Background
Oxytocic agents used for active management of the 3rd stage | Spontaneous vaginal delivery | Non-rotational delivery | Rotational delivery in theatre | Elective or Emergency Caesarean delivery |
---|---|---|---|---|
All women without cardiac disease in accordance with NICE guidelines on intrapartum care. | 10 i.u. oxytocin, intramuscular (im) | 5 i.u. oxytocin intravenous (iv), given as a slow bolus over 3–5 min | ||
Women with cardiac disease except those listed below. | 10 i.u. oxytocin, im | 5 i.u. oxytocin iv given as a an infusion over 10 min through a pump | ||
Women with the following cardiac conditions: • Single ventricle • Fontan circulation • Valvar stenosis • Severely impaired ventricular function [< 30% Ejection Fraction (EF)] | Management is individualised with consideration of a 5 iu infusion over 10 min through a pump |
Methods
-
Any medical disease (such as epilepsy, gestational diabetes or diabetes mellitus, cardiac disease, liver or renal disease, hypertension)
-
Pre-eclampsia or pregnancy induced hypertension
-
Body Mass Index (BMI) > 35 kg/m2
-
Malposition
-
Malplacentation
-
Multiple pregnancy
-
Estimated gestational age under 37 weeks
-
More than two episodes of reduced fetal movements
-
Fetal growth restriction
-
Estimated fetal weight over 4.5 kg.
Statistical methods
Results
Patient demographics
mWHO classification | |||||
---|---|---|---|---|---|
1 | 2 | 3 | 4 | Total | |
Congenital | |||||
Marfan or other aortopathy including bicuspid valve aortopathy | – | 2 | 10 | 1 | 13 |
Repaired septal defect (atrial, ventricular, atrioventricular) | 2 | 10 | 1 | – | 13 |
Repaired Tetralogy of Fallot | 10 | 2 | – | 12 | |
Repaired coarctation of the aorta | – | 8 | 1 | – | 9 |
Hypertrophic cardiomyopathy | – | 4 | 4 | – | 8 |
Complex disease, biventricular repair | – | 5 | 2 | – | 7 |
Systemic right ventricle (congenitally corrected transposition, transposition post atrial switch) | – | – | 5 | 1 | 6 |
Bicuspid aortic valve without aortopathy | 4 | – | – | – | 4 |
Transposition of the great arteries, post arterial switch | – | 4 | – | – | 4 |
Fontan | – | – | 2 | – | 2 |
Othera | – | 5 | 5 | – | 10 |
Total | 6 | 48 | 32 | 2 | 88 |
Acquired | |||||
Regurgitant valvular lesions | 4 | 13 | 4 | – | 21 |
Arrhythmia (normal echo) | 16 | 5 | – | – | 21 |
Stenotic valvular lesions | 1 | 4 | 8 | 1 | 14 |
Dilated cardiomyopathy or previous peripartum cardiomyopathy or other cardiomyopathy | 2 | 1 | 6 | – | 9 |
Ischaemic heart disease | 2 | 3 | 1 | – | 5 |
Total | 25 | 26 | 19 | 1 | 71 |
WHO Grade | |||||
---|---|---|---|---|---|
N | Controls | 1–2 | 3–4 | p-Value | |
Age at Delivery | 5413 | 28.5 ± 5.1 | 29.4 ± 5.9 | 30.1 ± 5.8 |
0.012
|
BMI | 4579 | 24.4 (21.9–27.6) | 26.2 (22.1–31.5) | 27.4 (23.8–32.3) |
< 0.001
|
Parity | 5384 |
< 0.001
| |||
0 | 2584 (49.3%) | 32 (33.0%) | 21 (43.8%) | ||
1 | 1569 (29.9%) | 35 (36.1%) | 9 (18.8%) | ||
2 | 664 (12.7%) | 17 (17.5%) | 10 (20.8%) | ||
3+ | 422 (8.1%) | 13 (13.4%) | 8 (16.7%) | ||
Gestation at Delivery (Completed weeks) | 5412 |
< 0.001
a
| |||
< 40 Weeks | 2088 (39.7%) | 79 (76.0%) | 45 (83.3%) | ||
40+ Weeks | 3166 (60.3%) | 25 (24.0%) | 9 (16.7%) | ||
Baby Weight (g) | 5407 | 3404 ± 431 | 3150 ± 641 | 2741 ± 641 |
< 0.001
|
Mode of delivery | 5413 |
0.002
b
| |||
Spontaneous Vaginal | 4054 (77.2%) | 53 (50.5%) | 23 (42.6%) | ||
Ventouse | 309 (5.9%) | 9 (8.6%) | 2 (3.7%) | ||
Forceps | 528 (10.0%) | 6 (5.7%) | 5 (9.3%) | ||
Caesarean Section | 363 (6.9%) | 37 (35.2%) | 24 (44.4%) | ||
Manual Removal | 5413 | 0.297b | |||
No | 5219 (99.3%) | 104 (99.0%) | 53 (98.1%) | ||
Yes | 35 (0.7%) | 1 (1.0%) | 1 (1.9%) |
Indications for operative vaginal delivery and CS in women with cardiac disease
Indications for Caesarean Section | N (%) |
---|---|
Maternal medical disease | 17 (28%) |
Previous CS | 12 (20%) |
Presumed fetal compromise | 11 (18%) |
Other | 6 (10%) |
Breech | 5 (8%) |
Delay 1st stage | 5 (8%) |
Growth restriction | 3 (5%) |
Failed induction | 2 (3%) |
Blood loss
Univariable analysis
N | Blood Loss (mL) | |||
---|---|---|---|---|
Median (IQR) | Geometric Mean | p-Value | ||
mWHO Grade |
< 0.001
| |||
Controls | 5254 | 250 (177–350) | 244.4 | |
1–2 | 105 | 300 (200–500) | 276.0 | |
3–4 | 54 | 400 (200–500) | 326.4 | |
Age at Delivery |
0.016
| |||
< 25 Years | 1248 | 250 (150–350) | 240.2 | |
25–29 Years | 1831 | 250 (150–350) | 244.1 | |
30–34 Years | 1622 | 250 (200–400) | 247.4 | |
35+ Years | 712 | 250 (200–400) | 256.0 | |
BMI |
0.014
| |||
≤ 25 | 2535 | 250 (200–350) | 244.8 | |
25–30 | 1455 | 250 (200–400) | 253.2 | |
> 30 | 589 | 250 (199–400) | 251.5 | |
Parity |
< 0.001
| |||
0 | 2637 | 300 (200–400) | 281.6 | |
1 | 1613 | 200 (150–300) | 222.4 | |
2 | 691 | 200 (150–300) | 209.3 | |
3+ | 443 | 200 (100–300) | 199.3 | |
Gestation at Delivery (Completed weeks) |
< 0.001
| |||
< 40 Weeks | 2212 | 200 (150–300) | 226.5 | |
40+ Weeks | 3200 | 250 (200–400) | 259.9 | |
Baby Weight |
< 0.001
| |||
< 3.0 kg | 949 | 200 (150–300) | 213.6 | |
3.0–3.4 kg | 2280 | 250 (150–350) | 237.8 | |
3.5–3.9 kg | 1705 | 250 (200–400) | 259.0 | |
4.0+ kg | 473 | 300 (200–450) | 314.4 | |
Mode of Delivery |
< 0.001
a
| |||
Spontaneous Vaginal | 4130 | 200 (150–300) | 214.7 | |
Ventouse | 320 | 300 (200–400) | 279.7 | |
Forceps | 539 | 350 (250–500) | 353.4 | |
Caesarean Section | 424 | 500 (400–700) | 521.9 | |
Manual Removal |
< 0.001
b
| |||
No | 5376 | 250 (193–350) | 244.8 | |
Yes | 37 | 400 (250–700) | 416.3 |
Vaginala | Caesarean Section | |||||||
---|---|---|---|---|---|---|---|---|
N | Median (IQR) | Geometric Mean | p-Value | N | Median (IQR) | Geometric Mean | p-Value | |
mWHO Grade | 0.810 | 0.079 | ||||||
Controls
| 4891 | 200 (150–300) | 230.6 | 363 | 500 (400–700) | 535.6 | ||
1 + 2
| 68 | 200 (150–300) | 219.7 | 37 | 450 (300–500) | 419.5 | ||
3 + 4
| 30 | 250 (200–400) | 234.2 | 24 | 500 (400–650) | 494.1 |
Multivariable analysis
Coefficient (95% CI) | p-Value | |
---|---|---|
mWHO Grade | 0.165 | |
Controls | – | – |
1–2 | −2.2% (−13.9, 11.2%) | 0.739 |
3–4 | 19.7% (− 1.2, 45.0%) | 0.066 |
Age at Delivery (per Decade) | 4.6% (1.2, 8.2%) |
0.008
|
BMI (per 10 kg/m2) | 1.0% (−2.9, 5.1%) | 0.624 |
Parity |
< 0.001
| |
0 | – | – |
1 | −11.0% (−14.6, −7.2%) |
< 0.001
|
2 | −16.9% (−21.4, − 12.3%) |
< 0.001
|
3+ | −19.9% (− 25.0, − 14.5%) |
< 0.001
|
Gestation at Delivery (Completed weeks) | −0.1% (− 1.7, 1.5%) | 0.889 |
Baby Weight (per kg) | 28.6% (23.4, 34.1%) |
< 0.001
|
Mode of Delivery |
< 0.001
| |
Spontaneous Vaginal | – | – |
Ventouse | 23.3% (15.0, 32.3%) |
< 0.001
|
Forceps | 47.5% (39.2, 56.2%) |
< 0.001
|
Caesarean Section | 121.1% (107.4, 135.6%) |
< 0.001
|
Manual Removal |
< 0.001
| |
No | – | – |
Yes | 59.1% (30.3, 94.1%) |
< 0.001
|