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PubMed1993

Interleukin-1 beta, -1 alpha, and -6 and prostaglandins in vaginal/cervical fluids of pregnant women before and during labor.

Interleukin-1 beta (IL-1 beta) is not detected in the amniotic fluid of normal human pregnancies before the initiation of parturition, but during labor, both at term and preterm, this cytokine is present in the amniotic fluid of 25-40% of pregnancies. A critical question, however, is whether this finding is indicative of a role for IL-1 beta (directly or indirectly) in the initiation of parturition or is the result of IL-1 beta formation and entry into amniotic fluid as a natural sequela of normal labor. The forebag of the amniotic sac is formed during labor in response to cervical dilatation, and on the decidual surface, the tissues of this structure become exposed and bathed by vaginal fluids as the cervix opens. Microorganisms and bacterial toxins are present in vaginal fluid before labor begins; these agents should act upon the exposed tissues of the forebag to cause inflammation and evoke an inflammatory response. This study was conducted to examine the likelihood that the inflammatory mediators found in amniotic fluid in increased amounts at parturition are produced in forebag tissues after the onset of labor because of obliged inflammation in these tissues. Vaginal/cervical fluids were collected by lavage from nonpregnant women and from pregnant women at term before and during labor. The amount of immunoreactive IL-1 beta in vaginal/cervical fluids of pregnant women during labor (mean +/- SEM, 91.5 +/- 16.9 ng; n = 17) was significantly greater (P < 0.001) than that in fluids collected before labor (7.8 +/- 3 ng; n = 14). The in vivo rate of IL-1 beta secretion directly from the decidua lining the forebag during labor was brisk (1.71 +/- 0.88 ng/cm2.min; n = 4), consistent with previous observations of higher levels of pro-IL-1 beta mRNA in decidual tissues adherent to the forebag compared with those in decidua adherent to chorion laeve of the upper compartment of the amnionic sac. The vaginal fluid content of prostaglandins (PGs) during labor [PGE2, 82.1 +/- 16.4 ng; PGF2 alpha, 141.5 +/- 30.5 ng; PGFM, 35.2 +/- 5.8 ng (mean +/- SEM; n = 13)] was significantly greater for PGE2 and PGF2 alpha (P < 0.05 and 0.004, respectively) than that before labor (PGE2, 42.6 +/- 9.4 ng; PGF2 alpha, 35.3 +/- 8.5 ng; PGFM, 21.7 +/- 4.6 ng; n = 12). In addition, there was a significant increase in the ratio of PGF2 alpha to PGE2 (P < 0.03) in vaginal fluids during labor.(ABSTRACT TRUNCATED AT 250 WORDS)

Amniotic Fluid↗
PubMed1981

[Alterations of oxytocin and prostaglandin E1, E2, F2 alpha levels in human plasma during labor (author's transl)].

In order to investigate the role of oxytocin (OT) and prostaglandins (PGs) in the mechanism of labor onset, changes of OT and PGs levels in human plasma were evaluated before labor, soon after the labor onset, and at the time of established labor in the following three groups. Group 1 consisted of 6 cases with spontaneous labor, group 2, of 6 cases with induced labor with PGF2 alpha drip infusion, and group 3, of 5 cases with induced with PGE2 vaginal suppository. OT concentrations were measured by RIA, PGE1, PGE2, and PGF2 alpha were extracted and determined by Inagawa's method. Levels of OT in group 1 were divided into two subgroups: subgroup 1 with high OT levels (24.0-116.2 microunits/ml) and subgroup 2 with low OT levels (below 7.2 microunits/ml) throughout labor. Changes of PGs level in subgroup 1 showed no definite tendency during labor, suggesting that OT appears to play the leading role in spontaneous labor. Those in subgroup 2 showed a particular behavioral pattern during labor, suggesting an important role played by PGs for the onset of labor following rupture of the membranes. The results of groups 2 and 3 are fully discussed in terms of labor process.

Female↗
PubMed1995

[Observations on serum and amniotic fluid hormone levels and ultrastructure of uterine myometrium before and during term labor].

OBJECTIVES: To evaluate the relationship between serum and amniotic fluid (AF) estradiol (E2), estriol (E3), progesterone (Po), cortisol (Co), human placental lactogen (hPL) concentrations and uterine contractions. To observe the ultrastructural changes of uterine myometrium before and during labor. METHODS: Sixty-eight term-pregnant women (before labor 18, in normal labor 16, uterine inertia 34) were enrolled for study. Serum and AF E2, E3, Po, Co, hPL concentrations were measured by radioimmunoassay in 56 out of the 68 subjects. Myometrium gap junction (GJ), dense body (DB), sarcoplasmic reticulum (SR) were observed under electron microscope in the remaining 12 subjects (before labor 6, Uterine inertia 6). RESULTS: (1) E2, E3 levels and E2/Po, E3/Po ratio in AF, but not in serum, increased successively in the groups before labor, in normal labor and uterine inertia with significant differences (P < 0.01). (2) Both serum and AF Co, hPL concentrations were significantly different before and during labor (P < 0.01, P < 0.05). (3) Serum E2, E3, Co and hPL levels elevated significantly in cases with uterine inertia after successful treatment with estradiol benzoate or oxytocin infusion. (4) Compared with the group before labor, the amount of myometrium GJ, DB, SR increased significantly after the onset of labor. CONCLUSIONS: The elevation of serum and AF Co, hPL concentrations may be involved in the initiation of labor. This may be one of the major factors affecting the uterine contractions. Appropriate serum and AF estrogen (E), progestin (P), E/P ratio may be related to normality of uterine contractions during labor. The increase of GJ, DB, SR amount in uterine myometrium may be the histologic basis for the onset of labor.

Adult↗
PubMed1995

92-kd type IV collagenase (matrix metalloproteinase-9) activity in human amniochorion increases with labor.

To determine whether specific collagenolytic enzymes are expressed in human fetal membranes with labor, we examined gelatinase activity in extracts of amniochorion by zymography. The 92-kd gelatinase (MMP-9) was barely detectable in extracts of fetal membranes before the onset of labor but was readily demonstrable in extracts prepared from membranes isolated from laboring women or membranes collected immediately after delivery. In contrast, the 72-kd gelatinase (MMP-2) was detectable in extracts from pre- and post-labor membranes. Ethylenediaminetetracetic acid and the tissue inhibitor of metalloproteinases, TIMP-1, inhibited the gelatinase activities detected by zymography, confirming that the enzymes are metalloproteinase. Assay of amniochorion gelatinase activity using a radiolabeled denatured collagen substrate revealed a more than twofold increase in activity comparing pre-labor with post-labor fetal membrane extracts. A function-blocking anti-MMP-9 monoclonal antibody inhibited pre-labor membrane gelatinase activity by approximately 11.5%, which was only slightly greater inhibition than observed with irrelevant monoclonal antibodies. However, post-labor membrane gelatinase activity was reduced by 53% by the function-blocking antibody, indicating that MMP-9 is a major contributor to the increased gelatinase activity extractable from post-labor membranes. Western blot analyses demonstrated increased MMP-9 protein in amniochorion extracts after onset of labor. MMP-9 protein and mRNA were co-localized in amnion epithelium, underlying macrophages and chorion laeve trophoblast and decidual cells after labor. We conclude that 1) MMP-9 activity and protein in human amniochorion increases with labor and 2) MMP-9 is expressed by amnion epithelium, macrophages and chorion laeve trophoblast and decidual cells. The increased expression of MMP-9 may result in degradation of the extracellular matrix of the fetal membranes and facilitate their rupture under both physiological and pathological conditions.

Amino Acid Sequence↗
PubMed1992

Elective induction versus spontaneous labor: a retrospective study of complications and outcome.

OBJECTIVE: This retrospective study was undertaken to identify whether electively induced labor places the mother or her fetus at increased risk as compared with her spontaneous labor cohort. STUDY DESIGN: This study compares the labor, delivery, and fetal outcome of 253 parturients in which labor was electively induced with 253 matched controls who began labor spontaneously. All patients were delivered at Huntington Memorial Hospital in Pasadena, California, during the calendar year 1990. The patients were between 37 and 41 weeks' gestation and had no medical or obstetric conditions necessitating induction. The cases and controls were matched for age group, parity, gestational age, and delivering obstetrician. RESULTS: Epidural anesthesia was used in 83.8% of patients in the induction group versus 55.7% in the spontaneous group. Patients with labor induced had a shorter first stage of labor. Meconium staining was found significantly more often in the spontaneous group than in the induced group (16.2% vs 6.7%). This contributed to a greater rate of neonatal consultations in the spontaneous labor group. Although cesarean section rates between the two groups were similar, nulliparous patients in the induction group with an estimated Bishop score of less than or equal to 5 had a 50% cesarean section rate. Iatrogenic prematurity was not encountered. No differences existed between the two groups with respect to intrapartum maternal complications, fetal complications, or postpartum complications. CONCLUSIONS: When compared with spontaneous labor, elective induction of labor at term does not appear to pose an increased risk to the mother or her fetus in a carefully selected patient population. However, elective induction of labor in a nulliparous patient with an unfavorable cervix should be discouraged.

Cohort Studies↗
PubMed1999

Effect of magnesium prophylaxis and preeclampsia on the duration of labor.

OBJECTIVE: Our goals were to compare duration of labor at term for (1) women with preeclampsia versus normotensive nulliparous women and (2) nulliparous women with preeclampsia who received magnesium for seizure prophylaxis versus those who did not. STUDY DESIGN: We performed a retrospective cohort study of all nulliparous, term vaginal deliveries from 1989 through 1995 at University of California, San Francisco. The perinatal database and medical records were reviewed for information on duration of labor, maternal and labor characteristics, and neonatal outcomes. The chi2 odds ratio, and Student t tests were used to compare categoric and continuous variables between women with preeclampsia and control women and between women with preeclampsia who did and those who did not receive magnesium. Logistic regression was used to evaluate variables predictive of labor duration. RESULTS: Our study subjects were 4083 normotensive nulliparous women and 154 women with preeclampsia. A sample size calculation revealed that 1764 normotensive control subjects were needed to show a 10% difference in labor duration with 80% power and alpha of 0.05. Among women with preeclampsia, 93 (60%) were treated with magnesium and 61 (40%) were not. More women with preeclampsia than normotensive women had induction of labor and received epidural anesthesia, prostaglandin gel, and oxytocin (P <.003). Total labor duration did not differ between women with preeclampsia and normotensive women (P =.15) or between women with preeclampsia who received magnesium and those who did not (P =.09). In comparison with normotensive women, those with preeclampsia had a higher rate of postpartum hemorrhage (31% vs 22%, P =.005), and the rate was even higher among preeclamptic women treated with magnesium versus those who received no magnesium (34% vs 26%, P =.002). Logistic regression, with prolonged first stage of labor (>12 hours) used as the outcome variable, indicated that epidural anesthesia (odds ratio 2.3, 95% confidence interval 1.9-2. 6), oxytocin (odds ratio 1.8, 95% confidence interval 1.6-2.2), and persistent occipitoposterior presentation (odds ratio 1.6, 95% confidence interval 1.1-2.4) were associated with prolonged labor, whereas preeclampsia (odds ratio 0.9, 95% confidence interval 0.7-1. 1) and treatment with magnesium were not (odds ratio 1.1, 95% confidence interval 0.9-1.4). Induction (odds ratio 0.5, 95% confidence interval 0.4-0.6) and birth weight <2500 g (odds ratio 0. 5, 95% confidence interval 0.4-0.8) were associated with faster labor. CONCLUSIONS: In term nulliparous women, neither preeclampsia nor magnesium prophylaxis affected labor duration.

Adult↗
PubMed1999

Prevalence and patterns of major depressive disorder in the United States labor force.

BACKGROUND AND AIMS OF THE STUDY: In this paper, we identify the 12-month and lifetime prevalence of major depressive disorder in and out of the labor force, and among the employed and unemployed. We examine whether prevalence by labor force and employment status varies by gender and over the life cycle. Finally, we examine whether people can "recover" from depression with time by identifying patterns of labor force participation and employment as time since most recent episode passes. METHODS: We examine data collected as part of the National Comorbidity Survey, a survey representative of the population of the United States designed to identify the prevalence of major mental illnesses. The National Comorbidity Study identified cases of major depression via the Composite International Diagnostic Interview. Using these data, we estimate univariate and bivariate frequency distributions of major depressive disorder. We also estimate a set of multivariate models to identify the effect of a variety of dimensions of major depression on the propensity to participate in the labor force, and be employed if participating. RESULTS: Lifetime and 12-month prevalence rates of depression are similar in and out of the labor force. Within the labor force, however, depression is strongly associated with unemployment. The negative relationship between depressive disorder and employment is particularly strong for middle age workers. Depression and the number of depressive episodes have a differing pattern of effects on labor market outcomes for men and women. We find evidence that labor force participation and employment rates for people with a history of depression increase significantly over time in the absence of additional depressive episodes. DISCUSSION: Labor market status represents an important dimension along which prevalence of major depression varies. The relationship between depression and employment status is particularly strong for middle aged persons, but becomes weaker as time passes since the last depressive episode. Continued exploration of the association between work (or lack of work) and depression may ultimately help in the prediction, treatment and assessment of the illness. IMPLICASIONS FOR PRACTICE AND POLICY: These results present a basic set of facts about the relationship between major depressive disorder and labor market outcomes. We have not, however, attempted to sort out the complexities of this relationship here. These complexities arise at almost every turn. For instance, the high level of prevalence of depression among the unemployed may be due to the possibility that the stresses associated with unemployment trigger depressive episodes or to the possibility that workers who are depressed are more likely to be fired or quit. IMPLICATIONS FOR FURTHER RESEARCH: Our continuing research attempts to address these problems. Understanding when and how depression affects labor market outcomes and when and how labor market outcomes affect depression is an important endeavor for those interested in treating the disease and understanding its consequences.

Journal Article↗
PubMed1998

Elective repeat cesarean delivery vs trial of labor: a comparison of morbidities in a community hospital setting.

Objective: In an attempt to reduce the cesarean delivery rate nationally, many obstetricians are offering a trial of labor to their patients who have had a prior low transverse cesarean delivery. Many studies have demonstrated the success and safety of a vaginal birth after cesarean. However, few studies have actually compared elective repeat cesareans with a trial of labor. Recent articles suggest that the morbidities associated with a failed trial of labor (TOL) may be more serious than that associated with an elective repeat cesarean delivery (RC/D). Our objective was to review and compare the morbidities and complications of repeat elective cesarean delivery versus patients attempting a trial of labor in our institution.Methods and Materials: A retrospective or nonconcurrent cohort study was conducted. Inclusion criteria included all women at our institution who had delivered from July 1993 through March 1997 and had a prior cesarean delivery. Patients were eligible for a trial of labor according to the recommendations of ACOG Practice Patterns. Exclusion criteria were nonvertex presentation, prior classical or T-incision, placenta previa, previous myomectomy, or multiple gestation. The patients were divided into those who underwent an elective repeat delivery and those who consented to a trial of labor. Outcomes studied included major complications (uterine rupture or operative injury) and minor complications (puerperal fever, postpartum hemorrhage requiring transfusion or operative intervention, or abdominal wound infection). Data were ascertained from medical records, the delivery log book, and the Quality Improvement data base. Prior to performing this study, a power analysis was conducted using an alpha of 0.05 and beta of 0.20. The required number in each arm was 2,280 to determine a 50% difference in outcome.Results: There were 1,148 women who had a repeat cesarean delivery during the study time period. Of that, 174 were excluded by the criteria, leaving 973 eligible. There were 1,030 women who underwent a trial of labor. Seven hundred seventy-three women successfully delivered vaginally (75%). The overall maternal morbidity was 2.4%; 0.8% had a major complication and 1.5% had a minor complication. The total complication rate was similar for both the trial of labor group (TOL) and the elective repeat cesarean delivery group (RC/D): 2.33% and 2.57%, respectively. However, major complications were more frequent among those that attempted a trial of labor than those who underwent an elective repeat cesarean delivery; 1.65% versus 0.1% (relative risk 16.08 with a 95% CI of 2.14-120.57; P =.00024). The relative risk for minor complications in the TOL group compared to the RC/D group was 0.28 with a 95% CI 0.12-0.64 (P =.001). Stratified analysis of the TOL group was performed. Compared to the RC/D group, those who failed VBAC had a relative risk for major complications of 56.85 using a 95% CI of 7.45-428.37. The successful VBAC group did not have statistically higher major complication rate (RR = 2.52, CI 0.23-27.74, P =.4).Conclusions: At our institution, there is a trend that major maternal complications are more frequent among those who have a trial of labor compared to those who have an elective repeat cesarean delivery. This trend was even more evident in those who failed a VBAC trial. When VBAC was successful, complications did not seem to be higher than repeat cesarean delivery. Our study did not have the power because of insufficient numbers in each arm. However, data collection is continuing to achieve the power to this study. This prompted us to reconsider the safety for a trial of labor. Perhaps more stringent criteria for selection of VBAC candidates and determination of when a trial of labor should be abandoned need to be defined. Ongoing study is warranted in this area.

Journal Article↗
PubMed2006

The prevalence of mental health problems in Ethiopian child laborers.

BACKGROUND: Child labor refers to a state when a child is involved in exploitative economical activities that are mentally, physically, and socially hazardous. There are no prevalence studies on the magnitude of psychiatric disorders among child laborers. METHODS: A cross-sectional population survey was conducted in Addis Ababa using the Diagnostic Interview for Children and Adolescents (DICA). Subjects were a random sample of 528 child laborers aged between 5 and 15 years and comprising child domestics, street-workers and private enterprise workers. These were compared with 472 non-economically active controls. RESULTS: The aggregate prevalence of any DSM-III-R childhood emotional and behavioral disorders was found to be 16.5%, with 20.1% and 12.5% among child laborers and controls respectively, OR = 1.89 (95% CI, 1.34-2.67, p < .01). Internalizing disorders such as mood disorders were significantly higher among the laborers than the non-laborers, OR = 6.65 (95% CI, 2.20-22.52, p = .0001). Anxiety disorder was seen over twofold among child laborers while psychosocial stressors were one and half times more likely among the study subjects than controls. When all factors were taken into account, child labor status was the only significant factor in determining DSM-III-R diagnosis. CONCLUSION: In this study childhood emotional and behavioral disorders are found to be more common among child laborers than among non-laborers. We recommend a larger study to look into childhood disorders and risk factors in child labor. As part of the concerted effort, government, NGOs, and the public should at least view child labor as a menace in a child's development, with risk of psychosocial difficulties.

Adolescent↗
PubMed1997

Lung liquid production rates and volumes do not decrease before labor in healthy fetal sheep.

Previous studies have suggested that the volume and production rate of fetal lung liquid decrease late in gestation, before the onset of labor, in preparation for the clearance of lung liquid at birth. In contrast, our earlier studies have not shown a decrease in lung liquid volume near term, although these studies were not continued to the onset of labor. Our aim was to determine the changes in lung liquid volume and production rate in fetal sheep during the last 2 wk of gestation up to the onset of labor at term (approximately 147 days). In eight chronically catheterized fetal sheep, the volume and production rate of fetal lung liquid were measured at 130, 135, and 140 days of gestation and then on every 2nd day until the onset of labor. Labor was detected by monitoring uterine muscle activity and intrauterine pressure changes. On the day of labor onset, which occurred at 147 +/- 1 days of gestation, fetuses weighted 5.0 +/- 0.2 kg. The volume of fetal lung liquid was 40.4 +/- 2.7 ml/kg at 19 +/- 1 days before labor onset and had not significantly changed by 0.7 +/- 0.2 days (44.8 +/- 5.1 ml/kg) before labor. Similarly, lung liquid production rates at 19 +/- 1 days before labor (5.1 +/- 1.8 ml.h-1.kg-1) were not significantly different from those at 0.7 +/- 0.2 days before labor (3.4 +/- 0.7 ml.h-1.kg-1). We conclude that, in healthy ovine fetuses, lung liquid volumes and production rates do not decrease before the onset of labor. Our results indicate that the entire volume of fetal lung liquid (approximately 222.5 +/- 36.6 ml) must be cleared after the onset of labor.

Animals↗
PubMed2001

The contribution of arthritis and arthritis disability to nonparticipation in the labor force: a Canadian example.

OBJECTIVE: To examine the factors affecting labor force participation and understand how arthritis affects labor force participation in a Canadian working population. METHODS: Data from the 1990 Ontario Health Survey population (n = 35,221) were used. Labor force participation was dichotomized as in the labor force and not in the labor force. Stratified logistic regression analyses by sex were carried out to identify factors associated with not being in the labor force, including arthritis, chronic disorders, and sociodemographic and family composition variables. RESULTS: Overall, 6.7% of men and 23.0% of women were not in the labor force compared with 18.6% and 36.0%, respectively, of men and women with arthritis. After controlling for other covariates, disability caused by arthritis was significantly associated with increased risk of being out of the labor force, with odds ratios of 2.70 for men and 1.91 for women. Low education, pain, and nonarthritis disability were also significantly associated with being out of the labor force. The effects of age and family structure on employment were sex dependent. Women were at higher risk at all age groups. Men with dependent children were more likely to work, as were women who lived alone. For women, having dependent children increased the likelihood of not being in the labor force. CONCLUSION: People with arthritis disability were more likely to be out of the labor force. It was not arthritis per se that limited people in labor force participation, but rather the arthritis disabilities.

Adult↗
PubMed1993

Factors that influence route of delivery--active versus traditional labor management.

OBJECTIVE: Our purpose was to compare maternal and fetal factors that influence the route of delivery with active management of labor and a traditional labor management protocol. STUDY DESIGN: Data were collected prospectively on 346 consecutive patients receiving active management of labor and 354 patients who were managed traditionally. Within each group demographic and labor characteristics of patients undergoing cesarean section were compared with those of patients having vaginal deliveries by means of the Student t test, chi 2 analysis, and stepwise logistic regression. RESULTS: With both active management of labor and traditional labor management success in achieving vaginal delivery was related to the station of the fetal vertex at admission, the need for oxytocin augmentation of labor, the uterine response to oxytocin, the use of epidural anesthesia, and the development of chorioamnionitis. By means of multiple logistic regression analysis maternal age, height, payor status, and birth weight were also identified as risk factors for cesarean section with traditional labor management but not with active management of labor. CONCLUSIONS: Differences were identified in risk factors for cesarean section between active management and traditional labor management. Active management of labor may diminish or eliminate some patient characteristics as risk factors for cesarean birth.

Adult↗
PubMed1996

Elevations of amniotic fluid macrophage inflammatory protein-1 alpha concentrations in women during term and preterm labor.

OBJECTIVE: To determine whether elevated concentrations of macrophage inflammatory protein-1 alpha (MIP-1 alpha) in amniotic fluid (AF) are related to term and preterm labor. METHODS: Amniotic fluid was obtained from women from five different clinical situations: 1) term cesarean delivery, no labor (n = 29); 2) normal term labor, no infection (n = 36); 3) preterm labor, delivery more than 1 week from sampling, no infection (n = 19); 4) preterm labor, delivery within 1 week from sampling, no infection (n = 18); and 5) preterm chorioamnionitis (n = 8). Amniotic fluid was collected aseptically at the time of amniocentesis, amniotomy, or hysterotomy. Concentrations of MIP-1 alpha were determined by enzyme-linked immunosorbent assay. Statistical analysis was by Wilcoxon rank-sum test, Kruskal-Wallis test, and unpaired t test. RESULTS: Women in normal term labor had significant elevations of AF MIP-1 alpha concentrations when compared with women at term undergoing repeat cesarean delivery (P < .001). In women with term gestation, AF MIP-1 alpha correlated well with cervical dilation (r2 = 0.479, P < .001). In women with preterm labor who later delivered within 1 week of presentation, AF MIP-1 alpha concentrations were higher than those from women who did not deliver within 1 week. Women who presented with clinically evident chorioamnionitis had the highest concentrations of AF MIP-1 alpha (P = .001). CONCLUSION: Women in labor have significantly elevated AF concentrations of MIP-1 alpha, particularly if labor is associated with intrauterine infection. We suggest that MIP-1 alpha is involved in the physiology of normal labor and in the pathogenesis of infection-associated preterm labor.

Amniotic Fluid↗
PubMed1997

Active management of labor: does it make a difference?

OBJECTIVE: Our goal was to evaluate whether active management of labor lowers cesarean section rates, shortens the length of labor, and overcomes any negative effects of epidural analgesia on nulliparous labor. STUDY DESIGN: We randomly assigned 405 low-risk term nulliparous patients to either an active management of labor (n = 200) or our usual care control protocol (n = 205). Patients who were undergoing active management of labor were diagnosed as being in labor on the basis of having painful palpable contractions accompanied by 80% cervical effacement, underwent early amniotomy, and were treated with high-dose oxytocin for failure to progress adequately in labor. RESULTS: The cesarean section rate in the active management of labor group was lower than that of controls but not significantly so (active management, 7.5%; controls, 11.7%; p = 0.36). The length of labor in the active management group was shortened by 1.7 hours (from 11.4 to 9.7 hours, p = 0.001). Fifty-five percent of patients received epidural analgesics; a reduction in length of labor persisted despite the use of epidural analgesics (active management 11.2 hours vs control 13.3 hours, p = 0.001). A significantly greater proportion of active management patients were delivered by 12 hours compared with controls (75% vs 58%, p = 0.01); this difference also persisted despite the use of epidural analgesics (66% vs 51%, p = 0.03). CONCLUSIONS: Patients undergoing active management had shortened labors and were more likely to be delivered within 12 hours, differences that persisted despite the use of epidural analgesics. There was a trend toward a reduced rate of cesarean section.

Adolescent↗
PubMed1999

Uterine rupture during induced or augmented labor in gravid women with one prior cesarean delivery.

OBJECTIVE: Our purpose was to examine the risk of uterine rupture during induction or augmentation of labor in gravid women with 1 prior cesarean delivery. STUDY DESIGN: The medical records of all gravid women with history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed. The current analysis was limited to women at term with 1 prior cesarean delivery and no other deliveries. The rate of uterine rupture in gravid women within that group undergoing induction was compared with that in spontaneously laboring women. The association of oxytocin induction, oxytocin augmentation, and use of prostaglandin E(2) gel with uterine rupture was determined. Logistic regression analysis was used to examine these associations, with control for confounding factors. RESULTS: Of 2774 women in the analysis, 2214 had spontaneous onset of labor and 560 women had labor induced with oxytocin or prostaglandin E(2) gel. The overall rate of rupture among all patients with induction of labor was 2.3%, in comparison with 0.7% among women with spontaneous labor (P =.001). Among 1072 patients receiving oxytocin augmentation, the rate of uterine rupture was 1.0%, in comparison with 0.4% in nonaugmented, spontaneously laboring patients (P =.1). In a logistic regression model with control for birth weight, use of epidural, duration of labor, maternal age, year of delivery, and years since last birth, induction with oxytocin was associated with a 4.6-fold increased risk of uterine rupture compared with no oxytocin use (95% confidence interval, 1.5-14.1). In that model, augmentation with oxytocin was associated with an odds ratio of 2.3 (95% confidence interval, 0.8-7.0), and use of prostaglandin E(2) gel was associated with an odds ratio of 3.2 (95% confidence interval, 0.9-10.9). These differences were not statistically significant. CONCLUSION: Induction of labor with oxytocin is associated with an increased rate of uterine rupture in gravid women with 1 prior uterine scar in comparison with the rate in spontaneously laboring women. Although the rate of uterine rupture was not statistically increased during oxytocin augmentation, use of oxytocin in such cases should proceed with caution.

Cesarean Section↗
PubMed1997

Maternal serum interleukin-6 during pregnancy and during term and preterm labor.

OBJECTIVE: To determine the normal concentrations of maternal serum interleukin-6 during the second and third trimesters of pregnancy and the different stages of term and preterm labor, and to examine the clinical usefulness of measuring this cytokine in the serum of women in preterm labor to diagnose asymptomatic intrauterine infections. METHODS: Maternal serum interleukin-6 concentrations were measured cross-sectionally in 315 gravidas in their second and third trimesters and during term and preterm labor. Placentas from women who delivered preterm were examined for histologic chorioamnionitis. RESULTS: At term, women in labor had significantly elevated median maternal serum interleukin-6 concentrations compared with those at term not in labor (4.7 pg/mL versus 2.2 pg/mL, P < .001). Women admitted in preterm labor who delivered had significantly higher median interleukin-6 concentrations than did those in preterm labor who responded to tocolysis (9.3 pg/mL versus 1.9 pg/mL, P < .001). Women in preterm labor who delivered preterm with evidence of chorioamnionitis had significantly higher serum concentrations of interleukin-6 than did those in preterm labor who delivered in the absence of chorioamnionitis (15.9 pg/mL versus 4.6 pg/mL, P = .006). CONCLUSION: Compared with antepartum gravidas, those in term or preterm labor had significantly higher concentrations of maternal serum interleukin-6 concentrations; extremely elevated levels were found in patients whose preterm labor was associated with intrauterine infection.

Female↗
PubMed2004

Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery.

BACKGROUND: The proportion of women who attempt vaginal delivery after prior cesarean delivery has decreased largely because of concern about safety. The absolute and relative risks associated with a trial of labor in women with a history of cesarean delivery, as compared with elective repeated cesarean delivery without labor, are uncertain. METHODS: We conducted a prospective four-year observational study of all women with a singleton gestation and a prior cesarean delivery at 19 academic medical centers. Maternal and perinatal outcomes were compared between women who underwent a trial of labor and women who had an elective repeated cesarean delivery without labor. RESULTS: Vaginal delivery was attempted by 17,898 women, and 15,801 women underwent elective repeated cesarean delivery without labor. Symptomatic uterine rupture occurred in 124 women who underwent a trial of labor (0.7 percent). Hypoxic-ischemic encephalopathy occurred in no infants whose mothers underwent elective repeated cesarean delivery and in 12 infants born at term whose mothers underwent a trial of labor (P<0.001). Seven of these cases of hypoxic-ischemic encephalopathy followed uterine rupture (absolute risk, 0.46 per 1000 women at term undergoing a trial of labor), including two neonatal deaths. The rate of endometritis was higher in women undergoing a trial of labor than in women undergoing repeated elective cesarean delivery (2.9 percent vs. 1.8 percent), as was the rate of blood transfusion (1.7 percent vs. 1.0 percent). The frequency of hysterectomy and of maternal death did not differ significantly between groups (0.2 percent vs. 0.3 percent, and 0.02 percent vs. 0.04 percent, respectively). CONCLUSIONS: A trial of labor after prior cesarean delivery is associated with a greater perinatal risk than is elective repeated cesarean delivery without labor, although absolute risks are low. This information is relevant for counseling women about their choices after a cesarean section.

Adolescent↗
PubMed1999

Comfort in labor and midwifery art.

PURPOSE: To examine the phenomenon of comfort in the context of childbirth. Enhancement of comfort for laboring women is a valued outcome of nursing and midwifery care. Interventions that increase comfort during labor support a woman's effort to participate more fully in the birth thereby keeping her more aware of her body, emotions, and experience. ORGANIZING CONSTRUCT: The concept of comfort is analyzed and defined in the context of laboring women. Comfort studied from a feminist perspective is suggested. SOURCES: A literature review of nursing, midwifery, and medical texts from the 1920s to 1998 provides information about labor, pain in labor, and goals of providers caring for laboring women. Research articles focusing on comfort are identified as they relate to the concept of comfort in labor. Writings of contemporary feminist authors provided the ideas for designing the study of comfort from a feminist perspective. METHODS: To develop a theory of comfort during labor, early nursing and midwifery texts were searched to identify goals of care. The meaning of comfort was analyzed from the early 1920s to the present by concept analysis. Validation of findings was sought from publications on comfort research. FINDINGS: Comfort can exist in spite of great pain and nurses and midwives may be able to assist laboring women to achieve a level of comfort during labor. Intervening to promote the comfort of laboring women can empower these women during birthing. CONCLUSIONS: For clinicians caring for birthing women, particularly midwives, promotion of comfort is a high priority. Increasing comfort can redefine the meaning of pain in childbirth. Increasing comfort may create a decreased need for medical interventions and lower costs.

Clinical Nursing Research↗