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Background Antenatal care plays a crucial role in ensuring optimal maternal and neonatal health outcomes. However, disparities in access to prenatal care persist, with a subset of pregnant women failing to register for antenatal care, referred to as "unbooked" or "unregistered" pregnancies. This study aims to investigate the impact of registration status on pregnancy outcomes, considering various demographic, clinical, and socioeconomic factors. Understanding the factors influencing registration status and its implications on maternal and fetal health outcomes is essential for developing targeted interventions to improve prenatal care access and enhance overall pregnancy outcomes. Objective To see the difference in obstetrical complications along with feto-maternal outcomes in both registered and unregistered antenatal cases and to determine the correlation of maternal and fetal outcomes with antenatal care. Materials and methods This two-year observational study at Dr. D.Y. Patil Medical College's Obstetrics and Gynecology IPD in Pimpri, Pune, examined maternal and fetal outcomes in registered and unregistered pregnancies. Consent was obtained, and patients were categorized as registered and unregistered based on the number of antenatal visits. This was an observational prospective cohort study. Data on socioeconomic factors like income and education were analyzed to assess their association with registration status. Maternal outcomes included preterm delivery and complications such as preeclampsia, gestational diabetes, oligohydramnios, premature rupture of membranes, anemia, and postpartum complications. Fetal outcomes included birth weight and NICU admissions. Statistical analyses, including Chi-square tests, Fisher's exact test, and logistic regression, were used to examine relationships between variables and registration status. Results This study analyzed 502 cases, comprising 251 registered and 251 unregistered pregnancies, to investigate the impact of antenatal registration on maternal and fetal outcomes. Significant associations were observed between socioeconomic factors, such as lower income and education levels in unregistered pregnancies. Specifically, 46 (18.3%) unregistered cases were in the lowest income bracket, while 103 (41.0%) were in the lower-middle bracket, and the majority (132, 52.2%) had only completed secondary education. Unregistered pregnancies were linked to a higher prevalence of adverse outcomes, including preterm delivery (101, 40.23%), anemia (178, 70.9%), hypertensive disorders (30, 11.9%), gestational diabetes mellitus (16, 6.37%), fetal growth restriction (39, 15.3%), low birth weight (181, 72.1%), and NICU admissions (112, 44.6%), compared to registered pregnancies. Conclusion In conclusion, this study highlights the significant impact of registration status on pregnancy outcomes, emphasizing the need for comprehensive interventions to improve prenatal care access and to promote maternal and neonatal health equity. By addressing socioeconomic barriers and implementing targeted interventions, healthcare systems can strive toward ensuring optimal pregnancy outcomes for all expectant mothers. This is done by ensuring that all antenatal patients are registered for prenatal care by involving a combination of strategies focused on support, education, and accessibility.

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Introduction Infertility affects an estimated 186 million individuals globally and is associated with numerous mental health issues. Trace elements are essential for reproductive health, yet the role of nickel in female fertility is not well understood. Previous research has shown conflicting evidence regarding nickel's impact on ovarian function and its potential to disrupt reproductive processes. Methods We utilized data from the National Health and Nutrition Examination Survey (NHANES) focusing on a cohort of 7,839 women, with an emphasis on 1,404 women aged 18 to 35. Logistic regression was employed to investigate the relationship between urinary nickel levels and fertility status, controlling for age, BMI, and race/ethnicity. Results The fertility analysis included 880 fertile and 106 infertile women, identifying age as a significant predictor of fertility status. Nickel exposure did not demonstrate a statistically significant association with fertility. The racial distribution within the groups showed a higher proportion of non-Hispanic White women in the fertile category and Mexican American women in the infertile group, although race was not a significant predictor in the regression model. Conclusions We found no significant relationship between nickel exposure and fertility status when adjusted for race, BMI, and age. Age was the only significant factor associated with fertility. These results highlight the complexity of the interplay between environmental exposures and reproductive health, suggesting that further research is necessary to elucidate the role of nickel and other trace elements in fertility.

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Prenatal congenital inguinal hernia is a rare condition, with limited cases reported in the literature. Accurate prenatal diagnosis is crucial for appropriate management and outcomes. We report a case of a 44-year-old woman at 36 weeks of gestation with well-controlled gestational diabetes diagnosed with prenatal congenital inguinal hernia. The patient's antenatal history included abnormal first-trimester screening tests for Down syndrome, but subsequent amniocentesis revealed no chromosomal abnormalities. Ultrasonography at 36 weeks showed an enlarged right scrotum with heterogeneous consistency and visible bowel peristaltic waves without signs of bowel obstruction, strangulation, or incarceration. At 39 weeks, oligohydramnios was diagnosed, leading to a decision for labor induction. However, the patient underwent a cesarean section upon her desire, giving birth to a male infant with congenital inguinal hernia. Both mother and child had a normal six-month postpartum follow-up. This case underscores the significance of detailed third-trimester ultrasonography in diagnosing prenatal congenital inguinal hernia. Early detection allows for better planning and management, highlighting the value of routine prenatal assessments for fetal organ status and early identification of malformations.

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OBJECTIVE: To determine whether longitudinal health data accounts for end-organ injury or death in the setting of chronic hypertension. DESIGN: Cohort of 64 799 deliveries to 61 854 women. SETTING: US claims data for the preiod 2008-2019. POPULATION: Women with a delivery hospitalisation and chronic hypertension. METHODS: Risk for a composite of acute end-organ injury or death during the delivery hospitalisation and 30 days postpartum was analysed. Adjusted logistic regression models were derived with discrimination for each model estimated by the C-statistic. Poisson regression was used to estimate adjusted risk ratios. Starting with models using data from pregnancy, further adjustment was performed accounting for healthcare use in the year prior to pregnancy, including hospitalisations, emergency department encounters, prescription medications and pre-pregnancy diagnoses. MAIN OUTCOME MEASURES: Acute end-organ injury or death. RESULTS: The composite outcome occurred among 5.7% of 64 799 deliveries. For patients with commercial insurance, filling non-hypertensive medications from ≥11 different classes, compared with none (adjusted risk ratio, aRR 4.07, 95% CI 2.86-5.79), three or more hospitalisations before pregnancy, compared with none (aRR 4.75, 95% CI 3.46-6.52), and chronic kidney disease diagnosed in the year before pregnancy (aRR 2.35, 95% CI 1.88, 2.94) were associated with increased risk. For pregnancies covered by commercial insurance, the C-statistic increased from 0.615 (95% CI 0.599-0.630) in the model with pregnancy data only to 0.796 (95% CI 0.783-0.808) for the model additionally including healthcare use in the year before pregnancy. Findings with Medicaid were similar. CONCLUSIONS: Prepregnancy care use predicted adverse maternal outcomes. These data may be important in risk stratification.

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Peripartum depression is a common complication of pregnancy with the potential for dangerous consequences to maternal and infant health if left untreated. The disorder was previously classified as a global public health issue due to the high prevalence of the disorder and the mismatch between available treatment options and successful completion of those options. The coronavirus disease 2019 (COVID-19) pandemic increased the incidence of mental health disorders globally, with an even greater effect on peripartum mothers. A preliminary study on fetal implications suggests the resulting increased maternal stress and depressive mood symptoms correlates to worsened fetal brain development. The pandemic highlighted existing barriers to the treatment of peripartum mood disorders. The drastic increase in the use of telemedicine as a modality of treatment in response to the public health crisis has the potential to address some of these barriers. Future global disasters are inevitable with peripartum mothers highly susceptible to worsened mental health outcomes. We are thus highlighting the responsibility of clinicians, professional organizations, and policymakers to support, identify, and facilitate the treatment of postpartum depression for this vulnerable population to prevent short-term and long-term repercussions.

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Stromal cells possess unique properties to regenerate themselves and cure various chronic illnesses. An easily available and ethical source for procurement of stromal cells is umbilical cord blood which is now being stored for future use. Vedic texts also describe the cord blood as a source of life. However, Indian traditions seem to preserve one more alternative for storage and procurement of stromal cells. Traditionally, in many parts of India, the umbilical cord stump is dried and stored for future use. It is used as a medicine for some illness and to treat infertility. Since Indian traditions are an excerpt of Vedic science, it points towards the possible emergence of dried stump as an easy and cost-effective means for stromal cell procurement and storage. The present review compiles the literature available on these traditional practices and stresses upon the need of rigorous experimental and theoretical research in the area.

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We investigated whether nonsurgical termination of pregnancy after 14 weeks of gestation increases the risk of preterm delivery in a subsequent pregnancy. We conducted a two-centre retrospective case-control study. Patients who underwent non-surgical termination of pregnancy after 14 weeks of gestation between 2012 and 2015 and who gave birth after 14 weeks of gestation to a live-born singleton infant were included. Control patients were those who gave birth after 37 weeks of gestation (the same month as a case patient) and had a second delivery of a singleton foetus after 14 weeks of gestation. The primary outcome was preterm delivery during the second pregnancy period. We included 151 cases and 302 controls and observed 13 (8.6%) preterm births during the second pregnancy in the case group versus 8 (2.6%) (odds ratio: 3.62; 95% confidence interval: 1.40-8.65, p < .001) in the control group. This result remained significant after multivariate analysis. Impact statementWhat is already known about this topic? Many studies have evaluated the association between first-trimester surgical or non-surgical termination of pregnancy and the risk of preterm birth in the subsequent pregnancy. However, no study has evaluated the association between second- or third-trimester non-surgical termination of pregnancy due to foetal disease and the risk of preterm birth in the subsequent pregnancy. A small number of studies have included a small proportion of patients who previously underwent non-surgical termination of pregnancy after 14 weeks of gestation and later experienced first-trimester termination during their second pregnancy. These studies focussed on the impact of the interpregnancy interval or pharmacological induction of labour on the risk of preterm delivery in the subsequent pregnancy.What did the results of this study add? This is the first study to specifically evaluate the association between second- and third-trimester non-surgical terminations of pregnancy and the risk of preterm birth in the subsequent pregnancy. When compared with term birth, nonsurgical termination of pregnancy was associated with the risk of spontaneous preterm birth and hospitalisation in the neonatal intensive care unit in the subsequent pregnancy.What are the implications of these findings for clinical practice and further research? Further studies are required to confirm our results, but information delivered to patients with a late termination of pregnancy and during their pregnancy follow-up for the subsequent pregnancy could be modified to provide this information.

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Carbon monoxide (CO) poisoning during pregnancy may cause deleterious effects to the fetus. Hyperbaric oxygen therapy (HBO) in pregnancy is proven to be safe and it is considered to be beneficial, reducing the severity of the fetal injuries. However, a number of issues are still to be discussed, among them the question of the carboxyhemoglobin (COHb) levels that trigger HBO therapy in pregnant CO poisoned patients. In this letter we report some practical suggestions for organizations wishing to develop their own protocols.

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Elevated beta-human chorionic gonadotropin (beta-hCG) levels in postmenopausal women is a finding known in the literature; however, it still commonly leads to unnecessary and extensive diagnostic workup. We present the case of a 48-year-old African-American postmenopausal female with acute kidney injury on chronic kidney disease (CKD) stage 5 and an incidental finding of elevated serum beta-hCG. Abdominal and transvaginal ultrasound showed no evidence of intrauterine or ectopic pregnancy or gestational trophoblastic disease. Menopausal status was confirmed with follicle-stimulating hormone (FSH) measurement, and following the improvement of renal status, beta-hCG levels were normalized to expected values for the patient's age group. The etiology of elevated beta-hCG was suspected to be from the pituitary as previous literature has shown decreasing beta-hCG levels in postmenopausal women following the administration of gonadotropin-releasing hormone (GnRH) antagonist.

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To evaluate maternal serum pregnancy-associated plasma protein-A (PAPP-A) levels at 11-14 weeks of gestation and preeclampsia risk in women with common congenital anatomic uterine abnormalities (AUAs). First trimester screening markers were compared between 12 AUA pregnancies, 60 age matched controls and 12 cases of early preeclampsia. PAPP-A level and birth weight were significantly lower in AUA compared to control and early preeclampsia group (p<.001). Preeclampsia was absent in the AUAs pregnancies group. Birth weight were similar in AUA group when we compared AUA and control group regarding weeks of gestation at delivery and lower but not significantly, when we compared AUA and early preeclampsia group. Our findings suggest that AUA pregnancies are associated with low first trimester maternal serum PAPP-A concentrations not predictive of susceptibility to preeclampsia.Impact statementWhat is already known on this subject? During first trimester screening for preeclampsia based on maternal pregnancy-associated plasma protein A (PAPP-A) levels, various parameters are used, such as the somatometric characteristics of pregnant woman, single or multiple pregnancy, smoking status, family history, diabetes, hypertension and measurement of blood pressure and uterine artery Dopplers.What do the results of this study add? Our pioneer study revealed that there is drastic difference in PAPP-A concentration in women with common anatomic uterine abnormalities (AUAs), in comparison with their age matched control women with normal uterus.What are the implications of these findings for clinical practice and further research? Based on our results, uterine anatomical deviations, is another factor which must be taken in account for preeclampsia risk calculation and further clinical consultation and follow up in those pregnancies. Lower PAPP-A levels in AUA cases is a weak predictor of susceptibility to preeclampsia and could be associated to smaller placental size rather than poor placentation and in future research the calculation of the uterine cavity functional dimension may lead to a more accurate clinical assessment.

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The provision of antenatal care in adolescents in refugee populations presents particular difficulties because of conflict, nutritional deficiencies, language barriers and lack of access to health care facilities. Due to the absence of prenatal care, associated medical complications can occur. A total of 525 adolescent women who gave birth to singletons agreed to participate in this study. Data about maternal demographic and obstetric characteristics, as well as neonatal outcomes were analysed. In conclusion, adolescent pregnancy continues to be an important social problem due to health support needs. However, the results of our present study are important in terms of showing that perinatal care is quietly improving in Turkey.Impact StatementWhat is already known on this subject? Adolescent pregnancies are at much higher risk than adult pregnancies in terms of complications. These complications include preterm delivery, intrauterine growth retardation, maternal morbidity and mortality, neonatal morbidity and mortality. According to various beliefs and traditions, marriages in early ages are observed in some societies and as a result, adolescents become pregnant. Additionally, the present study includes early adolescent aged pregnancies as 14,15 and 16. As far as we search in the literature, there is no reported about early adolescent pregnancies.What do the results of this study add? Often, such pregnancies occur more frequently in societies with low socioeconomic levels. For this reason routine pregnancy screening, support during pregnancy, prenatal care is not adequately provided. Some of the complications develop on them. Primarily, the adolescent pregnancies should be gotten under control, if not, some complications can be prevented by routine pregnancy follow-up and adequate provision of prenatal care and support.What are the implications of these findings for clinical practice and/or further research? As a guide on clinical practices and further studies; an effective method of contraception should be applied to sexually active women at early maternal age. If not, pregnancies should be kept under close follow-up and with adequate support to avoid complications.

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Reticulocyte parameters including reticulocyte haemoglobin equivalent (Ret-He) and immature reticulocyte fraction (IRF) are newly recognised hematological parameters that are being used for diagnosis and follow-up of anaemic patients. Reference intervals of these parameters have been established in different populations, however, the data relating to pregnancy are still lacking. One hundred and fifty-five first-trimester pregnant females were screened and the reference interval was calculated after selecting the patient with fixed criteria. R statistical software was used for statistical calculations. We tried to establish a reference interval of Ret-He content and IRF in first-trimester pregnancy in our study.IMPACT STATEMENTWhat is already known on this subject? Ret-He and IRF have been established as the marker of iron deficiency and iron-deficiency anaemia in different age groups and as a marker of response to iron therapy. However, literature is scarce regarding the reference intervals of these parameters, especially in pregnancy.What do the results of this study add? This study establishes the reference interval of newer reticulocyte parameters in first-trimester pregnancy which is not yet established in the literature. Establishing a reference interval is required for any laboratory parameters to be used in the clinical context.What are the implications of these findings for clinical practice and further research? The results of this study may help in making a clinical decision regarding iron deficiency in early pregnancy which is one of the common clinical problems in pregnancy. This study also serves as a baseline study for further studies of reference intervals for newer reticulocyte parameters in pregnancy. A similar study with a larger study population and follow-up with iron therapy may establish these parameters as one of the important markers of iron deficiency in pregnancy and help institute iron therapy on case-to-case basis.

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Near miss occurs in far greater numbers than maternal deaths and allows a more robust quantification on risk factors and determinants of life-threatening complications. A 'Three delay model' has been proposed in identification of causes of near miss and maternal deaths. There may be delay in seeking and obtaining health care: delay in recognising danger signs and deciding to reach source of care, delay in reaching appropriate source of care and delay in obtaining appropriate and adequate treatments. We compared various delays between near miss cases (n = 100) and controls (n = 200). Women who fulfilled criteria of near miss were taken as cases. Women who had obstetrical complications like near miss but were managed successfully and did not reach near miss state were labelled as controls. Near miss were then compared with maternal death. For normally distributed measurable data, outcome was compared using Student's t-test, for non-normally distributed/ordinal data, outcome was compared using Mann-Whitney's test. For categorical/classified data, association with outcome was analysed using Chi-Square test/Fisher's exact test.Delay in all three levels was seen among the groups. Lack of knowledge, non-availability of decision maker, and concern of cost of transport were main contributors of these delays.Impact StatementWhat is already known on this subject? Nonavailability of healthcare and low socio-economic status strongly correlate with maternal morbidity and mortality.What do the results of this study add? Lack of knowledge, non-availability of the decision maker, and concern of cost of transport were the main contributors of delay in seeking medical care. Majority of the cases of near miss were attributed to poor utilisation of health resources, ignorance and lack of emergency obstetric care at the primary level.What are the implications of these findings for clinical practice and/or further research? Patient and attendant education to ensure follow-up visits, recognise danger signs and report without undue delay, compliance to dietary modifications, medications given needs to be addressed at every visit to reduce the impact of socio-behavioural determinants on maternal near miss and mortality which are preventable in majority of cases.

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OBJECTIVE: To introduce the concept of extended or prolonged mechanical balloon labour induction as opposed to pharmacological methods and amniotomy after single balloon expulsion, by the novel use of side-by-side Foley catheter balloons. This method is of particular relevance when there is prior uterine surgery, fetal reserve is uncertain, the risk of vertical infection is high, or facilities for labour monitoring are limited. STUDY DESIGN: We conducted simulation studies to compare balloon circumferences and resistance to passage through a simulation cervix between different gauge, fluid distension volume and number of Foley catheters. We describe an illustrative clinical case. RESULTS: In simulation studies we found modest increases in Foley catheter balloon circumference with increased catheter gauge and with increasing volume of distending fluid. We found that retention of Foley balloon(s) by a flexible simulated cervix was increased with the gauge, distending volume and number of balloons used side-by-side. We describe the case of a mother with pre-eclampsia with severe features and compromised fetal reserve in whom the side-by-side balloon method achieved spontaneous delivery after a single balloon had been expelled without labour commencing. CONCLUSIONS: Institutional protocols for Balloon labour inductions should take into account the characteristics of locally-available balloon catheters. Further research is justified to determine the usefulness of extended mechanical labour induction with side-by-side balloon catheters, particularly with prior caesarean section, uncertain fetal reserve and settings with limited fetal monitoring capacity.

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OBJECTIVE: To assess whether pre-eclampsia (PE)-related placental/extraplacental membrane findings are linked to moderately elevated blood pressure (BP) in pregnancy and later-life hypertension. DESIGN: Prospective cohort. SETTING: 52 prenatal clinics, 5 Michigan communities. SAMPLE: The POUCH Study recruited women at 16-27 weeks' gestation (1998-2004) and studied a sub-cohort in depth. This sample (n = 490) includes sub-cohort women with detailed placental assessments and cardiovascular health evaluations 7-15 years later in the POUCHmoms follow-up study. METHODS: PE-related placental/extraplacental membrane findings (i.e. mural hyperplasia, unaltered/abnormal vessels or atherosis in decidua; infarcts) were evaluated in relation to pregnancy BP and odds of Stage 2 hypertension at follow up using weighted polytomous regression. Follow-up hypertension odds also were compared in three pregnancy BP groups: normotensives (referent) and moderately elevated BP with or without PE-related placental/extraplacental membrane findings. MAIN OUTCOME MEASURES: Stage 2 hypertension (SBP ≥140 mmHg and/or DBP ≥90 mmHg, or using antihypertensive medications) at follow up. RESULTS: After excluding women with pregnancy hypertension (i.e. chronic, PE, gestational), mural hyperplasia and unaltered/abnormal decidual vessels were each associated with Stage 2 hypertension at follow up: adjusted odds ratio (aOR) = 2.7, 95% CI 1.1-6.6, and aOR = 1.7 (95% CI 0.8-3.4), respectively. Women with moderately elevated BP in pregnancy and evidence of mural hyperplasia or unaltered/abnormal decidual vessels had greater odds of Stage 2 hypertension at follow up: aOR = 4.5 (95% CI 1.6-12.5 and aOR = 2.6, 95% CI 1.1-5.9, respectively. CONCLUSIONS: PE-related placental/extraplacental membrane findings help risk-stratify women with moderately elevated BP in pregnancy for later development of hypertension. TWEETABLE ABSTRACT: Placental findings associated with mother's risk of later-life hypertension.

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The aim of this study was to implement the Robson Ten Groups Classification System (RTGCS) to identify the main contributors to the caesarean section (CS) rate and to evaluate whether the introduction of a plan of obstetrical interventions reduced this rate. An observational retrospective cross-sectional study was conducted during two time periods at Alicante University General Hospital. In the pre-implementation period (2009-2012), RTGCS was applied to identify the main groups contributing to the overall CS rate. In the post-implementation period (2013-2017), RTGCS was applied again to identify changing trends in CS rates. In all, 11,034 deliveries during the pre-intervention period and 11,453 during the post-intervention period were analysed. The overall CS rate was 23.9% and 20.9%, respectively. There were no changes in perinatal outcomes. In the post-intervention period, there was a significant decrease of the CS rate in the groups of targeted interventions 1, 2, 3, 4, 5, and 8B.Impact statementWhat is already known on this subject? High CS rates are becoming a public health problem because of risks, costs, excessive medicalisation, and abuse of resources. RTGCS provides a framework for auditing and analysing CS rates.What do the results of this study add? RTGCS can identify the groups that have the greatest impact on the CS rate and monitor changes in it consequent to policy changes.What are the implications of these findings for clinical practice? The introduction of a strategic plan with evidence-based clinical interventions may have a greater effect on the CS rate than other features justifying the increase in the incidence of CS.

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BACKGROUND: Caesarean section (C-section) rates are often low among the poor and very high among the better-off in low- and middle-income countries. We examined to what extent these differences are explained by medical need in an African context. METHODS: We analyzed electronic records of 12,209 women who gave birth in a teaching hospital in Kenya in 2014. C-section rates were calculated by socioeconomic position (SEP), using maternal occupation (professional, small business, housewife, student) as indicator. We assessed if women had documented clinical indications according to hospital guidelines and if socioeconomic differences in C-section rates were explained by indication. RESULTS: Indication for C-section according to hospital guidelines was more prevalent among professionals than housewives (16% vs. 9% of all births). The C-section rate was also higher among professionals than housewives (21.1% vs. 15.8% [OR 1.43; 95%CI 1.23-1.65]). This C-section rate difference was largely explained by indication (4.7 of the 5.3 percentage point difference between professionals and housewives concerned indicated C-sections, often with previous C-section as indication). Repeat C-sections were near-universal (99%). 43% of primary C-sections had no documented indication. Over-use was somewhat higher among professionals than housewives (C-section rate among women without indication: 6.6 and 5.5% respectively), which partly explained socioeconomic differences in primary C-section rate. CONCLUSIONS: Socioeconomic differences in C-section rates can be largely explained by unnecessary primary C-sections and higher supposed need due to previous C-section. Prevention of unnecessary primary C-sections and promoting safe trial of labor should be priorities in addressing C-section over-use and reducing inequalities. Unnecessary primary C-sections and ubiquitous repeat C-sections drive overall C-section rates and C-section inequalities.

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The induction of labour is required for various indications in obstetrics. Various regimens and drugs are advocated for use in labour induction. Mifepristone is one such drug which has a definite role in first and second-trimester pregnancy terminations. However, its role in the third-trimester is still being reviewed. In the present study, the effect of mifepristone on cervical ripening was assessed and results interpreted.Impact statementWhat is already known on the subject? The role of mifepristone in termination of pregnancies at term is controversial. Some studies report onset of labour after giving mifepristone whereas others do not report any significant role.What do the results of the study add? Mifepristone has a role in improving Bishop score and can be used as a pre-induction cervical ripening agent before using other methods for labour induction. It does not report any adverse effects on the mother or foetus.What are the implications of these findings for clinical practice and/or further research? Mifepristone needs to be studied more in term pregnancies as induction of labour is increasingly required in today's scenario for various reasons. However, its role in improving the Bishop score as found in this study helps in decreasing dose of other labour inducing agents.

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An impaction of the foetal head at caesarean section is a topical concern in modern obstetric practice. The management options for this problem are well described but the incidence or even definition of impaction, is unknown. The primary aim of this study was to ascertain the incidence of impacted foetal head at CS in labour. This prospective study used data from all women undergoing CS during a 12-month period in a single unit. Following completion of all CS, the surgeon completed a questionnaire covering: cervical dilation at time of CS; if the surgeon felt there was a difficulty in delivering the foetal head as an indicator of impaction, as well as the other techniques utilised. Of 440 EMCS in labour, 18% (n = 81) reported a difficulty delivering the head, which was most common at cervical dilation ≥8 cm (n = 124, 48%). A difficulty with the delivery of the foetal head was associated with 36% increased measured blood loss. Impact statement What is already known on this subject? Impaction of the foetal head at a caesarean section is a recognised complication of CS in late labour but there are no reliable data on the incidence of the problem. It is poorly defined and yet many techniques and devices have been described to overcome this problem, however, optimal management remains uncertain. What do the results of this study add? The primary aim of this study was to determine the incidence of the impacted foetal head during CS in labour as determined by whether the surgeon experienced difficulty with delivery of the head. We report that at least some difficulty in delivering the foetal head at CS is common, and most often encountered when cervical dilation is ≥8 cm. When additional manoeuvres were required, the 'push' technique was exclusively adopted with implications for training. A difficulty in delivering the foetal head was associated with a 36% increase in the measured maternal blood loss. What are the implications of these findings for clinical practice and/or further research? Further multi-centre investigation is required to ascertain incidence of this obstetric problem with predicting factors determined. This work will inform decisions about the optimal management.

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Medical informed consent is the process by which a 'competent', non-coerced individual receives sufficient information including risks of a medical procedure and gives permission for it to occur. The capacity to give an informed consent might be impaired during labour. This study aimed to examine women's abilities to understand and remember during labour. Women were prospectively recruited at 36 weeks of gestation and randomised to undertake questionnaires which assessed their ability to understand and remember information. They were randomised to: (1) information given in labour only, written format (2) information in labour, verbal (3) information at 36 weeks plus labour, written (4) information at 36 weeks plus labour, verbal. Immediate comprehension and retention was assessed at 36 weeks, in labour, and 24-72 hours after birth. Forty-nine women completed the questionnaires regarding understanding and retention of information at 36 weeks, six intrapartum, and five postpartum (90% attrition). Women receiving information at 36 weeks and in labour versus in labour had a higher comprehension of pregnancy-related information, its retention, and total score. Women receiving information in late pregnancy and labour may comprehend and retain it better than women only receiving information during labour. Given small sample size, further research is needed to support these preliminary findings. Impact statement What is already known on this subject? The evidence regarding the capacity of labouring women to give informed consent is largely based on women's self-reported experiences or expert opinions and has mixed findings. Existing guidelines recommend that an informed consent should be given antenatally for both clinical practice and research. Studies show that obtaining an informed consent antenatally is neither feasible nor widely implemented. What do the results of this study add? A novel approach to providing empirical evidence regarding women's capacity to comprehend and retain information during labour. Our study confirms the difficulty with antenatal recruitment for intrapartum research. What are the implications of these findings for clinical practice and/further research? This raises ethical concerns regarding the current intrapartum research in which consent is largely sought at the time of the study. Emphasises the need to explore the question 'Do labouring women have the capacity to consent to research?' in order to ensure that women are protected during labour.

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