Fetal malposition in labour and health outcomes for women and their newborn infants: A retrospective cohort study

Decreasing Primary Cesarean Births by Increasing Effective Maternal Care at a Community-Based Hospital

Background: Nulliparous cesarean birth rates have plateaued at 25% since 2019. Cesarean births contribute to 37% of severe maternal morbidity and can increase costs by longer lengths of stay, increased admissions to the neonatal intensive care unit, further postoperative complications, and an increased likelihood of subsequent cesarean births. Local Problem: At this community hospital, the rate of cesarean births for nulliparous, term, singleton, and vertex (NTSV) pregnancies rose almost 3% in 2022. This quality improvement (QI) project was aimed to decrease NTSV cesarean births by increasing effective maternal care by 80% at a community-based hospital. Methods: The Plan-Do-Study-Act model was applied for this rapid-cycle QI over 8 weeks with four 2-week cycles. The data were collected every other day, reviewed biweekly to inform data collection, and analyzed for the next test of change. Interventions: A patient screening tool was used to identify nulliparous mothers, and a patient effective care checklist tool was used to improve effective maternal care. Results: Staff utilization overall resulted in 81% screening of 215 mothers and identified 116 nulliparous mothers. The average effective care score was 84%. The checklist improved effective maternal care to 84% and reduced the NTSV cesarean births by 7%. Conclusion: Identifying nulliparous mothers on admission and then providing effective care to women in labor has the potential to decrease the NTSV cesarean birth rate. It can be utilized by every laboring mother, furthering the reduction of cesarean births.

Effects of maternal posture and cognitive-behavioral interventions on labor outcomes in primigravidas with abnormal fetal head position: a randomized controlled clinical trial

OBJECTIVE

Fetal head malposition can result in neonatal and maternal complications. Fetal head malposition occurs frequently in labor. Appropriate and timely managements are required. Maternal posture and cognitive-behavioral interventions could improve labor outcomes in primigravidas with fetal head malposition.

METHODS

A randomized controlled clinical trial was performed between January and December 2022 (Chinese Clinical Trial Registry, ChiCTR2100049359). Eligible primigravidas were randomly assigned into four groups. Group A received traditional perinatal care. Group B, C, and D received posture management, posture management with music therapy, and posture management with video education, respectively, in addition to traditional perinatal care. The maternal postures referred to place pregnant women in certain positions (lateral, lateral-prone, hands and knees, open knee-chest) to change the anatomical structure of pelvis, thus, to facilitate the fetal downward movement and birth. Maternal and neonatal outcomes were recorded and compared.

RESULTS

A total of 136 primigravidas were included, with 34, 35, 34, and 33 women in group A, B, C, and D, respectively. The incidences of cesarean section were lower in groups B, C, and D than that in group A (5.7%, 2.9%, and 3.0% versus 20.6%, p < 0.05). The fetal position correction rates at the time of full dilation of cervix were higher in groups B, C, and D than that in group A (66.7%, 63.6%, 68.8% versus 27.6%, p < 0.05). Primigravidas in groups B, C, and D had better experiences and a lower anxiety level than those in group A (p < 0.001). The four groups had no statistically significant differences in the total labor duration, operative vaginal delivery, umbilical artery blood pH, and neonatal Apgar scores.

CONCLUSION

Fetal head malposition could happen in primigravidas. Maternal posture management and cognitive-behavioral interventions during labor could improve labor outcomes in primigravidas with fetal head malposition.

Magnitude and predictors of obstetric complications during delivery among postpartum women in Ethiopia: evidence from PMA Ethiopia longitudinal survey

INTRODUCTION

The majority of pregnancy-related complications were preventable. However, the magnitude of complications during pregnancy and childbirth was high in sub-Saharan Africa. There was limited evidence on the magnitude of obstetric complications during childbirth and its predictors among postpartum women in Ethiopia.

METHODS AND MATERIALS

The research used secondary data sources based on performance monitoring for action in Ethiopia's second cohort longitudinal survey. It was a national survey that was conducted in three large, predominantly agrarian regions (Oromia, Amhara, and SNNP) and one urban region (Addis Ababa) of Ethiopia between 2021 and 2023. It was conducted to track pregnant women's use of essential maternal and newborn health services. It involved the enrollment of pregnant women and tracking them at six weeks, six months, and one year after giving birth. The data collected at the beginning of the survey and six weeks after childbirth were used for the analysis. Sample weights were applied to account for differences in sample allocation and response rates across regions and urban/rural areas. Multi-collinearity and intra-cluster correlation were assessed before fitting the multilevel models to ensure the accuracy of the estimates. A multi-level logistic regression model was used to assess the magnitude and predictors for the occurrence of obstetric complications during delivery. The model fit was evaluated using Akaike's Information Criterion and Bayesian Information Criterion. Adjusted odds ratio with its 95% confidence interval was used to measure the strength of association for this study.

RESULTS

The magnitude of obstetric complications during delivery was found to be 33.86% with 95% CI (31.56, 36.24. Among the obstetric complications that occurred during delivery, about 15.73%with 95% CI(14.02, 17.61) of women experienced bleeding, 4.14% with 95% CI (3.30, 5.17) had their membrane rupture but labor did not start within 24 h, 2.29% with 95% CI(1.67, 3.13) had their membrane rupture before 9 months, 3.95% with 95% CI(3.16, 4.93) had faced malpresentation or malposition of the baby, 12.70% with 95% CI (11.18, 14.39) had prolonged labor lasting more than 12 h, and 12.40% with 95% CI (10.83,14.17) had convulsions. The odds of occurrence of obstetric complication during delivery among women from severely food insecure households were 1.88 times [AOR = 1.88; 95% CI (1.22, 2.90)] more likely to occur than women from food secure households. Moreover, the odds of occurrence for obstetric complications during delivery among women who had complications during their pregnancy were 2.39 times [AOR = 2.39; 95% CI (1.81, 3.16)] more likely to occur as compared to those women who had no complication during their pregnancy. On the other hand, women's who had 1-4 live births given before this delivery were 0.61 times [AOR = 0.61; 95% (0.43, 0.88)] less likely to develop complications as compared to those women's who had no prior live birth.

CONCLUSION AND RECOMMENDATION

Delivery-related obstetric complications during delivery in Ethiopia were high. Approximately one-third of postpartum women in Ethiopia experienced obstetric complications during delivery. Based on this study, women's from severely food insecure households, those women's who had no prior live birth, and women's who had complications during their pregnancy were more likely to develop delivery-related obstetric complications. Thus, policy makers and program implementers who were working on maternal and newborn health should give special attention for women's from severely food insecure households, women's who had no prior live births, and those women's who encountered obstetric complications during their pregnancy to decrease the occurrence of obstetric complications during delivery. In Ethiopia, various governmental organizations, such as the Ministry of Health and the Ministry of Agriculture, are dedicated to addressing food insecurity and improving nutritional access. The country has launched several effective nutritional programs, including the Productive Safety Net Program, the Targeted Supplementary Feeding Program, and the National Nutrition Program, aimed at alleviating food insecurity and enhancing nutrition. Ongoing efforts are crucial to tackle the food insecurity experienced by women, which can help to reduce obstetric related complications of women's during delivery. It is crucial for everyone involved in maternal and newborn health to prioritize addressing the factors that lead to obstetric complications during delivery in women in order to reach the goal of ending all preventable maternal and newborn deaths by 2030.

Rotational Forceps: Which technique is superior for blade insertion? A simulation study comparing direct, first posterior, and wandering maneuvers

OBJECTIVE

The Kielland's forceps is the most used forceps for assisting rotational operative births. There are various maneuvers described for blade insertion. Among these, the most used ones are the direct, first posterior, and wandering maneuver. The objective of this study was to compare these three maneuvers using a simulator.

STUDY DESIGN

In this experimental study, 144 rotational forceps-assisted births were conducted using a simulation model, with 72 starting in a right occiput-transverse position and 72 in a left occiput-transverse position. Each of the three maneuvers (direct, first posterior, or wandering) for blade insertion was performed 48 times by a total of 6 operators, comprising 3 obstetricians with over 10 years of experience and 3 trainees. The assessment of forceps application included evaluating the placement of the blades in terms of asymmetry and the distance from the lock to the posterior fontanelle. Additionally, the study evaluated the number of reinsertions and relocations required, the perceived difficulty of the procedure, and the operator's level of experience.

RESULTS

There were no statistically significant differences in terms of asymmetry with the three maneuvers. Regarding the distance from the lock to the posterior fontanelle, the best results were obtained with the direct maneuver. There were no differences in the number of reinsertions, relocations, and the perceived difficulty by the operators among the three maneuvers. Experienced obstetricians had better outcomes in terms of the need for reinsertions.

CONCLUSION

The direct maneuver offer advantages in the insertion of blades for rotational forceps.

The significance of positional care combined with doula delivery during childbirth in the correction of abnormal fetal position

OBJECTIVE

To explore the effects of positional care combined with doula delivery during childbirth in the correction of abnormal fetal position.

METHODS

In this retrospective study, a total 108 pregnant women with abnormal fetal orientation were included from February 2018 to February 2021 in the Jinan City People's Hospital. Among them, 54 patients who received positional care combined with doula delivery were included in the intervention group (IG), while the other 54 patients who received routine nursing were included in the control group (CG). The data of the fetal orientation correction, delivery method and the pain score of puerpera of two groups were collected. The length of delivery, delivery fear score, the degree of neonatal asphyxia and nursing satisfaction were observed as the secondary outcomes.

RESULTS

Compared with the CG, puerpera in the IG had more occipital anterior position, less occipital transverse and posterior position, higher eutocia rate, lower pain and fear scores and shorter length of delivery; the Apgar score and nursing satisfaction were higher in the IG (all P<0.05).

CONCLUSION

Positional care combined with doula delivery can effectively correct abnormal fetal orientation, improve the rate of eutocia, reduce puerpera's pain and fear, shorten the length of delivery, and improve the quality of neonatal outcome and patients' satisfaction.