Effect of COVID -19 pandemic on still births.

Introduction: The COVID-19 pandemic is testing the strength of the strongest medical management in the globe. In developing countries, this contagious disease is quickly spreading in the midst of various endemic medical conditions like HIV, tuberculosis, jungle fever, lack of healthy sustenance, and incessant episodes of rampant contaminations. This happens especially in a setting of frail healthcare systems which may scarcely adapt to the previously mentioned existing medical challenges. Purpose: The objective of this research is to examine the impacts of pandemic of COVID-19 on the stillbirth rates. Methodology: Study was conducted at department of obstetrics and gynecology Unit Gynae C Lady Reading Hospital Peshawar from 1st January 2019 to 31st August 2020. This comparative cross sectional study was carried out at using non probability consecutive sampling technique. Findings: A large number of patients admitted with the diagnosis of stillbirth during 2019 and 2020 were multiparas 57% and 62% respectively. Booking status was 64% during 2019 and dropped to 52% in pandemic year 2020.Percentages of stillbirth due to abruption, placenta previa, gestational diabetes mellitus(GDM), type II diabetes, malpresentation, intrauterine growth restriction (IUGR),obstructed labor, eclampsia, postdates and unknown causes in 2019 and 2020 have been given in the table.

Role of Decapitation in Management of A Case of Complete Shoulder Dystocia with Rupture Uterus - A Case Report

Complete Shoulder dystocia in the presence of scarred uterus is an acute obstetrical emergency and if not properly handled can lead to serious fetal and maternal complications. A G5P4AO previous II cesarean sections, presented in emergency after delivery of fetal head and impacted shoulders, at a small private clinic in a village, four hours back. On laparotomy, there was uterine rupture from the previous uterine scar along with posterior bladder wall rupture . The shoulder dystocia was relieved by decapitation and breech extraction abdominally. Subtotal hysterectomy and repair of the bladder wall was done. This case highlight the dilemma of lack of regular antenatal care and maternal education, malpractices by untrained health professionals and time lapse in referral system that is still a very serious and major issue in developing countries like Pakistan . Keywords: Shoulder dystocia, obstructed labor, and uterine rupture

Relation of Normal Childbirth Care Training to Midwives Knowledge and Attitudes at Bebesen Health Center Bebesen District of Central Aceh Regency in 2021

Background. Mortality and morbidity in pregnant and maternity women is a big problem in developing countries. In poor countries, about 25-50% of deaths of women of childbearing age are caused by pregnancy-related causes. It is estimated that every year 585,000 women die from pregnancy and childbirth. 99% of these deaths occur in developing countries. According to WHO, 60-80% of maternal deaths are caused by bleeding during childbirth, obstructed labor, sepsis, high blood pressure during pregnancy, and complications from unsafe abortion. The purpose of this study was to determine the relationship between normal delivery care (APN) training on the knowledge and attitudes of midwives at the Bebesen Health Center, Bebesen District, Central Aceh Regency in 2020. Methods. The research method uses an analytical survey method with a cross sectional approach, which is a study to study the dynamics of the correlation between risk factors and effects, by approaching, observing or collecting data at once. The population in this study was all 63 midwives. The sampling method uses a total sampling technique that uses all members of the population as a sample. Data collection was carried out from November 14-16, 2020. Results. The results showed that from the analysis obtained a value for the p-value of good knowledge as many as 20 respondents (31.7%) and a positive attitude that is as many as 32 respondents (50.8%). Conclusion. There is a relationship between normal delivery care training (APN) with knowledge with a p value of 0.014 (p < 0.05) and normal delivery care (APN) with changes in the attitude of midwives with a p value of 0.00 (p < 0.05) in Bebesen Public Health Center, Bebesen District, Central Aceh Regency.

731. Puerperal Sepsis Among Women with In-facility Births in Western Tanzania

Background Puerperal sepsis is an important cause of maternal mortality worldwide. As access to emergency obstetric services expands in resource-limited settings, rapid recognition and treatment of sepsis, and prevention of nosocomial infections that might lead to sepsis, is critical. We describe puerperal sepsis cases among women with in-facility births in the Kigoma region of Tanzania. Methods Demographic, obstetric history, pregnancy complication and outcome, as well as mortality data were collected for women who delivered in hospitals, health centers and dispensaries in the Kigoma region, Tanzania 2016 – 2018. Up to 3 maternal complications were recorded as free text. Puerperal sepsis included women where ‘sepsis’ was recorded as a complication during hospitalization. We calculated rates of puerperal sepsis and completed a descriptive analysis of patients. Results 203,604 women delivered infants in 197 participating facilities during the data collection period. Of these, 2228 (1.1%) had sepsis recorded, for an overall rate of 10.9 sepsis cases per 1000 deliveries. Although 48% of births occurred in dispensaries, sepsis complications were reported almost exclusively in hospitals and health centers (37.7 and 10.3 per 1000 deliveries, respectively). Sepsis rates varied across individual facilities, from 15.5 to 45.2 cases per 1000 deliveries in hospitals and 0 to 38.6 cases per 1000 deliveries in health centers. Women who developed sepsis had a median age of 25 (IQR 22 – 30) years and 1113 (56%) were nulliparous. 1763 (90%) of women who had sepsis delivered by caesarian delivery. Obstructed labor (827; 42%) was a common co-complication of sepsis; obstetric hemorrhage and uterine rupture were seen in 93 (5%) and 77 (4%) women with sepsis, respectively. 49 women with sepsis (3%) died prior to hospital discharge. Stillbirths and pre-discharge neonatal deaths complicated 107 (5%) and 74 (4%) deliveries to women with sepsis. Conclusion In the Kigoma region of Tanzania puerperal sepsis frequently occurs in women with obstructed labor and caesarian delivery. Further evaluation of both facility-level and individual factors that contribute to the incidence of sepsis in this population, particularly those related to invasive procedures, is critical for early recognition and prevention. issue Disclosures All Authors: No reported disclosures

The ‘occiput-spine angle’: a new sonographic index of fetal head deflexion during first stage of labor as predictor of course of labor and outcome

Background Labor is a physiologic process during which the products of conception (i.e. the fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus. Labor is achieved with changes in the biochemical connective tissue and with gradual effacement and dilatation of the uterine cervix as a result of rhythmic uterine contractions of sufficient frequency, intensity, and duration. Labor is divided into three stages that include cervical dilatation, fetal delivery and delivery of the placenta. Objective The aims of this study were to quantify the degree of fetal head deflection via the use of Ultrasound during the first stage of labor and to determine whether a parameter derived from ultrasound examination (the occiput-spine angle) has a relationship with the progress of labor, subsequent effect on maternal, fetal complications and rate of cesarean delivery. Methods This is a prospective cohort study which includes a total of 200 women with gestational age 37-42 weeks were assessed in this study in Ain shams Maternity hospital labor ward by 2 dimensional ultra sound. Examinations were performed after a verbal and written consent from the patient with the patient lying in the dorsal supine position. And exclusion of Occiput-posterior position, multigravida, Indication for cesarean, Medical disorder eg hypertension or diabetes, pre labor rupture of membranes to correlate between the Occiput- spine angle (OSA) and the outcome of labor regarding the progress of labor, incidence of cesarean section, maternal and fetal complications. Results This study demonstrates that the sonographic measurement of the angle formed by the fetal occiput and the spine (occiput-spine angle) is feasible and reproducible, the occiput-spine angle in the first stage of labor is positively correlated with the clinically established station and the risk of obstructed labor requiring an operative delivery ie, Occiput-spine angle have been statistically significantly lower in cases underwent operative delivery. Occiput-spine angle had a statistically significant low diagnostic performance in predicting operative delivery. Conclusion The occiput-spine angle in the first stage of labor correlates significantly with the risk of obstructed labor Compared with spontaneous vaginal deliveries, cases that require obstetric intervention demonstrated a smaller occiput-spine angle at a similar station, suggesting diminished flexion of the fetal head. For occiput anterior fetuses, the greater the degree of fetal head deflexion, the greater risk of operative delivery due to labor arrest.

Assessing feasibility and maternal acceptability of a biomechanically-optimized supine birth position: A pilot study

Background In order to manage a protracted second stage of labor, “eminence-based” birth positions have been suggested by some healthcare professionals. Recent biomechanical studies have promoted the use of an optimized supine birthing position in this setting. However, uncertainty exists regarding the feasibility of this posture, and its acceptability by women. This pilot study primarily aimed to assess these characteristics. Objective and methods In this monocentric prospective study, 20 women with a protracted second stage of labor were asked to maintain a biomechanically-optimized position for at least 20 minutes at full dilatation. This posture is similar to the McRoberts’ maneuver. Maintaining the position for 20 minutes or more was considered clinically relevant and indicative of feasibility and acceptability. Satisfaction with the position was assessed using a Visual Analogue Scale (VAS). A sub-group analysis was performed to assess eventual differences between more and less satisfied patients, according to the median of patients’ satisfaction scores. Results Seventeen patients (85%) maintained the optimized position for at least 20 minutes. The median satisfaction score of these participants was 8 (interquartile range: 1) out of 10. No significant differences were found between the two sub-groups (satisfaction score <8 vs satisfaction score ≥8) regarding general and obstetric characteristics, as well as obstetrical and fetal outcomes. Conclusion The optimized position is acceptable and feasible for women experiencing a protracted second stage of labor. Further clinical studies are needed to assess the efficiency of such positions when women undergo an obstructed labor.

Social Immersion for Women After Repair for Obstetric Fistula: An Experience in Guinea

Background: Reintegration of women after repair of their female genital fistula remains a challenge. The objective of this study was to document the medical pathway and the reintegration process of women through the “social immersion” program of EngenderHealth in Kissidougou and Labé (Guinea).Methods: This was a qualitative descriptive study with 55 participants, including women seeking fistula care and stakeholders involved in the social immersion for repaired women in Kissidougou and Labé. The study included collecting demographic and clinical data of women, interviews with women before and after surgery, after social immersion, and 3 months post-discharge. Municipal officials, health providers, and members of host families were also interviewed. The study protocol was approved by the Guinea National Ethics Committee for Health Research.Results: The study confirmed that obstetric fistula still occurs among women living in rural and underserved areas. Most women attended at least two to five antenatal care visits, but nine over 10 reported a tragic experience of child loss associated with the occurrence of fistula. Most of them received support from their husband/partner during referral after the obstructed labor and later in the search for treatment. Women and stakeholders reported a good experience of surgery and social immersion in both Kissidougou and Labé. About 3 months after discharge, women who were continent reported being happy with their new life compared to women discharged with repair failure and residual incontinence.Conclusion: The study found the positive impacts of social immersion on the quality of life of women after fistula repair, particularly for those women who had a successful repair. The approach can be included in fistula care programs, either through direct provision or through referral to programs that can provide this service.

Building a Country-Wide Fistula Treatment Network in Kenya: Results From the First Six Years (2014-2020)

It is estimated that one million women worldwide live with untreated fistula, a devastating injury primarily caused by prolonged obstructed labor when women do not have access to timely emergency obstetric care. Women with fistula are incontinent of urine and/or feces and often suffer severe social and psychological consequences such as profound stigma and depression. Obstetric fistula affects economically vulnerable women and garners little attention on the global health stage. Exact figures on fistula incidence and prevalence are not known. In Kenya, results from a population-based survey suggest that approximately 120,000 reproductive-aged women have experienced fistula-like symptoms.In 2013, Fistula Foundation designed a program to significantly increase country-wide fistula treatment capacity in Kenya by addressing key barriers that limit women’s ability to receive treatment. Launched as Action on Fistula, and later becoming the Fistula Treatment Network, this model created a network of hospitals, a training center for surgeons and healthcare providers, and robust community outreach and reintegration activities. The Fistula Treatment Network was implemented by Fistula Foundation in collaboration with the Ministry of Health and Kenyan non-governmental and community-based organizations. Fistula Foundation and its donors provided the program’s funding, with seed funding, representing about 30% of the program budget, provided by Astellas Pharma EMEA.Over a six-year period, 2014-2020, the network supported 6,223 surgeries at seven hospitals, established a fistula training center and trained eleven surgeons, trained 424 Community Health Volunteers, conducted extensive outreach to all 47 counties in Kenya, and contributed to the National Strategic Framework to End Female Genital Fistula. At 12 months post fistula repair, 96% of women in a community setting reported that they were dry and not experiencing any incontinence and the proportion of women reporting normal functioning increased from 18% at baseline to 85% at twelve-months. The Fistula Foundation’s Fistula Treatment Network model increased access to fistula care services, strengthened the healthcare workforce, improved understanding of fistula and reduced stigma in a community setting. This integrated approach is an effective and replicable model for building capacity to deliver comprehensive fistula care services in other countries where the burden of fistula is high.

Common Genitourinary Fistulas in Rural Practice: Treatment and Management

Acquired genitourinary fistulas are common in rural practice. They are pathological communications between the urinary and genital tracts, or between either of the tracts and gastrointestinal tract or skin. Vesicovaginal fistula is the commonest and most devastating. They may result from prolonged and obstructed labor, injuries during obstetric, gynecologic, pelvic and urologic procedures, circumcision, fall from heights, road traffic accidents and female genital mutilation. They present as urinary leakage with characteristic odor. Diagnoses are mainly clinical and confirmed by dye tests, contrast radiography and endoscopy. Treatment is individualized according anatomic sites and etiology. Timing of repair is of essence; delayed repair for obstetric and early for focal injuries. Multidisciplinary team approach and cooperation is encouraged in the management of some of these cases. The sustenance of the 2 – way referral system is emphasized in cases beyond the scope of rural practice. Repairs when undertaken by skilled compassionate fistula surgeons with attention to principles of fistula management and surgical treatment, success rate can approach 90%. Interposition of vascularized grafts have improved success rate. The burden of this condition will be reduced through integration of rural practitioners in the preventive strategies of health education of the public and girlchild; improvement of healthcare, education and transportation infrastructures.

Hypoxic Ischemic Encephalopathy in Neonates with Birth Asphyxia - A Hospital Based Study

Introduction: Each year approximately 4 million babies are born asphyxiated, which results in 1 million deaths and an equal number of serious neurological sequelae. One of the commonest organs involved in birth asphyxia is brain which may lead to a syndrome of clinical manifestation called Hypoxic Ischemic Encephalopathy (HIE). Aims: To find out possible maternal and neonatal risk factors for Hypoxic Ischemic Encephalopathy, to analyze clinical presentations and outcome of HIE in asphyxiated newborns. Methods: Hospital based observational study was carried out among fifty newborns with Apgar score less than 7 at 1 minute of life admitted in Nepalgunj Medical College Teaching Hospital, Kohalpur, Banke. Results: The incidence of birth asphyxia and birth asphyxia with HIE were 37.2 per 1000 live births and 14 per 1000 live births with male: female ratio of 1.27:1. Most of the neonates 22(44%) were in HIE stage II. Meconium stained amniotic fluid 18 (36%) was the most common intrapartum risk factor followed by maternal use of intrapartum medications 14 (28%), Premature Rupture of Membrane (PROM) 8 (16%), prolonged labor 5 (10%) and obstructed labor 6 (12%). Four (8%) asphyxiated neonates with HIE had cord prolapse and 7 (14%) had cord around the neck. The most common resuscitation done was bag and mask ventilation (56%) (P<0.05). Majority of the studied neonates were of normal birth weight (76%) and head circumference (84%) (P<0.05) with clinical presentations of respiratory distress (88%), seizures (44%), apnea (22%), bradycardia (8%), tachycardia (6%) and bulged anterior fontanel (6%). The overall mortality of neonates with HIE was 20% of which most were of HIE stage III. Conclusion: Certain measures could be taken to prevent birth asphyxia: early detection and intervention of high risk pregnancy, prompt and effective resuscitation of asphyxiates newborns.