Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture.

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.

Factors associated with severe maternal outcome in patients admitted to an intensive care unit in northeastern Brazil with postpartum hemorrhage: a retrospective cohort study.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide, particularly in low- and middle-income countries; however, the majority of these deaths could be avoided with adequate obstetric care. Analyzing severe maternal outcomes (SMO) has been a major approach for evaluating the quality of the obstetric care provided, since the morbid events that lead to maternal death generally occur in sequence. The objective of this study was to analyze the clinical profile, management, maternal outcomes and factors associated with SMO in women who developed PPH and were admitted to an obstetric intensive care unit (ICU) in northeastern Brazil. METHODS: This retrospective cohort study included a non-probabilistic, consecutive sample of postpartum women with a diagnosis of PPH who were admitted to the obstetric ICU of the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) between January 2012 and March 2020. Sociodemographic, biological and obstetric characteristics and data regarding childbirth, the management of PPH and outcomes were collected and analyzed. The frequency of maternal near miss (MNM) and death was calculated. Multiple logistic regression analysis was performed to determine the adjusted odd ratios (AOR) and their 95% confidence intervals (95% CI) for a SMO. RESULTS: Overall, 136 cases of SMO were identified (37.9%), with 125 cases of MNM (34.9%) and 11 cases of maternal death (3.0%). The factors that remained associated with an SMO following multivariate analysis were gestational age ≤ 34 weeks (AOR = 2.01; 95% CI: 1.12-3.64; p < 0.02), multiparity (AOR = 2.20; 95% CI: 1.10-4.68; p = 0.02) and not having delivered in the institute (AOR = 2.22; 955 CI: 1.02-4.81; p = 0.04). CONCLUSION: Women admitted to the obstetric ICU with a diagnosis of PPH who had had two or more previous deliveries, gestational age ≤ 34 weeks and who had delivered elsewhere were more likely to have a SMO.

Antibiotic administration and wound complications after obstetric anal sphincter injuries.

BACKGROUND: Obstetric anal sphincter injuries are associated with both short-term and long-term maternal morbidity. Antibiotic administration has been shown to decrease wound complications after obstetric anal sphincter injuries. However, the rate of antibiotic administration in a contemporary obstetrical population is not known. OBJECTIVE: This study aimed to describe the rate of antibiotic administration for obstetric anal sphincter injuries, to characterize factors associated with antibiotic administration on the day of delivery among women with obstetric anal sphincter injuries, and to determine if there was an association between antibiotic administration and reduced wound complications. STUDY DESIGN: This was a retrospective cohort study of women with a singleton vaginal birth complicated by obstetric anal sphincter injuries between 2016 and 2021 in a single healthcare system. Information about any antibiotic administration on the day of delivery was collected. Information on wound complications (determined by International Classification of Disease, 10th Revision, codes) that occurred within the first 6 months postpartum were available for patients who delivered at tertiary-care centers. Multivariable logistic regression analysis was used to identify factors associated with antibiotic administration and the association between antibiotics and wound complications. RESULTS: During the study period, 1550 women met the inclusion criteria of whom 855 (55.2%) received antibiotics. Antibiotic administration was higher at tertiary-care hospitals than at community-based hospitals (68.7 vs 26.8%; P<.001). In the adjusted analysis, antibiotic administration was higher among women with a fourth-degree laceration (adjusted odds ratio, 2.72; 95% confidence interval, 1.69-4.37) and lower among women of Asian or Pacific Islander heritage (adjusted odds ratio, 0.88; 95% confidence interval, 0.80-0.97). At tertiary-care hospitals, 43 women (4.1%) had a wound complication, and more than 80% of those presented within the first 2 weeks postpartum. Antibiotic use was associated with reduced rates of wound complications (adjusted odds ratio, 0.34; 95% confidence interval, 0.13-0.91). All patients received a regimen with gram-positive bacterial coverage; there was no association between type of antibiotic regimen administered and wound complications. CONCLUSION: Any antibiotic administration on the day of delivery was associated with a decreased rate of wound complications after obstetric anal sphincter injuries. However, only about half of the women with obstetric anal sphincter injuries received antibiotics. Optimizing antibiotic administration may help to reduce the risk of complications in this population.

Analysis of Variables that Influence the Success Rates of Induction of Labor with Misoprostol: A Retrospective Observational Study / Análise de variáveis que influenciam na taxa de sucesso da indução do parto com misoprostol: Um estudo observacional retrospectivo

Abstract Objective Determine the predictive criteria for success in inducing labor for live fetuses using misoprostol in pregnant women. Secondarily, the objective is to determine the rates of vaginal or cesarean delivery, duration of induction, interval of administration of misoprostol, the main causes of induction of labor and indication for operative delivery. Methods Medical records of 873 pregnant women admitted for cervical maturation from January 2017 to December 2018 were reviewed in a descriptive observational study of retrospective analysis, considering the following response variables: age, parity, Bishop Index, doses of misoprostol, labor induction time. Logistic regression models were used to predict success with misoprostol in non-operative deliveries. Results Of the 873 patients evaluated, 72% evolved with vaginal delivery, 23% of the cases were cesarean, 5% forceps or vacuum-extractor. For non-operative delivery the predictive variables at admission were age, parity, gestational age and dilation. During hospitalization, fewer vaginal touches,amniotomy or amniorrhexis with clear fluid lead to a shorter induction time and a greater chance of non-operative delivery. False positives and false negatives of the model were always below 50% and correct answers above 65%. Conclusion At admission, age less than 24 years, previous normal births, lower the gestational age and greater the dilation, were predictive of greater probability of nonoperative delivery. During hospitalization, the less vaginal touches and occurrence of amniotomy/amniorrhexis with clear liquid indicate shorter induction time. Future studies with a prospective design and analysis of other factors are necessary to assess the replicability, generalization of these findings.

Resumo Objetivo Determinar os critérios preditivos para o sucesso na indução do trabalho de parto para fetos vivos utilizando misoprostol em gestantes. Em segundo lugar, o objetivo é determinar as taxas de parto vaginal ou cesáreo, duração da indução, intervalo de administração de misoprostol, as principais causas de indução do trabalho de parto e indicação para parto operatório. Métodos Foram revisados os prontuários de 873 gestantes internadas para amadurecimento cervical entre janeiro de 2017 e dezembro de 2018 em um estudo descritivo observacional de análise retrospectiva, considerando as variáveis-resposta: idade, paridade, Índice de Bishop, doses de misoprostol, tempo de indução do trabalho de parto. Modelos de regressão logística foram utilizados para prever o sucesso com misoprostol em partos não operatórios. Resultados Dos 873 pacientes avaliados, 72% evoluíram com parto vaginal, 23% dos casos foram cesáreos, 5% fórceps ou vácuo-extrator. Para o parto não operatório as variáveis preditivas na internação foram idade, paridade, idade gestacional e dilatação. Durante a internação, um menor número de toques vaginais, amniotomia ou amniorrexe com líquido claro, levam a menor tempo de indução e maior chance de parto não operatório. Falsos positivos e falsos negativos do modelo sempre foram inferiores a 50% e respostas corretas acima de 65%. Conclusão Na internação, idade menor que 24 anos, ocorrência de partos normais anteriores, menor idade gestacional e maior dilatação, foram preditivos de maior probabilidade de parto não-operatório. Durante a internação, o menor número de toques vaginais, amniotomia/amniorrexe com líquido claro indicam menor tempo de indução. Estudos futuros com design prospectivo e análise de outros fatores são necessários para avaliar a replicabilidade, generalização desses achados.

Parto asincrónico en un embarazo gemelar. Primer reporte de caso en el Perú / Asynchronous delivery in a twin pregnancy. First case report in Peru

RESUMEN El parto asincrónico (PA) o parto diferido (PD) es una presentación poco prevalente de la gestación múltiple. Este ocurre cuando un feto nace por vía vaginal y el -o losfetos restantes se mantienen intraútero y nacen con una diferencia de días o semanas. Se realiza el primer reporte en el Perú de una gestante cuyo primer parto fue a las 20,1 semanas y el segundo a las 24,4 semanas, y se detalla el manejo y los resultados perinatales del caso. La evidencia sugiere que un PD mejora la supervivencia y reduce la morbimortalidad del segundo feto. Es imprescindible continuar la investigación en este tema para describir su prevalencia real, identificar candidatas ideales, estandarizar el manejo obstétrico y así optimizar resultados maternos y fetales.

ABSTRACT Asynchronous delivery (AD) or delayed interval delivery (DID) is a rare presentation of multiple gestation. This occurs when one fetus is delivered vaginally and the remaining fetus or fetuses are kept in utero and are born with a difference of days or weeks. This is the first report in Peru of a pregnant woman whose first delivery was at 20.1 weeks and the second at 24.4 weeks, and the management and perinatal results of the case are detailed. The evidence suggests that a DID improves survival and reduces morbidity and mortality of the second fetus. Further research on this topic is essential to describe its real prevalence, identify ideal candidates, standardize obstetric management and thus optimize maternal and fetal outcomes.

Perfil das pacientes com diagnóstico de hemorragia puerperal em uma maternidade filantrópica do município de São Paulo / Profile of patients diagnosed with puerperal hemorrhage in a philanthropic maternity hospital in São Paulo

Objetivo: A hemorragia puerperal (HPP) é um problema de saúde pública. A finalidade deste estudo foi estereotipar as pacientes diagnosticadas com HPP e saber seu desfecho ante a aplicação do protocolo da instituição. Foram avaliadas características anteparto e intraparto para encontrar perfil materno propenso ao desenvolvimento da HPP. Métodos: O método escolhido foi coorte com análise de prontuários no Hospital Filantrópico Beneficência Portuguesa, envolvendo 197 mulheres com diagnóstico de HPP, com administração de ácido tranexâmico de forma precoce, juntamente com ocitocina. O perfil predominante foi de idade materna não avançada, não brancas, multíparas, parto vaginal sem preparo de colo, ausência de síndrome hipertensiva e com idade gestacional de 39 semanas. A principal causa foi atonia uterina, seguida das lacerações de trajeto. Resultados: Além do ácido tranexâmico em conjunto com a ocitocina, a droga mais usada foi a metilergometrina; 71 (36%) mulheres precisaram de procedimentos, sendo o principal a sutura de trajeto e 45 (22,8%) precisaram de hemoderivados. Conclusão: A terapia farmacológica foi eficaz, com menor necessidade procedimentos e ausência de mortalidade.(AU)

Objective: Postpartum hemorrhage (PPH) is a public health problem. The purpose of this study is to stereotype patients diagnosed with PPH as well as know their outcome according to the institution's protocol. Antepartum and intrapartum characteristics were evaluated to find a maternal profile prone to the development of PPH. Methods: The method chosen was the cohort analysis of medical records at the Hospital Filantrópico Beneficência Portuguesa, involving 197 women diagnosed with PPH, with administration of tranexamic acid early, associated with oxytocin. As results, the predominant profile was non-advanced maternal age, non-white, non-primigravida, vaginal delivery without prior cervical ripening, without hypertensive syndrome and gestational age of 39 weeks. Results: The main cause was uterine atony, followed by trauma. In addition to tranexamic acid and oxytocin, the most used drug was methylergometrine; 71 (36%) women needed procedures, the main one was the path suture and 45 (22,8%) needed blood products. Conclusion: Pharmacological therapy was effective, with less need for procedures and no mortality.(AU)