Analysis of Medical and Social Causes of Obstructed Labour

Background: Obstructed labour is one of the major causes of maternal mortality (8%) in Bangladesh. It is also responsible for high rate of maternal and fetal morbidity. If we can identify the medical and social causes of obstructed labour in our country it may be helpful to find out the way to prevent this disease. Objectives: This study was to find out the medical and social causes of obstructed labour in our country. It also finds out the cause of delay in seeking care.Material & Methods:This study is a prospective observational study has been done in Dhaka Medical College Hospital, Dhaka from August 2004 to December 2005. One hundred patients who were admitted with obstructed labour during study period were included in this study.Results:In this study prevalence of obstructed labour was 3.59%. Among the patients who were admitted with obstructed labour 52% were within 20 to 25 years of age, 55% were primigravida, only 30% were on regular antenatal checkup. The medical causes of obstructed labour were cephalopelvic disproportion in 30%, malposition and malpresntation in 69% and cervical fibroid in 1 %. In this study 72% of study population had monthly income below 3,000 BTD, 27% had 3,001 � 5,000 BDT and only 1 % had above 5,000 BDT. Among them 8% patient had crossed the primary level of education and 35% were illiterate. The patients who were admitted with obstructed labour could not utilize the health facility in time and they had to go for trial of home delivery first. In 25% cases their husband and family members did not agree to bring them to hospital, 31.3% was because of ignorance, 14% was due to economic constraints, 13.3% wanted to avoid operative delivery, 9.4 % patient herself did not agree to come to hospital because it would disrupt house hold work and the rest 7% could not come due to long distance between home and health center and tertiary hospital. Modes of delivery were LSCS in 85%, craniotomy in 9% and evisceration in 4%. Maternal outcome was WF in 7% and puerperial sepsis in 18%. Perinatal death was 45%, MMR was 3% due to obstructed labour.Conclusions:SThe causes of obstructed labour are not only due to medical causes but also have social causes. The social causes depend on the socio-economic status and the level of education

Outcome of pregnancy in previous caesarean section: an observational study

Background: Presently, good obstetrics means an uncomplicated antenatal period, labour and puerperium for the mother and birth of a healthy body. Post caesarean section pregnancy has now become one of the most common high-risk cases tackled at any hospital. In this paper an attempt has been made to assess the outcomes of pregnancy in previous caesarean section.Methods: This study was conducted among patients in the department of gynecology and obstetrics at Al-Ameen Hospital from June 2016 to December 2018. For that purpose, a sample size of 100 was considered. Data were analyzed using SPSS software v. 23.0. and Microsoft office 2007.Results: The incidence of caesarean section was 10.25%. Anaemia, pregnancy-induced hypertension and diabetes mellitus found in this study is more coincidental. Placenta previa cases were also present. Cephalopelvic disproportion was the commonest indication of the previous section in this study. 20% of the cases have had their previous section due to cephalopelvic disproportion. 18% of the cases had delivered vaginally, 15 cases were delivered by forceps (72.2%) and 3 cases were delivered normally (27.8%). Maternal morbidity was found to be low and there was no maternal death.Conclusions: The patient whose primary section was done due to cephalopelvic disproportion should be assessed thoroughly in her current pregnancy before placing her to elective repeat section. As there is always the possibility of scar rupture in a case of post caesarean section pregnancy one must think twice before doing the primary section. More research is required to evaluate optimum time of management.

Pubic arch angle measurement by transperineal ultrasonography: a prospective cross-sectional study / Medida do ângulo do arco púbico por ultrassonografia transperineal: um estudo prospectivo transversal

Abstract Objective To evaluate the ability of the pubic arch angle (PAA) as measured by transperineal ultrasonography during labor to predict the delivery type and cephalic pole disengagement mode. Methods The present prospective cross-sectional study included 221 women in singleton-gestational labor ≥ 37 weeks with cephalic fetuses who underwent PAA measurement using transperineal ultrasonography. These measurements were correlated with the delivery type, cephalic pole disengagement mode, and fetal and maternal characteristics. Results Out of the subjects, 153 (69.2%) had spontaneous vaginal delivery, 7 (3.2%) gave birth by forceps, and 61 (27.6%) delivered by cesarean section. For the analysis, deliveries were divided into two groups: vaginal and surgical (forceps and cesarean). The mean PAA was 102 ± 7.5º (range, 79.3-117.7º). No statistically significant difference was observed in delivery type (102.6 ± 7.2º versus 100.8 ± 7.9º, p = 0.105). The occipitoanterior position was seen in 94.1% of the fetuses and the occipitoposterior position in 5.8%. A narrower PAA was found in the group of surgical deliveries (97.9 ± 9.6º versus 102.6 ± 7.3º, p = 0.049). Multivariate regression analysis showed that PAA was a predictive variable for the occurrence of head disengagement in occipital varieties after birth (odds ratio, 0.9; 95% confidence interval, 0.82-0.99; p = 0.026). Conclusion Ultrasonographic measurement of the PAA was not a predictor of delivery type, but was associated with the persistence of occipital varieties after birth.

Resumo Objetivo Avaliar a medida do ângulo do arco púbico (AAP) por ultrassonografia transperineal durante trabalho de parto em predizer tipo de parto e modo de desprendimento do polo cefálico. Métodos Um estudo prospectivo transversal foi conduzido com 221 mulheres em trabalho de parto com gestação única ≥ 37 semanas, com fetos em apresentação cefálica, foram submetidas à avaliação ultrassonográfica por via transperineal para aferição do AAP. Correlações com tipo de parto, modo de desprendimento do polo cefálico e características fetais e maternas foram realizadas. Resultados Um total de 153 (69,2%) mulheres apresentaram parto vaginal espontâneo, 7 (3,2%) parto a fórceps e 61 (27,6%) parto cesárea. Para fins de análise, dividiu-se os partos em dois grupos: partos vaginais e cirúrgicos (fórceps e cesáreas). A média do AAP foi 102 ± 7,5º (variação: 79,3-117,7º). Não foi observada significância estatística do AAP em relação ao tipo de parto (102,6 ± 7,2º versus 100,8 ± 7,9º; p = 0,105). Um total de 94,1% dos fetos desprenderam em variedade de posição occipito anterior e 5,8% em occipito posterior. Encontrou-se AAP mais estreitado no grupo de partos cirúrgicos (97,9 ± 9,6º versus 102,6 ± 7,3º; p = 0,049). A análise de regressão multivariada demonstrou que AAP foi uma variável de proteção para a ocorrência de desprendimento da cabeça em variedades occipito posteriores ao nascimento (odds ratio [OR]= 0,9; índice de confiança (IC) 95%: 0,82-0,99; p = 0,026). Conclusão A medida ultrassonográfica do AAP não foi preditora do tipo de parto, porém demonstrou associação com persistência de variedades occipito posteriores ao nascimento.

Foeto-Maternal Outcome of Obstructed Labour in a Tertiary Care Hospital of Kolkata

Obstructed labour is the situation where in spite of adequate uterine contraction the progressive decent of presenting part is arrested due to mechanical obstruction. Obstructed labour contributes to around eight percent of maternal deaths in India. It is also one of the leading causes of perinatal morbidity and mortality in developing countries. We wanted to study the risk factors and fetomaternal outcome in obstructed labour at Chittaranjan Seva Sadan College of Obstetrics, Gynaecology and Child Health. This will help us to assess obstetric near miss cases and to develop strategies to decrease the complications arising from obstructed labour.METHODSThis was a three year retrospective observational study conducted by reviewing the records of obstructed labour during the period April 2014 - March 2017. The study was approved by Institutional Ethics Committee. All the mothers who were admitted in the labour room with signs and symptoms of obstructed labour were included in this study. All the relevant information such as age, parity, socioeconomic status, risk factors, complications, mode of delivery, and fetomaternal outcome were collected.RESULTSThere were 219 cases of obstructed labour among a total of 23,815 deliveries. Most common cause for obstructed labour was cephalopelvic disproportion (77%) followed by malposition/malpresentation (17.3%). Majority of the patients (69.2%) belonged to poor socioeconomic group. Sepsis (10.6%) and pyrexia (9.6%) were the common complications. Neonatal mortality was 30.8% and maternal morbidity was 5.8%.CONCLUSIONSLack of health education, antenatal care, low socioeconomic condition, poor referral system and demographic factors are important contributory factors leading to adverse outcome of obstructed labour. This can be sorted out by proper antenatal care, improving health care delivery system and by timely referral of cases according to partograph monitoring.

Outcomes of induction in trial of labor after cesarean delivery

Background: The objective of this study is to evaluate the outcomes of induction of labor in women attempting trial of labor after cesarean delivery and to compare maternal and neonatal morbidity and mortality in women who were induced to those delivering spontaneously.Methods: The prospective study was carried out in the Department of Obstetrics and Gynecology in collaboration with the Neonatal Section, Department of Pediatrics at J.N. Medical College and Hospital, AMU Aligarh. The sample included 280 women with one previous cesarean section, of whom 130 women underwent induction of labor (study group) and 150 were admitted with spontaneous onset of labor. Prostaglandin gel and intracervical Foley’s were used for cervical ripening in the study group. Indication of cesarean section, mode of delivery, maternal and neonatal outcome were studied in between groups.Results: Overall rate of vaginal delivery after cesarean section was 45.3% and 56% in both study and control group respectively. The rate of cesarean section were higher in women who were induced and having unfavorable cervix. Maternal and neonatal morbidity were not significantly higher as compared in both groups, however one case of scar rupture was found in study group.Conclusions: Induction of labor in women with previous cesarean section had higher rates of cesarean section however it does not adversely affect neonatal and maternal morbidity. Overall vaginal birth is safe and effective in women with previous cesarean section by prostaglandin gel or intracervical Foley’s. Authors cautiously suggest, induction of labor should be considered in preselected patient with strict monitoring.

Análisis de la cesárea según la clasificación de Robson en un hospital público de Perú / Analysis of cesarean sections according to Robson´s classification in a public hospital in Peru

OBJETIVO: Analizar la cesárea según la clasificación de Robson en un hospital público peruano. MATERIALES Y MÉTODOS: Estudio transversal, analítico, de partos atendidos en el Hospital Hipólito Unanue de Tacna, clasificados según Robson. En dos periodos (2000-2009 y 2010-2018) se compararon las tasas de cesárea, su contribución absoluta y relativa, indicación y riesgos maternos y perinatales. Para el análisis estadístico se utilizó c2 y se consideró significación estadística al valor de p < 0.05 y razón de momios, con IC95%, con riesgo significativo cuando el IC fue mayor de 1 y p < 0.05. Los datos se obtuvieron del Sistema Informático Perinatal y se procesaron en el programa SPSS v26. RESULTADOS: De 64,375 partos analizados, la tasa global de cesárea fue de 38.6%, con incremento de 23.9% en 2000 a 55.8% en 2018, con predominio de los grupos 1, 3 y 5, que son los de mayor contribución absoluta y relativa. Las principales indicaciones de la cesárea fueron: desproporción céfalo-pélvica (grupos 1 a 4), sufrimiento fetal, cesárea anterior y preeclampsia. Los grupos 1 (OR = 2.63; IC95%: 1.28-5.39; p < 0.05) y 3 (OR = 3.06; IC95%: 1.62-5.79; p < 0.05) tuvieron significativamente mayor riesgo de muerte neonatal en comparación con los de parto. CONCLUSIONES: La tasa de cesárea se incrementó en los últimos 19 años, principalmente en los grupos 1, 3 y 5 según la clasificación de Robson. Los grupos 1 y 3 tuvieron mayor riesgo de mortalidad neonatal que el de los nacidos por parto. (AU)

OBJECTIVE: Analyze cesarean sections according to Robson's classification in peruvian public hospital. MATERIALS AND METHODS: Analytical cross-sectional study in 64375 deliveries attended at the Hipolito Unanue hospital in Tacna according to Robson´s classification. Cesarean rates, absolute and relative contribution, cesarean sections´ indications and maternal perinatal risks were compared in two periods (2000-2009, 2010-2018). Chi2 was used with statistical significance when p <0.05 and Odds Ratio (OR) with 95% Confidence Interval (95% CI) with significant risk when IC> 1 and p <0.05. The data was obtained from the Perinatal Informatic System and processed in SPSS version 25. RESULTS: The overall cesarean section rate was 38.6% with an increase of 23.9% in 2000 to 55.8% in 2018; a predominance of groups 1, 3 and 5 who had greater absolute and relative contribution. The main indications were cephalopelvic disproportion, fetal distress, previous caesarean section and preeclampsia. There was a significantly higher risk of neonatal death in groups 1 (OR = 2.6, 95% IC: 1.28-5.39, p <0.05) and 3 (OR = 3.1, 95% IC: 1.62-5, 79; p <0.05) compared with vaginal deliveries. CONCLUSIONS: The cesarean rate increased in the last 19 years, mainly in groups 1, 3 and 5 according to Robson's classification; Group 1 and 3 presented a greater risk of neonatal mortality compared with vaginal deliveries.

Measurement of retropubic tissue thickness using intrapartum transperineal ultrasound to assess cephalopelvic disproportion

PURPOSE: First, to describe a new method of assessing cephalopelvic disproportion by measuring the retropubic tissue thickness (RTT), and second, to determine whether RTT was associated with an eventual delivery by cesarean section. METHODS: Three-dimensional transperineal ultrasound scans were performed on 129 laboring nulliparous women to obtain 3-dimensional volume datasets for assessing RTT. RTT was measured off-line by three operators (A, B, and C) as the shortest distance between the capsule of the pubic symphysis and the outer border of the fetal skull. The intraoperator repeatability of operator A and the interoperator reproducibility among A, B, and C were determined. The RTT in women who were delivered by cesarean section due to failure to progress was compared to that of women who had a vaginal delivery. RESULTS: The intraoperator repeatability for RTT was 1.2 mm. The overall RTT interoperator interclass correlation was 0.97 (0.95-0.98). The RTT in women who had a spontaneous, instrumental, or cesarean delivery was 1.16±0.32 cm, 1.12±0.25 cm, and 0.94±0.25 cm, respectively. Women who were delivered by cesarean section had a significantly smaller RTT than women who had a spontaneous delivery (P=0.008). There was no statistically significant difference in RTT between patients who had a normal vaginal delivery and patients who had an instrumental delivery (P=0.990), or between those who had an instrumental delivery and those who had a cesarean delivery after the Bonferroni correction (P=0.120). CONCLUSION: RTT can be measured with satisfactory intraoperator repeatability and interoperator reproducibility. RTT was significantly smaller in women who eventually had a cesarean delivery than in those who had a vaginal delivery.

Amenazas a la seguridad de la paciente por la conducción del parto con oxitocina. Experiencia en un hospital público de Lima, Perú / Threats to the safety of the patient due to the delivery management with oxytocin. Experience in a public hospital in Lima, Peru

Resumen OBJETIVO Identificar las amenazas a la seguridad de la paciente en la práctica de la conducción del trabajo de parto con oxitocina y las repercusiones maternas y perinatales en un hospital público de tercer nivel de Lima, Perú. MATERIALES Y MÉTODOS Estudio cuantitativo, descriptivo, retrospectivo y transversal efectuado en pacientes embarazadas atendidas en un hospital público, de tercer nivel, de Lima, Perú, a quienes se indicó conducción del parto con oxitocina. Los datos se tabularon en Excel y SPSS v21. El análisis univariado incluyó frecuencia y porcentaje para las variables cualitativas; se emplearon medidas de tendencia central, dispersión y desviación estándar para variables cuantitativas. RESULTADOS Se revisaron 112 historias clínicas de pacientes sin alteraciones en el trabajo de parto a quienes se indicó conducción con oxitocina (29.5%; n = 33). La principal vía de término fue el parto vaginal (73.2%; n = 82) y del grupo con cesárea el motivo más común fue la desproporción céfalo pélvica (56.7%; n = 17). Se observaron complicaciones obstétricas en 25% (n = 28), de este grupo la principal fue la hemorragia posparto (46.4%; n = 13). El peso de los recién nacidos fue 3401 ± 394 gramos, 93.7 y 96.4% obtuvieron un Apgar entre 10 a 7 al primero y quinto minutos, respectivamente. CONCLUSIONES Las amenazas identificadas a la seguridad de la paciente fueron: conducción del parto con oxitocina en quienes no tenían alteraciones en el trabajo de parto y en quienes tuvieron desproporción céfalo-pélvica, a pesar de que es una contraindicación para el procedimiento.

Abstract OBJECTIVE Identify the threats to the safety of the patient in the practice of conducting labor with oxytocin and maternal and perinatal outcomes in a public tertiary hospital in Lima, during 2016. MATERIALS AND METHODS Quantitative, descriptive, retrospective and cross-sectional. A total 112 pregnants' medical histories were review who underwent augmentation of labour with oxytocin. Inclusion criteria's: term gestation, hospitalization with a 4 cm dilatation, fetuses in cephalic presentation. Exclusion criteria's: patients with previous or intercurrent pathologies to pregnancy. RESULT The augmentation with oxytocin made in pregnant women without alterations in labor (29.5%; n = 33). The main type childbirth was vaginal delivery (73.2%; n = 82) and of the group that underwent cesarean section, the most usual reason was cephalopelvic disproportion (56.7%; n = 17). Obstetric complications were observed (25%; n = 28), of this group the main was postpartum hemorrhage (46.4%; n = 13). The weight of the newborns oscillated between 3401 ± 394 g, 93.7% and 96.4% obtained an Apgar 10 to 7 at the 1st and 5th minute respectively. CONCLUSIONS The threats to the safety of the patient identified were the practice of augmentation of labor with oxytocin in pregnant women without alterations in labor and in pregnant women with cephalopelvic disproportion, although it is a contraindication to the procedure.

Pelvimetry by reformatted computed tomography in 290 female pelvis: morphometric variations regarding age / Pelvimetría mediante tomografía computadorizada reformada sobre 290 pelvis femeninas: variaciones morfométricas de acuerdo a la edad

The Mexican government passed a new reform of article 11 of the General Law in 2014 regarding Women's Access to a Life Free of Violence, which states that a cesarean section may not be performed if a vaginal birth is viable. Cesarean sections are excessively indicated in Northen Mexico, using the diagnosis of cephalopelvic disproportion due to a narrow pelvis. Currently, there is no standardized morphometry of the female pelvis in a Mexican population to establish adequate diagnostic parameter. Our study measures the pelvic diameters of the birth canal using abdominopelvic computed tomography (CT). Two hundred and ninety CT from Mexican women between the ages of 18 and 50 were collected and 3D reformatted in order to morphologically measure the pelvic diameters of clinical relevance. Measurements were conducted by two diagnostic imaging specialists. The mean and standard deviation of the measured diameters were: anatomical conjugate diameter (ACD) 11.65±0.99 cm, the obstetric conjugate diameter (OCD) 11.73±0.98 cm, diagonal conjugate diameter (DCD) 12.49±0.98 cm and Interspinous distance (ISD) 10.41±0.78 cm. Significant differences were found in all four mean diameters in between the 20­29 age groups versus the >40, as well as between the 30­39 groups versus the >40. Our study shows that as Mexican women get older, the mean pelvic diameters become narrower.

El Gobierno mexicano aprobó una nueva reforma del artículo 11 de la Ley General del 2014, relativa al acceso de las mujeres a una Vida Libre de Violencia, que establece que una cesárea no se puede realizar si un parto vaginal es viable. Los partos por cesárea son indicados excesivamente en el norte de Mexico, con el diagnóstico de desproporción céfalo-pélvica debido a una estrechez de la pelvis. Actualmente, no existe una morfometría estandarizada de la pelvis femenina en una población mexicana para establecer parámetros de diagnóstico adecuado. Nuestro estudio mide los diámetros pélvicos del canal de parto mediante tomografía compudotarizada (TC) abdomino-pélvica. Se usaron 290 TC de mujeres mexicanas entre 18 y 50 años, los que fueron reformateados en 3D para medir morfológicamente los diámetros pélvicos de relevancia clínica. Las mediciones fueron realizadas por dos especialistas en diagnóstico por imagen. La Media y DE de los diámetros medidos fueron: diámetro anatómico conjugado (DAC) 11,65±0,99 cm, diámetro obstétrico conjugado (DOC) 11,73±0,98 cm, diámetro diagonal conjugado (DDC) 12,49±0,98 cm y distancia interespinosa (DIE) 10,41±0,78 cm. Se encontraron diferencias significativas en las Medias de los cuatro diámetros entre los grupos de 20­29 años de edad frente a las >40 años, así como entre los grupos de 30­39 años frente a los >40 años. Nuestro estudio muestra que a medida que las mujeres mexicanas avanzan en edad, los diámetros pélvicos medios son más estrechos.