RESUMO
OBJECTIVE: This study aimed to evaluate if manual rotation, undertaken during labor, of fetuses in occiput posterior or occiput transverse position led to an increased rate of spontaneous vaginal delivery. DATA SOURCES: Searches were performed in MEDLINE, Ovid, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials with the use of a combination of keywords and text words related to "occiput posterior," "occiput transverse," and "manual rotation" from inception of the databases to July 2021. STUDY ELIGIBILITY CRITERIA: We included all randomized controlled trials evaluating manual rotation of fetuses in the occiput posterior or occiput transverse position during labor. METHODS: The primary outcome was the rate of spontaneous vaginal delivery. Meta-analyses were performed using the random effects model of DerSimonian and Laird to determine the relative risks or mean differences with 95% confidence intervals. RESULTS: A total of 643 records were screened with inclusion of 6 articles and 1002 randomized patients. All included studies compared manual rotation of fetuses in occiput posterior or occiput transverse position, all confirmed using ultrasound examinations, after complete cervical dilation with either no rotation or a sham rotation procedure. There was no difference in the rate of spontaneous vaginal delivery with manual rotation (relative risk, 1.07; 95% confidence interval, 0.95-1.20) nor was there any difference in any other maternal or fetal outcomes. In a subgroup analysis of occiput posterior fetuses, there was a 12.80-minute decrease in the length of the second stage of labor in the manual rotation group (mean difference, -12.80; 95% confidence interval, -22.61 to -2.99). There were no significant differences in any other maternal or fetal outcomes in the occiput posterior subgroup and no differences in the occiput transverse subgroup. CONCLUSION: Prophylactic manual rotation of fetuses in occiput posterior or occiput transverse position, confirmed using ultrasound examination, did not increase the rate of spontaneous vaginal delivery compared with no manual rotation. Manual rotation of the occiput posterior fetal head early during the second stage of labor was associated with a significant 12.8-minute decrease in the length of the second stage of labor with no changes in any other maternal or fetal outcomes. There were no differences demonstrated for fetuses rotated from occiput transverse position or for the combination of occiput posterior and occiput transverse fetuses. Because there is some evidence of benefit, prophylactic manual rotation can be offered to patients during the second stage of labor presenting with occiput posterior position of the fetal head documented during ultrasound examination.
Assuntos
Segunda Fase do Trabalho de Parto , Ultrassonografia Pré-Natal , Feminino , Feto/diagnóstico por imagem , Humanos , Apresentação no Trabalho de Parto , Gravidez , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
OBJECTIVE: This study aimed to evaluate the incidence of chorioamnionitis in women with singleton gestations with ≥36 weeks' prelabor rupture of membranes induced with oxytocin within or after 12 hours of prelabor rupture of membranes. DATA SOURCES: The search was conducted using MEDLINE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID, and Cochrane Library as electronic databases from their inception to May 2020. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials of women with singleton cephalic gestations and prelabor rupture of membranes at ≥36 weeks comparing induction of labor with oxytocin either ≤12 hours after prelabor rupture of membranes or >12 hours after prelabor rupture of membranes (expectant management group). STUDY APPRAISAL AND SYNTHESIS METHODS: The risk of bias in each included study was assessed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. All analyses were done using an intention-to-treat approach, evaluating women according to the treatment group to which they were randomly allocated in the original trials. The primary outcome was the incidence of chorioamnionitis. RESULTS: After exclusions, 9 randomized controlled trials including 3759 women were analyzed. Women with singleton cephalic gestations and prelabor rupture of membranes at ≥36 weeks who have induction of labor ≤12 hours after prelabor rupture of membranes have shorter time between prelabor rupture of membranes and delivery (-12.68 hours; 95% confidence interval, -16.15 to -9.21) and higher chance of delivering within 24 hours of prelabor rupture of membranes (91% vs 46%; relative risk, 1.93; 95% confidence interval, 1.59-2.35). Cesarean and operative vaginal deliveries were not significantly different between the groups. Induction of labor ≤12 hours after prelabor rupture of membranes was also associated with significantly fewer incidences of chorioamnionitis (5.3% vs 9.9%; relative risk, 0.62; 95% confidence interval, 0.40-0.97), endometritis (2.4% vs 4.2%; relative risk, 0.59; 95% confidence interval, 0.40-0.87), neonatal sepsis (6.1% vs 11.8%; relative risk, 0.46; 95% confidence interval, 0.27-0.79), and admission to neonatal intensive care unit (6.4% vs 12.0%; relative risk, 0.54; 95% confidence interval, 0.43-0.69) compared with women managed expectantly, usually at >24 hours. The subgroup analysis of 3323 women with induction of labor at ≤6 hours showed similar results, including similar significant reductions in chorioamnionitis, endometritis, neonatal sepsis, and admission to neonatal intensive care unit. CONCLUSION: Women with symptoms of prelabor rupture of membranes at ≥36 weeks should be evaluated promptly, and if prelabor rupture of membranes is confirmed, they should have induction of labor within 12 hours and perhaps even within 6 hours since the first symptom of prelabor rupture of membranes. This management is associated with significantly less morbidity, especially in terms of infections, for both the mother and the baby, with no evidence of any harm.
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Corioamnionite , Ruptura Prematura de Membranas Fetais , Corioamnionite/epidemiologia , Parto Obstétrico , Feminino , Ruptura Prematura de Membranas Fetais/epidemiologia , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Ocitocina , Gravidez , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
This document addresses the current coronavirus disease 2019 (COVID-19) pandemic for providers and patients in labor and delivery (L&D). The goals are to provide guidance regarding methods to appropriately screen and test pregnant patients for COVID-19 prior to, and at admission to L&D reduce risk of maternal and neonatal COVID-19 disease through minimizing hospital contact and appropriate isolation; and provide specific guidance for management of L&D of the COVID-19-positive woman, as well as the critically ill COVID-19-positive woman. The first 5 sections deal with L&D issues in general, for all women, during the COVID-19 pandemic. These include Section 1: Appropriate screening, testing, and preparation of pregnant women for COVID-19 before visit and/or admission to L&D Section 2: Screening of patients coming to L&D triage; Section 3: General changes to routine L&D work flow; Section 4: Intrapartum care; Section 5: Postpartum care; Section 6 deals with special care for the COVID-19-positive or suspected pregnant woman in L&D and Section 7 deals with the COVID-19-positive/suspected woman who is critically ill. These are suggestions, which can be adapted to local needs and capabilities.
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COVID-19/prevenção & controle , Parto Obstétrico/métodos , Cuidado Pós-Natal/métodos , Guias de Prática Clínica como Assunto , Complicações Infecciosas na Gravidez/prevenção & controle , Fluxo de Trabalho , Anestesia Epidural/métodos , Anestesia Obstétrica/métodos , COVID-19/diagnóstico , COVID-19/terapia , Estado Terminal , Feminino , Humanos , Trabalho de Parto Induzido/métodos , Trabalho de Parto , Tempo de Internação , Programas de Rastreamento , Alta do Paciente , Isolamento de Pacientes , Equipamento de Proteção Individual , Gravidez , Complicações Infecciosas na Gravidez/diagnóstico , Complicações Infecciosas na Gravidez/terapia , SARS-CoV-2 , Triagem/métodosAssuntos
COVID-19/prevenção & controle , Obstetrícia/métodos , Perinatologia/métodos , Guias de Prática Clínica como Assunto , Feminino , Monitorização Fetal/métodos , Humanos , Obstetrícia/educação , Perinatologia/educação , Cuidado Pós-Natal/métodos , Gravidez , Cuidado Pré-Natal/métodos , SARS-CoV-2 , Telemedicina , Ultrassonografia Pré-Natal/métodos , Visitas a PacientesRESUMO
OBJECTIVE: The aim of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effect of delayed versus immediate pushing in the second stage of labor on mode of delivery and other outcomes in women with neuraxial analgesia. DATA SOURCES: The research was conducted using MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID, and the Cochrane Library as electronic databases, from the inception of each database to August 2019. No restrictions for language or geographic location were applied. STUDY ELIGIBILITY CRITERIA: Selection criteria included only randomized controlled trials in pregnant women randomized to either delayed or immediate pushing during the second stage of labor. STUDY APPRAISAL AND SYNTHESIS METHODS: The primary outcome was mode of delivery. The summary measures were reported as relative risk or as mean difference with 95% confidence intervals using the random effects model of DerSimonian and Laird. An I2 (Higgins I2) value of greater than 0% was used to identify heterogeneity. RESULTS: Twelve randomized controlled trials, including 5445 women with neuraxial analgesia randomized to delayed versus immediate pushing during the second stage of labor, were included in the meta-analysis. Of the 5445 women included in the meta-analysis, 2754 were randomized to the delayed pushing group and 2691 to the immediate pushing group. No significant difference between delayed and immediate pushing was found for spontaneous vaginal delivery (80.9% versus 78.3%; relative risk, 1.05; 95% confidence interval, 1.00-1.10; 12 randomized controlled trials, 5540 women), operative vaginal delivery (12.8% versus 14.6%; relative risk, 0.89; 95% confidence interval, 0.75-1.08; 11 randomized controlled trials, 5395 women), and cesarean delivery (6.9% versus 7.9%; relative risk, 0.89; 95% confidence interval, 0.73-1.07; 11 randomized controlled trials; 5395 women). Women randomized to the delayed pushing group had a significantly shorter length of active pushing (mean difference, -27.54 minutes; 95% confidence interval, -43.04 to -12.04; 7 randomized controlled trials, 4737 women) at the expense of a significantly longer overall duration of the second stage of labor (mean difference, 46.17 minutes; 95% confidence interval, 32.63-59.71; 8 studies; 4890 women). The incidence of chorioamnionitis (9.1% versus 6.6%; relative risk, 1.37, 95% confidence interval, 1.04-1.81; 1 randomized controlled trial, 2404 women) and low umbilical cord pH (2.7% versus 1.3%; relative risk, 2.00; 95% confidence interval, 1.30-3.07; 5 randomized controlled trials, 4549 women) were significantly higher in the delayed pushing group. CONCLUSION: In women with spontaneous or induced labor at term with neuraxial analgesia, delayed pushing in the second stage does not affect the mode of delivery, although it reduces the time of active pushing at the expense of a longer second stage. This prolongation of labor was associated with a higher incidence of chorioamnionitis and low umbilical cord pH. Based on these findings, delayed pushing cannot be routinely advocated for the management of the second stage.