This study aimed to evaluate the outcomes associated with the implementation of simulation exercises to reduce the sequela of shoulder dystocia.
Electronic databases (Ovid MEDLINE, Embase, the ...Cumulative Index to Nursing and Allied Health Literature database, and Scopus) were initially queried in June 2020 and updated in November 2020. The following 3 concepts were introduced and refined using the controlled vocabulary of the database: vaginal birth, shoulder dystocia, and simulation training. There were no limitations to the year of publication as part of the search strategy.
We included all studies that reported on the frequency of shoulder dystocia and the associated complications before and after the implementation of interventional exercises to improve outcomes.
Two authors independently assessed the abstracts and full-text articles of all studies for eligibility and evaluated the quality of the included studies using the Newcastle-Ottawa Scale. Any inconsistencies related to study evaluation or data extraction were resolved by a third author. The coprimary outcomes of this systematic review and meta-analysis were neonatal brachial plexus palsy diagnosed following deliveries complicated by shoulder dystocia and persistence of brachial palsy at 12 months or later. The secondary outcomes were the frequency of shoulder dystocia and cesarean delivery. Study effects were combined using a Bayesian meta-analysis and were reported as risk ratios and 95% credible intervals (Crs).
Of the 372 articles reviewed, 16 publications, which included 428,552 deliveries with 217,713 (50.8%) deliveries during the preintervention and 210,839 (49.2%) deliveries during the postinterventional period, were included in the meta-analysis. The incidence of neonatal brachial plexus palsy after shoulder dystocia decreased from 12.1% to 5.7% (risk ratio, 0.37; 95% Cr, 0.26–0.57; probability of reduction 100%). The overall proportion of neonatal brachial plexus palsy decreased, but with less precision, from 0.3% to 0.1% (risk ratio, 0.53; 95% Cr, 0.21–1.26; probability of reduction 94%). Two studies followed newborns with brachial plexus palsy for at least 12 months. One study that reported on persistent neonatal brachial plexus palsy at 12 months among 1148 shoulder dystocia cases noted a reduction in persistent neonatal brachial plexus palsy from 1.9% to 0.2% of shoulder dystocia cases (risk ratio, 0.13; 95% confidence interval, 0.04–0.49). In contrast, the study that reported on persistent neonatal brachial plexus palsy at 12 months for all deliveries noted that it did not change significantly, namely from 0.3 to 0.2 per 1000 births (risk ratio, 0.77; 95% confidence interval, 0.31–1.90). Following the implementation of shoulder dystocia interventional exercises, the diagnosis of shoulder dystocia increased significantly from 1.2% to 1.7% of vaginal deliveries (risk ratio, 1.39; 95% Cr, 1.19–1.65; probability of increase 100%). Compared with the preimplementation period, the cesarean delivery rate increased postimplementation from 21.2% to 25.9% (risk ratio, 1.22; 95% Cr, 0.93–1.59; probability of increase 93%). We created an online tool (https://ccrebm-bell.shinyapps.io/sdmeta/) that permits calculation of the absolute risk reduction and absolute risk increase attributable to the intervention vis-à-vis the incidence of shoulder dystocia, neonatal brachial plexus palsy, and cesarean deliveries.
Introduction of shoulder dystocia interventional exercises decreased the rate of neonatal brachial plexus palsy per shoulder dystocia case; the data on persistence of neonatal brachial plexus palsy beyond 12 months is limited and contradictory. Implementation of the interventions was associated with an increase in the diagnosis of shoulder dystocia and rate of cesarean deliveries.
Objective Our purpose was to test the reliability of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) 3-Tier Fetal Heart Rate (FHR) classification system. ...Study Design Individual 15- to 20-minute FHR segments (n = 154) were independently reviewed without clinical data by 3 maternal-fetal medicine examiners and classified by NICHD category (I, II, III). Results Interobserver reliability was moderate (kappa 0.45) and varied by NICHD category (category I moderate kappa 0.48, category II moderate kappa 0.44, and category III poor kappa 0.0). The intraobserver agreement ranged from substantial to perfect (kappa 0.74-1.0). Conclusion Interobserver agreement of 3-Tier FHR classification System was moderate for NICHD categories I and II. Agreement for category III tracings was poor mainly due to lack of agreement regarding absent vs minimal variability.
OBJECTIVE:To use a large national database to compare composite maternal or neonatal morbidity among low-risk, full-term women.
METHODS:This cohort study, using the U.S. vital statistics datasets ...(2011–2015), evaluated low-risk nulliparous women with nonanomalous singleton gestations who labored at 39, 40, or 41 weeks of gestation (as reported in completed weeks of gestation; eg, 39 weeks include 39 0/7 to 39 6/7 weeks). The primary outcome, composite neonatal morbidity, included any of the followingApgar score below 5 at 5 minutes, assisted ventilation longer than 6 hours, seizure, or mortality. The secondary outcome, composite maternal morbidity, included any of the followingintensive care unit admission, blood transfusion, uterine rupture, or unplanned hysterectomy. Multivariable Poisson regression was used to estimate the association between gestational age and morbidity (using adjusted relative risk aRR and 95% CI).
RESULTS:Of 19.8 million live births during the study interval, 3.3 million met inclusion criteria43.5% were delivered at 39 weeks of gestation, 41.4% at 40 weeks, and 15.1% at 41 weeks. The overall rates of composite neonatal and maternal morbidity were 8.8 and 2.8 per 1,000 live births, respectively. Composite neonatal morbidity was higher for those delivered at 40 (aRR 1.22; 95% CI 1.19–1.25) and 41 (aRR 1.53; 95% CI 1.49–1.58) weeks of gestation when compared with 39 weeks. Composite maternal morbidity was also significantly higher with delivery at 40 (aRR 1.19; 95% CI 1.14–1.25) and 41 weeks of gestation (aRR 1.56; 95% CI 1.47–1.65).
CONCLUSION:Among low-risk nulliparous women, the rate of composite neonatal and maternal morbidity increases, albeit modestly, from 39 through 41 weeks of gestation.
OBJECTIVE:To compare the composite neonatal or maternal adverse outcome among low-risk, parous women at 39–41 weeks of gestation.
METHODS:This was a retrospective cohort study using the U.S. vital ...statistics data sets (2012–2016). We evaluated low-risk parous women with nonanomalous singleton gestations who delivered at 39, 40, or 41 weeks of gestation (as reported in completed weeks, eg, 39 weeks includes 39 0/7–39 6/7 weeks of gestation). The primary outcome, the composite neonatal adverse outcome, included any of the followingApgar score less than 5 at 5 minutes, assisted ventilation for longer than 6 hours, neonatal seizure, or neonatal mortality. The secondary outcome, the composite maternal adverse outcome, included any of the followingintensive care unit admission, blood transfusion, uterine rupture, or unplanned hysterectomy. We used multivariable Poisson regression analyses to estimate the association between gestational age and adverse outcome (using adjusted relative risks aRR and 95% CI).
RESULTS:Of 19.9 million live births during the study period, 5.4 million (27.1%) met inclusion criteria. Among them, 54.4% delivered at 39 weeks of gestation, 35.7% at 40 weeks, and 9.9% at 41 weeks. The overall rate of the composite neonatal adverse outcome was 4.86 per 1,000 live births. The risk of the composite neonatal adverse outcome was higher for those delivered at 40 (aRR 1.18; 95% CI 1.15–1.22) and 41 (aRR 1.59; 95% CI 1.53–1.65) weeks of gestation when compared with 39 weeks. The overall rate of the composite maternal adverse outcome was 2.31 per 1,000 live births. The risk of the composite maternal adverse outcome was also significantly higher with delivery at 40 (aRR 1.15; 95% CI 1.11–1.19) and 41 weeks of gestation (aRR 1.50; 95% CI 1.42–1.58) than at 39 weeks.
CONCLUSION:Though only modestly, the rates of the composite neonatal and maternal adverse outcomes increase, from 39 through 41 weeks of gestation, among low-risk parous women.
To estimate the frequency of severe maternal morbidity, assess its underlying etiologies, and develop a scoring system to predict its occurrence.Supplemental Digital Content is Available in the Text.
...This was a secondary analysis of a Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network cohort of 115,502 women and their neonates born in 25 hospitals across the United States over a 3-year period. Women were classified as having severe maternal morbidity according to a scoring system that takes into account the occurrence of red blood cell transfusion (more than three units), intubation, unanticipated surgical intervention, organ failure, and intensive care unit admission. The frequency of severe maternal morbidity was calculated and the underlying etiologies determined. Multivariable analysis identified patient factors present on admission that were independently associated with severe maternal morbidity; these were used to develop a prediction model for severe maternal morbidity.
Among 115,502 women who delivered during the study period, 332 (2.9/1,000 births, 95% confidence interval 2.6-3.2) experienced severe maternal morbidity. Postpartum hemorrhage was responsible for approximately half of severe maternal morbidity. Multiple patient factors were found to be independently associated with severe maternal morbidity and were used to develop a predictive model with an area under the receiver operating characteristic curve of 0.80.
Severe maternal morbidity occurs in approximately 2.9 per 1,000 births, is most commonly the result of postpartum hemorrhage, and occurs more commonly in association with several identifiable patient characteristics.
: II.
In pregnant women evaluated at 18/0 and 23/6 weeks + days of gestation without history of preterm delivery, a 16.7% detection rate for short cervix ≤15 mm can be achieved by risk factors BMI ≥30, and ...at least one previous miscarriage. Nevertheless, screening for short cervix by risk factors among low risk women might not be an effective alternative to universal cervical length screening.
To evaluate associations between maternal characteristics and a short cervix in patients without history of preterm delivery, and to determine if these characteristics can predict the presence of a short cervix.
This is a retrospective cohort study that included 18,592 women with singleton pregnancies without history of previous preterm deliveries who underwent universal transvaginal cervical length (TVCL) screening between 18 + 0 and 23 + 6 weeks/days of gestation. A short cervix was defined as a cervical length (CL) ≤25 mm, ≤20 mm, and ≤15 mm. Associations between maternal age, weight, height, body mass index (BMI), previous term deliveries, and history of previous miscarriages, with a short cervix were evaluated using logistic regression models.
The prevalence of a short cervix in our population was: CL ≤25 mm, 2.2% (n = 403); CL ≤20 mm, 1.2% (n = 224); and CL ≤15 mm, 0.9% (n = 161). Women with BMI >30 and/or previous abortions constituted 45.5% of the total population (8463/18,582). Significant associations with short cervix were observed for women with BMI ≥30, and for women with at least one previous abortion (p < .001). Parous women had a significantly lower association with a short cervix than nulliparous women (p < .001). Maternal age or height were not associated with a short cervix. Prediction of short cervix based on presence of any of the following: BMI ≥ 30 or previous abortions showed sensitivities of 55.8% (≤25 mm), 61.6% (≤20 mm), and 63.4% (≤15 mm) with similar specificity (50.1-54.6%) and likelihood ratio positive (1.2-1.5); and prediction based on BMI ≥ 30 and previous abortions showed sensitivities of 11.1% (≤25 mm), 14.7% (≤20 mm), and 16.7% (≤15 mm) with specificity 93%.
Among low risk women for spontaneous preterm delivery, those with a BMI ≥30 and/or previous miscarriages had a significantly increased risk for a short cervix at 18 + 0 and 23 + 6 weeks/days of gestation. Despite these significant associations, screening by maternal risk factors in a low risk population of pregnant women should not be an alternative to mid-trimester universal CL measurement.
Pregnancy in women with physical disabilities Signore, Caroline; Spong, Catherine Y; Krotoski, Danuta ...
Obstetrics and gynecology (New York. 1953)
117, Številka:
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Journal Article
Recenzirano
The Eunice Kennedy Shriver National Institute of Child Health and Human Development sponsored a 2-day workshop to assess the body of evidence on pregnancy in women with physical disabilities, ...identify gaps in knowledge, and formulate recommendations for further research. A multidisciplinary group of experts discussed available data on pregnancy outcomes among women with varying physically disabling conditions, medical and psychosocial risks for mothers and children, and barriers to prenatal care and parenting for women with physical disabilities. Existing evidence is limited by a preponderance of retrospective single-site studies of small sample sizes. For most women, pregnancy outcomes are favorable. However, increased rates of certain adverse outcomes, such as low birth weight (related to preterm birth or growth restriction) and cesarean delivery, have been reported in women with spinal cord injuries, rheumatoid arthritis, multiple sclerosis, or other conditions. Common morbidities across conditions may include urinary tract infections, decreased mobility and independence, skin ulceration, respiratory compromise, interpersonal abuse, stress, and mood disorders. Socioeconomic, physical, and attitudinal barriers to antenatal care and independent parenting can be problematic. Current evidence, although limited, indicates that most women with physical disabilities will have good pregnancy outcomes; however, some data suggest that rates of a range of complications may be more common among women with physical disabilities, depending on the nature and severity of the underlying condition. Many questions remain unanswered. Establishment of a systematic and comprehensive registry of pregnancy course and outcomes among women with physical disabilities is of high priority for addressing persistent gaps in knowledge.
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