Pelvic floor muscle function after grade II tears-Surface electromyography test-retest and differences between nulliparous and primiparous.

BACKGROUND: Vaginal birth is a risk factor for weakening of the pelvic floor muscles (PFM) and development of pelvic floor dysfunction (PFD). Perineal tears may decrease PFM function. PFM tone can be assessed with surface EMG (sEMG), but reliability studies of sEMG in women with perineal tears are lacking. The aims of this study were to evaluate test-retest and intrarater reliability of sEMG and compare PFM activation between nulliparous and primiparous. METHODS: A sEMG test-retest was performed in 21 women (12 nulliparous and 9 primiparous with grade II tears) to assess intra-rater reliability during rest and maximal voluntary contraction (MVC) of the PFM. Intraclass Correlation Coefficient (ICC), standard error of measurement (SEM) and minimal detectable change (MDC) were tested. A comparison between nulliparous' and primiparous' PFM activation during rest and MVC was performed. RESULTS: sEMG demonstrated fair reliability in nulliparous (ICC: 0.239; SEM: 5.2; MDC: 14.5) and moderate reliability in primiparous (ICC: 0.409; SEM: 1.5; MDC: 4.2) during rest. For peak MVC very good intrarater reliability was found in nulliparous (ICC: 0.92; SEM: 8.0; MDC: 22.2) and in primiparous (ICC: 0.823; SEM: 8.0; MDC: 22.2). Statistically significant lower PFM activation was found in primiparous women with perineal tear grade II than in nulliparous at rest (mean difference 9.1 µV, 95% confidence interval [CI] 3.0-19.0, p = 0.001), and during MVCpeak (mean difference 50.0 µV, 95% CI 10.0-120.0 p = 0.021). CONCLUSIONS: sEMG is reliable when measuring PFM activation in primiparous women with perineal tears grade II. Women with perineal tears grade II have lower PFM activation both during rest and MVC.

Sonographic knowledge of occiput position to decrease failed operative vaginal delivery: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: This study aimed to assess the efficacy of sonographic assessment of fetal occiput position before operative vaginal delivery to decrease the number of failed operative vaginal deliveries. DATA SOURCES: The search was conducted in MEDLINE, Embase, Web of Science, Scopus, ClinicalTrial.gov, Ovid, and Cochrane Library as electronic databases from the inception of each database to April 2021. No restrictions for language or geographic location were applied. STUDY ELIGIBILITY CRITERIA: Selection criteria included randomized controlled trails of pregnant women randomized to either sonographic or clinical digital diagnosis of fetal occiput position during the second stage of labor before operative vaginal delivery. METHODS: The primary outcome was failed operative vaginal delivery, defined as a failed fetal operative vaginal delivery (vacuum or forceps) extraction requiring a cesarean delivery or forceps after failed vacuum. The summary measures were reported as relative risks or as mean differences with 95% confidence intervals using the random effects model of DerSimonian and Laird. An I2 (Higgins I2) >0% was used to identify heterogeneity. RESULTS: A total of 4 randomized controlled trials including 1007 women with singleton, term, cephalic fetuses randomized to either the sonographic (n=484) or clinical digital (n=523) diagnosis of occiput position during the second stage of labor before operative vaginal delivery were included. Before operative vaginal delivery, fetal occiput position was diagnosed as anterior in 63.5% of the sonographic diagnosis group vs 69.5% in the clinical digital diagnosis group (P=.04). There was no significant difference in the rate of failed operative vaginal deliveries between the sonographic and clinical diagnosis of occiput position groups (9.9% vs 8.2%; relative risk, 1.14; 95% confidence interval, 0.77-1.68). Women randomized to sonographic diagnosis of occiput position had a significantly lower rate of occiput position discordance between the evaluation before operative vaginal delivery and the at birth evaluation when compared with those randomized to the clinical diagnosis group (2.3% vs 17.7%; relative risk, 0.16; 95% confidence interval, 0.04-0.74; P=.02). There were no significant differences in any of the other secondary obstetrical and perinatal outcomes assessed. CONCLUSION: Sonographic knowledge of occiput position before operative vaginal delivery does not seem to have an effect on the incidence of failed operative vaginal deliveries despite better sonographic accuracy in the occiput position diagnosis when compared with clinical assessment. Future studies should evaluate how a more accurate sonographic diagnosis of occiput position or other parameters can lead to a safer and more effective operative vaginal delivery technique.

Transabdominal and transperineal ultrasound vs routine care before instrumental vaginal delivery - A randomized controlled trial.

INTRODUCTION: The role of intrapartum ultrasound as an ancillary method to instrumental vaginal delivery is yet to be determined. This study aimed to compare the use of transabdominal and transperineal ultrasound with routine clinical care before performing an instrumental vaginal delivery, regarding the incidence of adverse maternal and neonatal outcomes. MATERIAL AND METHODS: A randomized controlled trial was conducted between October 2016 and March 2019 in two tertiary care maternity hospitals in Lisbon, Portugal. Women at term, with full cervical dilatation, singleton fetuses in cephalic presentation, and with an established indication for instrumental vaginal delivery, were approached for enrollment. After informed consent was obtained, randomization into one of two groups was carried out. In the experimental arm, women underwent transabdominal ultrasound for determination of the fetal head position and transperineal ultrasound for evaluation of the angle of progression, before instrumental vaginal delivery. In the control arm, no ultrasound was carried out before instrumental vaginal delivery. Primary outcomes were composite measures of maternal and neonatal morbidity. Composite maternal morbidity consisted of severe postpartum hemorrhage, perineal trauma, and prolonged hospital stay. Composite neonatal morbidity consisted of low 5-minute Apgar score, umbilical artery metabolic acidosis, birth trauma, and neonatal intensive care unit admission. RESULTS: A total of 222 women were enrolled (113 in the experimental arm and 109 in the control arm). No significant differences between the two arms were found in composite measures of maternal (23.9% in the experimental group vs 22.9% in the control group, odds ratio 1.055, 95% CI 0.567-1.964) or neonatal morbidity (9.7% in the experimental group vs 6.4% in the control group, odds ratio 1.571, 95% CI 0.586-4.215), nor in any of the individual outcomes. CONCLUSIONS: In this small randomized controlled trial that was stopped for futility before reaching the required sample size, transabdominal and transperineal ultrasound performed just before instrumental vaginal delivery did not reduce the incidence of adverse maternal and neonatal outcomes, when compared with routine clinical care.

Effect of simulation-based training on the accuracy of fetal head position determination in labor.

OBJECTIVES: The objective of this study was to evaluate the effect of simulation-based training on the accuracy of fetal head position determination by junior residents during the second stage of labour. STUDY DESIGN: This prospective study was conducted in a tertiary care university hospital. During an initial period of 12 weeks, 13 junior residents were asked to routinely evaluate fetal head position by digital examination during the second stage of labour, in women with term singletons in cephalic presentation. Digital examination was followed immediately by transabdominal ultrasound to confirm fetal head position, performed by an experienced physician. Following this initial period, all participants attended a workshop where simulation-based training of fetal head position determination was provided. A second 12-week period was subsequently completed, with similar characteristics to the initial one. The accuracy of clinical evaluations was assessed by the percentage of exact evaluations, the percentage of correct evaluations within a 45° error margin, and by Cohen's kappa coefficient of agreement. RESULTS: A total of 83 observations were performed in the initial period of the study and 74 observations were performed in the second period. The accuracy of fetal head position determination during the first period of the study was 59.0% (95% CI 47.7-69.7), k = 0.517 (95%CI 0.391 - 0.635), corresponding to a moderate agreement. Considering a 45° margin of error, accuracy was 71.1% (95% CI 60.1-80.5), k = 0.656 (95% CI 0.538 - 0.763), corresponding to substantial agreement. Following simulation-based training, the accuracy of fetal head position determination was 70.3% (95% CI 58.5-80.3), k = 0.651 (95% CI 0.526 - 0.785), corresponding to a substantial agreement. Considering a 45° margin of error, accuracy was 78.4% (95% CI 67.3-87.1), k = 0.745 (95% CI 0.631 - 0.854), corresponding to a substantial agreement. CONCLUSIONS: Although a trend towards increased accuracy in fetal head position determination was observed after simulation-based training, the difference was not statistically significant. Further studies are needed to clarify the role of simulation-based training for fetal head position determination during residency.

Prevalence of Late Preterm and Early Term Birth in Portugal.

INTRODUCTION: Late preterm birth (defined as birth between 34 and 36 complete weeks' gestation) and early term birth (defined as birth between 37 and 38 complete weeks' gestation) have become a topic of recent discussion as the morbidity associated with delivery at these gestational ages has become increasingly evident. Our objective was to evaluate the characteristics of late preterm and early term birth in Portugal. MATERIAL AND METHODS: We developed a survey questionnaire that was sent to the Obstetric Department of all public hospitals in Portugal. The questionnaire consisted on questions on prevalence and mode of delivery of late preterm and early term period and associated neonatal morbidity and mortality. The questions referred solely to single births occurred during 2013. RESULTS: We received completed questionnaires from 14 hospitals, corresponding to nearly one third (33.5%) of total deliveries in Portugal. We report 5.4% of late preterm and 27% of early term deliveries. Approximately two thirds of late preterm and three quarters of early term deliveries were spontaneous. The cesarean section rate was higher in late preterm (39.1%) than in early term (26.4%) births. Neonatal complications were more frequent in late preterm neonates (34.2%) when compared to early term neonates (14.2%). DISCUSSION: The prevalence of late preterm and early term birth in our cohort is comparable, although slightly reduced, to other published series. CONCLUSION: The obstetric community should raise efforts to limit deliveries below 39 weeks' gestation to the ones with a valid medical indication.

Introdução: Nos últimos anos, vários autores evidenciaram a morbilidade associada aos partos ocorridos entre as 34 e 36 semanas (pré-termo tardio) e entre as 37 e 38 semanas de gestação (termo precoce). Neste sentido, pretendemos realizar um estudo epide-miológico dos partos que ocorrem nestas idades gestacionais, em Portugal. Material e Métodos: Realizámos um inquérito, que foi aplicado a todos os hospitais públicos de Portugal, acerca da prevalência e via de parto nos partos pré-termo tardios e de termo precoce, e morbilidade e mortalidade neonatal associada. As questões referiam-se apenas a gestações de feto único e a partos ocorridos em 2013. Resultados: Incluímos 14 hospitais, correspondendo a 33,5% dos partos ocorridos em Portugal, em 2013. Verificámos que 5,4% dos partos ocorreram no período pré-termo tardio e 27% no termo precoce. Aproximadamente dois terços dos partos pré-termo tardio e três quartos dos partos de termo precoce foram espontâneos. A taxa de cesariana foi mais elevada entre as 34 e 36 semanas de gestação (39,1%) do que entre as 37 e 38 semanas (26,4%). As complicações neonatais foram mais frequentes após um parto pré-termo tardio (34,2%), quando comparadas com os de termo precoce (14,2%). Discussão: Na nossa amostra, a prevalência de parto pré-termo tardio e de termo precoce, ainda que ligeiramente inferior, é comparável à publicada em estudos anteriores. Conclusão: Á importante que a comunidade obstétrica nacional adote atitudes no sentido de limitar os partos antes das 39 semanas de gestação. Assim, nestas idades gestacionais os partos devem possuir uma indicação médica válida.