29, 95% CI 1.57–3.36). Among deliveries with fetal distress, there were significant increases in severe perinatal morbidity/mortality following attempted midcavity vacuum (ARR 1.28, 95% CI 1.04–1.61) and in severe maternal morbidity following attempted midcavity forceps Delivery (ARR 2.34, 95% CI 1.54–3.56). Conclusion Attempted midcavity operative Vaginal Delivery is associated with higher rates of severe perinatal morbidity/mortality and severe maternal morbidity, though these effects differ by indication and instrument. Tweetable abstract Perinatal and maternal morbidity is increased following midcavity operative Vaginal Delivery.

  • perinatal and maternal morbidity and mortality after attempted operative Vaginal Delivery at midpelvic station
    Canadian Medical Association Journal, 2017
    Co-Authors: Giulia M Muraca, Amanda Skoll, Sarka Lisonkova, Yasser Sabr, Rollin Brant, Geoffrey W Cundiff, K.s. Joseph
    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.