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[Prediction of labor onset and difficulty by the multivariate analysis (author's transl)].

Based on the multivariate analysis, we analysed the weekly change of the antepartum cervical ripe (consistency, effacement, dilatation, position) and the station, then predict the labor onset and difficulty retrospectively. 1) According to longterm observation of the internal examination of 210 primipara, in third trimester, the ripe type increased, and the unripe type decreased are found. Because of the intermediate type increased and unmovable in incidence relatively, so based on the former scoring method of mere addition of scores, it appears ineffective to predict the labor onset. 2) We studied primipara 385 and multipara 434 from 6 weeks before labor. Based on the multiple regression analysis, we could predict the labor onset. The predict value is higher in multipara than primipara, on the primipara, 78.2% antepartum 6 weeks, 82.2% 4 weeks, 92.6% 2 weeks, and on the multipara 84.6%, 82.2%, 96.2% respectively. 3) Based on the method of Mahalanobis' generalized distance, we could predict the labor difficulty in the primipara and multipara. Accuracy of abnormal prediction are 77.1% at 4 weeks formula, 77.2% at 2 weeks formula on primipara; 69.0%, 69.2% respectively on multipara. Accuracy of normal prediction 53.3%, 56.9% on primipara; 30.9% (4 weeks formula) on multipara are found. The abnormal prediction is better than the normal prediction. This method can early predict the labor onset and difficulty than the former scoring method of mere additional scores.

Analysis of Variance↗

[Induction of labor with misoprostol].

The results obtained with the induction of labor with a synthetic analogue of prostaglandin E1: misoprostol, are presented. We reviewed 149 cases of patients admitted to this hospital (The "Policlínico Escuela Eva Perón") for induction of labor throughout a 13-month period of time since 06/01/92 until 06/30/93. All patients had a medical indication for induction of labor, a single pregnancy, cephalic - vertex presentation, no previous surgical scars on uterus, no contraindications for vaginal delivery, Bishop score below 7, gestational age over 37 weeks, and a reactive NST (Non Stress Test). Misoprostol was used intravaginally in the posterior fornix, in one dose of 100 mcg. In those patients where the spontaneous rupture of membranes was not the cause of induction itself, these were artificially ruptured at the moment of admission if possible depending on obstetric conditions, or no longer than 2 hours afterward. All patients underwent continuous fetal hart rate monitoring, during the active phase of labor. There were no failures of induction since all patients reached the active phase of labor without using oxytocin. There was an extremely high percentage of vaginal deliveries being this figure 96.6%. Only 5 patients had to undergo a cesarean section, 2 because of arrest of labor and 3 because acute fetal distress. Four cases of acute intrauterine fetal distress were registered but none of them were caused by tachysystole or hypercontractility. The mean time from the beginning of induction to delivery was 5 hours and 20 minutes (+/- 2 hs, 40') 70.5% of patients giving birth before 6 hours since admittance.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

Comparing routine versus delayed amniotomy in spontaneous first labor at term. A multicenter randomized trial. UK Amniotomy Group.

OBJECTIVE: To measure the effect of a policy of routine amniotomy on nulliparous labor. DESIGN: A multicenter randomized controlled trial. SUBJECTS: Nulliparous women (1463) in spontaneous labor at term with intact membranes and a single cephalic fetus. INTERVENTIONS: Rupturing membranes routinely early in labor or leaving them intact for as long as possible. MAIN OUTCOME MEASURES: Duration of labor, operative and instrumental delivery rates, use of analgesia, perinatal death, neonatal convulsions, and admission to special care. RESULTS: Median duration of labor was 8.4 hours in the early rupture group and 9.4 hours in the late group. No clear trend for this difference emerged at any particular cervical dilatation at randomization. We found no difference in cesarean section, typical odds ratio (OR) 1.1 (95% CI, 0.65 to 1.8); operative vaginal delivery, OR 1.1 (95% CI, 0.83 to 1.5); use of epidural/spinal, OR 0.92 (95% CI, 0.72 to 1.2); use of pethidine, OR 1.0 (95% CI, 0.79 to 1.4); either method of analgesia, OR 0.96 (95% CI, 0.68 to 1.3); blood transfusion, OR 0.71 (95% CI, 0.28 to 1.8. We found no effect on fetal intubation, OR 1.40 (95% CI, 0.78 to 2.5), or on admission to special care, OR 1.28 (95% CI, 0.65 to 2.5). One fetus in the early amniotomy group had care, Or 1.28 (95% CI, 0.65 to 2.5). One fetus in the early amniotomy group had neonatal convulsions, but there were no perinatal deaths. CONCLUSIONS: Beyond a modest shortening of labor, a policy of routine amniotomy has little effect on important outcomes and should not be recommended.

Amnion↗

Normal and abnormal labor progress: I. A quantitative assessment and survey of the literature.

Quantitative labor data have been reported piecemeal in the literature; there is no previous unified report of the frequencies of each of the dysfunctional labor patterns (DLPs). In order to describe the labor process more clearly a labor diagnostic computer program was used to prospectively study an unselected series of 3,682 nearly consecutive labors from one institution. Cervicometric data for nulliparous and multiparous labor were very similar to the results of others. The absolute frequency with which each DLP was found to occur is compared with results in the literature. Protracted active phase dilatation was the most frequently occurring DLP and prolonged deceleration phase the least frequently occurring one. The relative frequencies of the DLPs, defined as the percentage of all DLPs that occurred, remained reasonably constant, regardless of parity or the absolute frequencies of the DLPs in a group of patients.

Adolescent↗

Early labor initiation with oral PGE2 after premature rupture of the membranes at term.

Two groups of healthy women at term, who were not in labor 3 hours after premature rupture of the membranes, were studied. In one group labor induction with oral prostaglandin E2 (PGE2) was begun 3 hours after rupture, and in the other group intravenous oxytocin induction was begun 12 hours after rupture. PGE2 was successful in initiating active labor in 88% of women treated. Of the women who were observed for 12 hours, one-half began labor spontaneously during that time. Women in whom labor was induced with PGE2 given 3 hours after rupture of the membranes had a shorter interval of rupture to delivery, a lower cesarean section rate, and shorter postpartum hospitalization. Although significant bradycardia did not occur in fetuses of those women given PGE2, 10% of infants whose mothers were receiving oxytocin were delivered by cesarean section for this reason. It is concluded that oral PGE2 is safe and effective for induction of labor in women with premature membrane rupture. The benefits, to both mother and fetus, of a shorter latent period are discussed.

Adult↗

The relationship of maternal anxiety, plasma catecholamines, and plasma cortisol to progress in labor.

The relationships among maternal anxiety, selected stress-related biochemical factors, and progress in three defined phases of labor were determined for 32 married, normal, primigravid women, 20 to 32 years of age. Comparisons of plasma epinephrine, norepinephrine, and cortisol in third-trimester pregnancy, during labor, and after delivery are provided. At the onset of Phase 2 of labor (3 cm. of cervical dilatation), self-reported anxiety and endogenous plasma epinephrine are significantly correlated. With the deletion of subjects to control for the effect of medications, higher epinephrine levels are significantly associated with lower uterine contractile activity at the onset of Phase 2 and with longer labor in Phase 2 (3 to 10 cm. of cervical dilatation). The relationship between epinephrine and progress in labor is explained by an adrenoreceptor theory.

Adult↗

The length of active labor in normal pregnancies.

OBJECTIVE: To measure the length of active labor (first and second stages) in a low-risk population of non-Hispanic white, Hispanic, and American Indian women, and to identify any differences among these ethnic populations. METHODS: Descriptive statistics are presented for 1473 low-risk women at term who delivered at the University of New Mexico Hospital. Data examined by ethnicity included demographics, intrapartum care and complications, and duration of the active-phase first stage (4 cm to complete cervical dilatation) and second stage (complete cervical dilatation to delivery) of labor. RESULTS: Compared with Friedman's criteria, 20% of these low-risk women had a prolonged active phase of the first stage, and 4% had a prolonged second stage, without excess maternal or infant morbidity. The mean length of active-phase, first-stage labor was 7.7 hours for nulliparas and 5.7 hours for multiparas (statistical limits 19.4 and 13.7 hours, respectively), with no differences according to ethnic group. The mean length of second stage was 53 minutes for nulliparas and 17 minutes for multiparas (statistical limits 147 and 57 minutes, respectively). American Indian nulliparas had significantly shorter second stages than non-Hispanic white women (P < .05). CONCLUSION: Active labor in healthy women lasted longer than is widely appreciated. Upward revision of clinical expectations for the length of active labor is warranted.

Adult↗

Length of normal labor in women of Hispanic origin.

Emanuel Friedman in the 1950s established means and statistical guidelines for normal lengths of labor. The childbearing population in the United States has changed considerably since Friedman's research was conducted. This study documented the duration of labor in a cohort of 240 Hispanic women who had normal vaginal births of singleton term infants from January 1995 through December 1998 and compared these results with the mean duration of the first and second stages of labor as established by Friedman. The mean duration of the active phase first stage labor duration for nulliparous Hispanic women was 6.2 hours, and for multiparous Hispanic women was 4.4 hours, both significantly longer than Friedman's group (P <.01). The mean duration of the second stage of labor in nulliparous Hispanic women was 54.2 minutes and for multiparous Hispanic women was 22.2 minutes, not significantly different from Friedman's group (P =.5 and P =.09, respectively).

Adolescent↗

Effect of epidural vs parenteral opioid analgesia on the progress of labor: a meta-analysis.

CONTEXT: Epidural labor analgesia, if selected by the patient, is associated with high cesarean delivery rates. Results of randomized trials comparing rates of cesarean delivery using epidural anesthesia vs parenteral opioids are inconsistent. OBJECTIVE: To review the effects of epidural vs parenteral opioid analgesia on cesarean delivery rates. DATA SOURCES: Studies were identified by searching MEDLINE from January 1966 through January 1998, the Cochrane Database of Perinatal Trials, and relevant nonindexed journals and abstracts. STUDY SELECTION: We included all studies that randomized patients to epidural vs parenteral opioid labor analgesia. DATA EXTRACTION: Two authors independently extracted data from 10 trials enrolling 2369 patients. Odds ratios (ORs) for categorical data, weighted mean differences (WMDs) for continuous data, and 95% confidence intervals (CIs) were calculated using a random-effects model. DATA SYNTHESIS: The risk of cesarean delivery did not differ between patients receiving epidural (8.2%) vs parenteral opioid (5.6%) analgesia (OR, 1.5; 95% CI, 0.81-2.76). Epidural patients had longer first (WMD, 42 minutes; 95% CI, 17-68 minutes) and second (WMD, 14 minutes; 95% CI, 5-23 minutes) labor stages. While epidural patients were more likely to have instrumented delivery (OR, 2.19; 95% CI, 1.32-7.78), they were no more likely to have instrumented delivery for dystocia (OR, 0.68; 95% CI, 0.31-1.49). After epidural analgesia, neonates were less likely to have low 5-minute Apgar scores (OR, 0.38; 95% CI, 0.18-0.81) or to need naloxone (OR, 0.24; 95% CI, 0.07-0.77). Women receiving epidural analgesia had lower pain scores during the first (WMD, -40 mm on a 100-mm scale; 95% CI, -42 to -38 mm) and second (WMD, -29 mm; 95% CI, -38 to -21 mm) stages of labor. The odds of dissatisfaction were lower with epidural analgesia (OR, 0.25; 95% CI, 0.20-0.32). CONCLUSIONS: Epidural labor analgesia is not associated with increased rates of instrumented vaginal delivery for dystocia or cesarean delivery. Patients receiving epidural analgesia have longer labors. Patient satisfaction and neonatal outcome are better after epidural than parenteral opioid analgesia.

Analgesics, Opioid↗

A double-blind randomized trial of two dose regimens of misoprostol for cervical ripening and labor induction.

OBJECTIVES: The objective of this study was to compare the efficacy and safety of two dosing regimens of misoprostol for cervical ripening and labor induction. METHODS: Patients who fulfilled the study criteria were randomized to received misoprostol 25 microg or 50 microg intravaginally every 3 h for a total of eight doses for cervical ripening or until labor was established. Endpoints for successful cervical ripening was achievement of Bishop score of nine or greater, and for labor induction reaching the active phase of labor in the first 24 h. The rates of success, duration of first and second stages of labor, type of delivery, significant side effects, and neonatal outcome were measured and compared between the two study groups. Two hundred and fifty-one patients were randomized in two groups--126 received 50 microg and 125 received 25 microg misoprostol. Demographics of the two study groups were similar. RESULTS: Patients in the 50 microg group had a shorter first stage (848 min vs. 1,122 min, P < 0.007), shorter induction-to-vaginal delivery interval (933 min vs. 1,194 min, P < 0.013), decreased incidence of oxytocin augmentation (53.9% vs. 68%, P < 0.015), and decreased total units of oxytocin (2,763 mU vs. 5,236 mU, P < 0.023), but there was a higher hyperstimulation rate (19% vs. 7.2%, P < 0.005). CONCLUSIONS: Successful induction rate, delivery types, and fetal outcome were similar in both groups. Although the rate of vaginal delivery and neonatal outcome were similar in both groups, the 50 microg regimen had shorter first and second stages of labor, and a higher hyperstimulation rate that was easily manageable, allowing for flexibility in using the higher dose in low-risk pregnancies.

Adult↗

A technique for the induction of labor by the extraovular administration of prostaglandin F2alpha.

Prostaglandin F2alpha (PG F2alpha) was administered to pregnant women at a dosage of 50 microng or 100 microng by extraovular route around the expected time of childbirth in order to induce labor. (1) PG F2alpha 50 microng or 100 microng dissolved in 10 ml of physiological saline solution was infused by extraovular administration through the cervical canal of the uterus with the use of Nelaton catheter No. 9. The catheter was then immediately withdrawn and the patient allowed to return home. (2) Instilation of 10ml of physiological saline solution was carried out for control purposes. (3) Those who reported labor contractions within 24 hours after the infusion were regarded as cases of excellent response, and those who reported labor contractions more than 24 hours after the infusion, or those who showed dilatation and improvement in effacement of the uterine cervical canal though without the occurrence of labor contractions were deemed to be cases of good response. The overall positive response rate (excellent plus good) was 78.9% for primiparae and 85.7% for multiparae in the group receiving 50 microng and 89.5% for primiparae and 100% for multiparae in the group receiving 100 microng. (4) Labor contraction were induced at a rate of almost 100% in those who showed dilatation of the cervical canal of the uterus to the extent of 3 cm or more and effacement to the extent of 50% or more. (5) It is advisable to perform reinfusion of PG F2alpha or instilation of PG F2alpha as a post-treatment in patients with good responses. (6) The infusion of PG F2alpha is effective for the induction of labor in older primiparae, cases of breech presentation and suspected cases of CPD. (7) There were some cases of enhanced response when PG F2alpha was given as posttreatment.

Cervix Uteri↗

Changes in fetal hemodynamics with terbutaline treatment and premature labor.

The aim of this study was to examine the fetal hemodynamic effects of terbutaline treatment and premature labor. Image-directed pulsed and continuous wave Doppler ultrasound studies, using 3.3-MHz and 5-MHz transducers (GE PASII and ATL echocardiographic machines), were used to assess fetal cardiac blood velocities in three groups of pregnancies matched for menstrual age (MA). Group 1: 13 normal pregnancies, mean MA 31 weeks. Group 2: 7 women in premature labor prior to tocolytic therapy, mean MA 32 weeks. Group 3: 8 women treated with terbutaline, average dose 18.8 mg daily, for previous premature labor, mean MA 31 weeks. Heart rate averaged 150 bpm, 135 bpm, and 127 bpm in the terbutaline, premature labor, and normal groups, respectively, and each were significantly different from each other. Products of time velocity interval and heart rate at the aortic valves were 1603 cm +/- 140 cm, 1413 cm +/- 190 cm and 1238 cm +/- 200 cm, and at the mitral valves 1102 cm +/- 170 cm, 812 cm +/- 110 cm, and 878 cm +/- 150 cm in the terbutaline, premature labor, and the normal groups, respectively. Aortic and mitral blood velocity products of time velocity integrals and heart rates were significantly higher (p = 0.01) in the terbutaline group relative to the normal group. In addition, the terbutaline group was significantly higher than the labor group at the mitral valve (p = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Flow Velocity↗

Explaining the pain of active labor: the importance of maternal confidence.

This study was designed to investigate the relationships between the perception of pain during active labor and nine predictor variables: age, parity, childbirth preparation, state anxiety, confidence in ability to handle labor, concern regarding the outcome of labor, fear of pain, cervical dilatation and frequency of uterine contractions. The sample included 134 low-risk women at term with a normal singleton pregnancy. Standard and stepwise regression was used to examine the ability of the selected variables to explain the variance in the sensory, affective, and evaluative components of pain as measured by the subscales of the Pain Rating Index of the McGill Pain Questionnaire. Although significant proportions of variance were explained for each component of pain, the study variables were most powerful in their ability to explain the variance in the affective component of active labor pain. The stepwise analysis suggested that of the nine variables, confidence in ability to handle labor was the most significant predictor of all components of pain during active labor.

Adolescent↗

Sonographic cervical length in singleton pregnancies with intact membranes presenting with threatened preterm labor.

OBJECTIVE: Less than 10% of women presenting with preterm contractions progress to active labor and delivery. This study investigates whether cervical length measurements by ultrasound can discriminate between true and false labor in women presenting with threatened preterm labor. METHODS: Cervical length was measured by transvaginal ultrasound in 253 women with singleton pregnancies presenting with painful uterine contractions at a median age of 31 (range, 24-35) weeks of gestation. Women presenting in active labor, defined by the presence of cervical dilatation of >or = 3 cm, those with ruptured membranes and those that underwent prior or subsequent cervical cerclage were excluded from the study. The clinical management was determined by the attending obstetrician without taking into account the cervical length. Primary outcome of the study was delivery within 7 days of presentation based on the results of randomized studies on the use of tocolytics in women with preterm labor that reported a prolongation of pregnancy by 7 days. RESULTS: Delivery within 7 days of presentation occurred in 21/253 (8.3%) pregnancies and this was inversely related to cervical length. Receiver-operating characteristics (ROC) curves established a cervical length of 15 mm as the most relevant cut-off level for the prediction of preterm delivery within 7 days. In 217 cases the cervical length was > or = 15 mm and only four of these (1.8%) delivered within 7 days. In the 36 women with cervical length < 15 mm, delivery occurred in 17 (47.2%) within 7 days. Logistic regression analysis demonstrated that significant independent contribution in the prediction of delivery within 7 days was provided by cervical length, contraction frequency at presentation, previous history of preterm delivery and vaginal bleeding. There was no significant contribution from gestation at presentation, ethnic origin, maternal age, parity, cigarette smoking or the administration of tocolysis, antibiotics or steroids. Similar results were shown in a subanalysis of 162 patients presenting at a gestational age below 32 weeks: 9/19 patients (47.4%) with a cervical length below 15 mm delivered within 7 days compared to 3/143 (2.1%) with a cervical length > or = 15 mm. Univariate as well as multivariate analyses confirmed cervical length to be a significant independent predictor of delivery within 7 days in this population. CONCLUSIONS: Sonographic measurement of cervical length helps to avoid overdiagnosis of preterm labor in women with preterm contractions and intact membranes.

Adolescent↗

Ultrasound detection of nuchal cord prior to labor induction and the risk of Cesarean section.

OBJECTIVES: To investigate the ability of ultrasound to detect the presence of a nuchal cord immediately prior to induction of labor and the association of its presence with delivery by Cesarean section. METHODS: A transabdominal ultrasound scan using gray-scale and color Doppler imaging was performed immediately prior to induction of labor in 289 women in a prospective study to assess the presence of a nuchal cord. The presence of a nuchal cord was classified as present, absent or uncertain. The outcomes of labor, delivery and the neonates were obtained from the patient notes after delivery. RESULTS: A nuchal cord was present at 18% of deliveries. The incidence was not affected by parity, fetal position or reduced amniotic fluid volume. The sensitivity of ultrasound in diagnosing a nuchal cord was 37.5%, with specificity, positive and negative predictive values of 80%, 29% and 85%, respectively. The presence of a nuchal cord did not significantly increase the risk of delivery by Cesarean section (35% vs. 28%; relative risk = 1.22; 95% CI, 0.80-1.87), instrumental delivery for fetal distress, an abnormal cardiotocograph in labor or at delivery, an Apgar score < 7 at 1 min, arterial cord pH < 7.1 or neonatal unit admission. CONCLUSIONS: The sensitivity of the ultrasound diagnosis of a nuchal cord is low prior to induction of labor at term. A nuchal cord does not appear to increase the risk of Cesarean section or of poor neonatal outcome. The low ultrasound detection rate of a nuchal cord limits its use in decision making prior to induction of labor in high-risk pregnancies.

Cesarean Section↗

Sonographic assessment of the cervix before, during and after a uterine contraction is effective in predicting the course of labor.

OBJECTIVE: To investigate whether the degree of change in cervical length during a uterine contraction is predictive of subsequent progression of labor. METHODS: The subjects were 73 uncomplicated parturient women at term. We observed the cervix before, during and after a uterine contraction by transvaginal ultrasound in the first stage of labor and determined the degree of cervical shortening during the contraction relative to the cervical length before contraction. We related the degree of cervical shortening to labor patterns at the time of the ultrasound examination, which were retrospectively determined by reviewing the partogram. RESULTS: The cervix was shortened in length by about 50% on average during a uterine contraction in the normal course of labor. The degree of cervical shortening was significantly greater in the normal latent and active phases than it was in the prolonged latent phase, protracted active phase and false labor, whereas there were no differences between the former two phases nor between the latter three phases. Nulliparous and parous women exhibited almost the same degree of shortening in the normal latent and active phases. CONCLUSIONS: Real-time ultrasound observation of the cervix during uterine contraction could help differentiate inefficient uterine contractions from normal ones and thus predict the subsequent course of labor.

Adolescent↗

Study of the third stage of labor by color Doppler sonography.

We wanted to evaluate whether improvement in ultrasound equipment in the last 5 years altered our perception of the phases of placental separation during the third stage of labor. We also investigated the influence of active management on the third stage of labor after sonographically verified placental separation. Between January and November 2001, the third stage of labor was examined in 55 women at 37-41 weeks of gestation by color Doppler sonography. The duration of blood flow between the myometrium and the placenta, the latent phase, the detachment phase, and the expulsion phase were measured and compared with the corresponding values of an earlier cohort of 57 patients investigated between November 1994 and August 1995. In the later cohort, both the duration of maternal blood flow and the detachment phase were significantly longer than in the earlier cohort (33 s +/- 48 s vs 0 s, P<0.0001 and 56 s+/-45 s vs 37 s+/-21 s, P<0.01, respectively), whereas the latent phase was significantly shorter (101 s+/-87 s vs 213 s+/-180 s, P<0.0001). There was no statistically significant difference in the length of the expulsion phase or the third stage of labor. The later cohort showed a statistically significantly more frequent multiphasic placental detachment ( P<0.05). Improvement in ultrasound equipment resulted in an earlier detection of the onset of placental separation, leading to a shorter latent phase and consecutively increased duration of the detachment phase, whereas the total duration of the third stage of labor remained unchanged. Furthermore, increased sensitivity of Doppler sonography led to a longer visualization of blood flow between the myometrium and the placenta in the normal third stage of labor.

Adult↗

Changes in amino acids and nitric oxide concentration in cerebrospinal fluid during labor pain.

This study analyzes the relationship between amino acids and pain perception during active labor. Cerebrospinal fluid (CSF) levels of the excitatory amino acids (EAAs)-glutamate, aspartate and their amide forms, inhibitory amino acids (IAAs)-glycine, gamma-amino butyric acid (GABA) and taurine and nitric oxide (NO) related compounds-arginine and citrulline (by-product of NO synthesis) were compared between pregnant women at term pregnancy with labor pain (n = 38) and without labor pain (Caesarian section; n = 30). The levels of aspartate, glycine, GABA and citrulline were significantly higher; whilst taurine was significantly lower in the labor pain group. These findings suggest that aspartate and NO are associated with labor pain. An inhibitory role for the IAA taurine and a pronociceptive role for glycine in labor pain are proposed.

Amino Acids↗