Four things hospitals can adapt to reduce Maternal Mortality

The USA has the highest maternal mortality rates in all the developed countries around the world. Black women are 3 to 4 times more likely to succumb to pregnancy or childbirth-related causes of deaths as compared to their white counterparts.

The Center for Disease Control identifies three significant potentially preventable complications of pregnancy and labor that contribute a lion share to rising the maternal deaths. The causes include postpartum hemorrhage, severe hypertension, and venous thromboembolism.

Drs. Hollier & Brown, co-authors of a new perspective published in the New England Journal of Medicine (NEJM), identifies 4 actions that can be quickly adopted by all hospitals and healthcare providers to address the preventable causes of maternal deaths.

This picture by NEJM enumerates the four causes.

Abstract 

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CDC: Meeting the Challenges of Measuring and Preventing Maternal Mortality in the United States

Women in the United States are more likely to die from childbirth or pregnancy-related causes than other women in high-income countries. More evidence is needed to understand the actual causes of death better, but research suggests that half of these deaths may be preventable. Racial disparities persist. The risk of pregnancy-related deaths for black women is three to four times higher than those of white women.

Watch this session of Grand Rounds to learn about efforts to analyze and prevent future deaths. Hear our speakers discuss the effects maternal deaths have on the family and on the community. You will also learn about how CDC has collaborated and intervened through public-private partnership efforts to prevent deaths associated with childbirth and pregnancy.

About CDC Public Health Grand Rounds

CDC Public Health Grand Rounds is a monthly scientific presentation featuring the important work that CDC is doing in the United States and around the world to protect people and save lives.  Experts discuss major public health issues, key challenges, cutting-edge scientific evidence, potential solutions, and recent developments. Each session is the result of a rigorous process which takes months to prepare. This attention to detail ensures that our audiences receive up-to-date, scientifically accurate, and usable information. Grand Rounds welcomes clinicians, researchers, students of public health, medicine and nursing, and the public that we serve to attend in person or watch the live webcast.

ISUOG Practice Guidelines: Intrapartum Ultrasound

Ultrasound in labor is not a proposed standard of care; however, several studies have reported it to be more accurate and reproducible than clinical examination. It is especially helpful in knowing the fetal position and station and prediction of the arrest of labor.

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) recently issued practice guidelines for Intrapartum Ultrasound. These Guidelines address exclusively the use of ultrasound in labor to determine fetal head station, position and attitude.

Intrapartum ultrasound can predict mode of delivery (vaginal or operative) and outcome of instrumental vaginal delivery. It is used in the labor ward as an adjunct to clinical digital examination to assess the position of the fetal head, fetal head station, progression, and attitude. 

Ultrasound in labor is performed using a transabdominal or transperineal approach depending upon the clinical situation. A wide-sector, low-frequency (< 4 MHz) exposure is best suited to ultrasound in labor.

Indication for Ultrasound in labor room

Slow progress or arrest of labor in the first or second stage

To determine the fetal head station and position before attempting instrumental vaginal delivery

Assessment of fetal head malpresentation.

While performing ultrasound in labor, data documentation includes fetal viability and FHR, fetal presentation, the position of the spine and occiput, the position of the placenta in relation to the cervix and presenting part.

While performing a transperineal ultrasound, the sonographer should also look for following parameters, especially before operative vaginal delivery (OVD):

Angle of progression (AoP)

Head–perineum distance (HPD)

Head direction with respect to the

pubic symphysis

Midline angle (MLA)

Here is an informative and detailed video by ISUOG about practice guidelines on intrapartum ultrasound

ISUOG practice guideline on intrapartum ultrasound

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Global cesarean section rates almost double since the turn of the century

Globally, the cesarean section rate has almost doubled since 2000, with wide geographical variations based on economic prosperity. The rate is unprecedently high, reaching almost 60% in some parts of Latin America and as low as 5% in southern Africa. The intervention is often overused unnecessarily in some parts of the world and denied to mothers in the area where it is needed the most. The linear increases in rates make it highly unlikely that it will be reversed soon.

The considerable variation in C-section rates indicates that the increase is not backed by scientific evidence, as evident by a whopping 6·2 million unnecessary caesareans performed each year, half of which are done in Brazil and China.

Lancet launched a three-part series on optimizing the cesarean section rates at the World Congress of Gynecology and Obstetrics (FIGO) on Oct 18. Simultaneously, the World Health Organization (WHO) also published guidelines on October 11 to reduce the incidence of unnecessary cesarean sections. 

The WHO guidance is unique because it includes the first ever non-clinical interventions to decrease the rising cesarean rates. The guidance consists of 3 sets of separate recommendations targeted at women, healthcare professionals, and health organization and systems.

Those addressed at women, stress the importance of health education to allay fear of childbirth and misconceptions. The WHO guidance states, comprehensive health education, including tailored information and support about childbirth fear, pain relief, and the advantages and disadvantages of cesarean sections, should be provided to all women.

Providers guidance is crucial in a sense it includes a mandatory second opinion for cesarean section indication, audit and timely feedback in good resource settings to bring down the cesarean rates. Another significant recommendation is the equal remuneration for the vaginal birth and cesarean deliveries.

The guidance also acknowledges other barriers towards practicing evidence-based medicines such as cultural beliefs, litigations, increased surgical skills of younger providers with decreasing confidence in conducting difficult vaginal births.

As the part of the Lancet series, the editorial by Wiklund and colleagues highlights the importance of investing in midwives and midwives-led care in bringing down the global cesarean section rate. Trained midwives can provide continuous and watchful support during labor, creating an atmosphere of trust that may calm the patients resulting in more natural births.

The series further analyzed the significant trends of cesarean section in Brazil and China. Both are emerging economies with the highest cesarean section rates seen in wealthier, educated women in private clinics as compared to less well-educated women (54.4% of births versus 19.4%). Wealthier women are 6 times more likely to have surgical delivery as compared to women from a low socioeconomic background.

FIGO also issued a position paper on how to curb the recent cesarean section epidemic. Gerard Visser, MD, from the University Medical Centre, Utrecht, the Netherlands, and chair of FIGO's Committee on Safe Motherhood and Newborn Health, and colleagues note, “Worldwide there is an alarming increase in C-section rates. The medical profession on its own cannot reverse this trend.

Drivers for the increasing C-section rates can vary between countries and include a loss of medical skills to confidently and competently attend a (potentially tricky) vaginal delivery, as well as medico-legal issues."

In the position paper, FIGO calls upon governmental bodies, UN partners, professional organizations, women's groups, and other stakeholders to join hands to bring down the global cesarean section rates.

The six recommendations by FIGO includes:

• Educating the women about benefits and harm of operative delivery
• Matching the rates of surgical and vaginal deliveries, especially in private practice
• Making mandatory for hospitals to publish their Cesarean section rates
• Ensuring that all hospitals adopt a uniform classification system for CS
• Reinvesting the money saved from lower cesarean section to improve the infrastructure
• Increasing access to skilled care, fetal monitoring and assisted births in low-income, rural areas

The authors further note that the only aspect that has consistently resulted in a significant reduction in CS rates has been an altered reimbursement model for doctors and hospitals that favor vaginal delivery. This has been shown in Portugal following wide dissemination of information on the increased risks of CS, as well as in governmental hospitals in Iran and in a large hospital setting in Shanghai.

WHO recommendations non-clinical interventions to reduce unnecessary caesarean sections

Lancet series: Optimising caesarean section use

Global epidemiology of use of and disparities in caesarean sections

Short-term and long-term effects of caesarean section on the health of women and children

Interventions to reduce unnecessary caesarean sections in healthy women and babies

Comments

FIGO position paper: how to stop the caesarean section epidemic

Appropriate use of caesarean section globally requires a different approach

Strategic measures to reduce the caesarean section rate in Brazil

Editorial

Stemming the global caesarean section epidemic

Profile

Ana Pilar Betrán: seeking the optimum use of caesarean section

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Dates fruit consumption during the last few weeks of pregnancy facilitates cervical dilatation and spontaneous labor

It is said that Mary gave birth to Jesus under a palm tree and ate date fruits to ease her labor pains. Almost 2000 years later scientist and researchers are turning towards dates to find safer alternatives for induction and augmentation of labor.

A prospective study carried out at the Jordan University of Science and Technology from 2007 to 2008 and published in 2011 in the Journal of Obstetrics and Gynaecology documented that consumption of 6 dates fruits (Phoenix dactylifera) per day for 4 weeks before the estimated due date resulted in significantly higher mean cervical dilatation at admission, intact membranes, and spontaneous labor. Spontaneous labor occurred in 96% of those who consumed dates, compared with 79% of women in the non-date fruit consumers (p = 0.024)

Results of a randomized controlled trial published in Iranian Journal of Nursing and Midwifery Research reports that consuming dates in late pregnancy shortens the labor significantly and eliminates the need of labor augmentation by oxytocin.

Another randomized trial published July 2017 in Journal of Obstetrics and Gynecology supports the findings of earlier studies and states that “dates consumption in late pregnancy is a safe supplement to be considered as it reduced the need for labor intervention without any adverse effect on the mother and child.”

Here is a very informative YouTube video about dates as the best food during late pregnancy by Dr. Michael Greger, M.D., FACLM. He is a physician, author, and internationally recognized speaker on many important public health issues and believes that food is medicine. Dr. Greger is the founder of the non-profit, science-based website NutritionFacts.org.

Abstract: Iranian Journal of Nursing and Midwifery Research
Abstract: Journal of Obstetrics and Gynaecology
Abstract: Journal of Obstetrics and Gynecology

Room air is as good as oxygen for fetal resuscitation during labor

In an intention to treat analyses, as compared to room air use of oxygen for intrauterine resuscitation of patients with category II fetal heart tracings does not result in a better fetal outcome or improve fetal metabolic status. The findings were published online July 23, 2018, in JAMA Pediatrics.

Two-thirds of women in labor are given oxygen in an attempt to reverse perceived fetal hypoxemia and prevent acidemia. It is also routinely administered to all laboring mother with intermediate risk for acidemia as evident by the category II fetal heart tracings.

American Academy of Pediatrics recommends against initial neonatal resuscitation with oxygen, as hyperoxygenation results in significant morbidity.

A 2012 review also states, “There is not enough evidence to support the use of prophylactic oxygen therapy for women in labor, nor to evaluate its effectiveness for fetal distress.”

Dr. Raghuraman from the Department of Obstetrics and Gynecology, Washington University School of Medicine in St Louis, St Louis, Missouri designed this randomized, noninferiority trial to test the hypothesis that room air is as good as oxygen in improving fetal metabolic status as represented by umbilical artery lactate. (ClinicalTrials.gov Identifier: NCT02741284)

Umbilical artery lactate is a marker of metabolic acidosis and neonatal morbidity.

Women in labor with singleton pregnancies at 37 weeks’ gestational age, admitted to a single tertiary center were eligible to be included in the study (705). Of these, 114 patients developed a category II tracing and were randomized to receive either room air without a face mask or 10 L of oxygen per minute by nonrebreather facemask until delivery.

There was no significant difference in the levels of umbilical artery lactate between the oxygen group (30.6 mg/dL) and the room air group (31.5 mg/dL). The two groups were also similar regarding pH, base deficit, the partial pressure of oxygen, and partial pressure of carbon dioxide.

The rates of operative vaginal delivery or cesarean section for non-reassuring fetal heart rate were also similar in both the groups.

Three other previous studies have also shown similar results, prompting Dr. Christopher P. Bonafide from Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, who co-authored an editorial related to this report to urge the medical societies responsible for issuing evidence-based guidelines for obstetrics such as the American College of Obstetricians and Gynecologists to re-examine the most current research and consider issuing new recommendations against maternal supplemental oxygen administration when fetal tracings are intermediate risk.

Dr. Nandini Raghuraman quotes to Reuters Health by email, "I found it very interesting that substituting room air for oxygen did not impact umbilical cord gases, we typically administer maternal oxygen supplementation in hopes of improving fetal status as interpreted by electronic fetal monitoring. Our results suggest that this may not be the case."

She further added, "Another important point this study raises is that we lack high-quality data for many of our commonly used intrauterine resuscitation techniques. The results call for a closer look and thorough understanding of how these techniques affect fetal and maternal physiology."

Three other previous studies have also shown similar results, prompting Dr. Christopher P. Bonafide from Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, who co-authored an editorial related to this report to urge the medical societies responsible for issuing evidence-based guidelines for obstetrics such as the American College of Obstetricians and Gynecologists to re-examine the most current research and consider issuing new recommendations against maternal supplemental oxygen administration when fetal tracings are intermediate risk.

Abstract

Editorial

ACOG: Management of intrapartum fetal heart rate tracings. ACOG practice bulletin no. 116

Cochrane review: Maternal oxygen administration for fetal distress

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Smaller “Occiput-spine angle” during first stage of labor increases risk of operative delivery-a new sonographic parameter to assess fetal head deflexion.

Occiput-spine angle
courtesy http://onlinelibrary.wiley.com/doi/10.1002/uog.14342/full

Clinical Pearls:

• Fetal deflexion in first stage of labor is directly correlated with higher chances of operative  delivery.
• A new sonographic parameter of Occiput-spine angle < 125 predicts high chances of prolonged labor and operative intervention.
• This finding is easily reproducible in subsequent observations.
• This parameter cannot be measured in  frank occiput posterior positions due to  technical limitations.

According to a population based study labor dystocia is the most common indication for primary cesarean section, followed by abnormal fetal CTG, fetal malpresentation, multiple gestation, and suspected fetal macrosomia.[1]

Fetal deflexed cephalic malpresentation is responsible for nearly 30% cases of labor arrest leading to operative intervention. The degree of fetal head extension results in variety of malpresentation including sinciput, brow, and face.[2]

The diagnosis of labor dystocia and fetal cephalic malpresentation is traditionally made by digital examination, but use of ultrasound is increasingly made in labor ward to support the clinical diagnosis especially in face and brow presentations. [3] [4]

A recent study published in July issue of American Journal of obstetrics and Gynecology [5] aimed to determine whether ultrasound measurements quantifying occiput-spine angle can be used as a parameter to determine the course, outcome and operative intervention in labor.

Study was conducted at maternity units of one of the oldest university in Europe at Bologna and Parma from January 2014 to April 2015. In this prospective cross-sectional study 108 pregnant women who presented with uncomplicated singleton pregnancies at term gestation of 37 weeks or beyond were recruited as study participants. The inclusion criteria were regular and active uterine contraction, with cervical dilatation between 3-6 cm, fetal head station at 0. Patients with occipital posterior position and PROM > 24 hours were excluded from the study.

A 2 dimensional sagittal sonogram of fetal head and cervical spine was taken and stored. On the image an offline measurement of the angle formed between the two lines drawn tangential to occipital bone and first vertebra was performed to quantify the  position of fetal head.                           

The results of the ultrasound were not known to the obstetrician who managed the labor. The labor outcome, mode of delivery and the result of ultrasound examination were correlated retrospectively.

After accounting for other confounding factors and excluding cesarean deliveries for non-reassuring FHS, multivariate logistic regression was performed. 

It was seen that out of 108 study subjects, spontaneous vaginal delivery occurred in 79 patients. Of the remaining patients  10 required vacuum assistance and 19 has to undergo cesarean section. The patients needed vacuum or cesarean section because of  labor arrest in 19 patients and nonreassuring fetal heart rate in 10 patients.

Multivariable logistic regression analysis showed that narrow occiput-spine angle values (OR 1.08; 95% CI 1.00−1.16; P = .04) and nulliparity (OR 16.06; 95% CI 1.71−150.65; P = .02) were independent risk factors for operative delivery. A larger occiput-spine angle width (i.e., >125°) showed to be significantly associated with a shorter duration of labor (hazard ratio = 1.62; 95% CI 1.07−2.45; P = .02).

This is a very important first study that correlated  fetal head deflexion objectively in the first stage of labor and  its impact on  labor outcome. The occiput spine angle in the first stage was directly related to the station of the fetal head, the deeper the head the greater the angle.

Cases that required intervention ,all had smaller occiput-spine angle at a similar station indicating diminished flexion of the fetal head. In all those fetuses with occiput-spine angle <125°, the duration of labor was considerably prolonged.

Other similar studies were conducted in the past but none measured the fetal deflexion quantitatively and the findings were not reproducible. About 30-50% of fetuses occupy a frank occiput posterior position in early first stage of labor and the measurements cannot be assessed in such cases. A  recent study have shown that in such patients the chances of operative delivery are quite high.

The study described a new sonographic parameter of occiput-spine angle that can predict with accuracy the chances of operative intervention. Fetuses with deflexed head resulting in smaller occiput-spine angle (<125°) are at increased risk for operative delivery.

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[1] http://www.ajog.org/article/S0002-9378(14)00055-6/fulltext

[2] Jacobson, L.J. and Johnson, C.E. Brow and face presentations. Am J Obstet Gynecol. 1962; 84:1881–1886

[3]Ghi, T., Maroni, E., Youssef, A. et al. Intrapartum three-dimensional ultrasonographic imaging of face presentations: report of two cases. Ultrasound Obstet Gynecol. 2012; 40: 117–118

[4] Lau, W.L., Cho, L.Y., and Leung, W.C. Intrapartum translabial ultrasound demonstration of face presentation during first stage of labor. J Obstet Gynaecol Res. 2011; 37: 1868–1871

[5] Ghi T, Bellussi F, Azzarone C, et al. The “occiput–spine angle”: a new sonographic index of fetal head deflexion during the first stage of labor. Am J Obstet Gynecol 2016;215:84.e1-7.