Severe Perineal Lacerations in Induction of Labor versus Expectant management: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: This study aimed to evaluate if induction of labor is associated with an increased risk of severe perineal laceration. DATA SOURCES: A systematic search was conducted in MEDLINE, Ovid, Scopus, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, and CINHAL using a combination of keywords and text words related to "induction of labor," "severe perineal laceration," "third-degree laceration," "fourth-degree laceration," and "OASIS" from inception of each database until January 2023. STUDY ELIGIBILITY CRITERIA: We included all randomized controlled trials comparing induction of labor to expectant management of a singleton, cephalic pregnancy at term gestation that reported rates of severe perineal laceration. STUDY APPRAISAL AND SYNTHESIS AND METHODS: The primary outcome of interest was severe perineal laceration, defined as third or fourth-degree perineal lacerations. We conducted meta-analyses using the random effects model of DerSimonian and Laird to determine the relative risks or mean differences with 95% confidence intervals. Bias was assessed using guidelines established by Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: A total of 11,187 unique records were screened and ultimately eight randomized controlled trials were included, involving 13,297 patients. There was no statistically significant difference in the incidence of severe perineal lacerations between the induction of labor and expectant management groups (209/6655 (3.1%) vs. 202/6641 (3.0%); relative risk (RR) 1.03, 95% confidence interval (CI) 0.85, 1.26). There was a statistically significant decrease in the rate of cesarean birth (1090/6655 (16.4%) vs. 1230/6641 (18.5%), RR 0.89, 95% CI 0.82, 0.95) and fetal macrosomia (734/2696 (27.2%) vs. 964/2703 (35.7%); RR 0.67: 95% CI 0.50, 0.90) in the induction of labor group. CONCLUSION: There is no significant difference in the risk of severe perineal lacerations between induction of labor and expectant management in this meta-analysis of randomized controlled trials. Furthermore, there is a lower rate of cesarean births in the induction of labor group, indicating more successful vaginal deliveries with similar rates of severe perineal lacerations. Patients should be counseled that in addition to the known benefits of induction, there is no increased risk of severe perineal lacerations.

Intrapartum Oxygen for Fetal Resuscitation: State of the Science.

Purpose of Review: This review aims to summarize the current evidence regarding maternal oxygen supplementation for Category II fetal heart tracings (FHT) in labor. We aim to evaluate the theoretical rationale for oxygen administration, the clinical efficacy of supplemental oxygen, and the potential risks. Recent Findings: Maternal oxygen supplementation is an intrauterine resuscitation technique rooted in the theoretic rationale that hyperoxygenating the mother results in increased oxygen transfer to the fetus. However, recent data suggest otherwise. Randomized controlled trials on the efficacy of oxygen supplementation in labor suggest no improvement in umbilical cord gases or other adverse maternal and neonatal outcomes compared to room air. Two meta-analyses demonstrated that oxygen supplementation is not associated with an improvement in umbilical artery pH or reduction in cesarean delivery. Although we lack data on definitive clinical neonatal outcomes with this practice, there is some suggestion of adverse neonatal outcomes with excess in utero oxygen exposure, including lower umbilical artery pH. Summary: Despite historic data suggesting the benefit of maternal oxygen supplementation in increasing fetal oxygenation, recent randomized trials and meta-analyses have demonstrated a lack of efficacy of this practice and some suggestion of harm. This has led to conflicting national guidelines. Further research is needed on short- and long-term neonatal clinical outcomes following prolonged intrauterine oxygen exposure.

Suture type for hysterotomy closure: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Recent randomized controlled trials have demonstrated an association between uterine closure technique at the time of cesarean delivery and short- and long-term operative outcomes with varied results. This systematic review and meta-analysis aimed to examine types of suture material used for cesarean delivery. DATA SOURCES: Scopus, PubMed, Cochrane Central Register of Controlled Trials, Ovid, and ClinicalTrials.gov were searched from inception of each database to October 2021. STUDY ELIGIBILITY CRITERIA: All randomized controlled trials that compared types of suture materials used for hysterotomy closure during low-transverse cesarean delivery at ≥24 weeks' gestation and examined maternal outcomes were included for this review. The primary outcome was estimated blood loss. Secondary outcomes included additional surgical complications. METHODS: Results were summarized as mean difference or risk ratio with associated 95% confidence intervals. The quality of studies was evaluated with the Cochrane Handbook for Systematic Reviews of Interventions for judging risk of bias. Heterogeneity was measured using I-squared (Higgins I2). RESULTS: This review included 7 randomized controlled trials, of which 3 compared multifilament with barbed suture (136 vs 136 participants), 3 compared multifilament with conventional monofilament suture (245 vs 244 participants), and 1 trial compared multifilament with chromic suture (4590 vs 4595 participants). Primary analysis showed no difference in estimated blood loss between the multifilament and the barbed suture group (mean difference, 46.2 mL; 95% confidence interval, -13.6 to 105.9), nor in change in hemoglobin concentration between the multifilament and the conventional monofilament group (mean difference, -0.1%; 95% confidence interval, -0.5 to 0.3). Secondary outcomes showed a reduction in operative time with barbed vs multifilament suture (mean difference, 1.9 minutes; 95% confidence interval, 0.03-3.8). Analysis also demonstrated an increased uterine scar thickness with use of conventional monofilament vs multifilament suture (mean difference, -1.05 mm; 95% confidence interval, -1.9 to -0.2). CONCLUSION: This meta-analysis does not support a specific type of suture material for uterine closure at cesarean delivery because of insufficient data. Although barbed suture was associated with an overall decrease in operative time, and use of conventional monofilament suture was associated with an increase in uterine scar thickness, the clinical utility of these differences is not clear. Further adequate randomized controlled trials are warranted for evaluation of different suture materials for hysterotomy closure.

Prophylactic rotation for malposition in the second stage of labor: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: This study aimed to evaluate if manual rotation, undertaken during labor, of fetuses in occiput posterior or occiput transverse position led to an increased rate of spontaneous vaginal delivery. DATA SOURCES: Searches were performed in MEDLINE, Ovid, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials with the use of a combination of keywords and text words related to "occiput posterior," "occiput transverse," and "manual rotation" from inception of the databases to July 2021. STUDY ELIGIBILITY CRITERIA: We included all randomized controlled trials evaluating manual rotation of fetuses in the occiput posterior or occiput transverse position during labor. METHODS: The primary outcome was the rate of spontaneous vaginal delivery. Meta-analyses were performed using the random effects model of DerSimonian and Laird to determine the relative risks or mean differences with 95% confidence intervals. RESULTS: A total of 643 records were screened with inclusion of 6 articles and 1002 randomized patients. All included studies compared manual rotation of fetuses in occiput posterior or occiput transverse position, all confirmed using ultrasound examinations, after complete cervical dilation with either no rotation or a sham rotation procedure. There was no difference in the rate of spontaneous vaginal delivery with manual rotation (relative risk, 1.07; 95% confidence interval, 0.95-1.20) nor was there any difference in any other maternal or fetal outcomes. In a subgroup analysis of occiput posterior fetuses, there was a 12.80-minute decrease in the length of the second stage of labor in the manual rotation group (mean difference, -12.80; 95% confidence interval, -22.61 to -2.99). There were no significant differences in any other maternal or fetal outcomes in the occiput posterior subgroup and no differences in the occiput transverse subgroup. CONCLUSION: Prophylactic manual rotation of fetuses in occiput posterior or occiput transverse position, confirmed using ultrasound examination, did not increase the rate of spontaneous vaginal delivery compared with no manual rotation. Manual rotation of the occiput posterior fetal head early during the second stage of labor was associated with a significant 12.8-minute decrease in the length of the second stage of labor with no changes in any other maternal or fetal outcomes. There were no differences demonstrated for fetuses rotated from occiput transverse position or for the combination of occiput posterior and occiput transverse fetuses. Because there is some evidence of benefit, prophylactic manual rotation can be offered to patients during the second stage of labor presenting with occiput posterior position of the fetal head documented during ultrasound examination.

Evaluation of an Initiative to Decrease the Use of Oxygen Supplementation for Category II Fetal Heart Rate Tracings.

OBJECTIVE: To examine compliance with a guideline to reduce exposure to supplemental oxygen for category II fetal heart rate (FHR) tracings in normally oxygenated laboring patients. METHODS: All patients in labor in an urban academic medical center from January 1 to July 31, 2020 were assessed. The preintervention group included those who delivered from January 1 to March 19, 2020. On March 20, 2020, a new guideline took effect that recommended no maternal supplemental oxygen for category II FHR tracings. The postintervention group delivered from March 20 to July 31, 2020. Exclusion criteria were planned cesarean delivery, multiple gestations, delivery at less than 24 weeks of gestation, intrauterine fetal death, and patients who received supplemental oxygen for an oxygen saturation lower than 95%. The primary outcome was the percentage of patients who received oxygen in labor analyzed by control charts and the rules of special cause variation. Chi-squared and t tests were used for secondary outcome assessment. P<.05 was considered significant. RESULTS: A total of 1,333 patients were included, 474 patients in the preintervention group and 859 in the postintervention group. Oxygen was administered to 22.6% of patients before guideline implementation, compared with 0.6% after the guideline. Special cause variation was detected with an 8-point shift starting the month that the guideline was implemented, indicating statistical significance. There were no differences in any studied secondary maternal or fetal outcomes, although our statistical power to detect differences in infrequent outcomes was limited. CONCLUSION: This quality-improvement study demonstrated significant adherence to the guideline that supplemental oxygen would no longer be given to patients with category II FHR tracings in the absence of maternal hypoxemia, with no significant change in maternal or perinatal outcomes.

Effect of intrapartum oxygen on the rate of cesarean delivery: a meta-analysis.

OBJECTIVE: This study aimed to determine if maternal intrapartum administration of oxygen altered the rate of cesarean delivery compared with room air. DATA SOURCES: This study was a systematic review and meta-analysis of randomized controlled trials. Searches were performed in MEDLINE, OVID, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials using a combination of key words related to "pregnant patients," "labor," "oxygen," "fetus," "newborn," and pregnancy outcomes from database inception until April 2020. The study was registered in PROSPERO (registration number CRD42020162110). STUDY ELIGIBILITY CRITERIA: The inclusion criteria were randomized controlled trials of maternal administration of oxygen compared with room air in labor. The exclusion criteria were quasi-randomized trials and oxygen administered for planned cesarean deliveries. The primary outcome was the rate of cesarean delivery. Secondary maternal and neonatal outcomes, including cord gas values, were analyzed. METHODS: The Cochrane Handbook guidelines were used to assess bias in trials. To calculate the relative risk or mean differences with confidence intervals, a random-effects model was employed. Subgroup analyses were performed for women who received oxygen for nonreassuring fetal heart rate monitoring or prophylactically. RESULTS: Five randomized controlled trials, including 768 women, were included in the meta-analysis, 3 using prophylactic oxygen and 2 using oxygen for nonreassuring fetal heart rate monitoring. The risk of bias was generally considered low. There was no statistically significant difference in the rate of cesarean delivery between patients administered oxygen and patients provided room air (16 of 365 [4.4%] vs 11 of 379 [2.9%]; risk ratio 1.5; 95% confidence interval, 0.7-3.3). In addition, there were no statistically significant differencs in the rates of cesarean delivery for nonreassuring fetal heart rate monitoring, operative vaginal deliveries, Apgar scores of <7, neonatal intensive care unit admissions, or cord blood gas values. There were no statistically significant difference when analyzing oxygen for nonreassuring fetal heart rate monitoring alone or prophylactic oxygen alone. Data regarding FHT is mixed, with one study suggesting an improvement and three suggesting no change. CONCLUSION: Maternal intrapartum oxygen administration was not associated with any differences in the rate of cesarean delivery or any secondary outcomes compared with room air overall and in the subgroups of therapeutic (for nonreassuring fetal heart rate monitoring) or prophylactic administration in this meta-analysis. Large randomized controlled trials are necessary to further examine any possible benefits or harms of oxygen administration in labor, particularly for nonreassuring fetal heart rate monitoring.

Blood type and postpartum hemorrhage by mode of delivery: A retrospective cohort study.

OBJECTIVE: To assess the relationship between postpartum hemorrhage and ABO blood type for vaginal delivery and cesarean delivery. STUDY DESIGN: This is a retrospective cohort study of data abstracted from the PeriBank database regarding demographics and delivery outcomes. All live singleton deliveries from January 2011 until March 2018 were included in this study. Exclusion criteria were sickle cell disease and multiple gestations. Analyses were conducted separately for cesarean delivery and vaginal delivery. Quantitative variables were analyzed with analysis of variance testing and categorical variables with chi square testing. Significant demographic differences between groups were controlled for using multivariate logistical regression. The primary outcome was the rate of postpartum hemorrhage by blood type (A, B, AB, and O), defined as blood loss >500 mL in vaginal delivery and >1000 mL in cesarean delivery. 43,437 patients were screened and 32,023 women met inclusion criteria (22,484 vaginal deliveries (70.2%) and 9539 cesarean deliveries (29.8%)). RESULTS: In the vaginal delivery group there were differences in age, parity, race, use of regional anesthesia, rate of induction of labor, and thrombocytopenia between blood types. In the cesarean delivery group, age, parity, and race were significantly different between blood types. There was no observed difference in the rate of postpartum hemorrhage by blood type for those who delivered via vaginal delivery when controlling for demographic differences (p = 0.2). In the cesarean delivery group, there was a significantly higher rate of postpartum hemorrhage in women with type O blood (5.2% type O vs 3.8% type A vs 4.4% type B vs 4.2% type AB, p = 0.035), including when controlling for demographic differences (p = 0.02). In both vaginal and cesarean delivery groups, there was no difference in rates of any of the secondary outcomes, including blood transfusion, hysterectomy, intrapartum dilation and curettage, and intensive care unit admission. CONCLUSION: Although this study found no statistically significant difference in clinical outcomes between blood types, type O blood may be an additional risk factor to consider for postpartum hemorrhage at the time of cesarean delivery.

Pregnant women with severe or critical coronavirus disease 2019 have increased composite morbidity compared with nonpregnant matched controls.

BACKGROUND: In March 2020, as community spread of severe acute respiratory syndrome coronavirus 2 became increasingly prevalent, pregnant women seemed to be equally susceptible to developing coronavirus disease 2019. Although the disease course usually appears mild, severe and critical cases of coronavirus disease 2019 seem to lead to substantial morbidity, including intensive care unit admission with prolonged hospital stay, intubation, mechanical ventilation, and even death. Although there are recent reports regarding the impact of coronavirus disease 2019 on pregnancy, there is a lack of information regarding the severity of coronavirus disease 2019 in pregnant vs nonpregnant women. OBJECTIVE: We aimed to describe the outcomes of severe and critical cases of coronavirus disease 2019 in pregnant vs nonpregnant, reproductive-aged women. STUDY DESIGN: This is a multicenter, retrospective, case-control study of women with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection hospitalized with severe or critical coronavirus disease 2019 in 4 academic medical centers in New York City and 1 in Philadelphia between March 12, 2020, and May 5, 2020. The cases consisted of pregnant women admitted specifically for severe or critical coronavirus disease 2019 and not for obstetrical indications. The controls consisted of reproductive-aged, nonpregnant women admitted for severe or critical coronavirus disease 2019. The primary outcome was a composite morbidity that includes the following: death, a need for intubation, extracorporeal membrane oxygenation, noninvasive positive pressure ventilation, or a need for high-flow nasal cannula O2 supplementation. The secondary outcomes included intensive care unit admission, length of stay, a need for discharge to long-term acute care facilities, and discharge with a home O2 requirement. RESULTS: A total of 38 pregnant women with severe acute respiratory syndrome coronavirus 2 polymerase chain reaction-confirmed infections were admitted to 5 institutions specifically for coronavirus disease 2019, 29 (76.3%) meeting the criteria for severe disease status and 9 (23.7%) meeting the criteria for critical disease status. The mean age and body mass index were markedly higher in the nonpregnant control group. The nonpregnant cohort also had an increased frequency of preexisting medical comorbidities, including diabetes, hypertension, and coronary artery disease. The pregnant women were more likely to experience the primary outcome when compared with the nonpregnant control group (34.2% vs 14.9%; P=.03; adjusted odds ratio, 4.6; 95% confidence interval, 1.2-18.2). The pregnant patients experienced higher rates of intensive care unit admission (39.5% vs 17.0%; P<.01; adjusted odds ratio, 5.2; 95% confidence interval, 1.5-17.5). Among the pregnant women who underwent delivery, 72.7% occurred through cesarean delivery and the mean gestational age at delivery was 33.8±5.5 weeks in patients with severe disease status and 35±3.5 weeks in patients with critical coronavirus disease 2019 status. CONCLUSION: Pregnant women with severe and critical coronavirus disease 2019 are at an increased risk for certain morbidities when compared with nonpregnant controls. Despite the higher comorbidities of diabetes and hypertension in the nonpregnant controls, the pregnant cases were at an increased risk for composite morbidity, intubation, mechanical ventilation, and intensive care unit admission. These findings suggest that pregnancy may be associated with a worse outcome in women with severe and critical cases of coronavirus disease 2019. Our study suggests that similar to other viral infections such as severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome coronavirus, pregnant women may be at risk for greater morbidity and disease severity.

Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study.

Background: The coronavirus disease 2019 pandemic has had an impact on healthcare systems around the world with 3 million people contracting the disease and 208,000 cases resulting in death as of this writing. Information regarding coronavirus infection in pregnancy is still limited. Objective: This study aimed to describe the clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnant women with positive laboratory testing for severe acute respiratory syndrome coronavirus 2. Study Design: This is a cohort study of pregnant women with severe or critical coronavirus disease 2019 hospitalized at 12 US institutions between March 5, 2020, and April 20, 2020. Severe disease was defined according to published criteria as patient-reported dyspnea, respiratory rate >30 per minute, blood oxygen saturation ≤93% on room air, ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen <300 mm Hg, or lung infiltrates >50% within 24-48 hours on chest imaging. Critical disease was defined as respiratory failure, septic shock, or multiple organ dysfunction or failure. Women were excluded from the study if they had presumed coronavirus disease 2019, but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported. Results: Of 64 hospitalized pregnant women with coronavirus disease 2019, 44 (69%) had severe disease, and 20 (31%) had critical disease. The following preexisting comorbidities were observed: 25% had a pulmonary condition, 17% had cardiac disease, and the mean body mass index was 34 kg/m2. Gestational age was at a mean of 29±6 weeks at symptom onset and a mean of 30±6 weeks at hospital admission, with a median disease day 7 since first symptoms. Most women (81%) were treated with hydroxychloroquine; 7% of women with severe disease and 65% of women with critical disease received remdesivir. All women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. The median duration of hospital stay was 6 days (6 days [severe group] and 10.5 days [critical group]; P=.01). Intubation was usually performed around day 9 on patients who required it, and peak respiratory support for women with severe disease was performed on day 8. In women with critical disease, prone positioning was required in 20% of cases, the rate of acute respiratory distress syndrome was 70%, and reintubation was necessary in 20%. There was 1 case of maternal cardiac arrest, but there were no cases of cardiomyopathy or maternal death. Thirty-two of 64 (50%) women with coronavirus disease 2019 in this cohort delivered during their hospitalization (34% [severe group] and 85% [critical group]). Furthermore, 15 of 17 (88%) pregnant women with critical coronavirus disease 2019 delivered preterm during their disease course, with 16 of 17 (94%) pregnant women giving birth through cesarean delivery; overall, 15 of 20 (75%) women with critical disease delivered preterm. There were no stillbirths or neonatal deaths or cases of vertical transmission. Conclusion: In pregnant women with severe or critical coronavirus disease 2019, admission into the hospital typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 [severe group] vs 12 [critical group]). Women with critical disease had a high rate of acute respiratory distress syndrome, and there was 1 case of cardiac arrest, but there were no cases of cardiomyopathy or maternal mortality. Hospitalization of pregnant women with severe or critical coronavirus disease 2019 resulted in delivery during the clinical course of the disease in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.