Protracted vacuum extraction and neonatal intracranial hemorrhage among infants born at term: a nationwide case-control study

Prevalence and associated factors of birth trauma in Ethiopia: A systematic review and meta-analysis

Birth trauma is described as organ or tissue damage caused by physical pressure during birth. Birth trauma ranges from minor problems that go away on their own to significant wounds that might result in infant morbidity and mortality over the long term. It is one of the critical issues that have received the least attention globally. In Ethiopia, evidence regarding the pooled prevalence of birth trauma among neonates is scarce. Therefore, this study estimated the pooled prevalence of birth trauma and associated factors in Ethiopia over the last decade. The Preferred Items for Systematic Reviews and Meta-analysis (PRISMA-2009) guidelines were followed. The PubMed, Scopus, Web of Science, Google Scholar and Google databases were searched. Articles published in the English language in the last decade were included. Data were extracted by a pre-prepared Excel sheet, and analysis was conducted using STATA version 14. Subgroup analysis was also undertaken to evaluate how the prevalence of birth trauma differs across regions of Ethiopia. The pooled prevalence of birth trauma in Ethiopia was 10.57% (95% CI: 3.08, 18.07), with a heterogeneity index (I2) of 92.6% (p < 0.001). Presentation other than vertex AOR 11.94 (95% CI: 6.25-17.62), P = 0.001 and I2 = 53%, labor assisted by forceps AOR 6.25 (95% CI: 2.95-10.10), P = 0.002 with I2 = 51.8% and labor assisted with vacuum AOR 17.47 (95% CI: 4.25-39.46), P = 0.0001 with I2 = 92.9% were factors associated with the pooled prevalence of birth trauma in Ethiopia. The pooled prevalence of birth trauma in Ethiopia is considerable. Non-vertex presentation, use of instrumental delivery and prolonged labor were factors significantly associated with birth trauma. Strengthening neonatal improvement activities (thermal protection, hygienic umbilical cord and skin care, early and exclusive breastfeeding, assessment for signs of serious health problems or need for additional care and preventive treatment), is need.

Intracranial Hemorrhage in Term and Late-Preterm Neonates: An Institutional Perspective

BACKGROUND AND PURPOSE

Distribution of intracranial hemorrhage in term and late-preterm neonates is relatively unexplored. This descriptive study examines the MR imaging-detectable spectrum of intracranial hemorrhage in this population and potential risk factors.

MATERIALS AND METHODS

Prevalence and distribution of intracranial hemorrhage in consecutive term/late-preterm neonates who underwent brain MR imaging between January 2011 to August 2018 were assessed. MRIs were analyzed to determine intracranial hemorrhage distribution (intraventricular, subarachnoid, subdural, intraparenchymal, and subpial/leptomeningeal), and chart review was performed for potential clinical risk factors.

RESULTS

Of 725 term/late-preterm neonates who underwent brain MR imaging, intracranial hemorrhage occurred in 63 (9%). Fifty-two (83%) had multicompartment intracranial hemorrhage. Intraventricular and subdural were the most common hemorrhage locations, found in 41 (65%) and 39 (62%) neonates, respectively. Intraparenchymal hemorrhage occurred in 33 (52%); subpial, in 19 (30%); subarachnoid, in 12 (19%); and epidural, in 2 (3%) neonates. Twenty infants (32%) were delivered via cesarean delivery, and 5 (8%), via instrumented delivery. Cortical vein thromboses were present in 34 (54%); periventricular or medullary vein thromboses, in 37 (59%); and cerebral venous sinus thrombosis, in 5 (8%). Thirty-seven (59%) had elevated markers of coagulopathy (international normalized ratio > 1.2, fibrinogen level < 234), 9 (14%) had a clinically meaningful elevation in the international normalized ratio (>1.4), and 3 (5%) had a clinically meaningful decrease in the fibrinogen level (<150). Three (5%) neonates had thrombocytopenia (platelet count < 100 × 103/μL).

CONCLUSIONS

While relatively infrequent, there was a wide distribution of intracranial hemorrhage in term and late-preterm infants; intraventricular and subdural hemorrhages were the most common types. We report a high prevalence of venous congestion or thromboses accompanying neonatal intracranial hemorrhage.

Magnitude of birth trauma and its associated factors in South Wollo public hospitals, northeast Ethiopia, August 2021: Institutional-Based Cross-Sectional Study

OBJECTIVE

The institutional-based cross-sectional study was designed to assess the magnitude of birth trauma and its associated factors in South Wollo, northeast Ethiopia.

SETTING

This study was conducted in the public hospitals of South Wollo, northeast Ethiopia. South Wollo is one of the 12 zones in the Amhara regional state with a total population of >3 million. There are 13 hospitals in South Wollo, of these 4 hospitals were selected randomly.

PARTICIPANTS

A total of 612 mother-newborn pairs were selected to conduct the study. However, data were collected from 594 mother-neonate pairs giving a response rate of 97%. The study participants were selected by applying a simple random sampling technique after proportional allocation of the total sample to each study hospital. Live neonates delivered during the study period were included, whereas stillborn, neonates born with major congenital malformation and neonates whose mothers died during the birth process were excluded.

RESULT

A total of 594 mother-newborn pairs were involved with a response rate of 97%. Seventy-eight newborns 13.13% (95% CI: 10.30 to 16.00) had experienced birth trauma. Prolonged labour (AOR: 5.78, 95% CI: 3.00 to 11.15), birth weight >4 kg (AOR: 9.18, 95% CI: 3.92 to 21.50), vacuum delivery (AOR: 6.74, 95% CI: 2.01 to 22.56), forceps delivery (AOR: 7.36, 95% CI: 1.96 to 27.58) and shoulder dystocia (AOR: 9.83, 95% CI: 4.13 to 23.50) were risk factors of birth trauma.

CONCLUSION

The prevalence of birth trauma was higher than the report from most of the African countries. Prolonged labour, instrumental deliveries, large birth weight and shoulder dystocia were the identified risk factors of birth trauma. The ministry of health and the local healthcare system should give attention to the maternal health services.

Ultrasound vs routine care before instrumental vaginal delivery: A systematic review and meta-analysis

INTRODUCTION

The objective was to report the role of intrapartum ultrasound examination in affecting maternal and perinatal outcome in women undergoing instrumental vaginal delivery.

MATERIAL AND METHODS

MEDLINE, Embase, CINAHL, Google Scholar and ClinicalTrial.gov databases were searched. Inclusion criteria were randomized controlled trials comparing ultrasound assessment of fetal head position vs routine standard care (digital examination) before instrumental vaginal delivery (either vacuum or forceps). The primary outcome was failed instrumental delivery extraction followed by cesarean section. Secondary outcomes were postpartum hemorrhage, 3rd or 4th degree perineal lacerations, episiotomy, prolonged hospital stay, Apgar score<7 at 5 min, umbilical artery pH <7.0 and base excess greater than -12 mEq, admission to neonatal intensive care unit (NICU), shoulder dystocia, birth trauma, a composite score of adverse maternal and neonatal outcome and incorrect diagnosis of fetal head position. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials (RoB-2). The quality of evidence and strength of recommendations were assessed using the Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. Head-to-head meta-analyses using a random-effect model were used to analyze the data and results are reported as relative risk with their 95% confidence intervals.

RESULTS

Five studies were included (1463 women). There was no difference in the maternal, pregnancy or labor characteristics between the two groups. An ultrasound assessment prior to instrumental vaginal delivery did not affect the cesarean section rate compared with standard care (p = 0.805). Likewise, the risk of composite adverse maternal outcome (p = 0.428), perineal lacerations (p = 0.800), postpartum hemorrhage (p = 0.303), shoulder dystocia (p = 0.862) and prolonged stay in hospital (p = 0.059) were not different between the two groups. Composite adverse neonatal outcome was not different between the women undergoing and those not undergoing ultrasound assessment prior to instrumental delivery (p = 0.400). Likewise, there was no increased risk with abnormal Apgar score (p = 0.882), umbilical artery pH < 7.2 (p = 0.713), base excess greater than -12 (p = 0.742), admission to NICU (p = 0.879) or birth trauma (p = 0.968). The risk of having an incorrect diagnosis of fetal head position was lower when ultrasound was performed before instrumental delivery, with a relative risk of 0.16 (95% confidence interval 0.1-0.3; I² :77%, p < 0.001).

CONCLUSIONS

Although ultrasound examination was associated with a lower rate of incorrect diagnoses of fetal head position and station, this did not translate to any improvement of maternal or neonatal outcomes.

Adverse outcomes in vacuum-assisted delivery after detachment of non-metal cup: a retrospective cohort study

PURPOSE

To evaluate neonatal and maternal outcomes associated with detachment of non-metal vacuum cup during delivery and to identify risk factors for these detachments.

METHODS

This retrospective cohort study included women with singleton pregnancy, who underwent vacuum-assisted vaginal delivery with a non-metal vacuum cup in a single academic institution, January 2014-August 2019. Failed vacuum deliveries were excluded. Primary outcomes were defined as subgaleal hematoma (SGH) and cord blood pH < 7.15. Secondary outcome included other neonatal complications and adverse maternal outcomes. Outcomes were compared between vacuum-assisted deliveries with and without cup detachment during the procedure.

RESULTS

A total of 3246 women had successful VAD and met the inclusion criteria. During the procedure, the cup detached at least once in 665 (20.5%) deliveries and did not detach in 2581 (79.5%). The cup detachment group experienced higher rates of SGH (8.9% vs. 3.5%, p = 0.001) and cord blood pH < 7.15 (9.8% vs. 7.1%, p = 0.03). There were also more neonatal intensive care unit admissions (NICU) (4.4% vs. 2.7%, p = 0.03) and more fetuses with occiput posterior position (70.8% vs. 79.4%, p = 0.001), the vacuum duration was slightly longer (6 ± 3.7 vs. 5 ± 2.9 min) and more neonates had birth weights > 3700 g (14.1% vs, 10.3%, p = 0.006). Interestingly, there were more males in that group (60.6 vs. 54.6, p = 0.005). All these factors remained significant after controlling for potential confounders.

CONCLUSIONS

Vacuum cup detachment has several predictive characteristics and is associated with adverse neonatal outcomes that should be incorporated into decisions made during the procedure.

Association between the number of pulls and adverse neonatal/maternal outcomes in vacuum-assisted delivery

OBJECTIVES

To determine the association between the number of pulls during vacuum-assisted deliver and neonatal and maternal complications.

METHODS

This was a single-center observational study using a cohort of pregnancies who underwent vacuum-assisted delivery from 2013 to 2020. We excluded pregnancies transitioning to cesarean section after a failed attempt at vacuum-assisted delivery. The number of pulls to deliver the neonate was categorized into 1, 2, 3, and ≥4 pulls. We used logistic regression models to investigate the association between the number of pulls and neonatal intensive care unit (NICU) admission and maternal composite outcome (severe perineal laceration, cervical laceration, transfusion, and postpartum hemorrhage ≥500 mL).

RESULTS

We extracted 480 vacuum-assisted deliveries among 7,321 vaginal deliveries. The proportion of pregnancies receiving 1, 2, 3, or ≥4 pulls were 51.9, 28.3, 10.8, and 9.0%, respectively. The crude prevalence of NICU admission with 1, 2, 3, and ≥4 pulls were 10.8, 16.2, 15.4, and 27.9%, respectively. The prevalence of NICU admission, amount of postpartum hemorrhage, and postpartum hemorrhage ≥500 mL were significantly different between the four groups. Multivariable logistic regression analysis found the prevalence of NICU admission in the ≥4 pulls group was significantly higher compared with the 1 pull group (adjusted odds ratio, 3.3; 95% confidence interval, 1.4-7.8). In contrast, maternal complications were not significantly associated with the number of pulls.

CONCLUSIONS

Vacuum-assisted delivery with four or more pulls was significantly associated with an increased risk of NICU admission. However, the number of pulls was not associated with maternal complications.

Cranial Ultrasound Is an Important Tool in the Recognition of Life-Threatening Infratentorial Hemorrhage in Newborns

Timely detection of severe infratentorial hemorrhage in neonates is crucial, especially in case of life-threatening brain stem compression and/or acute obstructive hydrocephalus, which need lifesaving neurosurgical intervention. Although the detection of infratentorial hemorrhage by ultrasound scanning is often considered as difficult, the use of additional acoustic windows and recognition of characteristic ultrasound features facilitate early diagnosis. In this case series, we report on newborns with severe, symptomatic infratentorial hemorrhage detected primarily by cranial ultrasound. We demonstrate the characteristic ultrasound features present in all cases and discuss how ultrasound diagnosis contributed to early diagnosis and treatment.

Birth-related subdural hemorrhage: prevalence and imaging morphology

BACKGROUND

Birth trauma accounts for 1-2% of the mortality in newborns with significant intracranial injuries presenting in the immediate postnatal period. However, a significant number of asymptomatic neonates harbor birth-related intracranial hemorrhage (ICH), with birth-related subdural hemorrhage (SDH) being a common occurrence on infant brain CT and MRI studies performed as a standard of care for a variety of reasons. Although clinically insignificant, birth-related SDH is frequently brought up in courts as an alternative explanation for SDH in suspected abusive head trauma.

OBJECTIVE

The aim of this study was to determine prevalence, imaging morphology and distribution of birth-related SDHs on brain CT and MRI studies obtained as a standard of care in infants up to 1 month old. We further tried to ascertain the relationship of birth-related SDHs with mode of delivery and birth weight.

MATERIALS AND METHODS

Infants up to the age of 1 month who had CT or MRI of the brain performed between Jan. 1, 2018, and March 29, 2020, were included in this retrospective observational study. In addition to the imaging data, we reviewed clinical history, birth history including birth weight and mode of delivery, and final diagnoses.

RESULTS

Two hundred six infants younger than 30 days (range 0-29 days, mean 11.9 days, median 11 days and standard deviation [SD] 8.4 days) had a CT or MRI study during the study period. Among these, 58 infants were excluded as per the exclusion criteria. Among the included 148 infants, 88 (59.5%) had no imaging evidence of SDH. An additional 56 (37.8%) infants were assessed as having birth-related SDH based on review of clinical data. Within the birth-related SDH cohort (56 infants), only supratentorial SDH was identified in 5 (8.9%), only infratentorial SDH was identified in 14 (25%), while SDHs within both compartments were identified in 37 (66.1%) infants. The most common location for supratentorial birth-related SDH was along the occipital lobes (31/42, 73.8%), with other common locations being along the posterior interhemispheric fissure (30/42, 71.4%) and fronto-parietal convexity (9/42, 21.4%). The distribution of posterior fossa SDH was along the tentorium (38/51, 74.5%), along the cerebellum (38/51, 74.5%) and in both the locations (25/51, 49.0%). The rate of SDH was significantly higher in vaginal delivery group (46/84, 54.7%) as compared to caesarean section group (10/57, 17.5%) (P<0.05). We did not find any statistically significant difference between the birth weights of normal and birth-related SDH cohorts (P>0.05).

CONCLUSION

Birth-related SDH is a common occurrence, with our study suggesting a prevalence of 37.8%. The most common distribution of birth-related SDH is within both the supra- and infratentorial compartments (66.1%) followed by infratentorial compartment (25%). The rate of birth-related SDH was significantly higher in vaginal delivery group as compared to caesarean section group.

The role of sonographic head circumference in the occurrence of subgaleal hemorrhage following vacuum delivery

OBJECTIVE

Subgaleal hemorrhage (SGH) is a severe neonatal morbidity that is associated with vacuum-assisted delivery (VAD). Large sonographic head circumference (sHC) was previously associated with complicated VAD. Nevertheless, the association of large sHC with SGH formation following VAD is underreported. We aim to evaluate the role of sonographic head circumference (sHC) with SGH formation following attempted VAD.

METHODS

A retrospective case-control study. Cases comprised singleton pregnancies for whom attempted VAD resulted in SGH with an sHC measured within 2 weeks from delivery. Controls were VAD deliveries which not resulted in SGH, with an sHC measured within 2 weeks from delivery. We matched controls in a 1:1 ratio by gestational age, parity and year of delivery.

RESULTS

Overall, 118 women were included in the SGH study group and were matched to 118 controls. Baseline maternal and fetal characteristics were similar between the groups except for higher neonatal birth weight in the SGH group (median 3422 vs. 3195 grams, p = .001). sHC did not vary between groups (median 336 mm in SGH groups vs. 333, p = .08). Rate of sHC >90th and >95th percentile did not significantly differ between the groups (13.6% vs. 8.5%, 6.8% vs. 3.4%, p = .21, p = .37, for SGH vs. controls, respectively). In multivariate regression analysis, sHC was not found to be independently associated with SGH - aOR (95% CI) 1.004 (0.97-1.03). Receiver operating characteristic curves of sHC for SGH formation underlined an area under the curve of 0.58 (95% CI) (0.51-0.65).

CONCLUSIONS

sHC is not associated with SGH formation following VAD.

HOW Collaborative position paper on the management of thrombocytopenia in pregnancy

Thrombocytopenia in pregnancy is a common occurrence, affecting up to 10% of women by the time of birth. These recommendations aim to provide pragmatic guidance on the investigation, diagnosis and management of thrombocytopenia in pregnancy; including safety of neuraxial anaesthesia and precautions required for birth. Management of neonatal thrombocytopenia is also addressed. The authors are clinicians representing haematology, obstetric medicine, maternal-fetal medicine, and anaesthesia. Each author conducted a detailed literature review then worked collaboratively to produce a series of unanimous recommendations. The recommendation strength is limited by the lack of high-quality clinical trial data, and represents level C evidence.

Safety and efficacy of sildenafil citrate to reduce operative birth for intrapartum fetal compromise at term: a phase 2 randomized controlled trial

BACKGROUND AND OBJECTIVE

Sildenafil citrate is a vasodilator used in erectile dysfunction and pulmonary hypertension. We tested whether it reduces emergency operative births for fetal compromise and improves fetal or uteroplacental perfusion in labor in a phase 2 double-blind randomized controlled trial.

STUDY DESIGN

Women at term in early labor or undergoing scheduled induction of labor at Mater Mother's Hospital, Brisbane, Australia, were randomly allocated 50 mg of sildenafil citrate orally 8 hourly up to 150 mg or placebo. Intrapartum fetal monitoring followed Royal Australian and New Zealand College of Obstetricians and Gynaecologists guidelines. Primary outcomes were (1) emergency operative birth (by cesarean delivery or instrumental vaginal birth) for intrapartum fetal compromise and (2) mean indices of fetal and uteroplacental perfusion using Doppler ultrasound. Analysis was by intention-to-treat.

TRIAL REGISTRATION NUMBER

ANZCTRN12615000319572 RESULTS: Between September 2015 and January 2019, 300 women were randomized equally to sildenafil citrate or placebo. Sildenafil citrate reduced the risk of emergency operative birth by 51% (18% vs 36.7%; relative risk, 0.49, 95% confidence interval, 0.33-0.73, P=.0004, number needed to treat = 5 [3-11]). There was no difference in indices of fetal and uteroplacental perfusion, but these were ascertained in only 71 women. Sildenafil citrate reduced the risk of meconium-stained liquor or pathologic fetal heart rate patterns by 43% (25.3% vs 44.7%; relative risk, 0.57, 95% confidence interval, 0.41-0.79, P=.0005), but its effects on fetal scalp sampling rates (2.0% vs 6.7%; relative risk, 0.30, 95% confidence interval, 0.08-1.07, P=.06) and adverse neonatal outcome (20.7% vs 21.3%; relative risk, 0.97, 95% confidence interval, 0.62-1.50, P=.89) were inconclusive. Only 3.6% of maternal levels of sildenafil citrate or its metabolite were detected in cord blood. No differences in maternal adverse events were seen.

CONCLUSION

Sildenafil citrate reduced operative birth for intrapartum fetal compromise, but much larger phase 3 trials of its effects on mother and child are needed before it can be routinely recommended.

Risk factors associated with subgaleal hemorrhage in neonates exposed to vacuum extraction

INTRODUCTION

Subgaleal hemorrhage (SGH) is a life-threatening neonatal condition that is strongly associated with vacuum assisted delivery (VAD). The factors associated with the development of SGH following VAD are not well-established. We aimed to evaluate the factors associated with the development of SGH following attempted VAD.

MATERIAL AND METHODS

A retrospective case-control study of women who delivered at a tertiary university-affiliated medical center in Jerusalem, Israel, during 2009-2018. Cases comprised all parturients with singleton pregnancies for whom attempted VAD resulted in neonatal SGH. A control group of VAD attempts was established by matching one-to-one according to gestational age at delivery, parity and year of delivery. Fetal, intrapartum and vacuum procedure characteristics were compared between the groups.

RESULTS

In all, 313 (89.5%) of the 350 attempted VAD were nulliparous. Baseline maternal and fetal characteristics were similar between the groups except for higher neonatal birthweight in the SGH group. In multivariate logistic regression analysis, only six independent risk factors were significantly associated with the development of SGH: second-stage duration (for each 30-minute increase, adjusted odds ratio [OR] 1.13; 95% confidence intervals [CI] 1.04-1.25; P = .006), presence of meconium-stained amniotic fluid (adjusted OR 2.61; 95% CI 1.52-4.48; P = .001), presence of caput succedaneum (adjusted OR 1.79; 95% CI 1.11-2.88; P = .01), duration of VAD (for each 3-minute increase, adjusted OR 2.04; 95% CI 1.72, 2.38; P < .001), number of dislodgments (adjusted OR 2.38; 95% CI 1.66-3.44; P < .001), and fetal head station (adjusted OR 3.57; 95% CI 1.42-8.33; P = .006). Receiver operating characteristic curves showed that VAD duration of ≥15 minutes had a 96.7% sensitivity and 75.0% specificity in predicting SGH formation, with an area under the curve equal to .849.

CONCLUSIONS

Vacuum duration, the number of dislodgments, the duration of second stage of delivery, fetal head station, the presence of caput succedaneum and the presence of meconium were found to be independently associated with SGH formation.