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PubMed1990

Outpatient use of prostaglandin gel for ripening of the cervix and induction of labor.

This case series reports the experience in a family practice center with the outpatient use of prostaglandin E2 (PGE2) gel in patients with a medical or obstetric indication for induction. A retrospective medical record review of a 15-month period was completed for 45 women receiving intravaginal PGE2 gel for cervical ripening before the induction of labor. A change in Bishop score was seen following application of the first gel in 21 women (54%). Six women (13%) had labor onset 1 to 16 hours after the initial gel placement, and an additional 19 women (42%) had labor onset within 48 hours of the final gel placement. Twenty-one women (47%) gave birth without the use of oxytocin, and only 11 women (24%) required oxytocin induction of labor. No significant differences were seen in type of delivery, delivery complications, or newborn outcome between categories of labor onset (spontaneous, PGE2 gel, oxytocin). Two complications followed gel insertions, one case of uterine hyperstimulation and one case of a brief episode of fetal bradycardia. Both women were identified within the monitoring period and subsequently were delivered of healthy term infants. This case series demonstrates the usefulness and lack of adverse effects of outpatient PGE2 gel as an adjunct in labor induction.

Administration, Intravaginal↗
PubMed1990

Management of preterm labor patients at home: does daily uterine activity monitoring and nursing support make a difference?

Daily home uterine activity monitoring and perinatal nursing support were compared with standard care in managing patients with recurrent preterm labor during the current pregnancy in an effort to reduce preterm birth. Sixty-seven successfully treated preterm labor patients were randomly assigned in this multicenter study to daily home uterine activity monitoring and perinatal nursing support or to a standard-care group. Recurrent preterm labor occurred in 15 (45%) of monitored patients and 19 (56%) of standard-care patients. The risk of preterm birth (before 37 weeks) for patients with recurrent preterm labor was significantly reduced (P = .025) in the monitored group (seven, or 47%) compared with the standard-care group (16, or 84%). The relative risk of delivering because of failed tocolysis was 2.8 for the standard-care group versus the monitored group. There were no patients in the monitored group who delivered at the first recurrence of preterm labor for failed tocolysis. The data suggest that home uterine activity monitoring and perinatal nursing support are helpful in achieving term birth through earlier detection and treatment of recurrent preterm labor.

Adult↗
PubMed1990

The incidence of preterm labor and specific risk factors.

A retrospective review of patients at high risk for preterm delivery because of twin gestation, uterine malformation, incompetent cervix, or previous preterm delivery was carried out to assess the rates of preterm labor and spontaneous preterm birth. Among the 119 patients with multifetal gestation, 46% had preterm labor and 36% delivered before 37 weeks' gestation. In the 58 patients with an anomalous uterus, the rate of preterm labor was 19%, and 14% had early deliveries. Of those with incompetent cervices (115), one-fourth had preterm labor and 17% had an early birth. When a history of one or more preterm deliveries was present, the preterm labor rate ranged from 41-68%, with an early delivery rate of 30-47%. Prophylactic tocolytic therapy did not prolong gestations significantly. Maternal smoking did not have an adverse effect on the incidence of preterm labor except in twin pregnancies, for which early delivery was more likely. The percentages for preterm delivery are slightly lower than those found in the literature; this may be attributable to improvement in preterm birth prevention efforts including patient education, more frequent examinations, home uterine activity monitoring, and daily nursing contact.

Female↗
PubMed1989

A comparison of early and delayed induction of labor with spontaneous rupture of membranes at term.

The management of women with spontaneous rupture of membranes at term in the absence of labor and with a cervix unfavorable for induction of labor is controversial. In this randomized study of 182 patients, we report the effects of delayed versus early induction of labor on maternal and neonatal outcome. Qualifying patients not in labor at 6 hours after spontaneous rupture of membranes were randomized to either immediate oxytocin induction (86 women) or expectant management with oxytocin induction at 24 hours if labor had not occurred spontaneously (96 women). The cesarean section rate did not differ between the two groups. Women in the delayed group had significantly longer hospitalization (P less than .003), and their infants were significantly more likely to receive antibiotics (P = .006). Infectious morbidity (positive cultures or x-ray-documented pneumonia) occurred in five of the neonates in the delayed group, all of whose mothers had an initial digital cervical examination, but in none of the neonates in the early group, a difference that did not reach statistical significance (P = .061). Five (28%) of 18 infants from the delayed group whose mothers had received an initial digital cervical examination became infected, compared with none of the 78 infants from the delayed group whose mothers did not have digital examinations (P less than .001). We conclude that there is no advantage to delaying induction of labor when women present at term with spontaneous rupture of membranes.

Adult↗
PubMedDate not supplied

[Doppler studies of arterial uterofetoplacental blood flow before and during labor].

The encouraging results obtained using pulsed Doppler sonography for antepartal diagnosis gave cause to use the method during labor. For this purpose a group with normal course of pregnancy was examined by Doppler sonography. This group was compared with a similar group examined by the same method at onset of labor with the cervix beginning to dilate, or with premature rupture. A comparison of the usual Doppler parameters, uterine arteries, umbilical artery and fetal aorta, recorded in contraction-free phases, showed no differences between the two groups. A third group was examined by Doppler sonography during labor with average or late cervix dilatation. In this case the Doppler parameters for the contraction phases were compared with those for the contraction-free phases. With adequate utero-placental supply during labor, the changes in the Doppler parameters for the uterine arteries due to contraction indicate a reduction in blood flow. The blood flow in the umbilical artery remains unaffected during normal labor. In the fetal aorta the blood flow velocity drops significantly due to contractions, while the peripheral resistance is unchanged. The elimination of the end-diastolic shift in frequency in the fetal aorta during labor indicates a fetal supply deficiency, as shown by Doppler measurements during birth in cases with pathologic cardiotokograms.

Aorta↗
PubMed1988

Comparison of peripheral, uterine and cord estrogen and progesterone levels in laboring and nonlaboring women at term.

Although a direct effect of steroid hormones on the initiation of labor has been shown in animals, conclusive data on human parturition are lacking. To elucidate steroid changes associated with human labor, venous serum samples were obtained at cesarean section from the maternal peripheral and uterine veins and umbilical cord vein of seven laboring and seven nonlaboring women at term. Assays of estradiol (E2), estriol (E3) and progesterone (P) revealed that: (1) there is a major concentration difference in all the steroids between peripheral and local values, (2) labor is associated with a significant rise in systemic and local E2 but no change in P, and (3) the increased production of E2 does not appear to be from a fetoplacental source. These data strongly support a modulating role for alterations in steroid hormones at the onset of human labor. The results demonstrate an increase in estrogen, rather than the classic "withdrawal", as the prime factor in E2:P ratio changes associated with labor and suggest that the source of the estrogen increase may be maternal rather than fetal.

Adult↗
PubMed1988

Histamine and ascorbic acid: a survey of women in labor at term and significantly before term.

In ascorbic acid-requiring species (human, guinea pig), elevations of circulating histamine occur as the result of marginal ascorbic acid status. Marginal ascorbic acid status during pregnancy is associated with preeclampsia, abruption, and prematurity. Furthermore, circulating histamine is known to be elevated in these complications perhaps as a result of placental dysfunction which diminishes normal placental histaminase. We hypothesized that women with preeclampsia and premature labor would have elevated histamine and the lowest concentrations of ascorbic acid. Plasma total whole blood histamine and ascorbic acid were surveyed in women in term (T) and preterm (PT) labor. Blood histamine was elevated in PT compared to T labor but so was plasma ascorbate, indicating that marginal ascorbate status does not cause the elevated circulating histamine observed in PT. However, marginal ascorbate status concomitant with reduced placental histaminase may contribute to further increases in circulating histamine and to any pathology which might result from elevated histamine. Regression analysis of histamine on ascorbate for T and PT labor revealed a significant inverse relationship between ascorbate and histamine only in PT labor (p less than 0.027). An unexpected finding was that a history of maternal cigarette smoking, to a degree which resulted in marginal ascorbic acid status, confounded the relationship between ascorbate and circulating histamine in T labor.

Adult↗
PubMed1986

Detection of preterm labor by ambulatory monitoring of uterine activity: a preliminary report.

Effective tocolytic therapy depends on the ability to make an early diagnosis of preterm labor. This study was designed to assess whether daily ambulatory home monitoring of uterine activity could facilitate early diagnosis of preterm labor. Of 76 patients at high risk for preterm labor who used daily ambulatory tocodynamometry, approximately half developed preterm labor. Evaluation when the diagnosis of preterm labor was first established has shown that in 8% of the patients the cervix was dilated more than 2 cm, shortened to less than 0.5 cm in 23%, and the fetal membranes were intact in all subjects. The same evaluation in 76 nonrandom contemporary controls matched for risk factors, maternal age, and parity has shown that more than 50% had a cervix dilated more than 2 cm, 38% had a cervix shorter than 0.5 cm, and 24% had rupture of the fetal membranes. Ultimately, 88% of the monitored patients and 59% of controls delivered at term. Comparisons between these groups indicate that intermittent home tocodynamometry may indeed be useful in making the early diagnosis of preterm labor.

Ambulatory Care↗
PubMedDate not supplied

Recent trends in cesarean birth and trial of labor rates in the United States.

A national probability survey was conducted to evaluate changes since 1979 in cesarean delivery and trial of labor rates after a previous cesarean delivery. Questionnaires were mailed to 538 hospitals and 87% responded. In 1979, of women with a prior cesarean birth 2.1% (+/- 0.3%) were given a trial of labor. By 1984, the rate increased fourfold to 8.0% (+/- 0.7%). Trials of labor increased dramatically with the size of the delivery service. The rates ranged from 2% in smaller hospitals to 25% in larger hospitals. More than 50% of the trials of labor were successful. However, the fraction of hospitals with no trials of labor remains high (54%). Cesarean birth rates increased from 14.1% (+/- 0.1%) in 1979 to 19.0% (+/- 0.2) in 1984. Hospitals with fewer births had a larger variation in cesarean birth rates; the fifth and 95th percentiles were 5% and 33%, respectively, for hospitals with fewer than 500 deliveries per year, and 14% and 31% for hospitals with 1000 deliveries or more per year. Fetal distress accounted for a larger proportion of primary cesarean deliveries in 1984 (21%) compared with 1979 (14%). The observed increase in the rate of trial of labor does not seem to be large enough to stem the rising cesarean delivery rate. This survey and other national surveys provide no evidence that the cesarean delivery rates are leveling off or decreasing.

Cesarean Section↗
PubMed1979

Steroids in human myometrium and maternal and umbilical cord plasma before and during labor.

Concentrations of estrone, estradiol, and progesterone in the myometrium, maternal peripheral vein, and mixed umbilical cord plasma were determined before and during labor by radioimmunoassay. Of the 29 patients studied, 4 underwent elective abortions by hysterotomy in the second trimester of pregnancy, and 25 underwent cesarean section (elective or during labor). The concentration of umbilical cord cortisol in the latter group of patients was also determined. Advanced labor was characterized by a high concentration of estrone in the maternal peripheral vein, the umbilical cord, and the myometrium. Concentrations of estradiol, progesterone, and cortisol in cord plasma also increased during labor. From the second trimester to term pregnancy, increases in the concentrations of estrone and estradiol in the myometrium were proportionately greater than those of progesterone. During labor, there were no significant changes in the myometrial concentrations of estrone, estradiol, or progesterone. During labor in term pregnancies, the myometrial concentration of estrone was higher than that of estradiol.

Abortion, Induced↗
PubMed1978

Maternal serum estrogen and progesterone concentrations preceding normal labor.

Simultaneous measurement of serum concentrations of estrone (E1), estradiol (E2), estriol (E3), and progesterone were carried out in multiple serial blood samples obtained during the last 3-10 weeks of pregnancy, labor, and the immediate postpartum period in 5 normal women. Estrogen and progesterone levels showed a small, but statistically significant diurnal variation during pregnancy. They did not change during labor; however, with the exception of E1 levels, all declined following delivery. Individual patterns preceding labor, derived from calculated moving mean values, showed no consistent decline in progesterone levels nor a surge in E1 and E2 concentrations whereas estriol levels showed a steady rise starting 14-28 days prior to the onset of labor. Whether this E3 elevation reflects fetal maturation and/or plays a role in the triggering mechanism of labor is unknow. Failure to detect changes in E1, E2, and progesterone levels in the maternal peripheral circulation does not preclude the possibility that alterations of metabolism of these hormones in the fetal or uterine compartments might be involved in the initiation of human labor.

Adult↗
PubMed1984

[The interaction of oxytocin-prostaglandin receptors in human myometrium and amnio-decidua throughout pregnancy and in labor].

This study was designed to investigate the interaction of oxytocin and prostaglandin F2 alpha at the receptor level (OXT-R and PGF2 alpha-R) between the myometrium and amnio-decidua throughout pregnancy and at parturition in an effort to clarify which of the two is the first and/or triggering factor involved in the instigation of myometrial contractions. In rat myometria, it was recognized that PGF2 alpha-R increased from day 20 of pregnancy and preceded that of OXT-R from day 22 and thereafter both reached peak levels at delivery. In human myometria, on the other hand, OXT-R showed an increase as gestation advanced and when labor was initiated, a significant decrease was found regardless of the route of labor, while the PGF2 alpha-R the binding capacity of which was only 1/20-1/30 of OXT-R, did not change throughout pregnancy or in labor. The binding affinity of OXT-R in amnio-decidua increased as gestation advanced, while its binding capacity remained unchanged and after the onset of labor that of the amnion decreased significantly even though it was only 1/6-1/7 that of the myometrium. The binding affinity of myometrial OXT-R was elevated following the addition of PGF2 alpha before the onset of labor, but the converse could not be shown. These findings suggest that the instigation and maintenance of human labor may be firstly and/or initially dependent on the increase of the binding activity between OXT and OXT-R in the myometrium, and the PGF2 alpha may facilitate such activity by the allosteric effect on OXT-R directly or on the plasma membrane to increase its binding affinity.

Amnion↗
PubMed1982

[Decrease or increase in maternal blood prolactin concentrations during labor (author's transl)].

Serum cortisol levels were previously shown to increase during labor and delivery in term-pregnants. In the present study, the same sera were investigated for the prolactin levels. The mean levels of 169.1 +/- 15.6 (SE) ng/ml prior to the onset of labor fell significantly to 98.8 +/- 15.6 and 116.8 +/- 15.6ng/ml immediately before and after delivery, respectively . However, the prolactin levels were found to have rather risen in 2 and 6 cases immediately before and after delivery, respectively. Increases in serm cortisol levels during labor in these cases were much greater than in other cases. This indicates that labor-stress, if powerful, can stimulate prolactin release in term-pregnants, as other kinds of stress in non-pregnants and animals. The present results may interpreted as follows: Unknown factors are inhibiting the prolactin release naturally stimulated with labor-stress, and the increased stimulation of labor-stress can release prolactin specially as immediately after delivery.

Female↗
PubMed1982

Late meconium passage in labor--a sign of fetal distress?

Although the passage early in labor of thick amniotic fluid heavily stained with meconium is recognized as an indication of potential fetal asphyxia, the significance of late passage of meconium-stained fluid in labor is less certain. One hundren twenty-eight patients with late passage of meconium in labor and 134 control patients were examined, using chi 2 and discriminant analysis, to determine if any relationships existed between fetal heart rate (FHR) patterns, late passage of meconium in labor, and neonatal morbidity. In the group with late meconium passage, adequate baseline FHR variability and nonperiodic accelerations were predictive of high Apgar scores, and repeated (over 20) variable decelerations were predictive of low Apgar scores. In the control group, none of the FHR patterns examined were predictive of Apgar score. Thus, the combination of late passage of meconium in labor with other intrapartum signs may indicate a fetus at risk for asphyxia when neither sign alone is predictive. The presence of late meconium passage demands close observation of the patient in labor, including assessment by electronic FHR monitoring.

Apgar Score↗
PubMed1981

[Relationship between the onset of labor and prostaglandins in rabbit tissues before and after delivery (author's transl)].

1) The studies were performed to elucidate the mechanism of onset of labor. It was investigated in relation to the movement of prostaglandins in individual tissues of pregnant rabbits before and after labor with the onset of labor. 2) The rabbit uterus duplex used is convenient material to investigate the movement of PGs in the same rabbit at the different term. 3) The concentrations of PGs were measured by RIA. 4) The concentrations of PGs in blood and amniotic fluid were not essential to explain account for the mechanism of onset labor. 5) From the results of the PGs values before and after labor, we have been considered that the relative PGs at the onset of labor were PG E1 and PG E2 in the placenta. We infer that PG F2 alpha plays a leading role in uterine contraction, because the large amount of PG F2 alpha presented in decidual parietalis during delivery, and PG E1 and PG E2 play a role in uterine contraction, too.

Amniotic Fluid↗
PubMed1995

Trial of labor vs. elective repeat cesarean section. AAFP Task Force on Clinical Policies for Patient Care.

A trial of labor after a previous low transverse cesarean section in the absence of ongoing contraindications is safe for most women. A comprehensive review and meta-analysis of the literature was conducted to determine outcomes, costs and women's preferences by method of delivery. About seven of 10 women who undergo a trial of labor after previous low transverse cesarean section can expect to deliver vaginally. The following differences in absolute risks were identified: a trial of labor was associated with a slightly increased risk of uterine rupture (0.24 percent) and a decreased risk of infection and fever (5.2 percent) and postpartum bleeding (0.59 percent) as compared with an elective repeat cesarean section. The difference in risk for newborns with an Apgar score of less than 7 at five minutes was 0.85 percent for infants delivered vaginally after a trial of labor versus infants delivered by elective repeat cesarean section. Financial cost (as measured by hospital charges) of cesarean delivery was 1.66 to 2.4 times greater than the cost of vaginal birth. This difference was due almost entirely to the longer length of hospital stay for women who had a cesarean delivery. When given the opportunity, about two-thirds of eligible women choose a trial of labor over elective repeat cesarean section. The reasons underlying women's preferences for a trial of labor or elective repeat cesarean section were diverse and changed during pregnancy. As a consequence, women's preferences for the method of delivery must be explored and respected throughout pregnancy and during the delivery process.(ABSTRACT TRUNCATED AT 250 WORDS)

Cesarean Section↗
PubMed1994

[Amniotic fluid index during labor in women with EPH gestosis].

Intrapartal cardiotocographic disturbances of fetal heart rate patterns, the way of delivery and the neonate state have been analyzed in the group of 61 women in labor with pregnancy complicated by EPH gestosis. The results have been compared with pre-labor values of amniotic fluid index (AFI) in that group. In the group of 30 women in labor with AFI < or = 5 cm the analysis revealed the higher prevalence of non stress test reactivity losses, severe variable decelerations, late decelerations, cesarean sections and lower birth weight in comparison with the group of 31 women in labor with AFI > 5 cm. The study revealed that pre-labor AFI value estimation is usefull in predicting possibilities of fetal compromise during labor in women with pregnancies complicated by EPH gestosis.

Adult↗
PubMed1994

Cervical sonography in preterm labor.

OBJECTIVE: To improve the accuracy of the diagnosis of preterm labor by comparing transvaginal sonography to digital examination of the cervix. METHODS: We performed transvaginal sonography in women with preterm labor who had completed a course of parenteral tocolysis. Cervical length was measured according to criteria reported previously. Cervical sonographic findings were not used in diagnosis or management. Sonographic cervical length was compared to digital assessment of dilation and effacement to assess the risk of preterm birth after treatment for preterm labor. RESULTS: Forty-eight singleton and 12 twin gestations were studied. Thirty women were nulliparous and 30 were parous. The mean (+/- standard deviation) gestational age was 31.1 +/- 2.7 weeks (range 24-35) at the examination and 35.6 +/- 2.9 weeks (range 26-43) at delivery. Twenty-four subjects delivered before 36 weeks' gestation and 36 delivered at or after 36 weeks. Cervical sonography was distinctly superior to digital assessment of dilation and effacement as a test for delivery before 36 weeks, when compared using receiver operating characteristic curves. This analysis indicated a cervical length of 30 mm as the best cutoff to maximize sensitivity and specificity. All 24 subjects who delivered preterm had cervical lengths less than 30 mm. Cervical sonography was especially useful in selecting women with preterm labor who would not deliver prematurely, ie, a high negative predictive value. None of 15 women whose cervical length was 30 mm or more delivered spontaneously before 36 weeks. CONCLUSION. Among women treated for preterm labor, a cervical length of at least 30 mm predicted a low likelihood of preterm birth. Cervical sonography may improve the accuracy of diagnosis in women treated for preterm labor.

Adult↗