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PubMed1998

Obstetric outcome following epidural analgesia with bupivacaine-adrenaline 0.25% or bupivacaine 0.125% with sufentanil--a prospective randomized controlled study in 1000 parturients.

BACKGROUND: Epidural analgesia (EDA) is the most efficient method for pain relief during labour, but there is still a debate as to whether it interferes with the normal process of delivery. Some authors argue that the incidence of instrumental deliveries, Caesarean section, malrotation and protracted labour is increased in parturients receiving EDA. METHODS: 1000 parturients were prospectively randomized to receive EDA either with a high dose of local anaesthetic (0.25% bupivacaine with adrenaline = HD) or with a low dose (0.125% bupivacaine with sufentanil 10 micrograms = LD). RESULTS: The incidence of instrumental delivery and Caesarean section and the need for oxytocin was reduced in the LD compared to HD group. The delivery time was similar with HD and LD among primiparous, but decreased significantly among multiparous in the LD group. The incidence of malrotation was low in both groups. The quality of analgesia was equal during the first stage in the 2 groups, but was lower in the LD group during the second stage. More parturients in the LD group ambulated, but this did not affect the incidence of instrumental delivery. CONCLUSION: It is concluded that a lower dosage of bupivacaine combined with sufentanil in epidural analgesia significantly improves the obstetric outcome as compared to a higher dosage of bupivacaine with adrenaline using intermittent bolus technique.

Analgesia, Epidural↗
PubMed2004

Calcium levels during the initiation of labor.

OBJECTIVE: To investigate the physiological role of calcium in the labor process. STUDY DESIGN: Eighty-eight term healthy pregnant women who gave birth to normal healthy neonates participated in our study. We compared calcium levels between pregnant women who had normal delivery and those who underwent scheduled cesarean section. The control group consisted of pregnant women with gestation > or =37 weeks without contractions. The groups were compared with respect to calcium levels: (a) in maternal blood serum; (b) in blood serum of the neonates and mothers; and (c) in blood serum between neonates. RESULTS: Significantly higher calcium levels were found in the group of pregnant women who delivered vaginally compared to those who delivered by scheduled cesarean section and those of the control group. CONCLUSION: We assume that the increased calcium levels during the first stage of labor are involved with a possible role of calcium in the mechanism of initiation of labor.

Adult↗
PubMed1980

Randomized trial of two beta-mimetic drugs (ritodrine and fenoterol) in acute intra-partum tocolysis.

The uterine inhibitory effect and potential maternal and fetal side effects of two beta-mimetic compounds, ritodrine hydrochloride and fenoterol hydrobromide, were compared in a randomized trial. The drugs were administered by intravenous infusion to 24 healthy term nulliparous women during effective first-stage labour; each of them received fenoterol (1, 2, or 4 microgram/min) or ritodrine (100, 200, or 400 microgram/min). There was no difference between the drugs in the intensity of the uterine inhibition. However, for a similar inhibitory effect, the duration of tocolysis was longer after ritodrine. During the intrapartum and neonatal periods, neither compound induced any change in the fetal parameters investigated, and their effects on maternal parameters were comparable.

Blood Pressure↗
PubMed2001

Fetal head moulding: finite element analysis of a fetal skull subjected to uterine pressures during the first stage of labour.

Fetal head moulding is a phenomenon which may contribute to satisfactory progress during delivery as it allows the fetal head to accommodate to the geometry of the passage. In contrast, excessive head moulding may result in cranial birth injuries and thus affect the infant shortly or even long after birth. One group of researchers in the past investigated the biomechanics of fetal head moulding from an engineering point of view and limited themselves to a static, linear model of the parietal bones. In this paper, we present a non-linear model of the deformation of a complete fetal skull, when subjected to pressures exerted by the cervix, during the first stage of labour. The design of the model involves four main steps: shape recovery of the fetal skull, the generation of a valid and compatible mesh for finite element analysis (FEA), the specification of a physical model and the analysis of deformation. Results of the analysis show good agreement with those obtained from clinical experiments on the quantitative assessment of fetal head moulding. The model also displays shapes after moulding which have been reported in previous studies and which are generally known in the obstetric and paediatric communities.

Biomechanical Phenomena↗
PubMed1990

[Computer-assisted analysis of the tocogram. Initial experience using a new evaluation procedure].

This paper describes first observations with a new computer aided analysis of tocogram. It seems that length of uterine contraction is an important parameter for quality of labour. In 9 from 12 cases promotion to constant length of labour with relatively low absolute duration of contractions was connected with a distinct increase of the velocity of cervical dilatation. The uniformity can be an important factor for the conversion into active phase of labour.

Adolescent↗
PubMed1993

Isoflurane in labour.

A comparison of the analgesic efficacy of Entonox (50% nitrous oxide in oxygen) and Entonox with 0.2% isoflurane was made in 18 consenting mothers during the first stage of labour. The inhalational gases were self-administered during contractions over a 3 h study period using a standard Entonox demand valve and breathing system. Isoflurane 0.2% was added from an Ohmeda Isotec drawover vaporizer and the inspired concentration of isoflurane was analysed continuously using a Datex Ultima analyser. Linear analogue scores for pain were significantly lower (p < 0.001) during the Entonox-isoflurane administration compared with Entonox alone. Drowsiness was not a clinical problem and there was a high acceptance rate for Entonox-isoflurane inhalational analgesia during labour.

Adolescent↗
PubMed2003

Epidural levobupivacaine, ropivacaine and bupivacaine in combination with sufentanil in early labour: a randomized trial.

BACKGROUND AND OBJECTIVE: To evaluate the efficacy, delay and duration of analgesia of three equianalgesic epidural doses of levobupivacaine, ropivacaine and bupivacaine during the first stage of labour. METHODS: One hundred and twenty-nine healthy primigravida in spontaneous labour who requested epidural analgesia were enrolled in a randomized observer-blinded study. Parturients were allocated to receive epidural levobupivacaine 0.0625%, ropivacaine 0.1% or bupivacaine 0.06259%. Sufentanil 10 microg was added to all solutions; the total volume of epidural solution was 20 mL. Pain was measured using a 100 mm visual analogue pain scale immediately before the epidural block, and at 5, 10, 15, 20 and 30 min thereafter. Motor block was evaluated using a modified Bromage scoring system. The adequacy of motor function for ambulation was also evaluated. Delay of analgesia was the time interval between the injection of the solution and the first painless contraction. Duration of analgesia was the time from the first painless contraction to the parturients' requests for further analgesia. RESULTS: Twelve parturients failed to complete the study. Eleven parturients had inadequate analgesia (four in Group Levobupivacaine, four in Group Ropivacaine and three in Group Bupivacaine; P > 0.05). Data was analysed from 34 parturients in Group Levobupivacaine, from 37 in Group Ropivacaine and from 35 in Group Bupivacaine. There were no differences in the delay of analgesia or in the number of parturients who were able to walk unaided. Levobupivacaine and ropivacaine produced more prolonged analgesia than bupivacaine (114 and 119 min, respectively, versus 89 min; P < 0.01). CONCLUSIONS: During early labour, equipotent low concentrations of levobupivacaine, ropivacaine and bupivacaine, all with the addition of sufentanil 10 microg, produced similar pain relief and motor block, but levobupivacaine and ropivacaine produced a longer lasting analgesia. About 10% of parturients had inadequate analgesia with a single bolus of the tested solutions.

Adult↗
PubMed1992

The effect of continuous low-dose epidural analgesia on uterine work during the active phase of the first stage of labour.

Fifty-six patients admitted to hospital in normal spontaneous labour were given a continuous epidural infusion of 10 ml (12.5 mg) of 0.125% bupivacaine during the 1st stage of labour. Uterine contractions were monitored with an intra-uterine pressure transducer and uterine work expressed both in Alexandria units and the area under the curve of the intra-uterine pressure recording summated over 15 minutes. Variables that have been shown to affect uterine contractions were strictly excluded. Our study showed that continuous low-dose epidural analgesia had no significant effect on uterine work during the active phase of the 1st stage of labour when cervical dilatation was 5 cm or more. If cervical dilatation was between 3 and 4 cm there was a 2.9% reduction. This reduction in uterine work was also not significant and in all patients spontaneously returned to its previous level within 91 minutes.

Adolescent↗
PubMed1989

The influence of pH-adjusted 2-chloroprocaine on the quality and duration of subsequent epidural bupivacaine analgesia during labor: a randomized, double-blind study.

A randomized, double-blind study was performed to determine whether pH-adjustment of 2-chloroprocaine hastens the onset of epidural analgesia, and improves the quality and duration of subsequent epidural bupivacaine analgesia during labor. One milliliter of either 8.4% sodium bicarbonate or normal saline was added to a 30-ml vial of 2% 2-chloroprocaine. At 0, 5, and 7 min, each patient received 2, 5, and 3 ml of 2-chloroprocaine, respectively. At 22 min, any patient who did not yet have satisfactory analgesia received an additional 5 ml of 2-chloroprocaine. At 35, and, again, at 36 min, each patient received 5 ml of 0.25% bupivacaine. The median onset of 2-chloroprocaine analgesia was slightly more rapid in the bicarbonate group than in the saline-control group (12 versus 14 min, P less than .05). Two of 31 women in the bicarbonate group, versus 10 of 31 women in the saline-control group, required an additional 5 ml of 2-chloroprocaine at 22 min to achieve satisfactory analgesia (P = .01). There was no significant difference between groups in median duration of subsequent bupivacaine analgesia (60 min in each group) or mean (+/- SD) dosage of bupivacaine during the first stage of labor (64 +/- 43 versus 72 +/- 57 mg). Also, there was no significant difference between groups in pain scores over time.(ABSTRACT TRUNCATED AT 250 WORDS)

Analgesia, Epidural↗
PubMed1998

Intrathecal sufentanil dose response in nulliparous patients.

BACKGROUND: Intrathecal sufentanil provides effective analgesia during the first stage of labor. A range of doses has been reported to provide adequate pain relief. This study determined the dose of intrathecal sufentanil that produced acceptable pain relief in 50% of nulliparous patients (ED50) who requested labor analgesia. METHODS: With institutional review board approval, 50 nulliparous patients requesting spinal opioid labor analgesia were enrolled into this prospective, randomized, double-blinded study. Each patient was in spontaneous labor at <5 cm cervical dilation. Patients received one of the following doses of intrathecal sufentanil: 1, 2, 3, 5, or 10 microg in 3 ml preservative-free saline (n = 10 for each dose). Pain, pain relief, hemodynamic, respiratory, and side effect data were collected at times 0, 2, 5, 10, 15, 20, 25, and 30 min. Probit analysis of the number of patients in each group who requested additional pain medicine at 30 min was used to determine the ED50. RESULTS: The groups were demographically similar. The ED50 of intrathecal sufentanil was 1.8 microg (SE, 0.6 microg; 95% CI, 2.96 to 0.54 microg). The incidence of side effects was similar among the groups. CONCLUSIONS: This is the first study to determine the ED50 of intrathecal sufentanil in spontaneously laboring nulliparous patients. As dose-response curves are determined for other labor analgesics, future studies can compare equianalgesic doses or dose combinations.

Adult↗
PubMed1995

Late fetal heart decelerations and changes in cerebral oxygenation during the first stage of labour.

OBJECTIVE: To test the hypothesis that late fetal heart rate decelerations are associated with a decrease in cerebral oxygenation. DESIGN: Changes in fetal cerebral concentrations of oxyhaemoglobin and deoxyhaemoglobin were measured by near infrared spectroscopy, before, during and after contractions with late fetal heart rate decelerations and compared with changes during contractions with no alteration of heart rate. SETTING: Teaching hospital obstetric unit. SUBJECTS: Ten women in labour at term. RESULTS: The changes in fetal cerebral oxyhaemoglobin and deoxyhaemoglobin concentrations that occurred during contractions were quantitatively similar, irrespective of the fetal heart rate changes. However, late fetal heart rate decelerations were associated with a significantly greater fall, after the uterine contraction, in the mean concentration of fetal cerebral oxyhaemoglobin of 0.52 mumol/100 g (SD 0.25) (P < 0.001) and a significantly greater rise in the mean concentration of deoxyhaemoglobin of 0.36 mumol/100 g (SD 0.35) (P < 0.01). CONCLUSION: Late fetal heart rate decelerations are associated with a significant decrease in cerebral oxygenation.

Adult↗
PubMed1977

Elective induction of labor conducted under lumbar epidural block. II. Labor induction by amniotomy and intravenous prostaglandin.

Labor was electively induced at term in 117 clinically normal nulliparae and parous women by combining low amniotomy with intravenous administration of prostaglandin F2 alpha (n = 64) or prostaglandin E2 (n = 53). Analgesia was obtained by continuous lumbar epidural block with bupivacaine. The procedure was very effective in producing vaginal delivery within 24 h after prostaglandin infusion (n = 115), but it was accompanied by an extremely high incidence of uterine hypertonus. Tentative explanations for the transient uterine hyperstimulation are a direct stimulatory effect of the local anesthetic on the contractility of the myometrial fiber and/or a temporarily higher amount of circulating oxytocic compound reaching the myometrium due to local vasodilatation as a result of sympathetic nerve blockade. In some cases uterine hypertonus was associated with slowing of the basal fetal heart rate and, when severe, with the appearance of late deceleration patterns and fetal acidosis. In other cases the fetal heart rate deceleration is explained by the toxic effect of bupivacaine on the myocard. Since both the myometrial hyperactivity and the FHR alterations were temporary, fetal biochemical parameters were unaffected at completion of the first stage of labor. Because with intravenous prostaglandin uterine hyperstimulation is more difficult to avoid and regional analgesia further increases the hazard of both hypertonus and fetal heart rate deceleration, the combined application of an intravenous prostaglandin and continuous epidural analgesia should not be introduced into obstetrical practice.

Adult↗
PubMed1980

Plasma oxytocin levels and disappearance rate after buccal Pitocin.

Plasma concentrations of oxytocin (OT) were determined by a highly specific and sensitive radioimmunoassay in (1) nine pregnant women near or at term who were given 400 units of buccal OT every 20 minutes to induce labor or to augment uterine contractions; (2) four adult males who were given 200 units and 400 units of buccal OT every 20 minutes in two separate experiments each lasting 2 hours; and (3) three adult males at regular intervals up to 45 minutes after discontinuation of buccal OT. Plasma concentrations of OT increased in all the women studied, and exceeded 50 picograms per milliliter in six of nine patients after buccal OT was given. However, the net increase in OT was less than 50 pg/ml in six of nine patients. In males, 90% of the plasma samples collected when 400 units of OT was given had detectable levels of OT, with mean levels of 24 to 32 pg/ml; when 200 units was used, only 53% of the plasma samples had detectable OT, and mean levels were consistently below 10 pg/ml. Plasma OT decreased to one third but not to baseline levels in the course of 45 minutes after OT was discontinued. The findings indicate that with 400 units of buccal OT every 20 minutes, plasma OT concentrations attained were similar to those found during the first stage of labor, and that the disappearance of OT from the plasma after discontinuation was slow.

Administration, Oral↗
PubMed1996

Fetal heart rate changes and cerebral oxygenation measured by near-infrared spectroscopy during the first stage of labour.

OBJECTIVE: To determine the relationship between contraction related changes in fetal heart rate and cerebral oxygenation measured by near-infrared spectroscopy during labour. STUDY DESIGN: A specially designed optical probe was inserted through the dilated cervix and placed against the fetal head in 30 women during labour. Alterations in fetal heart rate during the final hour of the first stage of labour were compared with changes in the cerebral haemoglobin oxygenation index (delta oxyhaemoglobin concentration - delta deoxyhaemoglobin concentration) measured before, during and after uterine contractions. RESULTS: Uterine contractions which were associated with either no alteration, accelerations or early decelerations of the fetal heart rate showed no significant changes in the haemoglobin oxygenation index. Variable, late and prolonged decelerations all showed significant decreases in the haemoglobin oxygenation index (P < 0.01) either during (variable) or after (variable, late and prolonged) the uterine contraction. CONCLUSION: The association between variable, late and prolonged FHR decelerations and significant falls in cerebral oxygenation during late labour suggests that these fetal heart rate patterns are associated with an increased risk of fetal cerebral hypoxia.

Adult↗
PubMed1998

Labour outcome of low-risk multiparas of 40 years and older. A case-control study.

Between January 1, 1994 and December 31, 1997 a total of 76 low-risk multiparas of 40 years and older with spontaneous onset of labour were delivered and were compared with 152 younger (25-30 years-old) low-risk multiparas of similar parity in a case-control study. The labour and perinatal outcomes of the 2 groups were compared. The duration of the first stage of labour was longer (233 minutes versus 149 minutes, p<0.0005) in the older women. Significantly more labours of older multiparas were complicated by intrapartum fetal distress (6.6% versus 1.3%, p<0.05); received intramuscular analgesia (11.8% versus 2.6%, p<0.01); and had operative deliveries (17.1% versus 4.6%, p<0.01). The incidence of instrumental delivery (11.8% versus 3.9%, p<0.05) and Caesarean section (5.3% versus 0.7%, p<0.05) were higher among older multiparas. The incidences of Syntocinon augmentation of labour, prolonged second stage, episiotomy and third stage complications such as perineal tear, primary postpartum haemorrhage, and retained placenta were similar in both groups. Both groups had similar perinatal outcomes. These women should be treated as others with high-risk pregnancies with appropriate careful attention during labour such as continuous fetal heart rate monitoring. They should be counselled to be made aware of the increased risks during labour.

Adult↗
PubMed1980

A randomized clinical trial of the Leboyer approach to childbirth.

To examine the effects of the Leboyer method of delivery, we randomly assigned 56 women to either a Leboyer or a conventional delivery and used a variety of clinical and behavioral measures to assess the outcome in mother and child. No differences were noted in maternal or newborn morbidity, in infant behavior in the first hour of life, at 24 or 72 hours post partum, or at eight months of age; or in maternal perceptions of her infant and the experience of giving birth, except that eight months after delivery, mothers who had used the Leboyer method were more likely to say that the event had influenced their child's behavior (P = 0.05). Women who expected a Leboyer delivery had shorter active labors (P = 0.03), suggesting that psychologic factors (expectations) influence physical outcomes in perinatal medicine. Our results suggest that the Leboyer procedure has no advantage over a gentle, conventional delivery in influencing infant and maternal outcomes.

Behavior↗
PubMed1993

Maternal and neonatal outcomes after prolonged latent phase.

OBJECTIVE: To examine the association of prolonged latent phase with cesarean risk, subsequent labor abnormalities, and other adverse maternal and neonatal outcomes. METHODS: Patients with prolonged latent phase were compared to patients with normal latent phase. We studied 10,979 singleton vertex deliveries of at least 37 weeks' gestation. Patients with risk factors for adverse outcome known before labor were excluded from the analysis. RESULTS: Seven hundred thirteen patients (6.5%) had prolonged latent phase. Subsequent labor abnormalities were more frequent among patients with prolonged latent phase (42.9 versus 16.3%; P < .05), as was cesarean delivery (24.4 versus 6.9%; P < .05). Need for neonatal resuscitation, thick meconium, maternal fever, low 5-minute Apgar score, intensive care nursery admission, lengthened maternal and newborn hospital stays, and higher estimated blood loss were all significantly more frequent in patients with prolonged latent phase after controlling for mode of delivery. Multivariate linear logistic regression models were created to determine whether these risks actually reflected the prolonged latent phase. The first model controlled for other labor abnormalities, parity, epidural use, and macrosomia and showed prolonged latent phase to be associated with an increased risk for cesarean delivery (relative risk [RR] 1.65, 95% confidence interval [CI] 1.32-2.06). The second model controlled for other labor abnormalities, postdates, thick meconium, mode of delivery, and prolonged rupture of membranes and showed that both the need for newborn resuscitation and 5-minute Apgar scores less than 7 were significantly more frequent in association with a prolonged latent phase (RR 1.37 and 1.97, 95% CI 1.15-1.64 and 1.23-3.16, respectively). CONCLUSIONS: Prolonged latent phase is independently associated with an increased incidence of subsequent labor abnormalities, need for cesarean delivery, depressed Apgar scores, and need for newborn resuscitation. The presence of prolonged latent phase should alert the clinician to an increased risk for further problems during the labor.

Adult↗
PubMed2004

Sublingual compared with oral misoprostol for cervical dilatation prior to vacuum aspiration: a randomized comparison.

The aim of the study was to compare the effect of oral and sublingual administration of misoprostol for cervical priming prior to vacuum aspiration. Thirty-two first-time-pregnant women with 8-12 weeks amenorrhea were randomly assigned to receive 400 microg misoprostol either orally or sublingually 3 h prior to surgery. The degree of baseline dilatation and the cumulative force needed for dilatation of the cervical canal did not differ between the two treatment groups. However, the number of patients in whom a strong force was needed was significantly higher following oral than following sublingual treatment. It was shown that sublingual administration is more effective than oral administration of misoprostol for cervical priming and is associated with less blood loss but a higher frequency of side effects.

Abortifacient Agents, Nonsteroidal↗