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Assess factors that impact risks and benefits of a trial of labor after cesarean
Describe the role of maternal autonomy in the decision for cesarean
Assess the patient’s chance for a successful trial of labor
Identify factors that patients may weigh when deciding the value successful VBAC holds for them
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The faculty reported the following relevant financial relationships with ineligible entities related to the educational content of this CE activity:
Faculty: Sara Petruska, MD has nothing to disclose.
Rebecca Dunsmoor-Su, MD receives a salary from Gennev, and consulting fees from ObG Connect. Dr. Dunsmoor-Su has a financial ownership Interest in Gennev and ObBest Practice LLC
The PIM planners and others have nothing to disclose.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
Results of the BUMPES Trial: Sitting Up or Lying Down to Promote Vaginal Delivery with an Epidural in the 2nd Stage of Labor?
BACKGROUND AND PURPOSE:
Recent Cochrane Review did not demonstrate a difference between upright or recumbent when assessing the chance of a spontaneous vaginal birth in women with epidural anesthesia
Brockehurst et al. (BMJ, 2017) sought to determine whether the upright position during the second stage of labor increases the chance of spontaneous vaginal birth in women with a low-dose epidural
Birth in the Upright Maternal Position with Epidural in Second stage (BUMPES) Trial
Multicenter randomized controlled trial (RCT)
≥ 16 years, ≥ 37 weeks gestation, nulliparous, singleton cephalic presentation, and intended to have a spontaneous vaginal birth
2nd stage with low dose epidual in situ
Subjects were assigned to the following groups:
Maintain pelvis in as vertical a plane as possible
Walking, kneeling, sitting etc. all acceptable
Lying down position
Up to 30 degrees inclination
Groups were stratified by center
Blinding of participants or clinicians not possible
Primary outcome was spontaneous vaginal birth
Secondary outcomes were
mode of birth, perineal trauma, infant Apgar score <4 at 5 minutes, admission to a neonatal unit
longer term outcomes included maternal physical and psychological health, incontinence, and infant gross developmental delay
1,556 participants were in the upright group and 1,537 in the lying down group
There were significantly fewer spontaneous vaginal births in the upright group (35.2%) vs the lying down group (41.1%) with adjusted risk ratio (RR) 0.86 (95% CI 0.78 to 0.94)
No evidence of difference for most of the secondary maternal, neonatal, or longer term outcomes including
Vaginal delivery, obstetric anal sphincter injury, infant Apgar score <4 at five minutes and maternal fecal incontinence at one year
There is a 5.9% absolute increase in the chance of spontaneous vaginal birth in the lying down group
Authors recognize limitations of the study
Inability to mask
Unless there is an indication to do otherwise, guidance and practice promote women using any position they find more comfortable and may have resulted in superior adherence in the upright group
No obvious mechanism to explain findings
When adding this current cohort of approximately 3,000 well randomized women to previous data, sum of evidence strengthens findings in this paper
Combining present results with previous data, odds ratio of upright vs lying down is 0.80 (95% CI 0.70 to 0.92)
Does Maternal Depression or Stress Affect Fetal Growth?
BACKGROUND AND PURPOSE:
Intrauterine fetal growth restriction (FGR or IUGR), defined as weight below the 10th percentile, has been associated with excessive maternal stress
Most studies are based on birth weight, and therefore cannot fully assess timing of various exposures in addition to confounders
Grobman et al. (Journal of Ultrasound in Medicine, 2017) sought to determine whether women reporting greater perceived stress or depression symptoms at start of or during pregnancy would demonstrate altered longitudinal fetal growth
NICHD Fetal Growth Study multicenter prospective (2009 – 2013)
Women screened at 8 weeks and 13 weeks 6 days gestation for stress/depression status and underwent serial sonographic examinations
Definition of high risk
Cohen Perceived Stress Scale (PSS): Score ≥ 15
Edinburgh Postpartum Depression Survey (EPDS): Score of ≥ 10 (13 used for sensitivity analysis)
Fetal weight growth curves and individual biometric parameters were created using serial sonographic data
Interaction between race/ethnicity and stress/depression scores were assessed
Multicenter longitudinal study of 2334 women
89% and 90% of women completed PSS and EPDS, respectively, at least once in all trimesters
Despite participant’s reported PSS or EPDS score, longitudinal growth curves and fetal weight were similar
Race/ethnicity did not modify biometric parameters
Quantified depressive symptoms and greater perceived stress are not associated with alterations in fetal growth throughout all three trimesters
Authors recommend further research to determine whether combination of stress and/or depression with environmental factors may alter fetal growth
This paper complements the Wing et al. study that likewise did not find an association between perceived maternal stress and neonatal growth measurements (summarized in ‘Related ObG Topics’ below)
The appropriate use of antenatal corticosteroids improves neonatal outcomes, including decreased severity and/or frequency of respiratory distress syndrome (RDS), intracranial hemorrhage, necrotizing enterocolitis and death. Antenatal corticosteroids, when appropriate, are administered in a clinical setting where patients are at risk for preterm delivery within 7 days, irrespective of membrane status and fetal number.
Risk of preterm delivery within 7 days
Between 24w0d to 33w6d – ‘Recommended’
Single course of corticosteroids
Between 23w0d and 23w6d – ‘May be Considered’
23w0d to 23w6d
Single course of corticosteroids
22w0d to 22w6d
Single course of corticosteroids
Note: ACOG and SMFM revised recommendation states
Antenatal corticosteroids may be considered at 22 0/7 weeks to 22 6/7 weeks of gestation if neonatal resuscitation is planned and after appropriate counseling
Some families may choose to forgo resuscitation and support after appropriate counseling
Between 20w0d and 21w6d – ‘Not Recommended’
Antenatal corticosteroids are not recommended due to lack of data suggesting benefit
Late preterm (34w0d – 36w6d)
If no previous corticosteroids
Single course of betamethasone
Not indicated in women diagnosed with clinical chorioamnionitis
Single course of betamethasone in specific populations
Population included in ALPS trial: Recommended
Nonanomalous singleton gestation
High risk for preterm delivery (medically indicated or spontaneous)
No prior antenatal steroids
Select populations not in the original ALPS trial: Suggest consideration for use in the following clinical scenarios
Multiple gestations reduced to a singleton gestation ≥14w0d
Expected to deliver in less than 12 hours
Low likelihood of delivery <37 weeks: Recommend against
Pregestational diabetes: Recommend against due to risk for worsening neonatal hypoglycemia
Repeat or Rescue Courses
Regularly scheduled repeat courses or serial (> 2) courses
If a patient has received one prior course of corticosteroids > 14 days ago, is less than 34w0d gestation and is at risk of preterm delivery within 7 days
a single repeat course of corticosteroids should be considered (change from previous ‘may’)
Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario (based on Cochrane meta-analysis)
Preterm prelabor rupture of membranes (PPROM)
There is insufficient evidence to make a recommendation for or against repeat or rescue courses
Dose and Regimen: give first dose even if 2nd dose unlikely
Macrosomia: Determination of EFW and Recommendations for Delivery
WHAT IS IT?
The term fetal macrosomia implies growth beyond an absolute birth weight of 4000 grams or 4500 grams, regardless of gestational age. The risk of morbidity for both infants and mothers increases when the birthweight is between 4000 and 4500 grams. Risks for maternal and newborn morbidity rise considerably with birthweights >4500g. A correct diagnosis can only be made after weighing an infant at birth, as ultrasound prediction is not precise.
Consider a prophylactic cesarean for suspected fetal macrosomia if the EFW (estimated fetal weight) is > 5000 grams in women without diabetes
Consider a prophylactic cesarean for suspected fetal macrosomia if the EFW is > 4500 grams in women with diabetes
Induction before 39w0d is not suggested for suspected fetal macrosomia as induction has not been shown to improve maternal or fetal outcomes
Suspected fetal macrosomia is not a contraindication to a trial of labor after cesarean
In the United States, 7.8% of all live-born infants weigh > 4000 grams and 1% weigh > 4500 grams. The most serious complication of fetal macrosomia is shoulder dystocia which complicates 0.2-3.0% of all vaginal deliveries. When the birthweight is > 4500 grams, the shoulder dystocia rate increases to 9-14%. The shoulder dystocia rate increases to 20-50% in the presence of maternal diabetes when the birthweight is > 4500 grams. ‘Large for gestational age (LGA)’ also refers to excessive fetal growth, but rather than absolute weight, LGA is usually defined as ≥90th percentile for a given gestational age.
Risk Factors for Macrosomia
Preexisting maternal diabetes
Uncontrolled gestational diabetes
Excessive gestational weight gain
Excessive inter pregnancy weight gain
Prior macrosomic infant
Maternal nonsmoking status
Maternal Risks Associated with Macrosomia
Increased risk of cesarean delivery
Fetal Risks Associated with Macrosomia
Shoulder dystocia leading to brachial plexus injury or clavicular fracture
Decreased 5 minute Apgar score
Increased rates of admission to the NICU, including longer stays
Obesity later in life
Accuracy of EFW Measurement
“Poor predictor of macrosomia”: Better at ruling out than identifying macrosomia
Sensitivity: 29% to 70%
Abdominal palpation maneuvers
Sensitivity: 16% to 68%
Specificity: 90% to 99%
PPV: 38% to 80%
In women with diabetes
“Clinical estimates of macrosomia are as predictive as those derived with ultrasonography”
Prediction of birth weight >4,500g
Sensitivity: 10% to 45%
Specificity: 57% to 99%
PPV: 11% to 44%
NPV: 92% to 99%
Prediction of birth weight >4,000g
Newborns>4,500 g: Mean absolute percent error of 13% | Increases with greater EFW
Nonmacrosomic newborns: Mean absolute percent error of 8%
Note: Upon review of current literature, ACOG states
No single formula based on ultrasound biometry performs significantly better than others for the detection of macrosomia more than 4,500 g
Similar to clinical estimates of fetal weight, ultrasonography can be used most effectively as a tool to rule out macrosomia, which may help avoid maternal and fetal morbidity
Vaginal Seeding describes the practice of using a gauze or swab to “transfer” vaginal fluids to an infant delivered by cesarean section by swabbing the infant’s mouth, face or body. The working theory behind this procedure is based on data suggesting decreased autoimmune disorders, asthma and allergic diseases in infants delivered vaginally. However, presently, there is no evidence to support the use of this practice in the general population due to lack of rigorous studies and outcomes data.
“The American College of Obstetricians and Gynecologists does not recommend or encourage vaginal seeding outside of the context of an institutional review board-approved research protocol, and it is recommended that vaginal seeding otherwise not be performed until adequate data regarding the safety and benefit of the process become available.
The American College of Obstetricians and Gynecologists only supports the performance of vaginal seeding in the context of an institutional review board-approved research protocol.”
Current evidence is very limited regarding outcomes and therefore studies are ongoing to determine actual risks
The pilot study inclusion criteria included
No group B streptococci
No signs of vaginosis
Vaginal pH <4.5
20% of pregnant women at term are group B streptococci carriers
Potential risk for lethal newborn infection if vaginal seeding conducted in the general population
Additional infectious risks to the neonate included undiagnosed
C trachomatis | N gonorrhea | HPV | Group A streptococci | HSV | Other infections
Above neonatal infections may be prevented with cesarean and no vaginal seeding
Counseling for Women Who Desire Vaginal Seeding
ACOG provides guidance on counseling if a patient insists on performing the procedure (herself)
Designated newborn’s pediatrician / family physician should be informed
Aside from a discussion (with documentation) regarding the above risks for newborn infection and consequent harms, ACOG states
Risk stratification is reasonable for such women in the form of testing for infectious diseases and potentially pathogenic bacteria. Serum testing for herpes simplex virus and cultures for group B streptococci, Chlamydia trachomatis, and Neisseria gonorrhea should be encouraged.
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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