Background: Systematic reviews of clinical trials frequently reveal heterogeneity in the number and types of outcomes reported. To counteract this, a Core Outcome Set (COS) may be applied. Objectives: A systematic review of all completed and ongoing COS related to pregnancy and childbirth Search strategy: COMET up to January 2020, Ovid MEDLINE, EMBASE, PsycINFO, Academic Search Elite, CINAHL and SocINDEX up to June 2019. Selection criteria: Studies which prioritized outcomes using some form of consensus method (such as the Delphi technique) were included. Data collection and analysis: All included studies were checked for compliance with the Core Outcome Set–STAndards for Reporting. Information about population, setting, method and outcomes was extracted. Main results: Nineteen completed studies and thirty-nine ongoing studies were included. The number of outcomes included in various COS ranged from 6 to 48. Most COS were for conditions related to physical complications during pregnancy. No COS were identified for perinatal mental health. Conclusion: This review discloses a growing number of COS within the field of pregnancy and childbirth. Many of the completed studies follow the proposed reporting. However, several of the COS included a large number of outcomes. There is a need to consider the number of outcomes which may be included in a COS while retaining its applicability in future research. Funding This article is adapted from a report undertaken by the SBU, who provided funding for the study. Keywords: Childbirth, Core outcome set, Maternal health, Obstetric care, Pregnancy

Objective: Given growing interest in alternatives to hospital birth, particularly given the COVID-19 pandemic, we developed a peripartum intervention risk calculator (PIRC) to estimate maternal and neonatal risk of requiring hospital-based peripartum intervention. Design: National cohort study. Setting: United States. Sample: Hospital births captured by the Pregnancy Risk Assessment Monitoring System from 2009-2018. Methods: The cohort was stratified by receipt of hospital-based interventions, defined as: 1) operative vaginal delivery (forceps or vacuum), 2) cesarean delivery, or 3) requiring neonatal intensive care unit admission. Gravidas with prior cesarean delivery or fetal malformation were excluded. Main Outcome Measures: Risk of requiring hospital-based intervention. Results: A total of 63,234 births were evaluated (72.6% full-term, 48.5% nulliparous) including 37.9% who received one or more hospital–based interventions. Gestational age was the most predictive factor of requiring hospital-based intervention, with lowest odds at 400/7-406/7 weeks. Previous live births (Ref: none; 1, OR 0.41; 2, OR 0.35; ≥3, OR 0.29; p<0.05 for all) were protective. Other predictors included advanced maternal age, high pre-pregnancy body mass index, maternal diabetes, maternal hypertension, and not exercising during pregnancy. The resulting seven-factor model demonstrated strong discrimination (optimism corrected C-statistic=0.776) and calibration (mean absolute error=0.009). Conclusions: We developed and validated the PIRC for predicting individualized risk for hospital-based intervention among gravidas based on seven readily accessible prenatal factors. This calculator can support personalized counseling regarding planned birth setting, helping to close a critical gap in current clinical guidance and providing an evidence-based risk assessment for those contemplating alternatives to hospital birth.

Objective To develop a Core Outcome Set (COS) for treatment of perinatal depression Design Systematic overview of outcomes reported in the literature and consensus development study using a Delphi survey and modified nominal group technique. Setting International. Population Two hundred and twenty-two participants, representing thirteen countries. Methods A systematic overview of outcomes reported in recently published research, a two-round Delphi survey, a consensus meeting at which the final COS was decided. Main results In the literature search, 1772 abstracts were identified and evaluated, 284 papers/protocols were assessed in full and 165 studies were finally included in the review. In all, 106 outcomes were identified and thus included in the Delphi survey. 222 participants registered for the first round of the Delphi survey and 151 (68%) responded. In the second round, 123 (55%) participants responded. The following 9 outcomes were agreed upon for inclusion in the final COS: self-assessed symptoms of depression, diagnosis of depression by a clinician, parent to infant bonding, self-assessed symptoms of anxiety, quality of life, satisfaction with intervention, suicidal thoughts, attempted or committed suicide, thoughts of harming the baby, and adverse events. Conclusions The relevant stakeholders prioritised outcomes and reached consensus on a COS comprising nine outcomes. We hope that this COS will contribute to consistency and uniformity of outcome selection and reporting in future clinical trials involving treatment of perinatal depression Funding This article is adapted from a report by SBU, which provided funding for the study. Keywords: perinatal depression, postpartum depression, antenatal depression, COS

OBJECTIVE: To determine the true financial costs of Planned Caesarean Section and Planned Vaginal Birth in England for the year 2018/19 after accounting for litigation and compensation for harm (LCFH) DESIGN: Sensitivity analysis BACKGROUND: Average base costs per delivery remitted to NHS maternity providers for Planned Caesarean Birth (PCB) and Planned Vaginal Birth (PVB) in 2018/19 were £3,948 and £3,270 respectively leading to a perception that PCB is more costly than PVB. Indemnity costs potentially related to planned mode of delivery, however, add an average of £1,571/delivery to overall costs. METHOD: Retrospective analysis of costs according to planned mode of birth was performed based on data and previous research published by NHS Resolution and NHS England. Weighting of results according to PCB and PVB rates was performed in a manner similar to the sensitivity analysis of PCB v PVB (without accounting for LCFH) performed by the National Institute for Health and Care Excellence (NICE) in 2011 RESULTS: Additional costs of LCFH resulted in revised costs of £4,245 and £5,030 for PCB and PVB respectively – a cost advantage of £785 per delivery in favour of PCB. CONCLUSION: Providers should not be discouraged from offering or women refused PCB on grounds of cost.

Objective The shape of the sacrum-coccyx was defined and compared in nulliparous, pregnant, and parous women to provide insight into anatomical adaptations that afford vaginal delivery. Design A retrospective study comparing midsagittal anatomical measurements based on MRI of the sacrum and coccyx from 63 subjects. Setting Magee-Womens Research Institute and Northshore University HealthSystem. Population 23 nulliparous, 14 pregnant, and 26 parous women who had an MRI taken that included the necessary bony anatomy. Methods Twelve measurements were taken on scans between the ages of 20 and 49 that had a pelvic MRI scan with or without contrast were analyzed. Subjects were categorized based on parity and gravidity. Main Outcome Measures Length, angles, and curvature indices describing midsagittal sacrum and coccyx shape Results Overall pregnant women had a significantly straighter and more posteriorly oriented coccyx when compared to nulliparous women. This was reflected by a change in 3 measures at the univariate level. The coccygeal curvature index was higher in pregnant (89.2  10.0) women relative to nulliparous (78.7  6.6, p=0.003) and parous (80.0  5.5, p=0.004) women. The sacrococcygeal curvature index and sacrococcygeal angle also increased in the pregnant as compared to the nulliparous group (73.3  5.8 versus 79.2  3.7, p=0.016; 92.8  10.9 versus 109.3  9.4, p=0.002, respectively) with no difference between pregnant and parous groups for these measurements. Conclusions Pregnancy-induced posterior motion of the coccyx, which allowed for the combined sacrum-coccyx shape to straighten, effectively widens the obstetric outlet for vaginal delivery.

Objective: To investigate the relationship between cannabinoid receptor expression within the placenta after delivery and the problem of preterm delivery. Design, setting, and participants: The retrospective, observational study was conducted on a multicenter material of 150 women. The study group included 115 women after premature delivery. The control group consisted of 35 women after term delivery. Methods. To determine the expression of cannabinoid receptors after the end of the third stage of labour, several sections were taken from the placenta. RNA isolation, reverse transcription, and Real-Time PCR were performed to assess the expression of the cannabinoid receptors in the placenta. Results: Cannabinoid receptor type 2 expression was lower in the placentas of women after preterm delivery. Urinary tract infections and bleeding at any stage of pregnancy occurred statistically more frequently in the study group and correlated with cannabinoid receptor type 2 expression. In the study group, the history of preterm labor, history of intrauterine fetal deaths, pregnancies terminated by a Caesarean section, and uterine tenderness correlated with lower expression of cannabinoid receptor type 2 and 1a. Conclusions: Cannabinoid receptors mRNA were present in human placental tissue during pregnancy. Decreased cannabinoid receptor type 2 expression in preterm delivered placentas should be further investigated, as perinatal endocannabinoid receptor expression could serve as a predicting tool of preterm birth. For example, liquid-based cytology could be used as a noninvasive perinatal method of measuring the expression level of cannabinoid receptors in decidual cells during pregnancy. KEYWORDS: Cannabinoid receptor; CB2; endocannabinoid system; preterm delivery; PTB

Objectives: to evaluate the effectiveness of uterine tamponade devices for atonic refractory postpartum haemorrhage (PPH) after vaginal birth, and the effect of including uterine tamponade devices in institutional protocols. Search strategy: databases in PubMed, EMBASE, CINAHL, LILACS and POPLINE. Study selection: randomised and non-randomised comparative studies. Outcomes: composite outcome including surgical interventions (artery ligations, uterine compressive sutures or hysterectomy) or maternal death, and hysterectomy. Results: all four included studies were at high risk of bias. The certainty of evidence rated as very low to low. One randomised study measured the effect of the the condom-catheter balloon compared to standard care and found unclear results for the composite outcome (RR 2.33, 95%CI 0.76-7.14) and hysterectomy (RR 4.14, 95%CI 0.48-35.93). Three comparative studies assessed the effect of including UBTs in institutional protocols. A stepped-wedge study suggested an increase in the composite outcome (RR 4.08, 95%CI 1.07-15.58), and unclear results for hysterectomy (RR 4.38, 95% CI 0.47-41.09) with the use of the condom-catheter or surgical glove balloon. One non-randomised study showed unclear effects on the composite outcome (RR 0.33, 95%CI 0.11-1.03) and hysterectomy (RR 0.49, 95%CI 0.04-5.38) after the inclusion of Bakri balloon. The second non-randomized study found unclear effects on the composite outcome (RR 0.95, 95%CI 0.32-2.81) and hysterectomy (RR 1.84, 95%CI 0.44-7.69) after the inclusion of Ebb or Bakri balloon. Conclusions: the effect of uterine tamponade devices for the management of atonic refractory PPH after vaginal delivery is unclear, as is the role of the type of device and the setting.

Placenta accreta spectrum and placenta praevia are a significant cause of obstetric haemorrhage, maternal morbidity and mortality worldwide. We report a novel surgical technique, which pre-emptively and prophylactically reduces intrapartum bleeding during caesarean sections for these conditions and hence reducing the risk for a caesarean hysterectomy. This technique is particularly useful in low resource healthcare settings where interventional radiology is not readily available and where the woman is keen on uterine preservation. In this report we present the surgical and clinical outcomes of a case series of 16 patients on whom this technique was piloted demonstrating its feasibility and safety.

BJOG-20-0640.R1 The evolving definition of pre-eclampsia

Objective: To demonstrate that a double balloon catheter combined with oxytocin decreases time between induction of labour and delivery (TID) as compared to a vaginal dinoprostone insert in cases of PROM at term. Design: Prospective, randomized, controlled trial. Setting: French university hospital Population: Patients undergoing labour induction for PROM at term with unfavorable cervix. Methods: We compared the double balloon catheter over a period of 12 hours with adjunction of oxytocin 6 hours after catheter insertion, versus dinoprostone vaginal insert. After device ablation, cervical ripening continued only with oxytocin. Main outcome measures: The primary outcome was TID. Secondary outcomes concerned delivery mode, maternal and fetal outcome and were adjusted for parity. Results: 40 patients per group were randomized. Each group had similar baseline characteristics. The study failed to demonstrate reduced TID (16.2 vs 20.2 hours, ES = 0.16 (-0.27 to 0.60), p=0.12) in catheter group versus dinoprostone except in nulliparous women (17.0 vs 26.5 hours, ES = 0.62 (0.10 to 1.14), p=0.006). The rate of vaginal delivery <24h significantly increased with combined induction (88.5% vs 66.6%, p=0.03). No statistical difference was observed concerning caesarean rate (12.5% vs 17.5%, p>0.05), chorioamnionitis (0% vs 2.5%, p=1), postpartum endometritis, maternal or neonatal outcomes. Procedure-related pain and tolerance to devices were found to be similar for the two methods. Conclusion: The double balloon catheter combined with oxytocin is an alternative for cervical ripening in case of PROM at term, and may reduce TID in nulliparous women.

Objective: To investigate the effect of delayed umbilical cord clamping on neonatal outcomes following caesarean delivery under general anaesthesia. Design: Prospective cohort study. Setting: West China Second University Hospital Sample: Neonates born by caesarean delivery under general anaesthesia after 35 gestational weeks. Methods: Neonates were assigned to Groups A or B if they received early or delayed cord clamping, respectively. Main Outcome Measures: Umbilical arterial blood gas analysis indicators, Apgar scores, resuscitation procedure incidence, peak bilirubin, and neonatal morbidity were compared between the two groups. Results: Group A had 29 and Group B had 21 participants. There were no significant differences in any of the outcome measures between the two groups. We classified five periods during caesarean delivery: aesthetic induction (Period 1), skin incision (Period 2), myometrium incision (Period 3), delivery of the neonate (Period 4), and time of cord clamping (Period 5). One-minute Apgar scores were negatively correlated with cord-clamping time (r=-0.426, P=0.002). Peak bilirubin value was correlated with Periods 2, 3, and 5 (r=0.347, P=0.014; r=0.411, P=0.003; r=-0.289, P=0.042, respectively). The remaining secondary outcomes were not correlated with any of the five periods. The peak bilirubin value was(9.712+0.006 × Period 2+0.006 × Period 3-0.026 × Period 5) (R2=0.313). . Conclusions: In caesarean delivery under general anaesthesia, delayed cord clamping within a certain period may partially prolong the duration of neonatal exposure to general anaesthesia drugs. However, delayed cord clamping is a safe and feasible technique for clinical application.

Aim: To develop clinical algorithms for the assessment and management of slow progress of labour. Population: Low-risk singleton, term, pregnant women in labour. Setting: Institutional births in low- and middle-income countries. Search Strategy: We systematically reviewed the literature on normal labour progression, and guidance on clinical management of abnormally slow progression from 1 December 2015 to 1 December 2020. Case scenarios: We developed two clinical algorithms: one for abnormally slow labour progression and arrest during first and one for second stage. Conclusions: Identifying abnormal progress of labour is often challenging. These algorithms may help to reduce misdiagnosis.

Background: There is variation in the reported incidence of levator avulsion (LA). Objective: Explore incidence of LA by mode of birth, imaging modality, timing of diagnosis and laterality of avulsion. Search strategy: We searched MEDLINE, EMBASE, CINAHL, AMED and MIDIRS with no language restriction from inception to April 2019. Study eligibility criteria: A study was included if LA was assessed by an imaging modality after the first vaginal birth or if only delivered by caesarean section. Case series and reports were not included. Data collection and analysis: RevMan v5.3 was used for the meta-analyses and SW SAS and STATISTICA packages for type and timing of imaging analyses. . Results: We included 37 primary non-randomized studies from 17 countries and involving 5594 women. Incidence of LA was 1%, 15%, 21%, 38.5% and 52% following caesarean, spontaneous, vacuum, spatula and forceps births respectively, with no differences by imaging modality. OR of LA following spontaneous birth vs. caesarean was 10.69. While the OR for LA following vacuum and forceps compared to the spontaneous birth were 1.66 and 6.32 respectively. LA was more likely to occur on the right side following spontaneous birth (p = 0.02) and unilaterally vs. bilaterally following spontaneous (P < .0001) and vacuum-assisted births (P = 0.0103) only. Incidence was higher if assessment was performed in the first 4 weeks postpartum. Conclusions: Forceps significantly increases incidence and severity of LA. Ultrasound and MRI are comparable diagnostic tools but early postpartum imaging may lead to over diagnosis of LA.

Objective To evaluate factors affecting cesarean section (CS) rates in groups 1, 2A, 3, 4A, 5 and 10 of the “Ten Group Classification System” (TGCS). Design Retrospective analysis of deliveries occurred from January 1996 to December 2019. Setting A single hospital in Milan. Population Pregnant women belonging to groups 1, 2A, 3, 4A, 5 and 10 of the TGCS. Methods A binary logistic regression analysis was conducted. Included independent variables were maternal age, neonatal birthweight, immigrant status, use of obstetric analgesia, presence of diabetes, hypertension and obesity. Main outcome measures The effect of independent variables on CS rate was expressed as odds ratio. Results A total of 30591 deliveries were recorded. Advanced maternal age was an independent risk factor (RF) in groups 1, 2A, 3, and 4A; diabetes was a risk factor in groups 1 and 5; obesity was a RF in groups 1 and 2A and a protective one in group 5; hypertension was a RF in groups 2A, 5 and 10; macrosomia was a RF in groups 1, 2A and 3; use of obstetric analgesia was either a RF in group 1, and a protective factor in groups 2A, 5 and 10; immigrant status was either a protective factor in groups 1 and 10, and a RF in group 4A. Conclusion The TGCS is a well-established method to compare CS rates between institutions; however, inside each group, many factors can influence the CS rate and they have to be taken into consideration when comparing CS rates.

Coronavirus disease 2019 (COVID-19) has a microembolic pathogenesis. We reviewed the incidence of microembolic complications of pregnancy during the COVID-19 pandemic period compared to the pre-pandemic period, specifically in-utero death (IUD) and placental abruption. Design A retrospective case review. Setting Patients were identified from the Datix reporting system and anonymised data was collected from the electronic health records. Population or Sample Women suffering an IUD or placental abruption during the review periods. Methods A retrospective review of the frequency and clinical characteristics of cases of IUD and placental abruption between 1st Jan 2020 – 30th June 2020 was compared to those from the 1st Jan 2019 – 30th June 2019. Main Outcome Measures To evaluate the frequency and clinical characteristics of women suffering IUD and placental abruption during the pandemic period in 2020, and compare them to the pre pandemic period in 2019. Results There was a increase in the rates of IUD from 2019 to 2020, 1.22/1000 births compared to 2.85/1000 births (p= 0.10). There was no difference in the rates of placental abruption (p= 0.03). Conclusions Our review has demonstrated a non-significant rise in the frequency of IUD in the pandemic period in 2020 compared to those in 2019. Additionally, there was a significantly lower lymphocyte count during the pandemic period- a marker known to be associated with COVID-19. This warrants further investigation to explore the link between COVID-19 and disorders of poor placental perfusion, particularly the rates of IUD.

This study includes 11 cases of PPH seen during Caesarean section by a single surgeon Dr. Sadhna Mathur during the last 7years where this hemostatic suture was used to control PPH from placental site in uterine cavity after the medical measures failed to control the bleeding from placental site(uterine cavity). The bleeding point was localized and a haemostatic suture in the overlying uterine musculature was applied. It was found to be completely effective hence it is being shared through this paper.

Objective: To study the relation between platelet parameters and severe postpartum haemorrhage (SPPH). Design: Retrospective cohort study. Setting: Birth centre of the University Medical Centre Utrecht. Population: 23,205 deliveries between 2009 and 2017. Methods: The predictors platelet count, mean platelet volume (MPV), plateletcrit, platelet distribution width (PDW), and immature platelet fraction (IPF) were measured within 72 hours prior to delivery. Multiple imputation was performed for missing data. Odds ratios were adjusted (aOR’s) for maternal age, multiple gestation, macrosomia, induction of labour, and preeclampsia. Main outcome measures: Severe postpartum haemorrhage (≥1,000mL of blood loss within 24 hours after delivery) Results: Of the 2,402 (10.4%) women with thrombocytopenia (<150*109/L), 10.3% developed SPPH, compared to 7.6% of women with a normal platelet count (aOR: 1.34, 95%-CI: 1.14–1.57). Women with a platelet count of <50*109/L were most at risk (aOR of 2.19 (1.01-4.72)) compared to the reference group with normal platelet counts; the aOR was 1.20 (0.77-1.87) for the 50-99*109/L platelet count group, and 1.30 (1.09-1.55) for the 100-149*109/L platelet count group. Plateletcrit was associated with SPPH (aOR 1.15 (1.08-1.21) per 0.05% decrease), and, although rarely present, a PDW ≥23% (n=22) also increased the odds of SPPH (aOR 6.13 (2.29-16.4)). Conclusions: Low platelet count, low plateletcrit, and a PDW ≥23% were associated with the occurrence of SPPH, independent of common PPH risk factors.

Objectives To estimate the prevalence of latent iron deficiency (LID) among pregnant women, assess LID in relation to parity, age, education, and household income, and to determine correlations between LID and red cell indices, red cell distribution width (RDW), and red cell morphology. Design Cross-sectional design Setting North Colombo Teaching Hospital, Sri Lanka. Sample Participants comprised 355 pregnant women with normal haemoglobin levels seeking antenatal care within < 20 weeks of gestation. Method Data were obtained from interviews and antenatal records. Participant full blood count (FBC), serum ferritin levels, and blood films were analysed. Main Outcome Measures Prevalence of LID, demographic data (age, parity, period of gestation, gap between pregnancies, income, and education), and blood film morphology. Results LID prevalence was 54%. Statistical significance for the gap between pregnancies being < 2 years was observed but not for participant’s age, parity, income, and education. Blood film morphology depicted statistically significant presence of hypochromic microcytic red cells and pencil cells. RDW was significant in indicating the presence of LID. Among those with LID, 25% had ferritin level in the iron deficiency range. Conclusions LID is highly prevalent in early pregnancy and 25% of participants had ferritin levels in the iron deficiency range. Presence of raised RDW, hypochromic microcytic red cells, pencil cells, and <2 years’ gap between pregnancies were indicators of LID. To identify pregnant women with LID, blood film, haemoglobin, and RDW could be recommended as basic tests, and ferritin test as an affirmative one.

Mini-commentary on BJOG-20-1459.R1: Caesarean birth and risk of subsequent preterm birth: retrospective cohort studyDeclarative title to be addedBradley de VriesSchool of Public HealthUniversity of SydneySydneyNew South WalesAustraliaWorldwide, preterm birth occurs in 11% of pregnancies and is the leading cause of childhood mortality. Complications from preterm birth are the most common cause of neonatal death in the United Kingdom, yet the incidence of preterm birth is not falling.In this issue of BJOG, Williams et al (BJOG xxxx) report on an observational study which identifies previous second stage caesarean birth as a risk factor for spontaneous preterm birth, confirming the results of other observational cohorts. Among women with one previous term birth, the adjusted odds ratio was 2.1 (95% confidence interval [CI] 1.3 to 3.1) for preterm birth before 37 weeks gestational age and 7.5 (95% CI 3.4 to 15) for preterm birth before 34 weeks, for previous second stage caesarean birth compared with previous vaginal birth. They adjusted for confounders not addressed in other studies including interpregnancy interval and maternal deprivation index, strengthening the existing evidence. The association is plausible because the cervix and lower uterine segment are anatomically merged in the second stage of labour and inadvertent cervical incision might damage the integrity of the cervix. The association was at least as strong as that described for previous excisional surgery for cervical dysplasia. Current National Institute of Clinical Excellence Guidelines recommend considering prophylactic cervical cerclage for an ultrasound-measured cervical length < 25mm if there is a history of cervical trauma. Given the plausibility and emerging epidemiological evidence, it would seem prudent to offer the same screening and treatment when there is a history of second stage caesarean birth.The observed association is relevant in other ways. Counselling about instrumental versus caesarean birth may be influenced by knowledge of future risks. Additionally, surgeons may need to be aware of the potential importance of avoiding inadvertent cervical incision, while still avoiding upper segment incision and its attendant risk of future intrapartum uterine rupture.The study by Williams et al is well designed, yet there remains potential for confounding not adjusted for in the analysis. Further, missing data for body mass index (1.6%) and cigarette smoking (13%) were classified as unknown and not imputed which can also cause bias. As there are only a handful of observational studies, it would be sensible to confirm the association, and explore potential causative mechanisms (e.g., by monitoring cervical length in subsequent pregnancies).Clinical prediction models for spontaneous preterm labour in asymptomatic women have been developed but need improvement before incorporation into clinical practice. Addition of new risk factors such as second stage caesarean birth and better understanding of the causes of preterm birth could improve these models and ultimately improve outcomes through offering prophylaxis with cervical cerclage, vaginal progesterone, or pessary for women at high risk.Given the massive personal, clinical, and economic burden imposed by preterm birth, the plausibility of the association, and the growing evidence from observational studies, I believe cervical surveillance warranted, with a view to offering prophylactic measures when there is a history of second stage caesarean birth.No disclosures: A completed disclosure of interest form is available to view online as supporting information.

Objective To investigate the impact of intrapartum fever on maternity and fetus. Design Retrospective cohort study. Setting Women’s Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China Population We studied intrapartum fever, as well as non-fever parturients, between January 1, 2018 and December 31, 2018. Methods We collected pregnancy outcomes of intrapartum fever and non-fever mother and neonatal data. Main outcomes and measures The obstetrics outcomes, complete blood cell count (CBC) and thereby converted neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and monocyte to lymphocyte ratio (MLR), as well as vaginal secretion were observed in women with and without intrapartum fever. Results Prepartum white blood cell (WBC), red blood cell (RBC), and hemoglobin (Hb) were all higher in febrile group, and WBC still higher but RBC and Hb lower after birth. Postpartum NLR and MLR were all higher in fever group but not preferred overtly difference before delivery. Additionally, the comparison of WBC, RBC, Hb, platelets (PLT), neutrophils, and monocytes in prepartum and postpartum all showed significant difference. Conclusions The differences of the prepartum WBC, RBC, Hb, and monocytes existed in the intrapartum fever and afebrile groups. Besides, the parturition could bring about the change of the value of CBC and intrapartum fever might aggravate or alleviate this change. Additionally, the intrapartum fever might not be caused mainly by infection and the difference between bacteria and fungus could reflect in the CBC. Keywords: Intrapartum fever, perinatal period, vaginal discharge examination

Objective We evaluated patient and professional’s experience with virtual antenatal clinic appointments during the COVID-19 pandemic, to determine satisfaction and enquire into the safety and quality of care received. Design, Setting, Population and Methods A total of 148 women who attended a virtual antenatal clinic appointment at our UK tertiary obstetric care centre over a two-week period provided feedback (62% response rate). A further 37 health care professionals (HCP) delivering care in the virtual antenatal clinics participated in another questionnaire study (82% response rate). Main Outcome Measures and Results We showed that women were highly satisfied with the virtual clinics, with 86% rating their experience as good/very good, and this was not associated with any statistically significant differences in age, ethnicity, number of previous births or pregnancy loss(es) (p>0.05). Even though, 56% preferred face-to-face appointments, 44% either expressed no preference or preferred virtual, and these preferences were not associated with significant differences in patient demographics (p>0.05). For HCP, 67% rated their experience of virtual clinics as good/very good; 78% described their experience as the same or better than face-to-face clinics; 15% preferred virtual clinics and 44% had no preference. Importantly, 67% found it easy/very easy to adapt to virtual clinics. Over 90% of HCP agreed virtual clinics should be implemented long-term. Conclusions Our study demonstrates high satisfaction with telephone, antenatal clinics during the pandemic, which supports the transition towards widespread digitalisation of antenatal care, suited to twenty first century patients and professionals. Funding None Keywords COVID-19, Virtual clinic, antenatal, satisfaction

Abstract Objective: We aimed to preliminarily assess whether low-dose aspirin（LDA）is beneficial in preventing preeclampsia in twin pregnancies. Design: An observational cohort study. Setting: Two hospital centers in Chongqing, China. Population: 932 twin-pregnant women. Methods: Among 932 participants, 277 in the First Affiliated Hospital of Chongqing Medical University were routinely treated with aspirin (100mg daily) from 12-16 weeks to 35 weeks of gestational age, while 655 in Chongqing Health Center for Women and Children were not taking aspirin during the whole pregnancy. We followed each subject and the individual details were recorded. Main Outcome Measures: The main outcome was to compare the incidence of preeclampsia in women with or without aspirin intaking. Results: LDA significantly reduced the risk of PE (OR: 0.48, 95% CI: 0.24-0.95, p=0.048) and ＜34 weeks preterm birth (OR: 0.50, 95% CI: 0.29-0.86, p=0.013), but showed possible benefits to lower the rate of SGA babies (OR: 0.74, 95% CI: 0.55-1.00, p=0.063). Moreover, the risk of postpartum hemorrhage was not increased by LDA (OR: 0.89, 95% CI: 0.35-2.26, p=1.000). Conclusions: Treatment with low-dose aspirin in women pregnant with twins could offer some protection against adverse pregnancy outcomes in the absence of any significantly increased risk of postpartum hemorrhage. Funding: The National Key Research and Development Program of China (2018YFC1002900), and National Natural Science Foundation of China (81520108013, 81771613, 81671488, 81871189). Keywords: Twin pregnancy, low-dose aspirin, preeclampsia, preterm birth, small for gestational age

Objective: to evaluate the efficacy of spontaneous pushing with pursed lips breathing compared to directed pushing during the second period of labor in the occurrence of episiotomy. Methods: this is a quasi-randomized clinical trial, with 62 low-risk pregnant women in the second stage of labor. They were randomly allocated in control (CG) (n = 31) and intervention (IG) (n = 31) groups. The IG performed spontaneous pushing with pursed lips breathing while the CG was oriented to perform directed pushing associated with Valsalva Maneuver (MV). Results: There was no difference between the groups regarding the occurrence of episiotomy (RR 1,1; 95%IC 1,0 to 1,2). However, there was a decrease in the duration of the maternal pushing by 3.2 minutes (MD 3,2; 95%CI 1,4 to 5,1) and a difference in maternal anxiety (Md (IQR) IG 46 (35-52), CG 51 (44-56) p:0,049), both favoring the IG. There was no difference in others maternal and neonatal outcomes Conclusions: spontaneous pushing with pursed lips breathing was effective in reducing the duration of the pushing and showed a difference in maternal anxiety, but did not decrease the occurrence of episiotomy, nor did it alter the other studied maternal and neonatal outcomes.

Title: Implementation of early management of iron deficiency in pregnancy during the SARS-CoV-2 pandemicStewart T1, Lambourne J2, Thorpe-Jones D1, Thomas DW1.1University Hospitals Plymouth NHS Trust, Plymouth, Devon, PL6 8DH. 2East Kent Hospitals NHS Foundation Trust, William Harvey Hospital, Kennington Road, Willesborough, Ashford, Kent, TN24 0LZ