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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↗
PubMed1993

The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial.

OBJECTIVE: Our purpose was to determine the effect of epidural analgesia on nulliparous labor and delivery. STUDY DESIGN: Normal term nulliparous women in early spontaneous labor were randomized to receive either narcotic or epidural analgesia. RESULTS: When compared with the group receiving narcotic analgesia (n = 45), the group receiving epidural analgesia (n = 48) had a significant prolongation in the first and second stages of labor, an increased requirement for oxytocin augmentation, and a significant slowing in the rate of cervical dilatation. Epidural analgesia was associated with a significant increase in malposition (4.4% vs 18.8%, p < 0.05). Cesarean delivery occurred more frequently in the epidural group (2.2% vs 25%, p < 0.05), primarily related to an increase in cesarean section for dystocia (2.2% vs 16.7%, p < 0.05). CONCLUSIONS: In a randomized, controlled, prospective trial epidural analgesia resulted in a significant prolongation in the first and second stages of labor and a significant increase in the frequency of cesarean delivery, primarily related to dystocia.

Adult↗
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↗
PubMed1999

Incidence and obstetric risk factors of postpartum anal incontinence.

BACKGROUND: Anal incontinence in young women may be the result of injury to the pelvic floor during vaginal delivery. This study was conducted to evaluate the relationship between obstetric risk factors and the prevalence of anal incontinence 3 months and 1 year after delivery. METHODS: Three hundred consecutive women who delivered in the obstetric ward of the Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, were prospectively interviewed 3 months postpartum with regard to the symptom of anal incontinence. Patients with anal incontinence that started after delivery were questioned about the type, frequency, and severity of the problem, concomitant stress urinary incontinence (SUI), previous colorectal assessment, and wish for further evaluation and treatment. Obstetric data were collected from the women's medical charts. Symptomatic patients were followed-up 1 year postpartum. RESULTS: Anal incontinence was reported by 21 patients: 19 were incontinent to gas, whereas only 2 patients were incontinent to solid feces (6.3% and 0.7% of the study population, respectively). Five patients (24% of the anal-incontinent patients) also had concomitant SUI. The length of the first and second stages of labor, operative vaginal delivery, and episiotomy were found to be associated (P < 0.05) with the development of anal incontinence at 3 months postpartum. At I year postpartum all patients with combined anal incontinence and SUI had persistent symptoms. CONCLUSION: The major obstetric risk factors for postpartum anal incontinence are prolonged first and second stages of labor, operative vaginal delivery, and the use of episiotomy.

Adult↗
PubMed1954

Infant survival in prematurity.

Reduction of neonatal mortality and the rate of stillbirth may be expected from improved management of spontaneous labor and delivery.Neither roentgenographic measurement nor the inception of fetal movement or heartbeat nor any other single test is an index of fetal maturity; all must be considered together. Prenatal care, particularly supplemented diet, will help to avoid premature delivery, or at least to prolong pregnancy; since the fetus undergoes accelerated growth during the last weeks of pregnancy, even slight extension of gestation increases the chances for survival. Analgesia in the first stage of premature labor is contraindicated. Only low spinal anesthesia and other types of conduction anesthesia should be employed for later stages. The fetal membranes should be preserved as long as possible, but premature rupture does not call for immediate termination of pregnancy. Deep episiotomy and prophylactic outlet forceps are routinely employed to hasten the second stage of premature delivery and to protect the immature fetus. Breech presentation is managed by unassisted expulsion or by forceps extraction of the head. The umbilical cord is not immediately severed on delivery; administration of oxytocic drugs after the second stage of labor, combined with gentle stripping of the cord, results in rapid transfer of increased amount of placental blood. The airways of the infant should be immediately cleared. Artificial respiration may be necessary and it must be gentle.All premature infants should receive supplementary oxygen to render breathing regular and more efficient. They should be insulated immediately in controlled temperature and humidity, and they should be handled little.

Breech Presentation↗
PubMed1998

The course of labor with and without epidural analgesia.

OBJECTIVE: Our purpose was to measure effects of epidural analgesia on labor compared with boluses of meperidine in a cohort of women with similar clinical circumstances. STUDY DESIGN: One hundred ninety-nine nulliparous women who were delivered spontaneously at term and who received oxytocin for labor augmentation before the initiation of analgesia were identified for analysis. All these women were managed in a low-risk labor unit according to a standardized protocol. This management protocol encouraged early amniotomy and the use of oxytocin when ineffective labor was diagnosed. RESULTS: The demographic characteristics of the two study groups were similar with respect to age, height, weight, and maternal age. The two groups had the same cervical dilatation on admission (3.3 cm) and at the time of analgesia administration (4.1 vs 4.2 cm), indicating similar progress of labor before oxytocin administration. The length of the active phase of labor was longer in the epidural group (7.9 vs 6.3 hours, p = 0.005), as was the second stage (60 vs 48 minutes, p = 0.03). The mean and maximal rates of oxytocin infusion were similar between the two study groups; however, the amount of oxytocin required for each centimeter of cervical change was more in the epidural group (22 vs 16 mU per cm of cervical change, p = 0.009). Neonatal outcomes were unaffected by the type of labor analgesia. CONCLUSION: Epidural analgesia decreases uterine performance during oxytocin-stimulated labor, resulting in an increase in the length of the first and second stages of labor.

Adolescent↗
PubMed2005

Using anovaginal distance at the beginning of labor to predict the likelihood of instrumental delivery.

OBJECTIVE: To investigate whether anovaginal distance in parturients has an impact on the instrumental delivery rate. STUDY DESIGN: In this study with prospective data collection and a convenience sample, 400 parturients planning for vaginal delivery at term with a singleton fetus in vertex presentation were enrolled. Anovaginal distance was measured in the lithotomy position during the latent phase of labor or early first stage. This distance is thought to reflect the angle of inclination of the birth canal axis. RESULTS: At the cutoff point of 25 mm for anovaginal distance, the odds ratio for instrumental delivery was 2.5 (95% CI 1.48-6.6, p<0.05). A final model of instrumental delivery, controlling for various confounding variables, correctly predicted 91.38% of the instrumental deliveries (p<0.0001). The variables anovaginal distance >25 mm (OR 2.9, 95% CI 1.2-6.7, p=0.01), parity (OR 0.54, 95% CI 0.29-0.99, p=0.046) and duration of second stage of labor (OR 1.01, 95% CI 1.004-1.01, p=0.001) significantly contributed to the prediction of instrumental delivery after controlling for the other parameters. CONCLUSION: Women with an anovaginal distance of >25 mm at the beginning of labor was 2.5 more likely to undergo instrumental delivery than were women with an anovaginal distance of <25 mm.

Adult↗
PubMed1990

Cerebral blood flow during labor in the human fetus.

A method is described for recording blood flow velocity waveforms from fetal cerebral vessels during labor, using a 2 MHz pulsed Doppler ultrasound technique. Fifteen healthy women with uncomplicated pregnancies and labor without signs of fetal distress participated in the study. With membranes ruptured and cervix orifice open 4-9 cm, the Doppler transducer was placed transvaginally on the fetal skull and the Doppler shift signals from the middle cerebral artery were located. The maximum velocity waveforms were recorded before, during and after uterine contractions and analysed off-line for pulsatility index (PI). No differences in the PI were found with regard to the uterine contractions. The results suggest an unchanged peripheral resistance in the fetal cerebral vascular bed during the first stage of normal labor.

Blood Flow Velocity↗
PubMed2005

Obstetrical parameters influencing the duration of the second stage of labor.

OBJECTIVE: To investigate the impact of parameters influencing the duration of the second stage of labor in vaginal deliveries. STUDY DESIGN: 1200 consecutive vaginal deliveries were analyzed. Descriptive statistics are reported for parity, duration of first and second stage of labor, maternal age, birth weight, position of the fetal head, epidural analgesia and oxytocin augmentation. Logistic regression analysis was performed to assess the contribution of different variables to the length of the second stage of labor. RESULTS: The mean length of the second stage was 70 min. In univariate analysis, parity, oxytocin augmentation and epidural analgesia, as well as occipito-posterior presentation were significant parameters associated with a prolonged second stage of labor. No correlation was found for birth weight and maternal age. In multivariate regression analysis, nulliparity and epidural analgesia were the strongest risk factors for a prolonged second stage. CONCLUSIONS: The impact of epidural analgesia on the second stage of labor should be considered in obstetrical management.

Adolescent↗
PubMed2005

Factors predicting severe perineal trauma during childbirth: role of forceps delivery routinely combined with mediolateral episiotomy.

OBJECTIVE: Anal sphincter injury and its sequelae are a recognized complication of vaginal childbirth. The aim of the present study was to identify risk factors for third- and fourth-degree perineal tears in patients undergoing either spontaneous or vaginal-assisted delivery by forceps routinely combined with mediolateral episiotomy. STUDY DESIGN: We retrospectively reviewed 5377 vaginal deliveries based on the analysis of the obstetric database and patient records of our department during a 5-year period from 1999 to 2003. Cases and control subjects were chosen randomly and patients' records were reviewed for the following variables: maternal age, parity, gestational age, tobacco use, gestational diabetes or pregnancy-induced hypertension, use of peridural anesthesia, duration of first and second stages of labor, use of mediolateral episiotomy, forceps combined with mediolateral episiotomy, induction of labor, infant head diameter, shoulder circumference, and birth weight. RESULTS: Of 5044 spontaneous vaginal deliveries 32 (0.6%) and of 333 assisted vaginal deliveries 14 (4.2%) patients sustained a perineal defect involving the external sphincter. An univariate analysis of these 46 cases and 155 randomly selected control subjects showed that low parity (P = .003; Mann-Whitney U test), prolonged first and second stages of labor (P = .001, P = .001), high birth weight (P = .031), episiotomy (P = .004; Fisher exact test), and forceps delivery (P = .002) increased the risk for sphincter damage. In multivariate regression models, only high birth weight (P = .004; odds ratio [OR] 1.68, 1.18-2.41, 95% confidence interval [CI]), and forceps delivery combined with mediolateral episiotomies (P < .001; OR 5.62, 2.16-14.62, 95% CI) proved to be independent risk factors. There was a statistical significant interaction of birth weight and head circumference (P = .012; OR 0.99, 0.98-0.99, 95% CI). Although the use of episiotomy conferred an increased risk toward a higher likelihood of severe perineal trauma, it did not reach statistical significance (P = .06; OR 2.15, 0.97-4.76, 95% CI). CONCLUSIONS: In consistence with previous reports, women who are vaginally delivered of a large infant are at a high risk for sphincter damage. Although the rate of these complications was surprisingly low in vaginally assisted childbirth, the use of forceps, even if routinely combined with mediolateral episiotomy, should be minimized whenever possible.

Adult↗
PubMed1994

The use of intrapartum intrathecal narcotic analgesia in a community-based hospital.

OBJECTIVE: To evaluate the use of intrapartum intrathecal narcotic analgesia in the obstetric population of our community-based hospital. METHODS: A protocol to administer intrapartum intrathecal narcotic analgesia was established at our institution in December 1992. All patients consenting to this procedure received a single lumbar intrathecal injection of 25 micrograms fentanyl and 0.25 mg morphine sulfate through a 25-gauge spinal needle. Only those patients with singleton pregnancies in the vertex presentation were included in this study. The study group was matched by gravidity and parity with singleton pregnancies delivered during the study period. Patients in the study group were asked to complete an analgesia satisfaction survey using a five-point Likert scale ranging from 0 for total dissatisfaction to 5 for total satisfaction. RESULTS: A total of 75 patients were assigned to each group; the control and study groups were similar with respect to age, race, estimated gestational age, infant birth weight, interval between rupture of membranes and delivery, and mode of delivery. The length of the first and second stages of labor and the incidence of fetal malposition were not significantly different between the two groups. Frequent side effects of this analgesia included complaints of pruritus (81.3%), urinary retention (53.3%), and nausea and vomiting (44.0%). Headaches were less common (9.3%), with two (2.7%) of seven patients requiring an epidural blood patch for relief. Infrequent side effects included respiratory depression (1.3%) and oversedation (1.3%). Patients were generally satisfied with the degree of pain relief obtained, rating it highly during the first and second stages of labor and in comparison to their previous labor experience. CONCLUSION: The use of intrapartum intrathecal narcotic analgesia provides a satisfactory level of pain relief without disrupting the normal course of labor.

Analgesia, Obstetrical↗
PubMed2001

Postpartum chills phenomenon: is it a feto-maternal transfusion reaction?

OBJECTIVE: To examine the theory that the postpartum shivering phenomenon is related to feto-maternal bleed during the third stage of labor. METHODS: One hundred laboring low-risk women who had a normal vaginal delivery were observed for the presence of postpartum chills. The duration of the first and second stages of labor changes in body temperature, maternal and fetal blood types and the use of epidural anesthesia were recorded. Following the delivery maternal blood was examined for the presence of fetal red blood cells using the Kleihauer-Betke stain. RESULTS: Complete data was available in 97 patients. Post-partum chills occurred in 31 of them (32%). Women with and without chills were similar in their maternal and gestational age, the use of epidural anesthesia, and length of second stage of labor. Women with chills delivered smaller babies but the difference did not reach significance. Maternal-fetal blood group incompatibility was significantly more common among shivering than non-shivering women (48% vs. 20% respectively, p=0.006). Kleihauer-Betke test was positive in 11 women. The only two women in this group who experienced chills had maternal-fetal blood group incompatibility. CONCLUSION: Post-partum chills are a common phenomenon. It may be the clinical presentation of feto-maternal transfusion reaction. The small number of positive Kleihauer-Betke tests may reflect its low sensitivity in the detection of small feto-maternal bleeds.

ABO Blood-Group System↗
PubMed2003

Persistent fetal occiput posterior position: obstetric outcomes.

OBJECTIVE: To evaluate the obstetric outcomes associated with persistent occiput posterior position of the fetal head in term laboring patients. METHODS: We performed a cohort study of 6434 consecutive, term, vertex, laboring nulliparous and multiparous patients, comparing those who delivered infants in the occiput posterior position with those who delivered in the occiput anterior position. We examined maternal demographics, labor and delivery characteristics, and maternal and neonatal outcomes. RESULTS: The prevalence of persistent occiput posterior position at delivery was 5.5% overall, 7.2% in nulliparas, and 4.0% in multiparas (P <.001). Persistent occiput posterior position was associated with shorter maternal stature and prior cesarean delivery. During labor and delivery, the occiput posterior position was associated with prolonged first and second stages of labor, oxytocin augmentation, use of epidural analgesia, chorioamnionitis, assisted vaginal delivery, third and fourth degree perineal lacerations, cesarean delivery, excessive blood loss, and postpartum infection. Newborns had lower 1-minute Apgar scores, but showed no differences in 5-minute Apgar scores, gestational age, or birth weight. CONCLUSION: Persistent occiput posterior position is associated with a higher rate of complications during labor and delivery. In our population, the chances that a laboring woman with persistent occiput posterior position will have a spontaneous vaginal delivery are only 26% for nulliparas and 57% for multiparas.

Apgar Score↗
PubMed2004

Labor course and delivery in epidural analgesia: a case-control study.

BACKGROUND: We aimed to establish if epidural analgesia is associated with a higher incidence of operative vaginal delivery, longer duration of labor and more frequent use of oxytocin than labor without analgesia. METHODS: We analyzed a cohort of 207 women with no risk factors who delivered with epidural analgesia in the labor unit of Spedali Civili, Brescia, Italy, during 2001. Length of the first and second stage of labor, mode of delivery, neonatal cord blood pH, neonatal Apgar score and neonatal outcomes were evaluated. RESULTS: Epidural analgesia was performed on request in 6%: in this group (group A) there were 141 (68%) nulliparae and 66 (32%) pluriparae; mean ( +/- standard deviation) gestational age at delivery was 39.4 +/- 1.3 weeks (range: 34.1-41.5 weeks). In this group, 184 (89%) had vaginal delivery and 23 (11%) delivered by Cesarean section. Among controls (group B), 368 (89%) had a vaginal delivery and 46 (11%) delivered by Cesarean section; vacuum extraction was used in 18 deliveries (9%) in group A and in 13 deliveries (3%) in group B. The duration of the second stage of spontaneous labor in the nulliparae of group A was significantly longer than in group B. No statistically significant differences were found between mean umbilical artery pH values of groups A and B. CONCLUSION: Our results confirm that epidural analgesia does not affect the rate of Cesarean delivery, while increasing the use of oxytocin augmentation, the duration of the second stage of labor and the rate of instrumental vaginal delivery.

Adult↗
PubMed1984

Induction of labor with prostaglandin E2 vaginal suppositories.

A prospective randomized study of 85 parturients was undertaken comparing the safety and efficacy of a 3-mg prostaglandin E2 vaginal suppository with intravenous oxytocin for the induction of labor. All patients were required to have a Bishop's score of 5 or higher. Labor was successfully induced in 98% of the patients in both groups by their respective methods. Sixty-four percent of the patients receiving a 3-mg prostaglandin E2 suppository required no intravenous oxytocin. More specifically, 82% (23/28) of the parous patients but only 29% (5/17) of the nulliparous patients who received a single 3-mg prostaglandin E2 suppository for labor induction did not require oxytocin augmentation (P less than .005). The first and second stages of labor were not significantly different for the two groups, and there was no significant difference in the incidence of cesarean section. A 3-mg prostaglandin E2 vaginal suppository may be a useful alternative to oxytocin for the induction of labor in carefully selected patients.

Adult↗
PubMed2003

Risk factors for perineal injury during delivery.

OBJECTIVE: We sought to identify risk factors for anal sphincter injury during vaginal delivery. STUDY DESIGN: This was a retrospective, case-control study. We reviewed 2078 records of vaginal deliveries within a 2-year period from May 1, 1999, through April 30, 2001. Cases (n = 91) during the study period were defined as parturients who had documentation of greater than a second-degree perineal injury. Control subjects (n = 176), who were identified with the use of a blinded protocol, included women who were delivered vaginally with less than or equal to a second-degree perineal injury. For each patient, we reviewed medical and obstetrics records for the following characteristics: maternal age, race, weight, gestational age, parity, tobacco use, duration of first and second stages of labor, use of oxytocin, use of forceps or vacuum, infant birth weight, epidural use, and episiotomy use. RESULTS: Of the 2078 deliveries that were reviewed, we discovered 91 cases (4.4%) of documented anal sphincter injury. The mean maternal age of our sample was 24.9 +/- 5.9 years). Nearly two thirds (63.2%) were white; 26.7% were black, and 10.1% were of other racial backgrounds. Forceps were used in 51.6% of deliveries that resulted in tears (cases), compared to 8.6% of deliveries without significant tears (control subjects, P <.05). Using cases and control subjects with complete data (cases, 82; control subjects, 144), delivery with forceps was associated with a 10-fold increased risk of perineal injury (odds ratio, 10.8; 95% CI, 5.2-22.3) compared to noninstrumented deliveries. The association was similar after adjustment for age, race, parity, mode of delivery, tobacco use, episiotomy, duration of labor (stages 1 and 2), infant birth weight, epidural, and oxytocin use (odds ratio, 11.9; 95% CI, 4.7-30.4). Nulliparous women were at increased risk for tears (adjusted odds ratio, 10.0; 95% CI, 3.0-33.3) compared with multiparous patients, but parity did not reduce the association between forceps-assisted deliveries and anal sphincter injuries. Increasing fetal weight was also a risk factor in both unadjusted and adjusted analyses. The performance of a midline episiotomy was associated with an increased risk of anal sphincter tear compared with delivery without an episiotomy in the univariate analysis (odds ratio, 4.9; 95% CI, 2.5-9.6), but this association was reduced in the adjusted analysis (odds ratio, 2.5; 95% CI, 1.0-6.0). The increased duration of both the first and second stages of labor increased injury risk in the unadjusted, but not adjusted, analysis. No significant association was observed between case status and the use of oxytocin or epidural anesthesia. Greater, but not significant, increased risk was associated with maternal indications for operative delivery compared with fetal indications. CONCLUSION: Our results are consistent with recent reports that identify forceps delivery and nulliparity as risk factors for recognized anal sphincter injury at the time of vaginal delivery. Further investigation should focus on the determination of whether the association of injury to instrumentation is causal or, in fact, modifiable. Because of the established association between sphincteric muscular damage and anal incontinence, patients should be counseled about the risk of anal sphincter injury when operative vaginal delivery is contemplated. Such patients should be followed closely in the postpartum setting to assess for the development of potential anorectal complaints.

Adult↗
PubMed1992

Labor in the gravida with 10 or more years between pregnancies.

It has been suggested that women who have had a pregnancy interval of 10 or more years would have prolonged labor in pregnancies after the first, as do primigravidas. In a series of 94 multiparas with 10 or more years between pregnancies and 63 age-matched, multiparous controls, there was no significant difference in the length of the latent phase of labor or of the first, second and third stages of active labor in the two groups. The concept of a "physiologic primigravida" in these cases should be abandoned.

Adult↗
PubMedDate not supplied

Use of upright positioning with epidural analgesia: findings from an observational study.

PURPOSE: To present research findings and related nursing implications from an observational study designed to evaluate the use of upright positioning during second stage labor with patients who had received low-dose epidural analgesia. STUDY DESIGN AND METHODS: This descriptive study evaluated outcomes from a sample of 74 healthy women having their first childbirth. They had all received epidural analgesia during the first and second stages of labor. Data were also collected by nurses on the use of birthing beds, and the extent of physical and emotional support the women needed while following the upright positioning study protocol. RESULTS: All women were able to maintain upright positions throughout the second stage of labor following epidural analgesia administration. No adverse neonatal outcomes or maternal problems (such as excessive vaginal bleeding) were documented. CLINICAL IMPLICATIONS: Although women were capable of assuming upright positions during second stage, the study results indicated that constant physical and emotional support was necessary for most women. Future research on methods to prepare women for multiple position options after administration of low-dose epidural analgesia should be undertaken. In addition, nurses should evaluate the benefits of upright positioning in terms of facilitating progress of labor.

Adolescent↗