Evaluation of vaginal birth safety in twin pregnancies with the first twin in cephalic presentation

Objective: To evaluate vaginal birth safety by comparing the results of cesarean birth in twin pregnancies with the first twin in vertex presentation. Material and methods: A retrospective cohort study of vertex-presenting twin pregnancies between 32 weeks 0 days and 38 weeks 6 days of gestation was conducted at our hospital from January 2013 to December 2014. The study population was divided according to the mode of birth. The primary outcome was early neonatal mortality, and secondary outcomes related to maternal and perinatal clinical characteristics were analysed between the groups. Results: Of 45,166 births, 1.92% (n = 869) were twin pregnancies. Of the 295 pregnancies meeting the study criteria, 30.16% (n = 89) were in the vaginal birth group, while the remaining 69.84% (n = 206) were in the cesarean birth group. In the vaginal birth group, all the first twins were delivered via vaginal birth, while among the second twins, 82.03% (n = 73) were delivered via vaginal birth, and the remaining 17.97% (n = 16) were delivered via cesarean birth. In the vaginal birth group, the early neonatal mortality rate was 22.4‰ (n = 2), and it was 9.7‰ (n = 2) in the cesarean birth group. All of the deaths occurred in pregnancies under 37 weeks of gestation. Conclusion: The neonatal outcomes between the vaginal birth and cesarean birth groups were similar in term pregnancies with the first in twin vertex presentation, whereas adverse neonatal outcomes were increased in the vaginal birth group in preterm second twin pregnancies.

A randomized comparative study of effect of intramuscular valathemate bromide (epidosin) and intramuscular camylofin dihydrochloride (anafortan) on cervical dilatation in labour

Background: Our aim is to search for a good cervical dilating agent which is not only more efficacious in cervical dilatation but also effective in relieving pain during labour with no or very little harmful effects on mother and foetus.Methods: The type of study was simple randomized comparative study. The present study was conducted in R. N. T. Medical College, Udaipur between October 2019 and December 2020. 118 patients were selected randomly. Two groups were made each consisting of 59 patients. First group received intramuscular camylofin dihydrochloride, second group received intramuscular (IM) valethamate bromide. Patients included in study group were: primigravidae/multigravidae, singleton full term gestation (37-40 weeks) with vertex presentation, cervical dilatation of ≥3 cm and patient excluded from study group with preclampsia, eclampsia, antepartum haemorrhage, any obstetric complications: cephalo pelvic disproportion, abnormal presentations.Results: Mean duration of active phase of first stage of labor was shorter in group I (313.17 minutes) than in group II (356.3 minutes) but not statistically significant. Mean cervical dilatation rate was significantly more in group I (2.02 cm/hour) than group II (1.81 cm/hour). Anafortan was effective in pain relief with mean pain score 5.31±1.06 while mean pain score for epidosin group was 7.37±1.07.Conclusions: In our study we observed that intramuscular camylofin dihydrochloride (anafortan) was more efficacious than IM valethamate bromide (epidosin) in shortening the duration of labor as well as in pain relief.

Predictive Factors for Successful Vaginal Delivery after a Trial of External Cephalic Version: A Retrospective Cohort Study of 946 Women

Objective Our aim was to find the factors which predict a vertex presentation of vaginal delivery (VD) in women who are admitted for a trial of external cephalic version (ECV). Study Design This is a retrospective cohort study of women who underwent a trial of ECV and delivered between November 2011 and December 2018 in a single tertiary center. The main outcome measure was successful VD of a fetus in the vertex presentation. Women who achieved VD in the vertex presentation or underwent cesarean delivery were compared on the basis of variety of predictive factors. Adverse neonatal and maternal outcomes were reported. Logistic regression was used for the multivariate analysis. Results A total of 946 women were included; 717 (75.8%) women had a successful ECV and 663 (70.1%) women had a VD in the vertex presentation. Parous women had 79.3% VD rate (570/719) and nulliparous women had 41.0% VD rate (93/227). Women with an amniotic fluid index (AFI) of 50 to 79, 80 to 200, and >200 mm had 34.8, 71.0, and 83.1% VD rate, respectively. Parous versus nulliparous women had an adjusted odds ratio (aOR) of 5.42 (95% confidence interval [CI] 3.90–7.52, p < 0.001), women with AFI 50 to 79 mm compared with AFI 80 to 200 mm had an aOR of 0.21 (95% CI 0.12–0.37, p < 0.001), and women with an AFI >200 mm compared with AFI 80 to 200 mm had an aOR of 1.74 (95% CI 1.03–2.92, p = 0.037) to achieve VD. The final prediction model for the chances of a VD based on data on admission for ECV was reported. The Hosmer-Lemeshow test was used to evaluate the goodness of fit of the model (p = 0.836). Conclusion Being parous and having an AFI >200 mm are positive independent predictive factors for achieving VD of a vertex presenting fetus after ECV. Whereas AFI 50 to 79 mm is a negative independent predictive factor. Key Points

Partogram: an important tool in managing labour!

Background: Various types and designs of partographs are being used at various centers. WHO introduced simplified version of partogram, for the use by skilled birth attendant. Preprinted paper versions of the partograph are availableMethods: 100 antenatal women were selected for study. Patients with vertex presentation and singleton pregnancy were taken. Patients who came late in labour and those with cephalopelvic disproportion were not included in the study. Cervical Dilatation in cms was assessed by per vaginal examination every 2 hourly, fetal Heart Rate every ½ hourly, uterine contractions and maternal pulse measured every ½ hourly, maternal BP and temperature were measured every 4th hourly.Results: Using WHO simplified partogram, characteristics of labour and neonatal outcome was evaluated. Among the 100 women included in the study, 78 required augmentation of labour, here 6 of them crossed the alert line and underwent LSCS. Of the 22 women who did not require augmentation, 4 crossed the alert line and underwent LSCS.We didn’t find any difference in monitoring of labour using simplified version of WHO partogram compared with other partograms, apparently it’s more simpler to plot and easy to understand.Conclusions: An alert line on partogram should be based on lower 10th centile rate of cervical dilatation of the local population. We found this rate as 1cm/hr, which corresponds to the slope of alert lineon standard partogram. Based on this we conclude, simplified partogram is good enough for monitoring labour progress.

Effectiveness of Moxibustion for Breech Presentation: A Prospective Study

Objective To evaluate the moxibustion for turning fetuses from breech to vertex presentation. Materials and Methods This was a single-center prospective study. All pregnant women carrying a fetus in breech presentation between the 32 and 35 gestational weeks were offered moxibustion application. The primary outcomes were vertex presentation at 37 weeks of gestation, vertex presentation at birth, and vaginal birth rates. A secondary analysis was performed to understand the effect of parity, type of breech presentation, body mass index (BMI), placental location, gender, and fetal birth weight on the presentation at birth. Results There were 63 cases in the study group and 245 cases in the control group. The rate of vertex presentation at term was found to be higher in the moxibustion group compared to controls (66.7 vs. 48.2%, p=0.022). There were 45 (71.4%) and 131 (53.5%) fetuses with vertex presentation at birth in the study and control groups, respectively (p=0.020). Overall, vaginal delivery rate was higher in the study group (50.8 vs. 37.1%, p=0.048). Multiparity and higher birth weight were associated with increased rates of vertex presentation in the moxibustion and control groups. Conclusion Moxibustion application increased the rate of vertex presentation at birth and also vaginal delivery rate compared with expectant management. Offering moxibustion between the 32nd and 36th week of gestation may provide women with a singleton fetus in breech presentation an opportunity for a vaginal birth.

EFFECT OF BALA TAILA MATRA BASTI AND YONIPICHU IN ACHIEVING SUKHAPRASAVA (NORMAL LABOUR) - A CASE STUDY.

Ayurveda is an indigenous system of medicine, emphasizing the Garbhavakranti (process of development of various components in Embryo) to prasavaprocess of normal labour) & Sutika (puerperium) very well. Nowadays due to changing lifestyle and daily habbits most of the women tend to go for caesarean section. Which has its own remote complications. Normal delivery is not only safe for mother but also for the baby. In Garbhini Paricharya Acharyas have mentioned Basti and yoni pichu moreover with Madhura aushadi siddha taila to facilitate sukhaprasava (eutocia). Aim- To study Bala taila Matra basti & Yonipichu in Sukhaprasava. Methodology- Use of Bala taila Matra basti & Yonipichu in Prakruta Garbhini for Sukhaprasava based on theoretical research using texts of Ayurveda. Result-A full-term spontaneous delivery (sukhaprasava) of a primi patient with vertex presentation of live female child of weight 3.2 kg on 15th February 2021 at 3.20pm.

Proposed cut-off for fetal scalp blood lactate in intrapartum fetal surveillance based on neonatal outcomes: a prospective observational study

Objective Determination of lactate in fetal scalp blood (FBS) during labor has been studied since the 1970s. The internationally accepted cut-off of >4.8mmol/L indicating fetal acidaemia is exclusive for the point-of-care device (POC) LactateProTM, which is no longer in production. The aim of this study was to present a new cut-off for scalp lactate based on neonatal outcomes with the use of StatstripLactate®/StatstripXpress® Lactate system, the only POC lactate meter designed for hospital use. Design Observational Study Setting January 2016 to March 2020 labouring women with an indication for FBS were prospectively included from seven Swedish and one Australian delivery unit. Population Inclusion criteria: singleton pregnancy, vertex presentation, ≥35+0 gestational weeks. Method Based on the optimal correlation between FBS lactate and cord pH/lactate, only cases with ≤25 minutes from FBS to delivery were included in the final calculations. Main outcome measures Metabolic acidosis in cord blood was defined as pH <7.05 plus BDecf >10 mmol/L and/or lactate >10 mmol/L. Results 3334 women were enrolled of which 799 were delivered within 25 minutes. The areas under the ROC curves (AUC) and corresponding optimal lactate cut-off values were as follows; metabolic acidosis AUC 0.87(95% CI:0.77-0.97), cut-off 5.7mmol/L; pH <7.0 AUC 0.83(95% CI:0.68-0.97), cut-off 4.6mmol/L; pH <7.05 plus BD ≥12mmol/L AUC 0.97(95% CI:0.92-1), cut-off 5.8mmol/L; Apgar score <7 at 5 minutes AUC 0.74(95% CI:0.63-0.86), cut-off 5.2mmol/L; and pH <7.10 plus composite neonatal outcome AUC 0.76(95% CI:0.67-0.85), cut-off 4.8mmol/L. Conclusions Suggested intervention threshold for fetal acidemia is scalp lactate of 5.2mmol/L using the StatstripLactate®/StatstripXpress®.

An observational study of parenteral paracetamol vis a vis tramadol as labour analgesics

Background: Labour although a physiological process, is associated with severe, excruciating pain. The delivery of the infant into the arms of a conscious and a pain free mother is one of the most exciting and rewarding moments in medicine ……..Moir. Labour analgesia plays an important role in making the process of labour comfortable for the mother. Drugs like paracetamol and tramadol with advantages of easy availability, being inexpensive and with no special technique of administration are a boon for labour analgesia. Our study aims to evaluate the efficacy of these two drugs as labour analgesics.Methods: Sixty cases in active labour fulfilling inclusion and exclusion criteria were selected for this study. All primigravidae at term gestation with singleton pregnancy having vertex presentation with no associated obstetric/ medical/surgical risk factors in spontaneous labour were selected. There were thirty patients who received Paracetamol as labour analgesic and thirty were in the tramadol group. It was an observational study.Results: The study revealed that paracetamol had a significant analgesic effect compared to tramadol at the fourth and the fifth hour of administration. However, the overall analgesic effect of both the drugs had no statistically significant difference. Maternal side effects and neonatal distress were less with paracetamol.Conclusions: This study showed that paracetamol had a better side effect profile for both mother and neonate along with a comparable, if not better, analgesic effect vis a vis tramadol.

COMPARISON OF FREQUENCY OF CESAREAN SECTION IN ELECTIVE INDUCTION OF LABOUR AT 40 +0 AND 41 +0 WEEKS OF GESTATION

Objective: To compare the frequency of cesarean section in elective induction of labour at 40 weeks and 41weeks of gestation. Study Design: Comparative cross-sectional study. Place and Duration of Study: Department of Gynecology & Obstetrics, Sialkot, from July to Dec 2017. Methodology: The pregnant females at full-term were divided in 2 groups. All patients aged 20-35 years andparity less than 5 with singleton alive pregnancy and vertex presentation at 40+0 weeks gestation were placedin group A and all singleton alive pregnancies with vertex presentation at 41+0 weeks in group B. Group A wasinduced at 40+0 weeks and group B was induced at 41+0 weeks of gestation. Induction of labour was performed and fetal heart rate monitoring was conducted every 15 minutes. Augmentation was completed and frequency of cesarean section recorded in both groups. Results: In this study a total of 100 patients were included. The mean age of the patients was 27.33 ± 4.87 years(range 20-35 years) with mean age of 26.54 ± 4.66 and 28.12 ± 4.99 years in group A and group B respectively.The cesarean section was performed in 20 (20%) patients, with 14 (28%) in group A and 6 (12%) in group B.Statistically significant difference of cesarean section was noted in both groups (p-value=0.046). Conclusion: There was a significantly lower rate of cesarean section in elective induction of labour at 41weeks as compared to 40 weeks of gestation.

EFFECT OF BALA SIDDHA TAILA MATRA BASTI AND YONI PICHU IN ACHIEVING SUKHPRASAVA: A CASE STUDY

Background: A primigravida female patient of age 22 years came to NIA Prasuti ward on date 25th August 2019 with chief complaint of Amenorrhea since 9 months and labor pain since morning with no history of leaking and bleeding per vaginal. Methodology: The patient first visited NIA OPD on 2nd April 2019 for routine Antenatal check up with 5th months of pregnancy. Thereafter she was regularly visiting NIA Prasutitantra OPD for her routine ANC check up and was given routine Ayurvedic anetanatal medications like Mukta Shukti Bhasma and Shatawari churna with milk, Punarnawa Mandoor with buttermilk. She also followed all prenatal advice given to her time to time. The patient had not reported any complication related to pregnancy, or medical problems and side-effects of medications during her course of pregnancy. Patient had given Bala siddha Taila Matra Basti from 37 weeks of gestation twice a week up to the delivery and Bala siddha Taila Yoni Pichu during her active phase of labor up to full dilatation of cervix. Result: A full term normal delivery with right medio-lateral episiotomy with vertex presentation delivered an alive healthy male child of weight 2.7kg on 25th August 2019 at 2:00pm.