New Year’s Day saw the Gauteng Department of Health welcoming 112 babies into the world, the lion’s share of more than 400 births in total for the country. According to data released by Gauteng Health on X/Twitter, in the province’s public healthcare facilities, there were a total of 59 boys and 53 girls. Thelle Mogoerane Regional Hospital topped the table with 10 babies, followed by Chris Hani Baragwanath Academic Hospital (CHBAH) with 9 babies. But all of this was relatively quiet compared to Christmas Day, which saw more than three times the New Years’ Day number.
MEC Nkomo Nomantu together with MMC for Health Rina Marx joined the postpartum mothers at Dr George Mukhari Academic Hospital on the morning of New Year’s Day in welcoming their new arrivals. Gauteng’s academic hospitals recorded 19 births, while there were 10 births at the tertiary hospitals. Regional and district hospitals had 69 births and community healthcare centres had 14.
Christmas Day saw 387 babies born, 201 of them girls and 186 boys. CHBAH welcomed the most, with 46 births, followed by Tembisa Hospital with 38.
Birthing women denied nitrous oxide(N20) to relieve labour pain as a result of the COVID pandemic received opioids instead, without any adverse outcomes for mother or child, according to a new study published in the Australian and New Zealand Journal of Obstetrics and Gynaecology. Some anaesthetists have also argued for reducing N20 use as it is a greenhouse gas.
The study, conducted at Lyell McEwin Hospital in Australia, looked at the impact of withholding nitrous oxide (N20), a decision adopted by many hospitals worldwide over fears of virus transmission from the aerosol-generating procedure.
Anaesthetist Professor Bernd Froessler and colleagues compared patient notes for all 243 women birthing at Lyell McEwin over a seven week period in March/April 2020, half of whom did not have access to N20.
They found that although opioid use “significantly increased” when N20 was withheld, there was no increase in epidural use and no change in labour duration, Caesarean section rates, birthing complications or newborn alertness.
Nitrous oxide is used by more than 50% of Australian women to relieve pain in labour, followed by epidurals (40%) and opioids (12%), according to the Australian Institute of Health and Welfare.
However, N20 represents 6% of global greenhouse gas emissions, with 1% due to medical use (ie, around 0.06% of total global warming is due to medical N20). This has led to a debate in medical circles whether it should be replaced with other methods of pain relief.
Many obstetricians argue that effective pain relief in childbirth should be the priority, particularly given the low percentage of emissions, but the Australian and New Zealand College of Anaesthetists has advocated for a reduction in N20 use in a bid to improve environmental sustainability in anaesthesia.
“Obviously no-one wants to deprive labouring women of adequate and easy pain relief but given there are other analgesic options, including epidurals and opioids, perhaps these could be considered,” said Prof Froessler.
UniSA statistician and researcher Dr Lan Kelly said that the findings should reassure women that pain relief besides N20 does not compromise their health or their baby’s.
However, in a recent Sydney Morning Herald article, principal midwifery officer at the Australian College of Midwives, Kellie Wilton, said mothers should not be made to feel guilty about their pain relief choices and suggested hospitals could introduce nitrous oxide destruction systems to allow for its ongoing use.
When nitrous oxide destruction systems were introduced in Swedish hospitals, the carbon footprint from the gas was halved.
During the first few months of the COVID pandemic, premature births from caesarean and induced deliveries fell by 6.5% – and remained consistently lower throughout, according to research reported in the journal Pediatrics. This is likely a result of fewer prenatal visits due to lockdown and social distancing rules, the researchers suggested, and call into question how many such interventions are necessary.
The study, the first to examine pandemic-era birth data at scale, raises questions about medical interventions in pregnancy and whether some decisions by doctors may result in unnecessary preterm deliveries, according to Assistant Professor Daniel Dench, the paper’s lead author.
“While much more research needs to be done, including understanding how these changes affected fetal deaths and how doctors triaged patient care by risk category during the pandemic, these are significant findings that should spark discussion in the medical community,” A/Prof Dench said.
In effect, the study begins to answer a question that never could have been resolved in a traditional experiment: What would happen to the rate of premature C-sections and induced deliveries if women didn’t see doctors as often, especially in person, during pregnancy?
Doing such a study would be unethical, but lockdown had a side effect of reducing prenatal care visits by more than a third, according to one analysis. That gave A/Prof Dench and colleagues an opportunity to evaluate the impacts, after all.
The researchers took records of nearly 39 million US births from 2010 to 2020, and compared them to expected premature births (born before 37 weeks) from March to December 2020.
The researchers found that in March 2020, when lockdowns began in the US, preterm births from C-sections or induced deliveries immediately fell from the forecasted number by 0.4%. From March 2020 to December 2020, the number remained on average 0.35% below the predicted values. That translates to 350 fewer preterm C-sections and induced deliveries per 100 000 live births, or 10 000 fewer overall.
Before the pandemic, the number of preterm C-sections and induced deliveries had been rising. Spontaneous preterm births also fell by a small percentage in the first months of the pandemic, but much less than births involving those two factors. The number of full-term caesarean and induced deliveries increased.
“If you look at 1000 births in a single hospital, or even at 30 000 births across a hospital system, you wouldn’t be able to see the drop as clearly,” said A/Prof Dench. “The drop we detected is a huge change, but you might miss it in a small sample.”
The researchers also corrected for seasonality, for example, preterm births are higher on average in February than in March, which helped them get a clearer picture of the data.
The research comes with caveats. Up to half of all preterm C-sections and induced deliveries are due to a ruptured membrane, which is a spontaneous cause. But in the data Dench and his team used, it’s impossible to distinguish these C-sections from the ones caused by doctors’ interventions. So, Dench and co-authors are seeking more detailed data to get a clearer picture of preterm deliveries.
Still, these findings are significant because the causes for preterm births are not always known.
“However, we know for certain that doctors’ interventions cause preterm delivery, and for good reason most of the time,” A/Prof Dench said. “So, when I saw the change in preterm births, I thought, if anything changed preterm delivery, it probably had to be some change in how doctors were treating patients.”
The researchers’ findings raise a critical question: Was the pre-pandemic level of doctor intervention necessary?
“It’s really about, how does this affect foetal health?” said A/Prof Dench. “Did doctors miss some false positives – did they just not deliver the babies that would have survived anyway? Or did they miss some babies that would die in the womb without intervention?”
A/Prof Dench plans to use foetal death records from March 2020 to December 2020 to answer this question. If he finds no change in foetal deaths at the same time as the drop in preterm births, that could point to “false positives” in doctor intervention that can be avoided in the future. Learning which pregnancies required care during the pandemic and which ones didn’t could help doctors avoid unnecessary interventions in the future.
“This is just the start of what I think will be an important line of research,” A/Prof Dench said.
A study published in Anesthesiologyfinds gastric emptying is substantially slower during labour – but somewhat faster in women who receive an epidural for anaesthesia.
There is an ongoing debate as to whether it’s safe for women to eat solid food during labour. Physician anaesthesiologists prefer that labouring women have an empty stomach because of the lower risk for aspiration of food in case general anaesthesia for a caesarean section becomes necessary.
“These results suggest anaesthesiologists should remain cautious about permitting solid food during labour, especially when epidural analgesia is not used,” according to the report by Lionel Bouvet, MD, PhD, and colleagues of Hospices Civils de Lyon, France.
Researchers assessed gastric emptying rates in four groups of women: 10 who were non-pregnant, 10 who were pregnant at full term (around 39 weeks) but not in labour, 10 in labour without an epidural, and 10 in labour who received an epidural for labour pain. On an empty stomach, each woman ate a light meal of yoghurt. Ultrasound scans were then used to compare the rate of stomach emptying among the four groups.
Stomach emptying was delayed for women in labour without epidural, in line with previous studies. The rate of stomach emptying from 15 to 90 minutes after eating was 52% in non-pregnant women and 45% in pregnant women at full term, compared to 31% for labouring women who received an epidural and 7% for women in labour without an epidural.
With epidural analgesia, gastric emptying occurred much faster during labour than during labour without epidural analgesia. After 90 minutes, the stomach was empty in 3 out of 10 labouring women who received an epidural, compared to 0 of 10 women in labour who had not received an epidural. By 2 hours, the stomach was empty in 6 of the women who received an epidural, compared to just 1 woman without an epidural.
Although clinical practice varies, current guidelines of the ASA and Society for Obstetric Anesthesia and Perinatology (SOAP) state that “Solid foods should be avoided in laboring patients,” reflecting a concern over the risk of aspiration in case anesthesia and surgery are needed. This new study is one of the first to systematically compare the extent of gastric emptying delay during late pregnancy and childbirth and with versus without epidural labor analgesia.
The results confirm a “statistically and clinically significant” longer time to an empty stomach among women in labour. However for those receiving epidural analgesia, stomach emptying appears to occur faster. Based on their findings, Dr Bouvet and co-authors suggest that a light solid meal “could probably be allowed” for women in labour who are receiving epidural analgesia and considered at a low risk of caesarean section within at least the next two hours.
“The report by Dr Bouvet and colleagues enables us to rethink our current practice of fasting during childbirth,” commented Anesthesiology editor Yandong Jiang, MD., PhD. “It is desirable that women giving birth with an epidural do not have the additional stress of hunger, but instead be allowed to eat a light meal.”
This contrasts with the ASA/SOAP recommendation that women in labour should consume only clear liquids to prevent aspiration, noted Mark Zakowski, MD, FASA, chair of ASA’s Committee on Obstetric Anesthesia. “This study clearly shows that stomach emptying is quite a bit slower for women in labor, and that if they eat even a light meal of about 4 ounces [about 120g] of yogurt, many will still have food in their stomach a few hours later,” Dr Zakowski said. “Since the need for emergency caesarean may arise at any time, the current ASA/SOAP guideline of clear liquids only during labour seems justified.”
