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Introduction Shoulder dystocia is a rare obstetric complication, and the risk of recurrence is important for planning future deliveries. Material and Methods The objectives of our study were to estimate the incidence and risk factors for recurrence of shoulder dystocia and to identify women at high risk of recurrence in a subsequent vaginal delivery. The study design was a nationwide register‐based study including data from the Danish Medical Birth Registry and National Patient Register in the period 2007–2017. Nulliparous women with a singleton fetus in cephalic presentation were included for analysis of risk factors in index and subsequent delivery. Results During the study period, 6002 cases of shoulder dystocia were reported with an overall incidence among women with vaginal delivery of 1.2%. Among 222 225 nulliparous women with vaginal births, shoulder dystocia complicated 2209 (1.0%) deliveries. A subsequent birth was registered in 1106 (50.1%) of the women with shoulder dystocia in index delivery of which 837 (77.8%) delivered vaginally. Recurrence of shoulder dystocia was reported in 60 (7.2%) with a six‐fold increased risk compared with women without a prior history of shoulder dystocia (risk ratio [RR] 5.70, 95% confidence interval [CI]: 4.41 to 7.38; adjusted RR 3.06, 95% CI: 2.03 to 4.68). Low maternal height was a significant risk factor for recurrence of shoulder dystocia. In the subsequent delivery, significant risk factors for recurrence were birthweight >4000 g, positive fetal weight difference exceeding 250 g from index to subsequent delivery, stimulation with oxytocin and operative vaginal delivery. In the subsequent pregnancy following shoulder dystocia, women who underwent a planned cesarean (n = 176) were characterized by more advanced age and a higher prevalence of diabetes in the subsequent pregnancy. Furthermore, they had more often experienced operative vaginal delivery, severe perineal lacerations, and severe neonatal complications at the index delivery. Conclusions The incidence of shoulder dystocia among nulliparous women with vaginal delivery was 1.0% with a 7.2% risk of recurrence in a population where about 50% had a subsequent birth and of these 78% had subsequent vaginal delivery. Important risk factors for recurrence were low maternal height, increase of birthweight ≥250 g from index to subsequent delivery and operative vaginal delivery. The risk of recurrent shoulder dystocia in a subsequent vaginal delivery is 7%. Maternal height, positive fetal weight difference >250 g between the index and subsequent delivery, high fetal weight and operative vaginal delivery are identified as significant risk factor.

Introduction and hypothesisDespite several studies that have reported risk factors for obstetric anal sphincter injuries (OASI), data from the Indian subcontinent are scarce. The purpose of this study was to identify risk factors for these sphincter injuries in an Indian population.MethodsThis was a case–control study within a retrospective cohort of vaginal deliveries at a tertiary care facility. All vaginal births beyond 24 completed weeks of gestation and birth weight ≥500 g from January 2008 to December 2012 were identified from the hospital electronic database. Cases were women with OASI sustained during vaginal delivery; the rest constituted controls. Potential risk factors for occurrence and severity of OASI were assessed initially using bivariate analysis and then a logistic regression model.ResultsThe incidence of sphincter injury was 2.1% of vaginal births and 1.1% of all deliveries, and major-degree (3c and 4th-degree) tears constituted 20.9% of tears. After adjusted analysis, significant predictors for injury included primiparity, delivery at or beyond 41 weeks of gestation, epidural analgesia, instrumental delivery, shoulder dystocia, birth weight ≥4000 g, and head circumference ≥35 cm. Episiotomy protected against sphincter injuries, particularly in forceps and ventouse deliveries. Shoulder dystocia was significantly associated with major-degree tears, while episiotomy appeared to be protective.ConclusionRisk factors are similar to those in other population groups; however, primiparity appears to be associated with lesser risk and forceps delivery with greater risk of sphincter trauma than previously reported.

Objective Describe characteristics of women whose decedents died during the neonatal period and explore factors associated with postnatal age at time of death. Methods Analysis of data collected at the Child Health and Mortality Prevention Surveillance (CHAMPS) South Africa study site. CHAMPS generates cause of death data in children across nine sites in low‐ and middle‐income countries. Postnatal age at time of neonatal death was evaluated by Kaplan–Meier methods. Factors associated with time to neonatal death were evaluated using Cox proportional hazards regression models. Analyses were conducted in Stata 15.0®. p < 0.05 was considered statistically significant. Results There were 225 neonatal deaths during the study period, of which 197 (87.5%) had data for mother‐neonate pairs, with 184 (81.7%) neonates having complete data. The median (IQR) maternal age at booking was 27 (23–34) years. Majority (72.3%, 142/197) of women were unmarried, unemployed (76.0%, 149/197) and were booked (85.0%, 141/166). There were 19.5% of women who had hypertensive disorders of pregnancy (HDP, 36/184) while 2.7% (5/184) had diabetes mellitus and 31.5% (58/184) were HIV positive. Most were early neonatal deaths (ENND; 79.4%, 146/184) and remainder (20.6%, 38/184) late neonatal deaths (LNND). The main underlying causes of death were prematurity (60.3%, 111/184), intrapartum hypoxia (17.4%, 32/184), neonatal sepsis (10.3%, 19/184) and congenital anomalies (9.2%, 17/184). Intrapartum hypoxia (Adjusted Hazard Ratio [aHR] = 2.01, 95% CI: 1.23–3.27, p = 0.01), assisted‐vaginal delivery compared to normal vaginal delivery (aHR = 1.96, 95% CI: 1.03–3.71, p = 0.04), preterm delivery (aHR = 1.62, 95% CI: 1.03–2, p = 0.04), Apgar score <7 at 5 min (aHR = 1.59, 95% CI: 1.01–2.31, p = 0.02) and a previous neonatal death ([aHR] = 1.33; 95% CI: 1.10–1.89, p = 0.04) were associated with earlier time to neonatal death. Conclusion Intrapartum complications were associated with earlier time to neonatal death. Improving intrapartum care can reduce neonatal deaths.

•Critical Assessment for Choosing Exclusion Criteria in Vaccine Trials involving Pregnant women.•Obstetric and maternal risk factors in pregnancy quantified based on review of published literature.•Heat Map Matrix of Obstetric Exclusion Criteria based on Phase of Trial.•Obstetric Risk Assessment facilitates inclusion criteria choice in maternal immunization trials. Vaccines designed for use in pregnancy and vaccine trials specifically involving pregnant women are rapidly expanding. One of the key challenges in designing maternal immunization trials is that developing exclusion criteria requires understanding and quantifying the background risk for adverse pregnancy outcomes in the pregnancy being studied, which can occur independent of any intervention and be unrelated to vaccine administration. The Global Alignment of Immunization Safety Assessment in Pregnancy (GAIA) project has developed and published case definitions and guidelines for data collection, analysis, and evaluation of maternal immunization safety in trials involving pregnant women. Complementing this work, we sought to understand how to best assess obstetric risk of adverse outcomes and differentiate it from the assessment of vaccine safety. Quantification of obstetric risk is based on prior and current obstetric, and maternal medical history. We developed a step-wise approach to evaluate and quantify obstetric and maternal risk factors in pregnancy based on review of published literature and guidelines, and critically assessed these factors in the context of designing inclusion and exclusion criteria for maternal vaccine studies. We anticipate this risk assessment evaluation may assist clinical trialists with study design decisions, including selection of exclusion criteria for vaccine trials involving pregnant women, consideration of sub-group classification, such as high or low risk subjects, or schedule considerations, such as preferred trimester of gestation for an intervention during pregnancy. Additionally, this tool may be utilized in data stratification at time of study analyses.

Birth fractures predominantly affect the clavicle, humerus or femur. Brachial plexus injury may co-exist with humeral or clavicular fractures. From January 2002 to December 2010, 8 neonates with fractures after caesarean section were treated under the supervision of the first author following obstructed labour and caesarean delivery. The most classical of the cases is a vertex-presenting neonate who was delivered by caesarean section for obstructed labour in a primipara in whom ipsilateral klumpke's palsy and fractures of the clavicle and humerus were confirmed. Literature review did not consider emergency caesarean delivery as one of the predisposing factors for such birth injuries. This case series, in addition to presenting emergency caesarean section as a predisposing factor for birth injuries, offers to suggest a manoeuvre that may reduce severity and rate of birth injuries in caesarean section for obstructed labour in our environment where obstructed labour is still rife. (Afr J Reprod Health 2012; 16[3]: 118-121). Les fractures pendant l'accouchement affectent principalement la clavicule, l'humérus ou le fémur. Les lésions du plexus brachial peuvent coexister avec les fractures de l'humérus ou claviculaire. Du janvier 2002 au décembre 2010, 8 nouveau-nés qui souffraient de fractures après une opération césarienne ont été traités sous la supervision du premier auteur. Ils étaient tous des cas du travail obstrué et l'accouchement césarien. Le plus classique des cas était un nouveau-né qui présentait du sommet qui a été accouché par l'opération césarienne pour dystocie dans une primipare chez qui la paralysie ipsilatérale Klumpke et fractures de la clavicule et l'humérus ont été confirmés. La revue de la littérature ne semble pas considérer l'accouchement césarien d'urgence comme l'un des facteurs prédisposant à ces traumatismes à la naissance. Cette série de cas, en plus de présenter l'opération césarienne d'urgence comme un facteur prédisposant aux traumatismes à la naissance, propose de suggérer une manœuvre qui peut réduire la gravité et le taux de traumatismes à la naissance en cas d'opération césarienne pour dystocie dans notre environnement où la dystocie est encore monnaie courante (Afr J Reprod Health 2012; 16[3]: 118-121).

This chapter contains sections titled: Cause and risk factors of obstetric haemorrhage Management of obstetric haemorrhage

This study was undertaken to determine the risk factors for maternal deaths in unplanned or unbooked obstetric admissions to the intensive care unit of a tertiary health centre. Hospital records of unbooked obstetric admissions to the intensive care unit of the hospital from January 1997 to December 2006 were retrospectively reviewed. Data collected included patients' demographics, diagnosis, duration of stay in the ICU and patient outcome. The intensive care unit records showed that there were 25 unbooked obstetric admissions. Major diagnoses for unplanned admissions to the ICU were preeclampsia/eclampsia (41.1%), obstetric haemorrhage (37.5%), and respiratory distress (12.5%). There were 12 deaths (48%). Organ dysfunction on admission, massive blood loss and late presentation were the risk factors for mortality. The high maternal mortality was mainly due to limited supply of blood products and inadequate prenatal care resulting in disease severity (Afr J Reprod Health 2011; 15[4]:51-54). L'étude a comme objectifs de déterminer les facteurs de risque pour les décès maternels concernant les admissions obstétriques imprévues ou non inscrites dans l'Unité de soins intensifs d'un centre de santé tertiaire. Nous avons passé en revue rétrospectivement les dossiers de toutes les admissions obstétriques dans l'unité de soins intensifs de l'hôpital qui n'étaient pas prévues et pas inscrites, à partir du janvier 1977 jusqu'au mois de décembre. Les données recueillies comprenaient les données démographiques, le diagnostic, la durée du séjour dans l'USI et la conséquence pour la patiente. Les dossiers dans l'unité de soins intensifs ont montré qu'il y avait vingt-cinq admissions qui n'étaient pas inscrites. Le diagnostic principal pour les admissions imprévues dans l'USI d'après cette étude, étaient la préclampsie/l'éclampsie (41,1%), l'hémorragie obstétrique (37,5%) et la détresse respiratoire (12,5%). Il y avait 12 décès (48%). Les facteurs de risque de mortalité pour cette étude étaient la dysfonction d'organe au moment de l'admission, une perte massive de sang et un retard dans la présentation Le taux élevé de la mortalité maternelle était du surtout à l'apport des produits sanguins limités et les soins prénatals inadéquats qui aboutissent à une sévérité de maladie (Afr J Reprod Health 2011; 15[4]:51-54).

Introduction and hypothesisOASI complicates approximately 6% of vaginal deliveries. This risk is increased with operative vaginal deliveries (OVDs), particularly forceps. However, there is conflicting evidence supporting the use of mediolateral/lateral episiotomy (MLE/LE) with OVD. The aim of this study was to assess whether MLE/LE affects the incidence of OASI in OVD.MethodsElectronic searches were performed in OVID Medline, Embase and the Cochrane Library. Randomised and non-randomised observational studies investigating the risk of OASI in OVD with/without MLE/LE were eligible for inclusion. Pooled odds ratios (OR) were calculated using Revman 5.3. Risk of bias of was assessed using the Cochrane RoB2 and ROBINS-I tool. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).ResultsA total of 703,977 patients from 31 studies were pooled for meta-analysis. MLE/LE significantly reduced the rate of OASI in OVD (OR 0.60 [95% CI 0.42–0.84]). On sub-group analysis, MLE/LE significantly reduced the rate in nulliparous ventouse (OR 0.51 [95% CI 0.42–0.84]) and forceps deliveries (OR 0.32 [95% CI 0.29–0.61]). In multiparous women, although the incidence of OASI was lower when a ventouse or forceps delivery was performed with an MLE/LE, this was not statistically significant. Heterogeneity remained significant across all studies (I2 > 50). The quality of all evidence was downgraded to “very low” because of the critical risk of bias across many studies.ConclusionsMLE/LE may reduce the incidence of OASI in OVDs, particularly in nulliparous ventouse or forceps deliveries. This information will be useful in aiding clinical decision-making and counselling in the antenatal period and during labour.

The COVID-19 pandemic has disrupted maternity services worldwide and imposed restrictions on societal behaviours. This national study aimed to compare obstetric intervention and pregnancy outcome rates in England during the pandemic and corresponding pre-pandemic calendar periods, and to assess whether differences in these rates varied according to ethnic and socioeconomic background. We conducted a national study of singleton births in English National Health Service hospitals. We compared births during the COVID-19 pandemic period (23 March 2020 to 22 February 2021) with births during the corresponding calendar period 1 year earlier. The Hospital Episode Statistics database provided administrative hospital data about maternal characteristics, obstetric inventions (induction of labour, elective or emergency cesarean section, and instrumental birth), and outcomes (stillbirth, preterm birth, small for gestational age [SGA; birthweight < 10th centile], prolonged maternal length of stay (≥3 days), and maternal 42-day readmission). Multi-level logistic regression models were used to compare intervention and outcome rates between the corresponding pre-pandemic and pandemic calendar periods and to test for interactions between pandemic period and ethnic and socioeconomic background. All models were adjusted for maternal characteristics including age, obstetric history, comorbidities, and COVID-19 status at birth. The study included 948,020 singleton births (maternal characteristics: median age 30 years, 41.6% primiparous, 8.3% with gestational diabetes, 2.4% with preeclampsia, and 1.6% with pre-existing diabetes or hypertension); 451,727 births occurred during the defined pandemic period. Maternal characteristics were similar in the pre-pandemic and pandemic periods. Compared to the pre-pandemic period, stillbirth rates remained similar (0.36% pandemic versus 0.37% pre-pandemic, p = 0.16). Preterm birth and SGA birth rates were slightly lower during the pandemic (6.0% versus 6.1% for preterm births, adjusted odds ratio [aOR] 0.96, 95% CI 0.94-0.97; 5.6% versus 5.8% for SGA births, aOR 0.95, 95% CI 0.93-0.96; both p < 0.001). Slightly higher rates of obstetric intervention were observed during the pandemic (40.4% versus 39.1% for induction of labour, aOR 1.04, 95% CI 1.03-1.05; 13.9% versus 12.9% for elective cesarean section, aOR 1.13, 95% CI 1.11-1.14; 18.4% versus 17.0% for emergency cesarean section, aOR 1.07, 95% CI 1.06-1.08; all p < 0.001). Lower rates of prolonged maternal length of stay (16.7% versus 20.2%, aOR 0.77, 95% CI 0.76-0.78, p < 0.001) and maternal readmission (3.0% versus 3.3%, aOR 0.88, 95% CI 0.86-0.90, p < 0.001) were observed during the pandemic period. There was some evidence that differences in the rates of preterm birth, emergency cesarean section, and unassisted vaginal birth varied according to the mother's ethnic background but not according to her socioeconomic background. A key limitation is that multiple comparisons were made, increasing the chance of false-positive results. In this study, we found very small decreases in preterm birth and SGA birth rates and very small increases in induction of labour and elective and emergency cesarean section during the COVID-19 pandemic, with some evidence of a slightly different pattern of results in women from ethnic minority backgrounds. These changes in obstetric intervention rates and pregnancy outcomes may be linked to women's behaviour, environmental exposure, changes in maternity practice, or reduced staffing levels.

Objective To assess the relative risk of perinatal mortality, severe preterm delivery, and low birth weight associated with previous treatment for precursors of cervical cancer.Data sources Medline and Embase citation tracking from January 1960 to December 2007.Selection criteria Eligible studies had data on severe pregnancy outcomes for women with and without previous treatment for cervical intraepithelial neoplasia. Considered outcomes were perinatal mortality, severe preterm delivery (<32/34 weeks), extreme preterm delivery (<28/30 weeks), and low birth weight (<2000 g, <1500 g, and <1000 g). Excisional and ablative treatment procedures were distinguished.Results One prospective cohort and 19 retrospective studies were retrieved. Cold knife conisation was associated with a significantly increased risk of perinatal mortality (relative risk 2.87, 95% confidence interval 1.42 to 5.81) and a significantly higher risk of severe preterm delivery (2.78, 1.72 to 4.51), extreme preterm delivery (5.33, 1.63 to 17.40), and low birth weight of <2000 g (2.86, 1.37 to 5.97). Laser conisation, described in only one study, was also followed by a significantly increased chance of low birth weight of <2000 g and <1500 g. Large loop excision of the transformation zone and ablative treatment with cryotherapy or laser were not associated with a significantly increased risk of serious adverse pregnancy outcomes. Ablation by radical diathermy was associated with a significantly higher frequency of perinatal mortality, severe and extreme preterm delivery, and low birth weight below 2000 g or 1500 g.Conclusions In the treatment of cervical intraepithelial neoplasia, cold knife conisation and probably both laser conisation and radical diathermy are associated with an increased risk of subsequent perinatal mortality and other serious pregnancy outcomes, unlike laser ablation and cryotherapy. Large loop excision of the transformation zone cannot be considered as completely free of adverse outcomes.