Search Results (23)

Precipitous deliveries in the emergency department are one of the highest-acuity events that emergency providers manage. These deliveries can range from uncomplicated to wrought with difficulty. They require emergency care providers to manage intrapartum complications, such as nuchal cords, shoulder dystocia, and breech presentation, and maternal complications such as uterine atony, birth canal trauma, and postpartum hemorrhage. Delivery may additionally necessitate resuscitative hysterotomy or neonatal resuscitation. Our narrative review discusses preparatory practices, normal labor and delivery progression, and brief guidelines for managing complications of precipitous deliveries for emergency medicine providers. Full article

Objective: Shoulder dystocia (ShD) is a rare but serious obstetric emergency associated with significant neonatal morbidity. This study aimed to evaluate the predictive performance of machine learning (ML) models based on fetal biometric ratios and clinical characteristics for the identification of ShD in pregnancies without clinical suspicion of macrosomia. Methods: We conducted a retrospective case-control study including 284 women (84 ShD cases and 200 controls) who underwent spontaneous vaginal delivery between 37 and 42 weeks of gestation. All participants had an estimated fetal weight (EFW) below the 90th percentile according to Hadlock reference curves. Univariate and multivariate logistic regression analyses were performed on maternal and neonatal parameters, and statistically significant variables (p < 0.05) were used to construct adjusted odds ratio (aOR) models. Supervised ML models—Logistic Regression (LR), Random Forest (RF), and Extreme Gradient Boosting (XGB)—were trained and tested to assess predictive accuracy. Performance metrics included AUC-ROC, sensitivity, specificity, accuracy, and F1-score. Results: The BPD/AC ratio and AC/FL ratio markedly enhanced the prediction of ShD. When added to other features in RF models, the BPD/AC ratio got an AUC of 0.884 (95% CI: 0.802–0.957), a sensitivity of 68%, and a specificity of 83%. On the other hand, the AC/FL ratio, along with other factors, led to an AUC of 0.896 (95% CI: 0.805–0.972), 68% sensitivity, and 90% specificity. Conclusions: In pregnancies without clinical suspicion of macrosomia, ML models integrating fetal biometric ratios with maternal and labor-related factors significantly improved the prediction of ShD. These models may support clinical decision-making in low-risk deliveries where ShD is often unexpected. Full article

Background/Objectives: As the incidence of diabetes mellitus (DM) is increasing rapidly worldwide, it is anticipated that an increasing number of women will enter pregnancy with pregestational diabetes mellitus (PGDM) in the future. Compelling evidence suggests that hyperglycemia in pregnancy is related to multiple adverse perinatal outcomes. This systematic review and meta-analysis aims to assess and quantify the association of PGDM with a range of adverse perinatal outcomes, providing a comprehensive understanding of its impact on pregnancy. Methods: The data sources of this systematic review and meta-analysis were Medline/PubMed, Scopus and Cochrane Library (January 1999 to August 2023), complemented by hand-searching for additional references. Observational studies reporting perinatal outcomes of pregnancies with PGDM diagnosed before pregnancy versus control pregnancies were eligible for inclusion. A systematic review and meta-analysis were conducted as per the PRISMA guidelines. Pooled estimate odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to determine the risk of adverse pregnancy outcomes between PGDM and control pregnancies. Results: The systematic search of the literature yielded 81 observational studies meeting inclusion criteria and in total, 137,237,640 pregnancies were included in the analysis. A total of 19 adverse perinatal outcomes were assessed, revealing a significant association with PGDM. In pregnancies with PGDM there was an increased risk of adverse perinatal outcomes, including gestational hypertension (OR 3.16, 95% CI 2.65–3.77), preeclampsia (OR 4.46, 95% CI 3.94–5.05), preterm delivery (OR 3.46, 95% CI 3.06–3.91), cesarean delivery (OR 3.12, 95% CI 2.81–3.47), induction of labor (OR 2.92, 95% CI 2.35–3.63), macrosomia (OR 2.23, 95% CI 1.76–2.83), LGA neonates (OR 3.95, 95% CI 3.47–4.49), low 5-min Apgar score (OR 2.49, 95% CI 2.07–2.99), shoulder dystocia (OR 3.05, 95% CI 2.07–4.50), birth trauma (OR 1.40, 95% CI 1.22–1.62), polyhydramnios (OR 5.06, 95% CI 4.33–5.91), oligohydramnios (OR 1.61, 95% CI 1.19–2.17), neonatal hyperbilirubinemia (OR 3.45, 95% CI 2.51–4.74), neonatal hypoglycemia (OR 19.19, 95% CI 2.78–132.61), neonatal intensive care unit (NICU) admission (OR 4.54, 95% CI 3.87–5.34), congenital malformations (OR 2.44, 95% CI 1.96–3.04), stillbirth (OR 2.87, 95% CI 2.27–3.63) and perinatal mortality (OR 2.94, 95% CI 2.18–3.98). Subgroup analyses indicated a higher risk of neonatal hypoglycemia, stillbirth and perinatal mortality in T1DM pregnancies compared with T2DM pregnancies. Conclusions: This study provides a robust synthesis of evidence underlying the strong association between PGDM and several adverse perinatal outcomes. Early detection, optimal glycemic control during the periconceptional and pregnancy periods, and proper antenatal care are critical to mitigate these risks. Full article

Maturity-onset diabetes of the young (MODY)—a monogenic form of diabetes—accounts for approximately 1–2% of all diabetes cases, with GCK-MODY being the second most commonly diagnosed type. Although the inherited nature of the disease implies that the interplay between maternal glycemia and fetal genotype directly influences neonatal outcomes, clinical guidelines for MODY-complicated pregnancies remain underdeveloped. A systematic literature search in the PubMed, Scopus, Web of Science, and Cochrane databases was conducted following the PRISMA guidelines. The study protocol has been logged in the PROSPERO registry with the identification number CRD42024609390. Data, such as MODY type, the gestational age at delivery, mode of delivery, insulin administration, mutational status of the fetus, fetal birthweight (FBW), occurrence of small-/large-for-gestational age fetus, shoulder dystocia, and neonatal hypoglycemia, were extracted and evaluated. Among 19 studies selected for the final analysis, 15 investigated perinatal outcomes in the GCK-MODY variant. Women diagnosed with GCK-MODY treated with insulin delivered approximately 1–2 weeks earlier than those managed with diet alone. FBW was significantly higher in GCK-negative as compared to GCK-positive offspring. Accordingly, fetal macrosomia was notably more common among unaffected neonates. In GCK-affected fetuses, insulin therapy was associated with a significantly lower FBW. Fetal genotype critically modifies perinatal outcomes in GCK-MODY pregnancies. In the absence of fetal genotyping, conservative management should be prioritized to mitigate the risks of fetal growth restriction and iatrogenic prematurity. As data regarding other types of MODY in pregnancy remain sparse, there is an urgent need for more research in this area. Full article

Background: A brachial plexus avulsion occurs when the nerve root separates from the spinal cord during birthing trauma, such as shoulder dystocia or a difficult vaginal delivery. A complete paralysis of the affected levels occurs post-brachial plexus avulsion. Despite being reported in 10–20% of brachial plexus birthing injuries, it remains poorly diagnosed during the acute stages of injury, leading to poor intervention approaches. The poor diagnosis of brachial plexus avulsion injury can be attributed to the currently unavailable biomechanics of brachial plexus avulsion. While the biomechanical properties of neonatal brachial plexus are available, the forces required to avulse a neonatal brachial plexus remain unknown. Methods: This study aims to provide detailed biomechanics of the required forces and corresponding strains for neonatal brachial plexus avulsion. Biomechanical tensile testing was performed on an isolated, clinically relevant piglet spinal cord and brachial plexus complex, and the required avulsion forces and strains were measured. Results: The reported failure forces and corresponding strains were 3.9 ± 1.6 N at a 27.9 ± 6.5% strain, respectively. Conclusion: The obtained data are required to understand the avulsion injury biomechanics and provide the necessary experimental data for computational model development that serves as an ideal surrogate for understanding complicated birthing injuries in newborns. Full article

Objective: To investigate the prevalence, risk factors, and complications associated with delivering macrosomic babies. Methods: Singleton term pregnancies (12,045) were studied. Macrosomia was categorized using the following two definitions: birthweight > 4 kg and birthweight ≥ 90th percentile (3.7 kg). Regression models were developed to identify significant risk factors for macrosomia such as maternal age, parity, pre-pregnancy body mass index, gestational weight gain, and hyperglycemia. Other models were constructed to identify the independent effect of macrosomia on outcomes such as shoulder dystocia, emergency cesarean section, stillbirth, and low APGAR scores. Results: The 50th centile birth weight of Saudi term infants is 3.18 kg; the 90th and 95th centiles were 3.70 and 3.91 kg, respectively. The prevalence of macrosomia (>4 kg) was 3.4%. The likelihood of macrosomia was associated with maternal age >40 years for newborns >4 kg, OR = 1.88, 95% CI (1.02–3.48), and maternal age < 18 for newborns ≥90th centile, OR = 5.23, 95% CI, (1.05–26.06). Regardless of the classification of macrosomia, it was associated with gestational age ≥41 weeks, parity > 4, pre-pregnancy BMI > 30, and maternal hyperglycemia. Macrosomia, using either definition, was associated with increased risk of shoulder dystocia, OR = 11.45, 95% CI (4.12–31.82) and OR = 9.65, 95% CI (3.89–23.94), and emergency CS, OR = 2.03, 95% CI (1.36–3.08) and OR = 1.77, 95% CI (1.34–1.52), for birthweight > 4 kg and ≥90th centile, respectively. Furthermore, newborns whose weights >4 kg were at greater risk to be stillborn, OR = 4.24, 95% CI (1.18–15.20), and to have low APGAR scores at birth, OR = 3.69, 95% CI (1.25–10.98). Conclusion: The risk of macrosomia among Saudi women significantly increases with maternal age, parity, gestational age, hyperglycemia, and pre-pregnancy obesity. Regardless of the definition used, delivering a macrosomic baby was associated with risks of shoulder dystocia and emergency cesarean section. Newborns (>4 kg) were at greater risk of stillbirth and low APGAR scores. Full article

(1) Background: Obstetric brachial plexus palsy (OBPP) is an unpredictable and unpreventable neurological injury, caused by shoulder dystocia during birth, that affects the brachial plexus and leads to motor and sensory deficits in the child’s upper extremity. The limited literature on early therapeutic assessment of newborns with OBPP highlights a gap in specialized care that, if filled, could enhance decision-making and support timely treatment. The objective of this paper is to analyze the therapeutic intervention techniques used at an early stage and their functional impact, from the occupational therapy discipline in the treatment of the upper extremity in babies and children with OBPP. (2) Method: Systematic review design and meta-analysis. A systematic review is a comprehensive analysis of existing research on a specific topic, using rigorous methods to identify, evaluate, and synthesize studies. Meta-analysis, often part of a systematic review, combines results from multiple studies to identify overall trends and enhance reliability, providing a clearer summary of evidence. Articles that included pediatric patients (from birth to 12 years of age) with a diagnosis of OBPP were reviewed. The results of the techniques used were analyzed according to each study, with the scale or method of assessment considered by the study for the presentation of data. The articles were assessed for methodological quality using the “PEDro Validity Scale”. (3) Results: A total of 2190 articles were found, with 108 analyzed and 22 fully meeting this study’s standards. Fourteen had a quantitative design, while the others included clinical guidelines. The most statistically reliable intervention techniques were CIMT (constraint-induced movement therapy) and splinting (dynamic and static), with second-tier techniques like joint manipulation, NMES, early infant management education, and serial casting used when needed. This study focused on children from birth to eight years old, with assessment tools primarily measuring upper limb range of motion, external rotation, supination, and impairment levels, though bimanual activity assessment was less common. (4) Conclusions: The early implementation of the techniques that provide us with the most data are CIMT, splinting, NMES, and joint manipulation linked to health education for families. In second place, we have the use of TB infiltrations and serial casts, when the treatment of the previous techniques fails in some cases. Full article

The term dystocia refers to labor characterized by a slow progression with delayed rates or even pauses in the dilation of the cervix or the descent of the fetus. Dystocia describes the deviation from the limits that define a normal birth and is often used as a synonym for the term pathological birth. Shoulder dystocia, also known as the manual exit of the shoulders during vaginal delivery on cephalic presentation, is defined as the “failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head”. This means that obstetric interventions are necessary to deliver the fetus’s body after the head has been delivered, as gentle traction has failed. Abnormal labor (dystocia) is expressed and represented in partograms or by the prolongation of the latent phase or by slowing and pausing in the phases of cervical dilatation and fetal descent. While partograms are helpful in visualizing the progress of labor, regular use of them has not been shown to enhance obstetric outcomes considerably, and no partogram has been shown to be superior to others in comparative trials. Dystocia can, therefore, appear in any phase of the evolution of childbirth, so it is necessary to simultaneously assess all the factors that may contribute to its abnormal evolution, that is, the forces exerted, the weight, the shape, the presentation and position of the fetus, the integrity and morphology of the pelvis, and its relation to the fetus. When this complication occurs, it can result in an increased incidence of maternal morbidity, as well as an increased incidence of neonatal morbidity and mortality. Although several risk factors are associated with shoulder dystocia, it has proven impossible to recognize individual cases of shoulder dystocia in practice before they occur during labor. Various guidelines have been published for the management of shoulder dystocia, with the primary goal of educating the obstetrician and midwife on the importance of a preplanned sequence of maneuvers, thereby reducing maternal and neonatal morbidity and mortality. Full article

Introduction and Hypothesis: Obstetric anal sphincter injuries (OASIs) complicate 5.8% of vaginal deliveries. Our objective was to assess if the primary delivery provider, a nurse-midwife versus physician obstetrician, is associated with OASIs. Methods: We performed a secondary analysis of the Consortium of Safe Labor, a multicenter, retrospective cohort study. Included were nulliparous women with singleton, vaginal delivery at ≥37 weeks from 2002 to 2008. Women were excluded if delivery was complicated by shoulder dystocia or from sites without midwife deliveries. Student’s t-tests, chi-squared analysis, and Fisher’s exact test were used as appropriate. Multivariable logistic regression and propensity score-matching analyses were performed. Results: Of 228,668 births at 19 sites, 2735 births from 3 sites met the inclusion criteria: 1551 physician and 1184 midwife births. Of all births, 4.2% (n = 116) were complicated by OASIs. Physician patients were older, more often White, privately insured, with higher BMI, more medical co-morbidities, and labor inductions/augmentations. Midwife patients had higher fetal gestational age and infant birth weights (all p < 0.05). OASIs were more common in physician compared to midwife births (5.9% vs. 2.0%, p < 0.0001). This difference persisted in multivariable logistic regression. OASIs were 2.4 (95%CI 1.5–3.9) times more likely with physician delivery when controlling for maternal heart disease, episiotomy, increasing maternal age, decreasing maternal BMI, non-White race, and increasing birthweight. The AUC was 0.78. With propensity score matching, OASI rates remained higher amongst physician births (6.6% vs. 1.8%, p < 0.0001; aOR 3.8 (95%CI 2.0–7.1)). Conclusion: OASIs were more common in physician compared to midwife deliveries even when controlling for other associated factors. Full article

Recommendations for weight gain during pregnancy are based on pre-pregnancy body mass index (BMI). Pregnancy is a risk factor for excessive weight gain and many endocrine problems, making it difficult to return to pre-pregnancy weight and increasing the risk of postpartum obesity and, consequently, type 2 diabetes and metabolic syndrome. Both excessive gestational weight gain (EGWG) and obesity are associated with an increased risk of gestational hypertension, pre-eclampsia, gestational diabetes, cesarean section, shoulder dystocia, and neonatal macrosomia. In the long term, EGWG is associated with increased morbidity and mortality, particularly from diabetes, cardiovascular disorders, and some cancers. This study aims to present recommendations from various societies regarding weight gain during pregnancy, dietary guidance, and physical activity. In addition, we discuss the pathophysiology of this complication and the differential diagnosis in pregnant women with EGWG. According to our research, inadequate nutrition might contribute more significantly to the development of EGWG than insufficient physical activity levels in pregnant women. Telehealth systems seem to be a promising direction for future EGWG prevention by motivating women to exercise. Although the importance of adequate pre-pregnancy weight and weight gain during pregnancy is well known, an increasing number of women gain excessive weight during pregnancy. Full article

One in 20 births could be affected by hypermobile Ehlers–Danlos syndrome or Hypermobility Spectrum Disorders (hEDS/HSD); however, these are under-diagnosed and lacking research. This study aimed to examine outcomes and complications in people childbearing with hEDS/HSD. A large online international survey was completed by women with experience in childbearing and a diagnosis of hEDS/HSD (N = 947, total pregnancies = 1338). Data were collected on demographics, pregnancy and birth outcomes and complications. Participants reported pregnancies in the UK (N = 771), USA (N = 364), Australia (N = 106), Canada (N = 60), New Zealand (N = 23) and Ireland (N = 14). Incidences were higher in people with hEDS/HSD than typically found in the general population for pre-eclampsia, eclampsia, pre-term rupture of membranes, pre-term birth, antepartum haemorrhage, postpartum haemorrhage, hyperemesis gravidarum, shoulder dystocia, caesarean wound infection, postpartum psychosis, post-traumatic stress disorder, precipitate labour and being born before arrival at place of birth. This potential for increased risk related to maternal and neonatal outcomes and complications highlights the importance of diagnosis and appropriate care considerations for childbearing people with hEDS/HSD. Recommendations include updating healthcare guidance to include awareness of these possible complications and outcomes and including hEDS/HSD in initial screening questionnaires of perinatal care to ensure appropriate consultation and monitoring can take place from the start. Full article

Births involving shoulder dystocia or tight nuchal cords can deteriorate rapidly. The fetus may have had a reassuring tracing just before birth yet may be born without any heartbeat (asystole). Since the publication of our first article on cardiac asystole with two cases, five similar cases have been published. We suggest that these infants shift blood to the placenta due to the tight squeeze of the birth canal during the second stage which compresses the cord. The squeeze transfers blood to the placenta via the firm-walled arteries but prevents blood returning to the infant via the soft-walled umbilical vein. These infants may then be born severely hypovolemic resulting in asystole secondary to the loss of blood. Immediate cord clamping (ICC) prevents the newborn’s access to this blood after birth. Even if the infant is resuscitated, loss of this large amount of blood volume may initiate an inflammatory response that can enhance neuropathologic processes including seizures, hypoxic–ischemic encephalopathy (HIE), and death. We present the role of the autonomic nervous system in the development of asystole and suggest an alternative algorithm to address the need to provide these infants intact cord resuscitation. Leaving the cord intact (allowing for return of the umbilical cord circulation) for several minutes after birth may allow most of the sequestered blood to return to the infant. Umbilical cord milking may return enough of the blood volume to restart the heart but there are likely reparative functions that are carried out by the placenta during the continued neonatal–placental circulation allowed by an intact cord. Full article

This retrospective cohort study assessed the association between nuchal cord and adverse outcomes during vacuum-assisted delivery (VAD). Women with singleton pregnancies, 34–41-weeks gestation, who underwent VAD, from 2014 to 2020 were included. The primary outcome was umbilical cord pH ≤ 7.1. Secondary outcomes were neonatal intensive care unit admission, Apgar scores, pH < 7.15, subgaleal hematoma, shoulder dystocia and third/fourth-degree perineal tear. Outcomes were compared between neonates with (1059/3754, 28.2%) or without (71.8%) nuchal cord after VAD. No difference in cord pH ≤ 7.1 was found between groups. The nuchal cord group had a lower rate of nulliparity (729 (68.8%) vs. 2004 (74.4%), p = 0.001) and higher maternal BMI (23.6 ± 4.3 vs. 23.1 ± 5, p = 0.017). Nuchal cord was associated with higher rates of induction (207 (19.5%) vs. 431 (16%), p = 0.009) and lower birthweights (3185 ± 413 vs. 3223 ± 436 g, p = 0.013). The main indication for VAD in 830 (80.7%) of the nuchal cord group was non-reassuring fetal heart rate (NRFHR) vs. 1989 (75.6%) controls (p = 0.004). The second stage was shorter in the nuchal cord group (128 ± 81 vs. 141 ± 80 min, p < 0.001). Multivariate regression found nulliparity, induction and birthweight as independent risk factors for nuchal cord VAD. Although induction and NRFHR rates were higher in VAD with nuchal cord, the rate of umbilical cord acidemia was not. Full article

Clinical estimation of fetal weight is an integral component of obstetric care that might dictate the timing and mode of delivery. Inaccurate fetal weight estimation might result in unnecessary interventions or in underestimating potential risks, resulting in inappropriate intrapartum care. This retrospective study assessed factors associated with under- or overestimation of birthweight and evaluated the obstetric implications. It included singleton births ≥24 w with clinically estimated fetal weight (EFW) up to 1 week before delivery, during 2014–2020. Estimates >±10% of the actual birthweight were considered inaccurate and categorized as overestimation (>10% heavier than the actual birthweight) or underestimation (>10% smaller than the birthweight). Multivariable logistic regression was performed to reveal factors associated with inaccurate EFW. Maternal characteristics and obstetric outcomes were compared. The primary outcomes for the overestimation group were the neonatal composite adverse outcome, induction of labor and cesarean delivery rates. The primary outcomes for the underestimation group were rates of shoulder dystocia, 3rd- or 4th-degree perineal lacerations, and failed vacuum extraction. Among 38,615 EFW, 5172 (13.4%) were underestimated, 6695 (17.3%) were overestimated and 27,648 (69.3%) accurate. Multivariable logistic regression found increasing gestational age as an independent risk-factor for underestimation (odds ratio (OR) 1.15 for every additional week, 95% confidence interval (CI) 1.12–1.2). Major factors independently associated with overestimation were nulliparity (OR 1.95, CI 1.76–2.16), maternal obesity (OR 1.52, CI 1.33–1.74), smoking (OR 1.6, CI 1.33–1.93), and oligohydramnios (OR 1.92, CI 1.47–2.5). Underestimation was an independent risk-factor for shoulder dystocia (OR 1.61, CI 1.05–2.46) and 3rd- or 4th-degree perineal lacerations (OR 1.59, CI 1.05–2.43). Overestimation was an independent risk-factor for neonatal composite adverse outcome (OR 1.15, CI 1.02–1.3), induced labor (OR 1.30, CI 1.21–1.40) and cesarean delivery (OR 1.59, CI 1.41–1.79). Clinicians should be aware of factors and adverse obstetric implications associated with over- or underestimation of birthweight. Full article

This retrospective cohort study investigated the association between ultrasonographic estimated fetal weight (EFW) and adverse maternal and neonatal outcomes after vacuum-assisted delivery (VAD). It included women with singleton pregnancies at 34–41 weeks gestation, who underwent ultrasonographic pre-labor EFW and VAD in an academic institution, over 6 years. Adverse neonatal and maternal outcomes included shoulder dystocia, clavicular fracture, or third- and fourth-degree perineal tears. A receiver–operator characteristic curve was used to identify the optimal weight cut-off value to predict adverse outcomes. Fetuses above and below this point were compared. Multivariate analysis was used to control for factors that could lead to adverse outcomes. Eight-hundred and fifty women met the inclusion criteria and had sonographic EFW within two-weeks before delivery. Receiver–operator characteristic curve analysis found that ultrasonographic EFW 3666 g is the optimal threshold for adverse outcomes. Based on these results, outcomes were compared using EFW 3700 g. The average EFW in the ≥3700 g group (n = 220, 25.9%) was 3898 ± 154 g (average birthweight 3710 ± 324 g). In the group <3700 g (n = 630, 74.1%), average EFW was 3064 ± 411 g (birthweight 3120 ± 464 g). Shoulder dystocia and clavicular fractures were more frequent in the higher EFW group (6.4% and 2.3% vs. 1.6% and 0.5%, respectively; p < 0.05). Women in the ≥3700 g group experienced more third- and fourth-degree perineal tears (3.2% vs. 1%, p = 0.02). Multivariate logistic regression analysis found maternal age, diabetes and sonographic EFW ≥ 3700 g as independent risk-factors for adverse outcomes. Sonographic EFW ≥ 3700 g is an independent risk-factor for adverse outcomes in VAD. This should be considered when choosing the optimal mode of delivery. Full article