"Nobody gave me information": Hospital experiences of Ghanaian families after maternal mortalities.

Background: Rates of maternal mortality are highest in low-resource settings. Family members are often involved in the critical periods surrounding a maternal death, including transportation to health centers and financial and emotional support during hospital admissions. Maternal death has devastating impacts on surviving family members, which are often overlooked and understudied. Objective: Our study aimed to explore the hospital experiences of family members surrounding a maternal death, and to define their access to and need for institutional and psychosocial support. Study Design: This mixed methods cross-sectional study was conducted at an urban tertiary hospital in Ghana. Maternal mortalities from June 2019 to December 2020 were identified using death certificates. Participants, defined as husbands or other heads of households in families affected by maternal mortality, were purposively recruited. An interview guide was developed using grounded theory. In-person semi-structured interviews were conducted in English or Twi to explore impacts of maternal mortality on family members, with a focus on hospital experiences. Surveys were administered on types of and needs for institutional support. Interviews were audio recorded, translated, transcribed, coded with an iteratively-developed codebook, and thematically analyzed. Survey data was descriptively analyzed. Results: Fifty-one participants included 26 husbands of the deceased woman, 5 parents, 12 siblings, and 8 second-degree relatives. Interviews revealed an overall negative hospital experience for surviving family members, who expressed substantial dissatisfaction and distress. Four themes regarding the hospital experience emerged from the interviews: 1) poor communication from healthcare workers and hospital personnel, which contributed to 2) limited understanding of the patient's clinical status, hospital course, and cause of death; 3) maternal death perceived as avoidable; and 4) maternal death perceived as unexpected and shocking. Survey data revealed that only 10% of participants were provided psychosocial support following the maternal death event, yet 93.3% of those who did not receive support desired this resource. Conclusion: The hospital experience was overall negative for family members and a lack of effective communication emerged as the root cause of this negative perception. Strategies to improve communication between healthcare providers and families are essential. In addition, there is an unmet need for formal mental health resources for families who experience a maternal death.

Pregnancy and parenthood.

Singh asserts that the parent-child relationship engenders a moral responsibility for the newborn. Simultaneously, he contends, drawing on the argument from potentiality, that the fetal stage of human development does not establish the parent-child relationship. Consequently, within Singh's proposed relational framework, moral responsibility for the developing fetus does not manifest. Thus, Singh advocates for abortion, citing the absence of moral responsibilities arising for the pregnant woman for the fetus. In this article, I critique Singh's argument from potentiality, identifying flaws and highlight the incoherence of the argument pertaining to the parent-child relationship.

The Association Between State-Level Prenatal Substance Use Policies and Rates of Maternal Mortality in the United States: A Legal Epidemiology Study.

Little research has explored relationships between prenatal substance use policies and rates of maternal mortality across all 50 states, despite evidence that prenatal substance use elevates risk of maternal death. This study, utilizing publicly available data, revealed that state-level mandated testing laws predicted maternal mortality after controlling for population characteristics.

Validation of Database Autopsy for Review of Pregnancy-Associated Deaths in Canada.

The database autopsy method was developed to determine probable causes of maternal deaths in the Canadian Institute for Health Information's hospital discharge abstract database, but the method has yet to be validated. Using immediate cause of death information from Quebec's hospitalization database as the gold standard, this study assessed the validity and reliability of the database autopsy method for pregnancy-associated deaths. The method had high sensitivity and specificity for identifying the most common causes of these deaths, as well as high interobserver agreement. We conclude that the database autopsy method is valid and reliable overall.

Maternal mortality due to obstetric hemorrhage by surgical injury during cesarean section: A nationwide study.

INTRODUCTION: Obstetric hemorrhage remains a largely preventable cause of maternal mortality globally. The contribution of uterine atony to hemorrhage-related maternal mortality has decreased in France, while the contribution of other causes of obstetric hemorrhage such as surgical injury during cesarean has been reported to increase. However, little evidence exists regarding the risk factors and care processes of women who died from this cause of hemorrhage. Therefore, we aimed to describe the clinical profile, underlying mechanisms, and preventability factors among women who died from obstetric hemorrhage by surgical injury during cesarean section. MATERIAL AND METHODS: Nationwide analysis of all hemorrhage-related maternal deaths by surgical injury during cesarean in France identified by the nationwide permanent enhanced maternal mortality surveillance system (ENCMM) between 2007 and 2018. We described the characteristics of the women, delivery hospitals, circumstances of hemorrhage, features of obstetric and resuscitation/transfusion care, and main preventability factors. RESULTS: Between 2007 and 2018, hemorrhage-related maternal mortality in France decreased from 1.6/100 000 live births (95% CI 1.1-2.2) (39/2 472 650) in 2007-2009 to 0.8/100 000 live births (95% CI 0.5-1.3) (19/2 311 783) in 2016-2018. Hemorrhage-related maternal mortality ratio due to surgical injury during cesarean increased from 0.08 (95% CI 0.01-0.3) (2/2 472 650) to 0.2 (95% CI 0.07-0.5) (5/2 311 783) per 100 000 live births. Among the 18 women who died from surgical injury during cesarean over the 12-year study period, we report a high prevalence of obesity (67%, 12/18), previous cesarean (72%, 13/18), and second-stage cesareans (56%, 10/18). In 22% (4/18), cesarean section was performed in a hospital providing <1000 births annually, with no blood bank (39%, 7/18) or no adult intensive care (44%, 8/18) on-site. Overall preventability of deaths was 94% (17/18). Main preventability factors were related to delay in hemorrhage diagnosis (77%, 14/18) due to late recognition of abnormal parameters (33%, 6/18) and late bedside ultrasound (56%, 10/18), and delay in management due to insufficient surgical skills (56%, 10/18). CONCLUSIONS: In France, surgical injury during cesarean section is an increasing, largely preventable contributor to hemorrhage-related maternal mortality, as other causes of fatal hemorrhage have become less frequent. The profile of these women showed a high prevalence of obesity, previous cesarean, second-stage cesarean, and delivery in hospitals with limited medical and surgical resources, which suggests explanatory mechanisms for the fatal outcome and opportunities for prevention.

Complexities of implementing Maternal and Perinatal Death Surveillance and Response in crisis-affected contexts: a comparative case study.

BACKGROUND: Maternal and Perinatal Death Surveillance and Response (MPDSR) systems provide an opportunity for health systems to understand the determinants of maternal and perinatal deaths in order to improve quality of care and prevent future deaths from occurring. While there has been broad uptake and learning from low- and middle-income countries, little is known on how to effectively implement MPDSR within humanitarian contexts - where disruptions in health service delivery are common, infrastructural damage and insecurity impact the accessibility of care, and severe financial and human resource shortages limit the quality and capacity to provide services to the most vulnerable. This study aimed to understand how contextual factors influence facility-based MPDSR interventions within five humanitarian contexts. METHODS: Descriptive case studies were conducted on the implementation of MPDSR in Cox's Bazar refugee camps in Bangladesh, refugee settlements in Uganda, South Sudan, Palestine, and Yemen. Desk reviews of case-specific MPDSR documentation and in-depth key informant interviews with 76 stakeholders supporting or directly implementing mortality surveillance interventions were conducted between December 2021 and July 2022. Interviews were recorded, transcribed, and analyzed using Dedoose software. Thematic content analysis was employed to understand the adoption, penetration, sustainability, and fidelity of MPDSR interventions and to facilitate cross-case synthesis of implementation complexities. RESULTS: Implementation of MPDSR interventions in the five humanitarian settings varied in scope, scale, and approach. Adoption of the interventions and fidelity to established protocols were influenced by availability of financial and human resources, the implementation climate (leadership engagement, health administration and provider buy-in, and community involvement), and complex humanitarian-health system dynamics. Blame culture was pervasive in all contexts, with health providers often facing punishment or criminalization for negligence, threats, and violence. Across contexts, successful implementation was driven by integrating MPDSR within quality improvement efforts, improving community involvement, and adapting programming fit-for-context. CONCLUSIONS: The unique contextual considerations of humanitarian settings call for a customized approach to implementing MPDSR that best serves the immediate needs of the crisis, aligns with stakeholder priorities, and supports health workers and humanitarian responders in providing care to the most vulnerable populations.

The profile of patients with postpartum hemorrhage admitted to the obstetric intensive care: a cross-sectional study.

Objective: In Brazil, postpartum hemorrhage (PPH) is a major cause of maternal morbidity and mortality. Data on the profile of women and risk factors associated with PPH are sparse. This study aimed to describe the profile and management of patients with PPH, and the association of risk factors for PPH with severe maternal outcomes (SMO). Methods: A cross-sectional study was conducted in Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) obstetric intensive care unit (ICU) between January 2012 and March 2020, including patients who gave birth at the hospital and that were admitted with PPH to the ICU. Results: The study included 358 patients, of whom 245 (68.4%) delivered in the IMIP maternity, and 113 (31.6%) in other maternity. The mean age of the patients was 26.7 years, with up to eight years of education (46.1%) and a mean of six prenatal care. Uterine atony (72.9%) was the most common cause, 1.6% estimated blood loss, 2% calculated shock index (SI), 63.9% of patients received hemotransfusion, and 27% underwent hysterectomy. 136 cases of SMO were identified, 35.5% were classified as maternal near miss and 3.0% maternal deaths. Multiparity was associated with SMO as an antepartum risk factor (RR=1.83, 95% CI1.42-2.36). Regarding intrapartum risk factors, abruptio placentae abruption was associated with SMO (RR=2.2 95% CI1.75-2.81). Among those who had hypertension (49.6%) there was a lower risk of developing SMO. Conclusion: The principal factors associated with poor maternal outcome were being multiparous and placental abruption.

The Impact of the Use of e-Partogram on Maternal and Perinatal Outcomes: A Scoping Review.

To overcome shortcomings of the paper partograph, enhance care during labor and delivery, improve record keeping, and help decision-making, several countries have focused on adopting low-cost digital applications. This scoping review highlights the usability and current status of the digital partogram in obstetric care. We conducted a thorough search involving the databases ScienceDirect, PubMed, and Google Scholar for relevant studies from inception till September 2023 by using the keywords "partograph", "electronic", and "obstetric" as well as the Boolean operators "AND" and "OR". Based on the selection criteria, 25 studies exploring the application of electronic partographs (e-partographs) in obstetric care were included in the review. The majority of the studies examined the efficiency and reported the effectiveness of e-partographs in comparison to paper partographs. The e-partograph has also demonstrated a clear benefit in that the healthcare providers filled out the data, and a reminder mechanism was placed, which might help determine whether the labor process was normal or needed more care. Moreover, an e-partograph was simple to adopt and use for obstetric caregivers and had the potential to save time. To sum up, digital partograph produces superior results to paper partograph. The use of an e-partograph can keep deliveries on track while lowering the need for cesarean sections and prolonged labor. The e-partograph provides essential benefits to its users and also provides a warning system with audible and visual cues that might be utilized to detect difficulties during delivery.

Traumatic pelvic ring fracture during pregnancy: a systematic review.

Purpose: This systematic review aims to investigate the management and outcomes of pelvic ring fractures (PRFs) during pregnancy, emphasizing maternal and fetal mortality rates, mechanisms of injury, and treatment modalities. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a comprehensive search of databases from 2000 to 2023, identifying 33 relevant studies. Data extraction included demographics, fracture types, treatment methods, and outcomes. Risk of bias was assessed using the JBI criteria. Results: Maternal mortality stood at 9.1%, with fetal mortality at 42.4%. Maternal factors impacting mortality included head trauma and hemodynamic instability. Fetal mortality correlated with mechanisms like motor vehicle accidents and maternal vital signs. Surgical and conservative treatments were applied, with a majority of pelvic surgeries performed before delivery. External fixators proved effective in fracture stabilization. Conclusion: Pelvic ring fractures during pregnancy present significant risks to maternal and fetal health. Early stabilization and vigilant monitoring of maternal vital signs are crucial. Vaginal bleeding/discharge serves as a critical fetal risk indicator. The choice between surgical and conservative treatment minimally influenced outcomes. Multidisciplinary collaboration and tailored interventions are essential in managing these complex cases.

Acute febrile illness in pregnancy: Spectrum of disease and impact on maternal and foetal outcome.

Acute febrile illness (AFI) in pregnancy is a neglected cause of maternal and foetal mortality and morbidity in low-and middle-income countries. This prospective cohort studied antenatal and postpartum women admitted with acute fever to a tertiary care university teaching hospital from July 2014 to March 2015 for aetiology, maternal and foetal complications, and the impact on maternal mortality ratio (MMR) and perinatal mortality rate. Among the 180 women admitted with AFI, urinary tract infection 54(30%) was the commonest cause, followed by airborne infections (67; 37.2%), peripartum or wound infections (25; 13.8%) and vector-borne diseases (21; 11.6%). Maternal deaths were 4 (2%) and foetal deaths 9 (5%). Post-operative gram-negative sepsis was the most common cause of maternal mortality. The MMR was ten times higher with AFI 2778 against 197 (p < 0.0001) among the other hospital deliveries during the same period. Screening for asymptomatic bacteriuria , maintaining aseptic precautions, and vaccination may impact maternal and foetal morbidity significantly.

Planning, Implementation, and Evaluation of a Postpartum Nurse Home Visit Service to Improve Health Equity.

OBJECTIVE: To describe how a college of nursing and urban academic medical center partnered with the local health department to plan, implement, and evaluate a universal nurse home visit service to improve health equity in the postpartum period. DESIGN: Evidence-based practice. SETTING/LOCAL PROBLEM: Wide health disparity in rates of maternal and infant morbidity and mortality in Chicago, Illinois. PATIENTS: All patients who gave birth at the medical center and lived in Chicago. INTERVENTION/MEASUREMENTS: A nurse home visit was offered after birth to all eligible patients beginning in March 2020. We used data from a Web-based platform to determine key performance indicators for the program and examined patient demographics to determine equitable delivery of the service for all visits provided in 2022. RESULTS: There were 1,488 patients eligible for a home visit and 714 who received a home visit. The average contact rate was 76%, the scheduling rate was 63%, the completion rate for scheduled visits was 76%, and the population reach was 48%. Sixty-eight percent of families visited were from high-economic-hardship zip code areas of the city. Eighty-one percent of visits resulted in at least one referral to meet a family's need, and 98% of patients surveyed rated their visit as "very helpful." CONCLUSION: The successful implementation of this public-private partnership was due in part to an organizational culture that supports health equity initiatives, the inclusion of system-wide stakeholders, having a process in place to monitor outcomes, and hiring a diverse team of nurses who prioritize respectful patient-centered care.

Healthcare system variability and inpatient maternal mortality in the United States.

OBJECTIVE: To examine the association of inpatient maternal mortality with variability in healthcare services delivery such as hospital size, urban/rural designation, teaching/non-teaching status, regional location, and insurance coverage. METHODS: This is a pooled, cross-sectional analysis of the National Inpatient Sample (2012-2014). Information on maternal demographics, clinical conditions, and birth outcomes were identified using respective ICD9-CM codes. Bivariate and multivariate analysis using logistic regression models were used to describe maternal characteristics and to calculate the risk of mortality with each independent variable. RESULTS: The weighted sample included 12,409,939 hospital records (82.6% are 18-34-year-old and 49.5% are Caucasians). Maternal death during hospitalization occurred in 1310 cases (12/100,000 live birth). Women with cardiovascular disorders, hemorrhage or sepsis were 33.6, 4.7, and 5.4 times more likely to suffer inpatient maternal mortality. Compared to small-sized hospitals, delivery at medium or large size hospitals is associated with higher mortality, adjusted odds ratios (aOR) 1.8 (1.4-2.3), and 2.2 (1.8-2.8), respectively. Adjusted OR for inpatient maternal mortality in urban non-teaching or urban teaching compared to rural hospitals were 2.2 (1.7-3.0) and 2.9 (2.2-3.9), respectively. Women in the South have higher maternal mortality compared to Northeast, aOR 1.7 (1.5-2.1). Women coved with public insurance experience higher inpatient maternal mortality compared to those with private insurance, aOR: 2.6 (2.1-3.2) and 1.9 (1.6-2.1), respectively. CONCLUSION: Factors related to variability in healthcare delivery may play a role in inpatient maternal mortality. Some could be explained by the case mix and the clinical conditions affecting birthing outcomes. A qualitative analysis is needed to explore how these factors relate to increased maternal mortality in certain hospital settings.

Factors affecting antenatal care attendance in Soweto, Johannesburg: The three-delay model.

BACKGROUND:  Antenatal care remains critical for identifying and managing complications contributing to maternal and infant mortality, yet attendance among women in South Africa persists as a challenge. AIM:  This study aimed to understand the challenges faced by women attending antenatal care in Soweto, Johannesburg, using the three-delay model. SETTING:  This study was conducted in Soweto, Johannesburg. METHODS:  An exploratory, descriptive and qualitative research design was used, and in-depth interviews were conducted with 10 pregnant women and four women who had recently given birth. RESULTS:  Findings indicate delays in seeking care due to factors such as pregnancy unawareness, waiting for visible signs, and fear of human immunodeficiency virus (HIV) testing. Challenges such as transportation difficulties, distance to clinics, and facility conditions further impeded the initiation of antenatal care. Late initiation often occurred to avoid long waits, inadequate facilities, language barriers and nurse mistreatment. CONCLUSION:  From this study, we learn that challenges such as unawareness of pregnancy, cultural notions of keeping pregnancy a secret, fear of HIV testing, long waiting lines, high cost of transportation fees, clinic demarcation, shortage of essential medicines, broken toilets and verbal abuse from nurses have delayed women from initiating antenatal care early in Soweto, Johannesburg.Contribution: Challenges of women with antenatal care attendance in South Africa must be addressed by implementing community-based health education interventions, institutionalising HIV psycho-social support services and improving quality of antenatal care services in public health facilities.

Role of prophylactic tranexamic acid in reducing blood loss during cesarean section: A double-blind placebo-controlled randomized controlled trial.

Background: Postpartum hemorrhage (PPH) is defined by the World Health Organization as blood loss of ≥500 mL within 24 h of delivery. Globally, hemorrhage accounts for 27.1% of maternal deaths, making it the leading direct cause of maternal death. PPH has been identified in more than two-thirds of reported hemorrhage-related deaths, causing 38% of maternal deaths in India. Tranexamic acid, an antifibrinolytic, has been used to control bleeding after PPH is identified. Materials and Methods: Antenatal women admitted for elective cesarean section were randomized into two arms: the case group (received one gram of tranexamic acid 20 min prior to skin incision) and the control group (received a placebo), each group consisting of 36 participants. Clinical Trials Registry - India (CTRI) registration number - CTRI/2021/02/031579. Results: The mean (±standard deviation [SD]) intraoperative blood loss in the case group was 241.25 (±67.83) mL, and in the control group, it was 344.92 (±146.67) mL (P = 0.001), while postoperative blood loss did not differ significantly between the groups (P = 0.1470). In terms of the difference in hemoglobin, there was a significant difference between the two groups (P = 0.001). No significant maternal or neonatal side effects were found. Conclusion: Preoperative tranexamic acid, when given in elective cesarean section, significantly reduces intraoperative blood loss.

Evaluating a clinical mentorship intervention on maternal and neonatal complications in primary health facilities in Blantyre district, Malawi: A longitudinal analysis of the Global Action in Nursing program.

BACKGROUND: While Malawi has made great strides increasing the number of facility-based births, maternal and neonatal mortality remains high. An intervention started in 2019 provided short-course training followed by year-long longitudinal bedside mentorship for nurse midwives at seven health facilities in Blantyre district. The intervention was initiated following invitation from the district to improve outcomes for patients during childbirth. This study examined the impact of the intervention on the reporting of obstetric and neonatal complications and related care. METHODS: Patient level data were collected from the District Health Information System 2 database from intervention and non-intervention facilities. Bivariate analysis explored the impact of longitudinal bedside mentorship on select District Health Information System 2 variables at six-month intervals. Outcomes were then analyzed using nonlinear quantile mixed models to better account for the impact of time and clustering at the facility level. RESULTS: Significant changes were found in the reporting of obstetric and neonatal complications over time at intervention facilities compared to non-intervention facilities. Intervention facilities showed statistically significant increases in the reporting of prolonged labor, pre/eclampsia, fetal distress, retained placenta, and premature labor. There was also a statistically significant decrease in the reporting of no complications in the multivariate model (95%CI: -0.8 to -0.2). In both the bivariate and multivariate models, the reporting of 'None' significantly decreased (0.8 % median), while the reporting of prematurity (0.2 % median) and asphyxia (0.3 % median) both significantly increased. The missingness of data at intervention facilities decreased to almost zero compared to non-intervention facilities. DISCUSSION: The increase in reported maternal and neonatal complications suggests improved early identification of complications at the facility level. The improved accuracy of patient data from intervention facilities shows the impact mentorship has on data quality which is crucial for the allocation of resources. By highlighting the apparent dose-response relationship of longitudinal bedside mentorship, this study will inform the broader use of mentorship in training programs. Future research is needed to explore the impact of longitudinal mentorship on quality of care.

Community health promotion and medical provision and impact on neonates (CHAMPION2) and support to rural India's public education system and impact on numeracy and literacy scores (STRIPES2): an update to the study protocol (v 11) for a cluster randomised trial in Madhya Pradesh, India.

BACKGROUND: This update outlines amendments to the CHAMPION2/STRIPES2 cluster randomised trial protocol primarily made due to the COVID-19 pandemic and nationwide lockdown in India in 2020. These amendments were in line with national guidelines for health research during the COVID-19 pandemic. METHODS: We did not change the original trial design, eligibility, and outcomes. Amendments were introduced to minimise the risk of COVID-19 transmission and ensure safety and wellbeing of trial staff, participants, and other villagers. CHAMPION2 intervention: participatory learning and action (PLA) and fixed day service (FDS) meeting were revised to incorporate social distancing and hygiene precautions. During the COVID-19 pandemic, PLA participation was limited to pregnant women and birthing partners. STRIPES2 intervention: before/after-school classes were halted for a period and then modified temporarily (reducing class sizes, and/or changing meeting places) with hygiene and safe distancing practices introduced. DATA COLLECTION: The research team gathered as much information as possible from participants by telephone. If the participant had no telephone or could not be contacted by telephone, data were collected in person. COVID-19 precautions: trial teams were trained on COVID-19 precautions and used personal protective equipment whilst in the villages for trial-related activities. After restarting the trial between June and September 2020 in a phased manner, some trial activities were suspended again in all the trial villages from April to June 2021 due to the second wave of COVID-19 cases and lockdown imposed in Satna, Madhya Pradesh. Trial timelines were also revised, with outcomes measured later than originally planned. TRIAL REGISTRATION: Clinical Trial Registry of India CTRI/2019/05/019296. Registered 23 May 2019. https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=MzExOTg=&Enc=&userName=champion2 .

Why is ethnicity a risk factor for postpartum haemorrhage?

Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and morbidity on a global scale. Ethnic background is known to be a determinant of variation in the outcomes of women receiving maternity care across the world. Despite free maternity healthcare in the UK National Health Service, women with an ethnic minority background giving birth have an increased risk of PPH, even when other characteristics of the mother, the baby and the care received are considered. Improving PPH care has significant implications for improving health equity. The underlying causes of ethnic disparities are complex and multifaceted. It requires a deep dive into analysing the unique patient factors that make these women more likely to suffer from a PPH as well as reflecting on the efficacy of intra and postpartum care and prophylactic treatment these women receive.

Society for Maternal-Fetal Medicine Consult Series #71: Management of previable and periviable preterm prelabor rupture of membranes.

Previable and periviable preterm prelabor rupture of membranes are challenging obstetric complications to manage, given the substantial risk of maternal morbidity and mortality with no guarantee of fetal benefit. The following are Society for Maternal-Fetal Medicine recommendations for the management of previable and periviable preterm prelabor rupture of membranes prior to the period when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient: (1) we recommend that pregnant patients with previable and periviable preterm prelabor rupture of membranes receive individualized counseling about the maternal and fetal risks and benefits of both abortion care and expectant management to guide an informed decision. All patients with previable and periviable preterm prelabor rupture of membranes should be offered abortion care. Expectant management can also be offered in the absence of contraindications (GRADE 1C); (2) we recommend antibiotics for pregnant individuals who choose expectant management after preterm prelabor rupture of membranes at ≥ 24 0/7 weeks of gestation (GRADE 1B); (3) antibiotics can be considered after preterm prelabor rupture of membranes at 20 0/7 to 23 6/7 weeks of gestation (GRADE 2C); (4) administration of antenatal corticosteroids and magnesium are not recommended until the time when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient (GRADE 1B); (5) serial amnioinfusions and amniopatch are considered investigational and should be used only in a clinical trial setting; they are not recommended for routine care of previable and periviable preterm prelabor rupture of membranes (GRADE 1B); (6) cerclage management after preterm prelabor rupture of membranes is similar to cerclage management after preterm prelabor rupture of membranes at later gestational ages; it is reasonable to either remove the cerclage or leave it in situ after discussing the risks and benefits and incorporating shared decision-making (GRADE 2C); (7) in subsequent pregnancies after a history of previable or periviable preterm prelabor rupture of membranes, we recommend following guidelines for management of pregnant persons with a prior spontaneous preterm birth (GRADE 1C).

Trend analysis of caesarean sections using modified Robson's classification in a teaching institution in Uttarakhand.

Background: Globally, the rising caesarean section (CS) rate is of great concern as it is associated with increased maternal morbidity and mortality in subsequent pregnancies. It is essential to reanalyze the CS trend and curb the rising menace using a standardized uniform auditing system. This study aimed to analyze and evaluate the trend of CS using Modified Robson's Ten Group classification system (RTGCS) in a teaching institution in Uttarakhand. Methodology: This cross-sectional study from October 2022 to March 2023 included 260 women undergoing elective or emergency CS. Data on maternal demographics, obstetrics, labour, and fetal outcomes were recorded. Indications for CS were analyzed using modified RTGCS. Results: The overall CS rate for the study period at our hospital was 31.4%. The major contributors to CS were Group 2 (21.5%), Group 10 (21.5%), and Group 5 (20.7%), while Group 6 and Group 8 contributed 10% and 7.6%, respectively. Group 9 had the least share (1%) in the study population. The two main indications for which CS was performed were prior Lower Section Caesarean Section (LSCS) and fetal distress, contributing to 24.6% and 19.2%, respectively. CS for breech presentation was done in 16% of the total cases. Conclusion: Modified RTGCS is an easy and effective method for auditing CS, preventing unnecessary procedures, and improving maternal care. Its implementation is crucial in addressing the increasing prevalence of CS and ensuring better maternal and fetal outcomes.