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PubMed1991

Outcomes of 1001 midwife-attended home births in Toronto, 1983-1988.

A retrospective descriptive study of 1001 midwife-attended home births in Toronto, Ontario, was carried out between January 1983 and July 1988. Interviews with 26 midwives and reviews of client records provided data on maternal age, socio-economic status, gestation, ruptured membranes, length of labor, episiotomies and perineal lacerations, transfer to hospital of mother or baby or both, infant resuscitation, and breastfeeding. Of 1001 planned home births, 361 involved primiparous women, of whom 245 (68%) remained at home and 116 (32%) required transfer of mother or baby to hospital during labor or the first four postpartum days. Of the 640 multiparous births, 591 (92%) women remained at home and 49 (8%) required transfer to hospital. Among women transferred, 91 had spontaneous vaginal births, 34 had forceps deliveries, and 35 had cesarean sections. Variables significantly associated with maternal transfer for both primiparas and multiparas were length of latent and active phases of the first stage of labor, length of the second stage of labor, and duration of ruptured membranes. Five neonates were transferred and two died, one each after birth at home and in hospital. There were no maternal deaths. The proportion of mothers breastfeeding without supplement at 28 days postpartum was 98.6 percent.

Adult↗

PubMed1989

Induction of labor by oral prostaglandin E2 in protracted pregnancy.

Induction of labor was performed in 20 pregnant females with postmaturity (greater than 294 days) using either oral PGE2 tablets (0.5 mg) or i.v. oxytocin drip (each group n = 10). The induction-establishment interval was significantly shorter in the oxytocin group (P less than 0.005). Moreover, the uterine activity (in Alexandria units) at 3 h post-induction and at the end of the first stage of labor, was significantly higher with i.v. oxytocin (P less than 0.005). However, the induction-delivery interval did not differ in both groups. All cases delivered spontaneously with a satisfactory Apgar score.

Administration, Oral↗

PubMedDate not supplied

[Cardiotocographic changes in epidural analgesia with bupivacaine].

During the first stage of labor in a large number of births, temporarily pathologic patterns become manifest in the cardiotocogram after epidural analgesia. Statistical comparisons showed a significant level of correlation (in the region of 1%) between pathologic heart rate pattern and a fall in blood pressure after the main epidural dose (in all cases, premedication was given before commencement of analgesia). This jeopardy to the fetus in the first 20-30 minutes after administration of the main dose, visible in the cardiotocogram, makes it imperative for the clinician to pay the utmost attention to all women in labor during this period, not just those regarded as risk patients. After 10-20 minutes, labor is intensified, and this can coincide with possible jeopardy to the fetus. As this change in the course of labor manifests itself inordinately strongly in the labor-frequency parameter, and since absolute intrauterine pressure did not represent a threat to life in any of the cases described here, the authors feel that monitoring of labor by external tocometry is sufficient for clinical needs.

Anesthesia, Epidural↗

PubMed1991

[Changes in the values of estrogen stimulated neurophysin, oxytocin and prostaglandin in the maternal blood after the administration of dehydroepiandrosterone-sulfate to the pregnant women near term].

UNLABELLED: In order to examine the effect of dehydroepiandrosterone-sulfate (DHA-S) on the production of uterus-contractive substances in perinatal women, the concentrations of estrogen stimulated neurophysin (ESN), oxytocin, 13, 14-dihydro-15-keto-Prostaglandin F2 alpha(PGF2 alpha) and DHA-S related steroids in the maternal blood of 12 cases of primigravida were serially estimated after intravenous administration of 200mg DHA-S twice a week from 38 weeks of gestation till the onset of labor. RESULTS: 1) The duration of labor was significantly shortened in the DHA-S group (mean; 9.3 +/- 2.8 hours) compared to the 11 control cases (13.5 +/- 5.2 hours). 2) i) The ESN concentration, which correlated well with that of free estradiol-17 beta, increased significantly at 1 week after the Ist administration. ii) The oxytocin concentration, which correlated well with that of ESN, increased significantly at 39 weeks of gestation, the first stage of labor and especially at delivery compared to the control. iii) The PGF2 alpha concentration, which increased in parallel with those of DHA-S, estrone-S and pregnenolone-S, increased significantly at delivery in comparison with the control and correlated well with estrone-S in the DHA-S group. CONCLUSION: These findings suggest that DHA-S administration to perinatal women may enhance the production of ESN, oxytocin and PGF2 alpha in the fetoplacento-maternal compartment, which may result in the shortening of labor.

Dehydroepiandrosterone↗

PubMed2002

ST analysis of the fetal electrocardiogram during labor: Nordic observational multicenter study.

OBJECTIVE: To assess the diagnostic power of cardiotocography (CTG) plus the ST interval of the electrocardiogram (ECG) clinical guidelines with combined fetal heart rate and ST waveform analysis of the fetal ECG recorded during labor, to identify an adverse labor outcome (neonatal neurological symptoms and/or metabolic acidosis). STUDY DESIGN: An observational, multicenter study was undertaken in 12 Nordic labor wards. A total of 573 women in labor were monitored using a prototype of the STAN S 21 recorder with fetal ECG data and computerized ST analysis. RESULTS: Fifteen cases of intrapartum fetal hypoxia identified from neurological neonatal symptoms and/or cord artery pH < 7.05 with base deficit in extracellular fluid > 12.0 mmol/l were recorded. All these cases were identified by CTG + ST clinical guidelines. Five developed neonatal symptoms and had ECG abnormalities during the first stage of labor and, of the remaining ten, eight showed ST changes during active pushing in the second stage. Another eight cases had acidemia only and normal neonatal outcome. Seven of these displayed CTG + ST abnormalities. The high sensitivity of CTG + ST to predict fetal acidosis was associated with a marked increase in positive predictive values compared with conventional CTG. CONCLUSION: The STAN clinical guidelines identify fetuses at risk of intrapartum asphyxia.

Acidosis↗

PubMedDate not supplied

Maternal prolactin secretion is phasic during induced term and post-term labor.

OBJECTIVE: We hypothesized that regimens of labor induction do not alter the biphasic secretion of maternal prolactin (PRL) seen during spontaneous labor. METHODS: Serial blood samples drawn from 12 women before, during, and after induced labor were assayed for PRL and hCG and compared with cervical dilatation and uterine contraction frequency (UCF). Induction methods were cervical ripening with dinoprostone gel (Prepidil) followed by oxytocin infusion (n = 1), amniotomy followed by oxytocin (n = 4), oxytocin followed by amniotomy (n = 3), amniotomy only (n = 2), and oxytocin only (n = 2). RESULTS: Regardless of the induction method, PRL decreased with advancing cervical dilatation during the first stage of labor and reached a nadir at full dilatation. Prolactin levels then increased rapidly during the second stage, correlating significantly with the increase in UCF, and peaked at 1 hour postpartum before decreasing. Levels of hCG increased during labor and peaked just before or at delivery before rapidly decreasing. CONCLUSIONS: The biphasic secretion of maternal PRL is a fundamental characteristic of active term labor and occurs regardless of the method used to induce labor.

Amnion↗

PubMed1994

Cervical ripening in women with previous cesarean deliveries.

OBJECTIVE: To evaluate the safety and efficacy of preinduction cervical ripening in women with previous cesarean deliveries undergoing induction of labor. METHODS: Retrospective study of women with previous low transverse cesarean deliveries who underwent ripening of an unfavorable cervix prior to induction of labor (n = 89). Multiparas without previous cesarean deliveries undergoing ripening and induction of labor during the same time period were used for comparison (n = 61). Ripening was performed with prostaglandin E2 (PGE2) gel, or an osmotic dilator, or both. Induction of labor with oxytocin followed the American College of Obstetricians and Gynecologists' guidelines. Outcome data were analyzed using the unpaired Student's t-test or chi 2-test as appropriate. Significance was established at P < 0.05. RESULTS: The mean gestational age was 39.6 +/- 2.6 and 38.2 +/- 2.9 weeks for the study and comparison groups, respectively. There were no differences between the groups in Bishop score, duration of the first stage of labor, maximum dose of oxytocin, indications for cesarean delivery, puerperal morbidity, birthweight, Apgar scores or NICU admissions. Sixty-four percent (57 of 89) of study women delivered vaginally compared with 82% (50 of 61) of women in the comparison group (P < 0.03). The data were analyzed separately for those women undergoing cervical ripening with PGE2 gel only. No differences were observed between the groups in any of the categories mentioned above. CONCLUSION: Cervical ripening appears to be safe and effective in women with previous low transverse cesarean deliveries undergoing induction of labor with an unfavorable cervix.

Adult↗

PubMed1978

Segmental epidural analgesia and postpartum sequelae.

The incidence of the postpartum sequelae of headache, backache, pain in the legs and difficulties in micturiton, was studied in 219 normal vaginal deliveries. 135 of the parturients received continuous segmental epidural analgesia at the level of Th 10--12 for pain relief during the first stage of labour. The remaining 84 parturients served as controls. The results showed that segmental epidural analgesia did not increase the occurrence of postpartum sequelae either in primiparous or in multiparous parturients.

Adolescent↗

PubMed2006

Impact of walking epidural analgesia on obstetric outcome of nulliparous women in spontaneous labour.

BACKGROUND: To explore the effects of walking epidural analgesia on obstetric and neonatal outcomes, we performed a case-control study. METHOD: Each nulliparous woman receiving walking epidural analgesia using 0.0625% bupivacaine (n = 44) was matched to two nulliparous historical controls receiving 0.125% or 0.25% bupivacaine (n = 88 each) for epidural analgesia while recumbent. RESULTS: Maternal and obstetric parameters, fetal status and presentation, and oxytocin use were comparable among groups. Those receiving walking epidural analgesia walked for a mean of 60 min (range: 20-75 min). In the control groups the mean total durations of labour were shorter (58 min in the 0.125% group and 99 min in the 0.25% group, P < 0.05). Significantly fewer walking epidural analgesia cases than controls required instrumental vaginal delivery (P < 0.05). No other differences in obstetric or fetal outcome were observed and no mother fell or stumbled while walking. CONCLUSION: Although it was associated with a prolonged first stage of labour, walking epidural analgesia appeared safe for nulliparous women and their babies.

Adult↗

PubMed2002

Paracervical block and elective abortion: the effect on pain of waiting between injection and procedure.

OBJECTIVE: Our purpose was to assess the effect on pain and patient satisfaction of waiting between paracervical block and dilation during first-trimester abortions. STUDY DESIGN: One hundred ninety-nine women seeking pregnancy termination were randomly assigned to a no-wait group (group 1) and a 3- to 5-minute wait between injection and dilation group (group 2). Subjects rated their pain on a visual analog scale at four times: prior to procedure, with dilation, with aspiration, and 30 to 45 minutes after procedure. RESULTS: No significant differences were observed in pain or satisfaction ratings reported by group 1 (n = 93) and group 2 (n = 101). A significant decrease in pain with dilation (1.21 cm decrease, P =.009) and aspiration (1.15 cm decrease, P =.0015) was observed among patients who received fentanyl. CONCLUSION: Delay between paracervical injection and dilation during first-trimester abortion does not have an impact on patient pain or satisfaction. Fentanyl decreased pain scores by 20% to 25% during the procedure.

Abortion, Induced↗

PubMed2006

Effect of chronic maternal methadone therapy on intrapartum fetal heart rate patterns.

OBJECTIVE: Treatment of maternal opioid dependence with methadone is associated with a delay in fetal heart rate (FHR) accelerations in nonstress tests. The objective of this investigation was to determine the effect of methadone maintenance therapy on intrapartum FHR patterns. METHODS: This retrospective cohort study compared intrapartum FHR tracings from 56 methadone-treated patients > or =36 weeks gestation with a control group of nonsubstance using patients matched for maternal age, parity, gestational age, and ethnicity. Blinded FHR interpretation included the recording of baseline, variability, accelerations, and late or severe variable decelerations. The 8-point FHR scoring system was based on the National Institute of Child Health and Human Development Research Planning Workshop guidelines. We considered a 25% reduction in the score during the latent phase to be significant. RESULTS: The median maintenance dose of methadone was 70 mg daily, with a range between 20 mg and 130 mg. Each patient tested negative for other substances on urine screening before admission. The significantly lower FHR score in the methadone group (mean difference, 1.4; 95% confidence interval, 1.1 to 1.7) was attributed to a lower baseline (P <.05), less moderate or marked variability (P <.01), and a lower proportion of accelerations during the first stage of labor (P <.01). A higher proportion of methadone-exposed fetuses had late or severe variable decelerations in the second stage (44.2% vs 22.9%; P <.03). Analgesic needs, operative vaginal or cesarean delivery rates, and Apgar scores less than 7 at 1 and 5 minutes were not significantly different between the two groups. CONCLUSIONS: Chronic maternal methadone treatment affects intrapartum FHR patterns by reducing the variability, baseline, and proportion of accelerations during the first stage. These subtle drug-induced effects do not compromise intrapartum decision-making or immediate newborn adjustments.

Adult↗

PubMed1992

Four-quadrant assessment of amniotic fluid volume: distribution's role in predicting fetal outcome.

OBJECTIVE: The amniotic fluid (AF) index has been shown to be a useful tool in the area of antepartum surveillance. An intrapartum AF index less than or equal to 5.0 has been shown to have predictive value with respect to increased perinatal morbidity. This study was designed to determine whether the distribution of the AF within the AF index is related to perinatal outcome. METHODS: Patients presenting for labor and delivery had an AF index determined and were divided into two groups. Patients with greater than 50% of their AF distributed in the upper quadrants were placed in the "upper-greater" group. The remaining patients were placed in the "lower-greater" group. The distribution data were compared with the following variables: meconium staining, 1- or 5-minute Apgar score of less than 7, persistent variable decelerations in the first stage of labor, late decelerations, neonatal intensive care unit admission, cesarean delivery for fetal distress, and umbilical arterial and venous pH less than 7.20. RESULTS: A total of 218 patients were evaluated, 125 in the upper-greater group and 93 in the lower-greater group. The upper-greater group had a greater incidence of meconium staining (32.8 versus 9.7%; P < .0001), 1-minute Apgar score of less than 7 (12.0 versus 2.2%; P < .007), variable decelerations (53.6 versus 19.4%; P < .00001), late decelerations (16.0 versus 0%; P < .0001), cesarean delivery for fetal distress (7.2 versus 0%; P < .008), umbilical arterial pH less than 7.20 (29.6 versus 8.9%; P < .0105), and umbilical venous pH less than 7.20 (8.9 versus 0%; P < .0398). These results were maintained regardless of the overall AF index. CONCLUSIONS: The distribution of the fluid within the AF index is predictive of perinatal outcome. In addition, the presence of a high negative predictive value for all of the perinatal indices studied enhances the value of this technique as a potential screening tool. Application of these results could provide additional guidelines in defining the intrapartum management and therapy of patients presenting for labor and delivery.

Adult↗

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↗

PubMed1998

Lack of effect of walking on labor and delivery.

BACKGROUND AND METHODS: Walking during labor may reduce patients' discomfort and improve outcomes. We conducted a randomized trial of walking during active labor to determine whether it altered the duration of labor or other maternal or fetal outcomes. Women with uncomplicated pregnancies between 36 and 41 weeks' gestation and in active labor were randomly assigned either to walking or to no walking (usual care). Pedometers were used to quantify walking, and the time spent walking was recorded. RESULTS: Of the 536 women assigned to the walking group, 380 actually walked. Their mean (+/-SD) walking time was 56+/-46 minutes. There were no significant differences between the women assigned to the walking group and the 531 women assigned to the usual-care group in the duration of the first stage of labor (6.1 hours in both groups, P=0.83), the need for labor augmentation with oxytocin (23 percent vs. 26 percent, P=0.25), and the use of analgesia (84 percent vs. 86 percent, P=0.59). Similarly, the percentages of women requiring delivery by forceps (4 percent vs. 3 percent, P=0.35) and cesarean section (4 percent vs. 6 percent, P=0.25) were not significantly different. These labor and delivery outcomes were unrelated to walking in both nulliparous and parous women. The infants' outcomes were also similar in the two study groups. CONCLUSIONS: Walking neither enhanced nor impaired active labor and was not harmful to the mothers or their infants.

Adult↗

PubMed1984

Maternal and neonatal effects of epidural morphine for labor and delivery.

To determine the efficacy of epidural morphine during labor and delivery, 40 healthy parturients who requested epidural analgesia were randomly given either a single injection of morphine sulfate (2 mg, n = 9; 5 mg, n = 10; or 7.5 mg, n = 11) or 0.5% bupivacaine (n = 10). Bupivacaine provided excellent analgesia in all patients. Morphine (2 or 5 mg) did not produce adequate analgesia and needed to be supplemented by local anesthesia. Morphine (7.5 mg) gave satisfactory analgesia in 7 of 11 patients until the end of the first stage of labor, and, in an additional patient, for almost 13 hr, at which time cephalopelvic disproportion was diagnosed. In all patients given epidural morphine, local anesthesia was needed for the second stage of labor if instrumentation or episiotomy was required. The only side effect was pruritus, which occurred in three patients. Epidural morphine did not produce neonatal depression, as evidenced by Apgar scores and neurologic and adaptive capacity scores. We conclude that 7.5 mg of epidural morphine can give satisfactory pain relief during labor but not delivery, and that 2 or 5 mg of morphine is ineffective. Although 0.5% bupivacaine provided better anesthesia, epidural morphine might prove useful for selected patients.

Acid-Base Equilibrium↗

PubMed1993

Epidural anesthesia during labor and stress incontinence after delivery.

OBJECTIVE: To test the hypothesis that epidural anesthesia during labor prevents the development of stress incontinence after vaginal birth. METHODS: We interviewed 208 primiparas about stress incontinence 3 months postpartum. The women who developed stress incontinence after delivery were interviewed again 1 year postpartum. RESULTS: Twelve of 45 women (27%) who had epidural anesthesia developed stress incontinence de novo after vaginal delivery, versus 21 of 163 (13%) who did not receive epidural anesthesia, a marginally significant difference (P = .05). Those who had epidural anesthesia also had a significantly longer first stage of labor. One year after delivery, three of 42 (7%) in the epidural anesthesia group had stress incontinence, compared with five of 163 (3%) in the control group. CONCLUSION: Our results do not support the hypothesis that epidural anesthesia protects against the development of stress incontinence after vaginal delivery.

Adolescent↗

PubMed2003

Role of cytokines and other inflammatory mediators.

In spite of impressive advances in biochemistry and molecular biology, it has not yet been possible to fit the individual biochemical components of cervical ripening and dilatation to a uniform clinical moiety or to uncover any regulatory mechanisms. The production of interleukin-8 by activated fibroblasts and macrophages plays a key role in cervical ripening, since this cytokine induces chemotaxis, activation, and degranulation of neutrophilic granulocytes with the consequent release of various proteases, including collagenase. In addition, the extravasation of neutrophilic granulocytes is mediated-as in the early stage of an acute inflammatory reaction-by a brief increase in adhesiveness of vascular endothelium. This is known to be modulated by the cytokine-induced increase in the expression of endothelial adhesion molecules. Furthermore, an increase in pro-inflammatory cytokine and proteinase concentrations in preterm delivery seems to occur at earlier stages of cervical dilatation than in term delivery. It is also well known that in patients with chorioamnionitis, the levels of pro-inflammatory cytokines are elevated in amniotic fluid, maternal serum, cervical secretion, placenta, and other compartments of the placento-maternal unit, and are associated with preterm uterine contractions. We have demonstrated for the first time that cytokine concentrations in the lower uterine segment in patients with chorioamnionitis are strongly elevated. We conclude from our data that increased concentrations of pro-inflammatory cytokines may also play a pivotal role in cervical softening and dilatation during chorioamniotic infection. Our data agree with the hypothesis of Liggins who stated nearly 20 years ago that cervical ripening may be an inflammatory reaction, which leads to increased prostaglandin synthesis, preterm labour and finally to preterm delivery.

Cell Adhesion Molecules↗

PubMed1987

Continuous transcutaneous carbon dioxide measurement from the fetal scalp during labor and during first minutes of extrauterine life.

An electrode for continuous transcutaneous carbon dioxide (tcPco2) monitoring was attached to the fetal scalp in 25 consecutive vaginal deliveries. In six patients the electrode fell off or was deliberately removed when the fetal head was on the pelvic floor, while eight patients were delivered with the electrode in situ, making it possible to study changes in the fetal carbon dioxide level when the fetus changed from placental to lung breathing. The mean recording time was 136 minutes (range 10-348). Fifteen patients were recorded until delivery and analysis of cord blood showed a statistically highly significant correlation between tcPco2 in both umbilical venous and arterial blood. The mean fetal tcPco2 during the late first stage of labor was 56 torr (range 40-75; n = 18). The post partum tcPco2 level in newborns was stable 20 minutes after delivery with a mean level of 51 torr (range 40-60). Fetuses with a normal fetal heart rate tracing showed a lower mean tcPco2 level than fetuses with fetal heart rate tracing abnormalities. The experience with the current technique indicates that both Apgar score and fetal heart rate tracing are rather crude methods to judge fetal blood gas status.

Blood Gas Monitoring, Transcutaneous↗