Timing and mode of delivery in twins : the ongoing controversy

Tese de doutoramento, Medicina (Ginecologia e Obstetrícia), Universidade de Lisboa, Faculdade de Medicina, 2014

Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial

Background

Epidural analgesia is the most effective labour pain relief but is associated with increased rates of instrumental vaginal delivery and other effects, which might be related to the poor motor function associated with traditional epidural. New techniques that preserve motor function could reduce obstetric intervention. We did a randomised controlled trial to compare low-dose combined spinal epidural and low-dose infusion (mobile) techniques with traditional epidural technique.
Methods

Between Feb 1, 1999, and April 30, 2000, we randomly assigned 1054 nulliparous women requesting epidural pain relief to traditional (n=353), low-dose combined spinal epidural (n=351), or low-dose infusion epidural (n=350). Primary outcome was mode of delivery, and secondary outcomes were progress of labour, efficacy of procedure, and effect on neonates. We obtained data during labour and interviewed women postnatally.
Findings

The normal vaginal delivery rate was 35·1% in the traditional epidural group, 42·7% in the low-dose combined spinal group (odds ratio 1·38 [95% CI 1·01–1·89]; p=0·04); and 42·9% in the low-dose infusion group (1·39 [1·01–1·90]; p=0·04). These differences were accounted for by a reduction in instrumental vaginal delivery. Overall, 5 min APGAR scores of 7 or less were more frequent with low-dose technique. High-level resuscitation was more frequent in the low-dose infusion group.

Mode of delivery and problems in subsequent births : a register-based study from Finland

Objective

The purpose of this study was to investigate the effects of delivery on problems in subsequent births.
Study design

This was a cohort study that used register data for 73,104 mothers who had their first birth from 1987 to 1989 and subsequent births from 1987 to1998. Three analyses were performed: (1) examination of second births by mode of delivery in the first birth, with adjustment for confounders, (2) same parameter, with exclusion of women with persistent problems, and (3) examination of third births for women with a first birth vaginal delivery.
Results

More complications and poorer infant outcome were found at later births when the first or second birth was by cesarean delivery than after a first spontaneous vaginal delivery, even when women with persistent problems were excluded. Women with instrument first births had a similar rate of complications in the second birth to women with spontaneous vaginal births, but some infant outcomes were poorer.
Conclusion

Problems that are subsequent to cesarean delivery are unlikely to be explained entirely by indications for cesarean delivery.

Medical students' personal choice for mode of delivery in Santa Catarina, Brazil: a cross-sectional, quantitative study

Background: The increase in overall rates of cesarean sections (CS) in Brazil causes concern and it appears that multiple factors are involved in this fact. In 2009, undergraduate students in the first and final years of medical school at the University of Santa Catarina answered questionnaires regarding their choice of mode of delivery. The aim of the study was to evaluate whether the education process affects decision-making regarding the waay of childbirth preferred by medical students.Methods: A cross-sectional, quantitative study was conducted based on data obtained from questionnaires applied to medical students. The questions addressed four different scenarios in childbirth, as follows: under an uneventful pregnancy; the mode of delivery for a pregnant woman under their care; the best choice as a healthcare manager and lastly, choosing the birth of their own child. For each circumstance, there was an open question to explain their choice.Results: A total of 189 students answered the questionnaires. For any uneventful pregnancy and for a pregnant woman under their care, 8.46% of the students would opt for CS. As a healthcare manager, only 2.64% of the students would recommend CS. For these three scenarios, the answers of the students in the first year did not differ from those given by students in the sixth year. In the case of the student's own or a partner's pregnancy, 41.4% of those in the sixth year and 16.8% of those in the first year would choose a CS. A positive association was found between being a sixth year student and a personal preference for CS according to logistic regression (OR = 2.91; 95%CI: 1.03-8.30). Pain associated with vaginal delivery was usually the reason for choosing a CS.Conclusions: A higher number of sixth year students preferred a CS for their own pregnancy (or their partner's) compared to first year students. Pain associated with vaginal delivery was the most common reason given for haven chosen a CS. The students' preference for childbirth changed over time during their graduation in favor of cesarean sections. This finding deserves considerable attention when structuring medical education in Obstetrics.

The influence of BMP-2 and its mode of delivery on the osteoconductivity of implant surfaces during the early phase of osseointegration

Osteogenic agents, such as bone morphogenetic protein-2 (BMP-2), can stimulate the degradation as well as the formation of bone. Hence, they could impair the osteoconductivity of functionalized implant surfaces. We assessed the effects of BMP-2 and its mode of delivery on the osteoconductivity of dental implants with either a naked titanium surface or a calcium-phosphate-coated one. The naked titanium surface bore adsorbed BMP-2, whilst the coated one bore incorporated, adsorbed, or incorporated and adsorbed BMP-2. The implants were inserted into the maxillae of adult miniature pigs. The volume of bone deposited within a defined "osteoconductive" (peri-implant) space, and bone coverage of the implant surface delimiting this space, were estimated morphometrically 1-3 weeks later. After 3 weeks, the volume of bone deposited within the osteoconductive space was highest for coated and uncoated implants bearing no BMP-2, followed by coated implants bearing incorporated BMP-2; it was lowest for coated implants bearing only adsorbed BMP-2. Bone-interface coverage was highest for coated implants bearing no BMP-2, followed by coated implants bearing either incorporated, or incorporated and adsorbed BMP-2; it was lowest for uncoated implants bearing adsorbed BMP-2. Hence, the osteoconductivity of implant surfaces can be significantly modulated by BMP-2 and its mode of delivery.

Effect of mode of delivery on early oral colonization and childhood dental caries: a systematic review

Background: Oral colonization starts at birth by vertical transmission. Objective: To determine whether mode of delivery influences the oral colonization of infants and contributes to the risk of childhood dental caries. Methods: A systematic review was conducted in the electronic database Web of Science for articles published from January 1995 to December 2015 by using a set of keywords. Results: From 2,644 citations identified through electronic search, ten studies met the inclusion criteria. According to the studies mode of delivery influences oral microbial density, oral microbial profile and the timing of oral colonization by cariogenic microbiota. However, there are no consistent results concerning either the prevalence of children harboring cariogenic microbiota or the prevalence of early childhood caries by mode of delivery. Conclusion: Mode of delivery influences early oral colonization. However, it seems that other determinants rather than mode of delivery could be major contributors to the development of early childhood caries. Keywords: Early childhood caries, early oral colonization, acquisition of oral microflora, mode of delivery

“Trying, But Failing” : The Role of Inhaler Technique and Mode of Delivery in Respiratory Medication Adherence

Peer reviewed

Obstetric mode of delivery and child psychological development

Background/aims: Objective of the current thesis is to investigate the potential impact of birth by Caesarean section (CS) on child psychological development, including autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), behavioural difficulties and school performance. Structure/methods: Published literature to date on birth by CS, ASD and ADHD was reviewed (Chapter 2). Data from the UK Millennium Cohort Study (MCS) were analysed to determine the association between CS and ASD, ADHD and parent-reported behavioural difficulties (Chapter 3). The Swedish National Registers were used to further assess the association with ASD, ADHD and school performance (Chapters 4-6). Results: In the review, children born by CS were 23% more likely to be diagnosed with ASD after controlling for potential confounders. Only two studies reported adjusted estimates on the association between birth by CS and ADHD, results were conflicting and limited. CS was not associated with ASD, ADHD or behavioural difficulties in the UK MCS. In the Swedish National Registers, children born by CS were more likely to be diagnosed with ASD or ADHD. The association with elective CS did not persist when compared amongst siblings. There was little evidence of an association between birth by elective CS and poor school performance. Children born by elective CS had slight reduction in school performance. Conclusions: The lack of association with the elective CS in the sibling design studies indicates that the association in the population is most probably due to confounding. A small but significant association was found between birth by CS and school performance. However, the effect may have been due to residual confounding or confounding by indication and should be interpreted with caution. The overall conclusion is that birth by CS does not appear to have a causal relationship with the aspects of child psychological development investigated.

Comparison of two modes of delivery of an exercise prescription scheme

AIM: Green Prescription (GRx) referrals from health professionals have been shown to be effective for increasing the physical activity levels of patients. Little is known about which methods of delivering the programme represents the best value for money. The purpose of this paper was to compare the cost and outcomes of two modes of delivery of a GRx programme. One mode offered phone support involving monthly telephone calls over a 3-4 month period to encourage physical activity participation. A second mode offered community support via weekly face-to-face support group meetings in which physical activities were offered. METHODS: The evaluation involved staff interviews, patient interviews and analysis of GRx records for the 2007 calendar year. RESULTS: There was a large rate of drop-out (68%) from GRx referral to registration. For those who registered, there was a clear preference for community support, and engagement of Maori and Pacific peoples was higher in this mode of delivery. The proportion (but not absolute number) of people who successfully completed their mode of delivery was higher with phone support. However, participants in community support self-reported a significantly greater number of days of exercise per week than those in phone support. The total expected cost per person for phone support was $102.07 and $108.15 for community support. A greater proportion of participants in community support were very satisfied overall with their mode of delivery. CONCLUSION: The two modes were comparable in cost and outcomes, though there was greater penetration of target ethnic populations in community support. Providing a choice of GRx mode of delivery allows participants to choose based on their personal and cultural needs.

Comparison of two modes of delivery of an exercise prescription scheme

SummaryGreen Prescription (GRx) is a referral from a health professional for a patient to become more physically active. In Auckland, GRx is delivered either on the telephone or face-to-face. A comparison of the two modes of delivery (telephone vs. face-to-face) was conducted. This evaluation involved staff interviews, patient interviews and analysis of GRx records for the 2007 calendar year. Results indicated that the modes of delivery were similar in terms of costs as well as outcomes. However, the face-to-face mode of delivery was more popular with Maori and Pacific peoples. Providing a choice of GRx mode of delivery allows participants to choose based on their personal and cultural needs.AbstractAimGreen Prescription (GRx) referrals from health professionals have been shown to be effective for increasing the physical activity levels of patients. Little is known about which methods of delivering the programme represents the best value for money. The purpose of this paper was to compare the cost and outcomes of two modes of delivery of a GRx programme. One mode offered phone support involving monthly telephone calls over a 3-4 month period to encourage physical activity participation. A second mode offered community support via weekly face-to-face support group meetings in which physical activities were offered.MethodThe evaluation involved staff interviews, patient interviews and analysis of GRx records for the 2007 calendar year.ResultsThere was a large rate of drop-out (68%) from GRx referral to registration. For those who registered, there was a clear preference for community support, and engagement of Māori and Pacific peoples was higher in this mode of delivery. The proportion (but not absolute number) of people who successfully completed their mode of delivery was higher with phone support. However, participants in community support self-reported a significantly greater number of days of exercise per week than those in phone support. The total expected cost per person for phone support was $102.07 and $108.15 for community support. A greater proportion of participants in community support were very satisfied overall with their mode of delivery.ConclusionThe two modes were comparable in cost and outcomes, though there was greater penetration of target ethnic populations in community support. Providing a choice of GRx mode of delivery allows participants to choose based on their personal and cultural needs.

The influence of delivery mode on consumer choice of university

This paper reports on an empirical investigation into the importance of study mode in the choice of university by Australian student-consumers, using conjoint methods. Traditional approaches to investigating student choice have overlooked study mode because they assume a norm of face-to-face attendance on-campus. Three segments were identified based on the relative importance which students placed on the university, study mode and tuition fees in making their choice, and the segments were distinguishable on some demographic and situational variables. The findings have relevance to universities across national and reputational markets in making their decisions about how to deliver educational products.

The effect of a slow mode of BMP-2 delivery on the inflammatory response provoked by bone-defect-filling polymeric scaffolds

We investigated the inflammatory response to, and the osteoinductive efficacies of, four polymers (collagen, Ethisorb, PLGA and Polyactive) that bore either an adsorbed (fast-release kinetics) or a calcium-phosphate-coating-incorporated (slow-release kinetics) depot of BMP-2. Titanium-plate-supported discs of each polymer (n = 6 per group) were implanted at an ectopic (subcutaneous) ossification site in rats (n = 48). Five weeks later, they were retrieved for a histomorphometric analysis of the volumes of ectopic bone and foreign-body giant cells (a gauge of inflammatory reactivity), and the degree of polymer degradation. For each polymer, the osteoinductive efficacy of BMP-2 was higher when it was incorporated into a coating than when it was directly adsorbed onto the material. This mode of BMP-2 carriage was consistently associated with an attenuation of the inflammatory response. For coated materials, the volume density of foreign-body giant cells was inversely correlated with the volume density of bone (r(2) = 0.96), and the volume density of bone was directly proportional to the surface-area density of the polymer (r(2) = 0.97). Following coating degradation, other competitive factors, such as the biocompatibility and the biodegradability of the polymer itself, came into play.