Fetal growth velocity in diabetics and the risk for shoulder dystocia: a case-control study.

INTRODUCTION: Shoulder dystocia complicates up to 3% of vaginal births. The clinical ability to predict shoulder dystocia is limited, especially among diabetic women. We sought to evaluate if fetal growth trajectory measured from ultrasonographic (US) estimated fetal weight (EFW) percentiles was associated with increased risk for shoulder dystocia. METHODS: We performed a case-control study among women diagnosed with diabetes at a single institution between 2005 and 2015. Two diabetic controls without shoulder dystocia based on the year of delivery were included for each woman with a shoulder dystocia. Women with a single EFW measurement, delivery by cesarean, or multiple gestation were excluded. Demographic and US data were collected. Fetal growth trajectory was calculated from EFW measurements in the last two growth ultrasound scans performed closest to delivery. We compared the odds of EFW percentile change per week above specific thresholds for shoulder dystocia cases versus controls. The following cutoffs were generated: a mean percentile per week increase of > 0%, ≥ 0.5%, ≥ 1%, and ≥ 2%. Among those with EFW percentile changes that decreased (<0%), we evaluated whether odds of an abdominal circumference (AC) > 75th percentile or an EFW > 75th percentile was higher for women with shoulder dystocia. The primary exposure was increased growth trajectory. Secondary outcomes included analysis of the following adverse neonatal outcomes: (i) low 5 minutes Apgar score, (ii) rates of NICU admission, and (iii) neonatal demise. RESULTS: Of 3954 diabetics, we identified 68 cases with shoulder dystocia and 136 controls who did not have shoulder dystocia. Women who experienced a shoulder dystocia were more likely to be of advanced maternal age as compared to those without a shoulder dystocia (41.9% versus 23.5, p = .01); all other demographic characteristics were similar between groups. At growth trajectory cutoffs of > 0%, ≥ 0.5%, ≥ 1%, and ≥ 2% per week, odds ratios were increased among shoulder dystocia cases versus controls (OR = 1.8, 95% confidence interval (CI) = 0.9-3.3; OR = 1.6, 95% CI = 0.8-3.2; OR = 1.7, 95% CI = 0.7-3.9; and OR = 1.8, 95% CI = 0.6-5.3; respectively); however, this was not statistically significant. For women with fetal growth trajectories that decreased (< 0%), shoulder dystocia was associated with increased odds of fetal AC > 75th percentile and overall growth > 75th percentile (OR = 3.3, 95% CI = 1.5-7.1, OR = 4.8, 95% CI = 1.3-17.4, respectively). There was no difference in neonatal outcomes between shoulder dystocia cases and controls. CONCLUSION: Future research is required to determine if fetal growth velocity proves to be a useful tool in identifying women at increased risk for shoulder dystocia. Larger studies are required for precise estimates of risk, and associated neonatal outcomes.

A randomized trial of the bactericidal effects of chlorhexidine vs povidone-iodine vaginal preparation.

BACKGROUND: Precesarean vaginal preparation significantly reduces postpartum infections. Although povidone-iodine is the most commonly used vaginal antiseptic, evidence suggests that chlorhexidine gluconate may be more effective. OBJECTIVE: We aimed to compare the bactericidal effect of chlorhexidine gluconate and povidone-iodine on vaginal bacterial colony counts in pregnancy. MATERIALS AND METHODS: We conducted a prospective randomized controlled trial of vaginal preparation with 0.5% chlorhexidine gluconate vs 10% povidone-iodine vs saline in women undergoing cesarean delivery at ≥34 weeks' gestation. Women in labor or those with ruptured membranes, chorioamnionitis, abnormal placentation, or allergy to study agents were excluded. Vaginal specimens were collected aseptically in the operating room immediately before and 5-10 minutes after vaginal cleansing with 3 sterile sponge sticks. Our primary outcome was postintervention aerobic and anaerobic bacterial colony counts, assessed by blinded investigators. Two-way analysis of variance with simple-effects analysis and Tukey post hoc test were used for multiple group comparisons. Secondary outcomes included baseline colony counts, change in colony counts, adverse events, and maternal infections. RESULTS: A total of 29 women consented and underwent vaginal preparation with chlorhexidine gluconate (n=10), povidone-iodine (n=9), or saline (n=10). Groups were similar with respect to maternal age, body mass index, race, ethnicity, parity, group B streptococcus status, and gestational age. There were no differences in baseline colony counts. Vaginal preparation with povidone-iodine resulted in lower aerobic and anaerobic colony counts compared with chlorhexidine gluconate and saline (P≤.01 and P≤.0001, respectively). Povidone-iodine eliminated more than 99.9% of bacteria, whereas chlorhexidine gluconate and saline eliminated more than 99% and 95% of bacteria, respectively. Although all agents decreased aerobic and anaerobic bacterial counts, 0.5% chlorhexidine gluconate was no more effective than saline in reducing anaerobic bacteria. There were no reported adverse effects or postpartum infections. CONCLUSION: Compared with 0.5% chlorhexidine gluconate, 10% povidone-iodine was more effective in reducing vaginal bacterial colony counts before cesarean delivery.

Effect of Delayed vs Immediate Umbilical Cord Clamping on Maternal Blood Loss in Term Cesarean Delivery: A Randomized Clinical Trial.

Importance: The American College of Obstetricians and Gynecologists recommends a delay in umbilical cord clamping in term neonates for at least 30 to 60 seconds after birth. Most literature supporting this practice is from low-risk vaginal deliveries. There are no published data specific to cesarean delivery. Objective: To compare maternal blood loss with immediate cord clamping vs delayed cord clamping in scheduled cesarean deliveries at term (≥37 weeks). Design, Setting, and Participants: Randomized clinical trial performed at 2 hospitals within a tertiary academic medical center in New York City from October 2017 to February 2018 (follow-up completed March 15, 2018). A total of 113 women undergoing scheduled cesarean delivery of term singleton gestations were included. Interventions: In the immediate cord clamping group (n = 56), cord clamping was within 15 seconds after birth. In the delayed cord clamping group (n = 57), cord clamping was at 60 seconds after birth. Main Outcomes and Measures: The primary outcome was change in maternal hemoglobin level from preoperative to postoperative day 1, which was used as a proxy for maternal blood loss. Secondary outcomes included neonatal hemoglobin level at 24 to 72 hours of life. Results: All of the 113 women who were randomized (mean [SD] age, 32.6 [5.2] years) completed the trial. The mean preoperative hemoglobin level was 12.0 g/dL in the delayed and 11.6 g/dL in the immediate cord clamping group. The mean postoperative day 1 hemoglobin level was 10.1 g/dL in the delayed group and 9.8 g/dL in the immediate group. There was no significant difference in the primary outcome, with a mean hemoglobin change of -1.90 g/dL (95% CI, -2.14 to -1.66) and -1.78 g/dL (95% CI, -2.03 to -1.54) in the delayed and immediate cord clamping groups, respectively (mean difference, 0.12 g/dL [95% CI, -0.22 to 0.46]; P = .49). Of 19 prespecified secondary outcomes analyzed, 15 showed no significant difference. The mean neonatal hemoglobin level, available for 90 neonates (79.6%), was significantly higher with delayed (18.1 g/dL [95% CI, 17.4 to 18.8]) compared with immediate (16.4 g/dL [95% CI, 15.9 to 17.0]) cord clamping (mean difference, 1.67 g/dL [95% CI, 0.75 to 2.59]; P < .001). There was 1 unplanned hysterectomy in each group. Conclusions and Relevance: Among women undergoing scheduled cesarean delivery of term singleton pregnancies, delayed umbilical cord clamping, compared with immediate cord clamping, resulted in no significant difference in the change in maternal hemoglobin level at postoperative day 1. Trial Registration: ClinicalTrials.gov Identifier: NCT03150641.