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PubMed2001

The prediction and prevention of intrapartum fetal asphyxia in term pregnancies.

OBJECTIVE: This study was undertaken to examine the roles of clinical risk scoring, electronic fetal heart rate monitoring, and fetal blood gas and acid-base assessment in the prediction and prevention of intrapartum fetal asphyxia in term pregnancies. STUDY DESIGN: The outcomes of 166 term pregnancies with biochemically confirmed fetal asphyxia (umbilical artery base deficit at delivery, >12 mmol/L) were examined. This population included 83 pregnancies delivered abdominally matched with 83 pregnancies delivered vaginally. Antepartum and intrapartum clinical risk factors and neonatal complications were documented. Fetal assessments included fetal heart rate patterns in the fetal heart rate record and fetal capillary blood gas and acid-base assessments. Fetal asphyxia was classified as mild, moderate, or severe on the basis of umbilical artery base deficit (cutoff >12 mmol/L) and neonatal encephalopathy and other organ system complications. RESULTS: Fetal asphyxial exposures were as follows: mild, 140; moderate, 22; and severe, 4. Intervention and delivery during the first or second stage of labor occurred in 98 of the 166 pregnancies. Predictive fetal heart rate patterns were the primary indication leading to intervention and delivery during the first or second stage of labor. Clinical risk factors when present were secondary indications in the clinical decision to intervene. Fetal blood gas and acid-base assessment was a useful supplementary test in 41 pregnancies. Intervention and delivery may have prevented the progression of mild asphyxia in 78 pregnancies and may have modified the degree of moderate or severe asphyxia in 20 pregnancies. CONCLUSION: Although fetal heart rate patterns will not discriminate all asphyxial exposures, continuous fetal heart rate monitoring supplemented by fetal blood gas and acid-base assessment can be a useful fetal assessment paradigm for intrapartum fetal asphyxia. Such an assessment paradigm will not prevent all cases of moderate or severe fetal asphyxia. However, prediction and diagnosis with intervention and delivery during the first or second stage of labor could prevent the progression of mild asphyxia to moderate or severe asphyxia in some cases.

Acid-Base Imbalance↗
PubMed2000

Ropivacaine, 0.1%, plus sufentanil, 0.5 microg/ml, versus bupivacaine, 0.1%, plus sufentanil, 0.5 microg/ml, using patient-controlled epidural analgesia for labor: a double-blind comparison.

BACKGROUND: This study compared the administration of 0.1% ropivacaine and 0.5 microg/ml sufentanil with that of 0.1% bupivacaine and 0.5 microg/ml sufentanil via patient-controlled epidural analgesia route during labor. METHODS: Two hundred healthy pregnant women at term with a single fetus with a vertex fetal presentation were randomized in a double-blind fashion to receive either 0.1% ropivacaine and 0.5 microg/ml sufentanil or 0.1% bupivacaine and 0.5 microg/ml sufentanil using a patient-controlled epidural analgesia pump (5-ml bolus dose, 10-min locked-out period, no basal infusion). Pain score on a visual analog scale, Bromage score (0-3), level of sensory block, patient-controlled epidural analgesia ratio, drug use, supplemental boluses, and side effects were recorded at 30 min and then hourly. Mode of delivery, duration of first and second stages of labor, umbilical cord pH, Apgar scores of the newborn, and a measure of maternal satisfaction were recorded after delivery. RESULTS: No differences were seen between the two groups for pain scores on a visual analog scale during labor, volume of anesthetic solution used, mode of delivery, or side effects. Motor block during the first stage of labor was significantly less in the ropivacaine group than in the bupivacaine group (no motor block in 97.8 of patients vs. 88.3%, respectively; P < 0.01). Duration of the second stage of labor was shorter in the ropivacaine group (1.3 +/- 1.0 vs. 1.5 +/- 1.2 h [mean +/- SD]; P < 0.05). Maternal satisfaction was greater in the bupivacaine group (91 +/- 13 mm for contraction, 89 +/- 19 mm for delivery on a visual scale: 0 = not satisfied at all, 100 = fully satisfied) than in the ropivacaine group (84 +/- 21 and 80 +/- 25 mm; P < 0.0001). Patients in the ropivacaine group requested more supplemental boluses to achieve analgesia during the second stage of labor than those in the bupivacaine group (29.7 vs. 19.8%, respectively, requested one or more supplemental boluses; P < 0.05). CONCLUSIONS: Delivered as patient-controlled epidural analgesia, 0.1% ropivacaine and 0.5 microg/ml sufentanil produce less motor block but are clinically less potent than 0.1% bupivacaine and 0.5 microg/ml sufentanil.

Adult↗
PubMed2006

Water birth, more than a trendy alternative: a prospective, observational study.

OBJECTIVE: To prospectively assess the effect of water birth on maternal and fetal outcomes in a selected low-risk collective of a tertiary obstetrical unit. METHOD: In this prospective observational study, 513 patients of a low-risk collective, who requested a water birth, were studied during the years 1998-2002. Primary outcome measurements included the maternal and fetal parameters. Secondary outcome measurements comprised data on the incidence of water births in an interested, low-risk population in an academic hospital. RESULT: All groups were similar in terms of demographic and obstetric data. Significant differences were observed in maternal outcome parameters, which included the use of analgesia/anesthesia during labor, the duration of first and second stages of labor, perineal tears and episiotomy rate. No differences were seen in all observed fetal outcome parameters including APGAR scores, arterial and venous pH, admission rate to neonatal intensive care unit and infection rate. CONCLUSION: Water birth is a valuable and promising alternative to traditional delivery methods. The maternal and fetal outcomes were similar to traditional land births. However, currently there still exist some deficits in the scientific evaluation of its safety. Therefore, the selection of a low-risk collective is essential to minimize the risks with the addition of strictly maintained guidelines and continuous intrapartum observation and fetal monitoring. Based on our results and the literature, water births are justifiable when certain criteria are met and risk factors are excluded.

Apgar Score↗
PubMed1993

Effect of intravenous beta-sympathomimetic tocolysis on human fetal serum erythropoietin levels.

OBJECTIVE: The major stimulus for erythropoietin production is tissue hypoxia. We sought to investigate the relationship of beta-sympathomimetic administration for tocolysis and fetal serum erythropoietin. STUDY DESIGN: Umbilical cord blood was obtained from infants whose mothers received intravenous beta-sympathomimetic tocolysis and who were delivered at < or = 34 weeks' gestation. Serum erythropoietin was measured by radioimmunoassay. On the basis of the presumed 2- to 4-hour half-life of fetal erythropoietin, the infants were divided into two groups. In group 1 (n = 16) beta-sympathomimetic therapy was discontinued < 24 hours before delivery; in group 2 (n = 11) it was discontinued > or = 24 hours before delivery. RESULTS: Group 1 fetuses had significantly higher erythropoietin levels than did group 2 fetuses (37.3 vs 13.9 mU/ml, p = 0.02). The duration of beta-sympathomimetic tocolysis and the maximum infusion rate were not different. The two groups did not differ in gestational age, birth weight, route of delivery, presence of labor, or duration of first or second stage of labor. CONCLUSIONS: We speculate that intravenous beta-sympathomimetic tocolytic therapy stimulates fetal erythropoietin production by decreasing fetal oxygenation as a result of the reversible fetal metabolic effects of the tocolysis. These data suggest that beta-sympathomimetic tocolysis should be undertaken cautiously if fetal compromise is suspected, fetal well-being should be assessed carefully if tocolysis is undertaken, and treatment should be discontinued promptly if a clear benefit is not realized.

Erythropoietin↗
PubMed1994

The experience of two-epidural-catheter for painless labor.

'Two epidural-catheters' method was used to relieve labor pain during the first and second stage of labor course. Six milliliters of a mixture of '0.15% bupivacaine +0.03% xylocaine +0.0005% fentanyl' was the main agent given through the epidural catheter every 2 hours when the cervix was 3-4 cm dilated with 4 ml of 1% xylocaine as test dose. Addition doses of the mixture were given when needed. Fifty two, ASA I-II, parturients (primigravida: 43, multipara: 9) were included in this study. The mode of delivery was: 59.6% by vacuum, 36.4% by normal spontaneous delivery (NSD), and 4% by Cesarean Section (C/S). 88.5% of newborns had Apgar score > or = 7 at 1 minute and all had Apgar score > or = 7 at 5 minutes. 38(73%) of 52 parturients were fully satisfied with the analgesic effect during the whole labor course and 14(27%) of 52 parturients were partially satisfied with the analgesic effect owing to 1) intolerable lower abdominal pain (11 cases), 2) mild painful episiotomy (1 case), and backache (2 cases). No motor block was noted. Good analgesic effect during the second stage labor course could be obtained by our 'Two-Epidural-Catheter' method and no significant complications of newborns and parturients were noted in our study.

Adolescent↗
PubMed1977

Steroid hormone changes in fetal blood during labor.

Radioimmunoassays of pregnenolone, progesterone, dehydroepiandrosterone (DHA) 16 alpha-hydroxy-DHA, estriol, and cortisol were performed on a total of 0;1 ml; of fetal plasma, collected during the course of normal vaginal delivery. The mean hormone concentrations +/- standard errors of fetal blood in the first and second stages of labor and of the umbilical arterial and venous blood at delivery were as follows: pregnenolone, 0.53 +/-0.06, 1.13 +/- 0.16, 1.48 +/- 0.14, and 1.34 +/- 0.27 micrograms per milliliter; progesterone, 0.12 +/- 0.01, 0.14 +/- 0.01, 0.26 +/- 0.02, and 0.34 +/- 0.02 micrograms per milliliter; DHA, 0.98 +/- 0.11, 0.94 +/- 0.08, 1.51 +/- 0.25, and 1.23 +/- 0.11 micrograms per milliliter; 16 alpha-hydroxy-DHA, 1.54 +/- 0.22, 1.49 +/- 0.31, 2.27 +/- 0.25, and 1.82 +/- 0.21 micrograms per milliliter; cortisol, 1.82 +/- 0.15, 1.91 +/- 0.24, 2.39 +/- 0.19, and 2.35 +/- 0.17 micrograms per milliter; cortisol, 0.11 +/- 0.01, 0.09 +/- 0.01, 0.16 +/- 0.02, and 0.14 +/-0.01 micrograms per milliliter. Except for cortisol, the levels in the fetal blood of all the steroids studied rose significantly at delivery of the infant, when compared to the titers in the first stage of labor. During delivery, increased titers of pregnenolone and DHA, steroids which are of fetal adrenal origin, suggest enhanced adrenal activity during the final phase of labor.

Adrenal Cortex Hormones↗
PubMed1994

The role of continuous background infusions in patient-controlled epidural analgesia for labor and delivery.

The use of a background infusion with intravenous patient-controlled analgesia (IV-PCA) increases drug consumption without any additional contribution to analgesia. There are no data on the potential advantage of a background infusion administered with patient-controlled epidural analgesia (PCEA) for labor and delivery. Sixty women were randomized to one of four groups and received either: (a) demand dose PCEA (demand dose = 3 mL; lockout interval = 10 min); (b) continuous infusion plus demand dose PCEA (two separate infusion rates: 3 mL/h and 6 mL/h); or (c) a fixed-rate continuous epidural infusion (CEI) at 12 mL/h. All patients received 0.125% bupivacaine with 2 micrograms/mL of fentanyl. The study protocol was double-blind and placebo-controlled. Visual analog pain scores, motor strength, and bilateral pinprick analgesia were assessed every half hour by a blinded observer. Pain scores, cephalad extent of sensory analgesia, and motor block were no different among the study groups during the first and second stages of labor. Cumulative hourly bupivacaine use was similar among all PCEA study groups. However, use of PCEA (in whatever mode) provided a 35% dose-sparing effect in comparison to CEI. The PCEA groups receiving no background infusion or a 3-mL/h background infusion had a greater need for physician-administered supplemental bupivacaine during the first stage of labor. While not statistically significant, a trend toward increased need for supplementation was seen in these same patient groups over the entire course of labor and delivery.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1997

[Clinical study on shortening the birth process using psychological suggestion therapy].

To investigate the effect of psychological suggestion therapy on the birth process, a specially designed, prospective study of psychological suggestion ("insubstantial comfort") was undertaken in 120 healthy, full-term primipara with singleton pregnancy and cephalic presentation. All cases were randomly divided into 2 groups, the birth processes and final modes of delivery were analyzed in 60 cases interfered with the psychological suggestion therapy and 60 cases with spontaneous birth processes as control group. The results showed that a significant shorter time of the first and second stages of labor in the study group than that in the control group (P < 0.01). Based on this study, it is suggested that the conversation concerning about the evaluation of individual birth process between the mother-to-be and nurse should be controlled carefully for the purpose of advancing of birth process. The nurse should apply the psychological suggestion therapy during the birth process, specially when answering the question raised by mother-to-be about the quantity of the cervical dilataion. It is also suggested that the purpose of the rectal examination taking during the first stage of labor should be given some kind of meaning of psychotherapy.

Autosuggestion↗
PubMed1989

Pulsatile administration enhances the effect and reduces the dose of oxytocin required for induction of labor.

Pulsatile administration of oxytocin was compared with continuous infusion of oxytocin for induction of labor in pregnant rats. The dosages consisted of intravenous injections of 0, 2.5, and 5 mU oxytocin every 10 minutes and intravenous infusion of 1 mU/minute of oxytocin in 0.9% sodium chloride. These doses are within the range of endogenously secreted pulses. All treatments began on day 22 at 2 p.m. and continued for 8 hours. Pulsatile administration resulted in a marked reduction in the dose of oxytocin required to induce labor. Using 5 mU pulses, birth was induced with 18.4%, and using 2.5 mU pulses, with 24% of the dose needed using continuous infusion. Parturition was advanced by 12 hours on the average by oxytocin treatment, but no significant differences were observed between the various oxytocin dosage regimens in this regard or in regard to gestation length, induction-delivery interval, duration of delivery, or the proportion of living or dead pups. Significantly more uterine activity was induced with each mU of oxytocin using pulsatile administration than using continuous infusion. There was no evidence for down-regulation of oxytocin receptors during a continuous infusion of oxytocin. We postulate that the greater efficacy of oxytocin pulses to induce uterine activity and delivery in comparison to continuous infusions is due to a more effective stimulation of prostaglandin F2 alpha release from the decidua. The amount of oxytocin needed for induction of labor with 2.5 mU pulses was similar to the decrease in neurohypophyseal oxytocin content during the first stage of spontaneous labor, and uterine activity elicited was also similar to that observed during spontaneous labor.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed2000

Epidural PCA with bupivacaine 0.125%, sufentanil 0.75 microgram and epinephrine 1/800.000 for labor analgesia: is a background infusion beneficial?

Eighty term parturients requesting epidural analgesia for labor pain treatment were randomly assigned to receive bupivacaine 0.125%, sufentanil 0.75 microgram/ml and epinephrine 1/800.000 by PCA modality with or without a basal rate of 3 ml/hr. A loading of 10 ml using the same mixture was administered while the PCA-demand dose consisted of 3 ml (lock out time 12 minutes). Total consumption, duration of labor, pain scores during the first and second stage of labor, maternal satisfaction and side-effects did not differ among both groups. Only when short labours were considered total consumption was lower in those treated with the demand modality only but they tended to experience more pain during the second stage. We conclude that for shortlasting labors, a low dose epidural PCA regimen results in a dose-sparing effect when compared to PCEA combined with a background infuson. For longer-lasting labors no differences between the two modalities could be observed.

Adult↗
PubMed2006

[The effect of immersion baths on the length of childbirth labor].

The objectives of this experimental, randomized, controlled trial study were to evaluate the effect of immersion baths on the length of the first stage of childbirth labor and on the frequency and length of the uterine contractions. Data were collected in a philanthropic public maternity hospital of the city of São Paulo whose month average is 1,100 births. The sample was comprised of 108 women in labor--54 in the control group and 54 in the experimental group that had immersion baths. The results showed that immersion baths did not have any influence on the length of labor and on the frequency of uterine contractions. However, the length of contractions was statistically shorter in the experimental group (experimental 41.9 versus control 44.6 min). The conclusion was that immersion baths are an alternative for the woman's comfort during labor, since it provides relief to her without interfering on the labor progression or jeopardizing the baby.

Baths↗
PubMed1994

Blunt versus sharp expansion of the uterine incision in low-segment transverse cesarean section.

OBJECTIVE: Both blunt and sharp expansion of the initial incision at transverse cervical cesarean birth have advocates, on the basis of theoretic concerns. We sought to study the incidence of complications, including unintended extension, associated with each of these methods by comparison by means of a prospective, randomized study. STUDY DESIGN: Women scheduled to undergo nonemergency cesarean birth were assigned to blunt and sharp expansion groups. Other than expansion of the incision, standard technique was used throughout surgery. Data, including length and number of unintended extensions, vessel laceration, and length of surgery, were recorded immediately. RESULTS: The blunt (n = 139) and sharp (n = 147) expansion groups were similar with regard to indication and duration of labor. No difference in the incidence of unintended extension, postoperative endometritis, duration of surgery, or estimated blood loss was noted. The frequency of unintended extension (1.4%, 15.5%, and 35.0% for no labor and first and second stages, respectively) correlated with the stage of labor. CONCLUSION: Blunt and sharp expansions of the uterine incision are equivalent in ease and safety.

Adult↗
PubMed1999

Early amniotomy -- high risk factor for cesarean section.

OBJECTIVE: To evaluate the effect of early amniotomy on mode of delivery and pregnancy outcome in comparison to a group of patients admitted with premature rupture of membranes at term. STUDY DESIGN: The study population consists of all women (n=338) whose labor was induced by amniotomy, between the years 1988 to 1995. The comparison group were all women (n=1865) who were admitted with premature rupture of membranes during the same period. RESULTS: Cesarean section was significantly higher in the amniotomy group than in the comparison group (162 (47.9%) vs. 348 (18.7%), P<0.001). This significant difference was noted only for those who did not had a previous cesarean section (106 (42.4%) vs. 224 (13.8%), P<0.001). Non progressive labor during the first stage was threefold higher in the amniotomy group than in the control group (30.8% vs. 10.9%, P<0.001). Abnormal fetal heart rate patterns were detected during labor in 52 patients (15.4%) of amniotomy group, as compared to 141 cases (7.6%) in the control group (P<0.001). To assess the independent contribution of early amniotomy to having cesarean section in the present delivery, a multiple logistic model was used. Early amniotomy (odds ratio [OR] 3.07, 95% confidence interval [CI] 2.36-4.01), as well as a previous cesarean section (OR 5.04, 95% CI 3.90-6.52) and high parity (OR 1.07, 95% CI 1.03-1.26) were all found as independent risk factors for cesarean section. CONCLUSIONS: Early amniotomy appears to be associated with an increased risk for cesarean section.

Adult↗
PubMed2000

[The analysis of 135 water births].

DESIGN: The authors showed the results of the study of the influence of warm tub bath during delivery on 135 women. MATERIALS AND METHODS: In a prospective study 135 women bathed in a warm tub bath during first and second stage of labor after a strictly normal pregnancy, ending with spontaneous delivery at term. A control group consisted of 135 women fulfilling the same criteria, but who did not take the bath during labor. The newborns weight, their condition, perineum injury, time of first and second stage of delivery and number of periteotomies was analyzed. CONCLUSIONS: The observed features were undistinguishing.

Female↗
PubMed1989

Are there two biological parts in the second stage of labor?

In 228 patients, fetal blood pH, pCO2 and lactic acid were measured in two distinguishable parts of the second stage of labor. The 'first' part begins at full cervical dilatation and ends when the mother starts her first voluntary bearing down efforts. In our study, the fetal acid-base status did not change in this part, regardless of a late developing hypoxia. In contrast, higher levels of lactic acid and pCO2 and lower pH values were observed in the 'final' part of the second stage, indicating increasing acidosis. In this 'final' part, the fetuses with clinical signs of distress, as defined by an ominous Apgar score at birth, showed quicker and larger acid-base shifts than did the normal fetuses. Thus the two parts of the second stage of labor actually differ in their potential to stimulate fetal acidosis. Since such fetal acidosis may develop especially during the 'final' part of labor, we have concluded that special particular attention should be devoted to this part.

Acid-Base Equilibrium↗
PubMed1994

Sensory evoked facial muscle electromyography for the quantification of acute labor pain.

Assessment of the adequacy of epidural analgesia for acute pain management can be difficult on occasion. This investigation used non-invasive sensory evoked facial muscle electromyography (SEFE) as well as a Verbal Assessment Scores (VAS) to assess severe pain in healthy parturients during the first stage of active labor. Institutional Review Board approval and patient informed consent were obtained from 12 healthy parturients who were in active labor and who had requested epidural analgesia for labor pain. SEFE microvoltage was recorded prior to epidural placement when a patient reported severe pain and again when a patient reported no pain with a subsequent uterine contraction. VAS assessments (0 = no pain and 10 = the worst pain ever experienced) were also recorded at identical time intervals. Statistical analysis was done using the paired two tailed Student's t-test. Each patient served as their own control. A statistically significant decrease in SEFE microvoltage (p < 0.001) was noted when analgesia was established (VAS = 0) in each patient. It was concluded in this pilot study that SEFE can be effective in quantifying acute severe nociception and thus can provide a continuous objective indicator of the effectiveness of analgesic regimens in an acute obstetric pain setting. Its applicability in other acute pain areas remains to be investigated.

Acute Disease↗
PubMed1998

Fetal oxygen saturation and uterine contractions during labor.

Oxygen availability to the fetus during uterine contractions has not been widely reported. We examined whether fetal oxygen saturation (FSpO2) values and signal quality (SQ) were affected by uterine contractions. An intrauterine pressure catheter and a Nellcor FS14 fetal oxygen saturation sensor (Nellcor Puritan Bennett Inc., Pleasanton, CA) were placed transvaginally during the first stage of 17 labors. Fetal SPO2 and SQ units were recorded on a beat-to-beat basis and 10 sec averages of the data calculated over 25 contractions per patient. Five epochs were determined: (1) 30 sec prior to a contraction; (2) during a contraction; (3) 50 sec following completion of a contraction; (4) noncontraction periods, excluding epochs 1 or 3; and (5) equivocal, that is, overlap of epochs 1-3. Mean FSpO2 was lowest during epoch 3 (45.0) and highest during epoch 2 (47.3%) (p <0.001). This small difference is unlikely to be of any clinical significance, however. Mean signal quality was lowest in epoch 1 (42.8 units) and highest in epoch 4 (48.0 units) (p <0.05), that is, in noncontraction periods. We conclude that FSpO2 and SQ were unaffected by uterine contractions.

Female↗
PubMed1991

Safety of term vaginal breech delivery.

Of 247 women who were pregnant of one healthy child in breech presentation at term, 13 (5.3%) were delivered by a primary cesarean section. The other 234 (94.7%) were allowed to attempt vaginal birth. In these women, the only factor to determine the possibility of a vaginal delivery was normal progression of labor during the first stage, without secondary arrest or signs of fetal distress. 109 Women (44.1%) were delivered spontaneously according to Bracht, 87 (35.2%) had an assisted breech delivery, and 38 (15.4%) underwent a secondary cesarean section. There were two perinatal deaths (0.8%). One of them was directly related to the trial of labor. Two children with a birth trauma had an uneventful recovery. The 1 min Apgar score in all breech delivery groups was more often lower than in a control group of children, who were born spontaneously at term in vertex presentation. However, the 5 min Apgar score and the mean umbilical artery pH were within normal limits in all groups. The secondary cesarean section rate was inversely related to vaginal parity of the mother, and directly related to the newborns' birth weight. There was no relation between the secondary cesarean section rate and the type of breech presentation. It is concluded, that a trial of labor in carefully selected patients with a child in breech presentation at term is a safe procedure, that can be successfully completed in almost 80% of cases. In retrospect, low vaginal parity and high birth weight of the newborn have a negative influence on normal progression of labor.

Adult↗