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PubMed1978

Laminaria as an adjunct in induction of labor.

The safety and efficacy of laminaria tents as an adjunct to labor induction near term were examined in a prospective, controlled, and randomized study involving insertion of laminaria into the cervical canal the evening prior to planned induction. Six of 35 subjects in whom laminaria were used entered labor spontaneously and delivered overnight, compared with 1 of 39 controls. Of the remainder, the Bishop score increased an average of 3.7 points, a highly significant change, in the laminaria-treated group compared with no change in the controls. Labor, induced primarily by amniotomy with intravenous oxytocin then given to patients in whom regular contractions did not begin within 8 hours, was shorter with laminaria use than in controls, though the amniotomy-to-delivery interval did not differ significantly. However, comparison of the subgroup with cervices relatively unfavorable for induction, indicated by an initial Bishop score of 5 or less, showed both length of labor and amniotomy-to-delivery interval to be significantly shorter (each by an average of 3 hours) in the laminaria-treated group compared with controls. Complications, including febrile morbidity, did not differ. We conclude that laminaria tents are both effective and safe as an adjunct to labor induction, acting by accelerating the preparatory changes in the cervix which normally occur in late pregnancy.

Dilatation↗
PubMed1992

An intravaginal controlled-release prostaglandin E2 pessary for cervical ripening and initiation of labor at term.

The purpose of this randomized, double-blind study was to evaluate the efficacy and safety of a new controlled-release hydrogel pessary for ripening the cervix and initiating labor. Subjects had an entry Bishop score of 4 or less and gestational age of 37 or more weeks. One hundred fourteen women received a placebo pessary and 101 received the hydrogel pessary, containing 10 mg of prostaglandin (PG) E2. Compared with the placebo group, those given the PGE2 pessary were more likely to have an increase in Bishop score of 3 or more (60 or 59% versus 21 or 18%; P less than .0001), change to a Bishop score of 6 or higher (59 or 58% versus 18 or 16%; P less than .0001), and active labor (68 or 67% versus 15 or 13%; P less than .0001). Including the crossover study, uterine hyperstimulation (28 of 182, 15%) and fetal heart rate abnormalities (18 of 182, 10%) in PGE2-treated subjects were reversed on removal of the pessary with no apparent harm to the mother or fetus. These temporary adverse effects appeared while the pessary was in place and after the onset of active labor. Oxytocin was unnecessary in 89 of 182 (49%) of the PGE2-treated cases and was used more often to augment than to induce labor. We conclude that the described controlled-release PGE2 vaginal pessary induces appreciable cervical ripening and frequently initiates active labor with little or no need for oxytocin. The pessary may cause uterine hyperstimulation or fetal heart rate abnormalities, but these would be expected to reverse on removal of the pessary.

Delayed-Action Preparations↗
PubMed1994

Vibroacoustic stimulation of the fetus entering the second stage of labor.

OBJECTIVE: To evaluate the fetal heart rate (FHR) response to vibroacoustic stimulation of fetuses entering the second stage of labor as a predictor of neonatal outcome. METHODS: Three hundred sixteen cases and 316 controls were studied during the second stage of labor. All cases had vibroacoustic stimulation on entering the second stage of labor using an electronic artificial larynx. For control patients, the artificial larynx was not activated. The patients were stratified into groups based on the quality of FHR response: acceleration (n = 124), acceleration followed by deceleration (n = 120), and no response (n = 72). RESULTS: Subsequent FHR accelerations and accelerations followed by decelerations were significantly more frequent in the study group than in controls (77.2 versus 15.2%; P < .05). The frequencies of low 5-minute Apgar scores (below 7) and low umbilical cord arterial pH (below 7.20) did not differ significantly in the group with the acceleration response when compared to those with acceleration followed by deceleration and the no-response groups. The incidence of nuchal cord was significantly higher for the group with a response pattern of acceleration followed by deceleration than for the acceleration and no-response groups (39.2 versus 10.5 versus 11.1%; P < .05). CONCLUSIONS: Vibroacoustic stimulation in the second stage of labor is associated with FHR reactivity, but the quality of FHR response does not predict neonatal outcome and therefore appears to have little value in enhancing the management of the second stage of labor. However, an acceleration followed by deceleration response suggests the presence of nuchal cord.

Acoustic Stimulation↗
PubMed1978

The pharmacologic inhibition of premature labor.

Oxytocin, elevated estrogen-progesterone ratio, fetal corticosteroids, prostaglandins, catecholamines, and changes in uterine blood flow have all been implicated as triggers of labor. In approximately one-third of cases of threatened premature labor contractions stop spontaneously. Thus placebo-controlled randomized trials of any new drug for inhibition of premature labor are necessary, as the spontaneous cessation of contractions always favors the claimed therapeutic efficacy. Alcohol inhibits the release of endogenous oxytocin and has an additional direct effect on the myometrium. In one study alcohol was more effective than placebo in the postponement of delivery. Isoxsuprine, ritodrine, and terbutaline have also been shown to be better than placebo in the inhibition of premature labor, and the beta adrenergic agents appear to be more effective than alcohol. Prostaglandin inhibitors such as indomethacin are currently under investigation. Success is correlated with early administration of the therapy, which requires treating some patients whose contractions might have stopped spontaneoulsy. As different factors may be involved in triggering premature labor, if one therapeutic approach fails another should be initiated promptly.

Adrenal Cortex Hormones↗
PubMed1989

Dilemmas in the pharmacological management of preterm labor.

It is the thesis of the author that the use of Ritodrine in the treatment of premature labor is potentially dangerous and possibly even lethal. Ritodrine is being overused in the attempt to control and delay premature labor. Only 25 to 50 per cent of patients complaining of premature labor pains actually proceed to true preterm labor. Because there is no definitive screening test to firmly establish the diagnosis of preterm labor, many women are treated unnecessarily with a drug that many obstetricians question as to its efficacy, safety, and cost. If it is used, it must be in a hospital with adequate facilities both in manpower and the ability to identify and treat the medical and obstetrical complications. Ritodrine is too potentially dangerous to be used as an attempt to "do something" it there are questionable indications.

Clinical Protocols↗
PubMed2004

Maternal temperature monitoring during labor: concordance and variability among monitoring sites.

OBJECTIVE: Elevated maternal temperature in labor is associated with adverse immediate and long-term neonatal outcomes. Conventional methods of temperature measurement may not reflect the intrauterine temperature, which constitutes the fetal environment. The purpose of this study was to ascertain the most reliable noninvasive method of temperature monitoring in labor that would best reflect changes in intrauterine temperature. METHODS: Women in labor receiving epidural analgesia had temperature readings taken every 10 seconds from the uterine cavity, ear canal, and skin surface of the leg and abdomen and hourly from the mouth. RESULTS: Eighteen patients were studied for a mean of 228 minutes (range 56-464 minutes). The best indicator of intrauterine temperature was oral temperature, with a mean intraclass correlation coefficient of 0.6 (95% confidence interval 0.42, 0.77). On average, oral temperature underestimated intrauterine temperature by 0.8 degrees C (95% confidence interval 0.7 degrees C, 1 degrees C). Allowing for this, oral temperature greater than 37.2 degrees C detected an intrauterine temperature greater than 38 degrees C with a sensitivity of 81% and a specificity of 96%. The intraclass correlation coefficients of all other sites with intrauterine temperature were poor (0.1 or less). As expected, the temperature at all sites increased as labor progressed. CONCLUSION: Oral temperature, measured carefully, has an acceptable correlation with intrauterine temperature and is recommended for routine detection of maternal pyrexia in labor. Continuous skin and external auditory canal temperature measurements did not correlate well. LEVEL OF EVIDENCE: II-3

Adult↗
PubMed2004

Timing of birth after spontaneous onset of labor.

OBJECTIVE: To describe naturally occurring birth patterns in low-risk women with singleton gestations and spontaneous onset of labor at term. MATERIALS AND METHODS: The timing of birth of women who delivered in the low-risk labor unit at Parkland Hospital, Dallas, Texas, between January 1, 2000, to December 31, 2000, was analyzed. Women admitted to this unit were between 36(0/7) and 41(6/7) weeks of gestation, were in spontaneous labor, and had a singleton gestation. Women with contraindications to labor, significant medical problems, a known fetal anomaly, and stillbirths were excluded from analysis. The frequency of birth was analyzed in relation to the time of day, day of week, and month of the year. RESULTS: Low-risk women (n = 6608) met the study criteria and were included in the analysis. No association was found between the day of the week and the frequency of births (P =.31). Births were most common between the hours of 1 to 2 pm and least common between the hours of 10:00 to 12:00 hours (Central Standard Time, P =.04). Births were more common in the fall, September through November, and least common in the winter, December through February. Daylight Saving Time did not affect these results. CONCLUSION: Birth after the spontaneous onset of labor is most common in the early afternoon, and most births occur in the fall. There is no natural association between spontaneous birth in low-risk women and the day of the week. LEVEL OF EVIDENCE: II-2

Adolescent↗
PubMed2006

Early labor assessment and support at home versus telephone triage: a randomized controlled trial.

OBJECTIVE: To compare rates of cesarean delivery among women who were triaged by obstetric nurses, either by telephone or by means of home visits. METHODS: Healthy, nulliparous women in labor at term with uncomplicated pregnancies residing in the City of Vancouver, British Columbia, and suburbs between November 2001 and October 2004 were randomized when they sought advice about when to come to hospital. Women randomized to telephone triage (n=731) were provided with advice by telephone. Women randomized to a home visit (n=728) were triaged after a "hands-on" assessment in their homes. RESULTS: The relative risk (RR) for cesarean delivery among home-triaged women compared with those receiving only telephone support was 1.12 (95% confidence interval [CI] 0.94-1.32). The study was designed to have 80% power to detect a RR less than 0.78 or greater than 1.27 for cesarean delivery. Significantly fewer women in the home visit group were admitted to hospital with cervical dilatation at 3 cm or less (RR 0.85, 95% CI 0.76-0.94). Significantly more women in the home visit group managed their labor without a visit to hospital for assessment (RR 1.54, 95% CI 1.23-1.92). There were no statistically significant differences in use of narcotic analgesia, epidural analgesia, and augmentation of labor. Adverse neonatal outcomes were rare and did not differ between study groups. CONCLUSION: Early labor assessment and support at home versus support by telephone reduces the number of visits to hospital in latent phase labor but does not impact cesarean delivery rates among healthy nulliparous women. CLINICAL TRIAL REGISTRATION: ISRCTN, www.controlled-trials.com/isrctn, MCT-44153 LEVEL OF EVIDENCE: I.

Adult↗
PubMed2004

Patient-controlled epidural technique improves analgesia for labor but increases cesarean delivery rate compared with the intermittent bolus technique.

BACKGROUND: We tested the hypothesis that patient-controlled epidural analgesia for labor (PCEA) provides better analgesia and satisfaction than the intermittent bolus technique (bolus) without affecting the mode of delivery. METHODS: We randomized 187 parturients to receive labor analgesia using either the PCEA or bolus technique. The PCEA group received a starting bolus of 14 mg of bupivacaine and 60 micro g of fentanyl in a 15-ml volume, followed by a background infusion (bupivacaine 0.08% and fentanyl 2 microg ml(-1)) 5 ml h(-1) with a 5-ml bolus and 15-min lock-out interval. The bolus group received boluses of 20 mg of bupivacaine and 75 micro g of fentanyl in a 15-ml volume. RESULTS: Parturients in the PCEA group had significantly (P < 0.05-0.01) less pain during the first and second stages of labor. There was no difference in the spontaneous delivery rate between the groups, but the cesarean delivery rate was significantly (P < 0.05) higher (16.3% vs. 6.7%) in the PCEA group than in the bolus group. Bupivacaine consumption was significantly (P < 0.01) higher (11.2 mg h(-1) vs. 9.6 mg h(-1)) and the second stage of labor was significantly (P < 0.01) longer (70 min vs. 54 min) in the PCEA group than in the bolus group. Patient satisfaction was equally good in both groups. CONCLUSION: The PCEA technique provided better pain relief. This was associated with higher bupivacaine consumption, prolongation of the second stage of labor, and an increased rate of cesarean section.

Adolescent↗
PubMed2006

Post-void residual volume in labor: a prospective study comparing parturients with and without epidural analgesia.

BACKGROUND: This prospective, non-randomized study compared post-void residual volume in laboring and postpartum women with or without epidural analgesia. METHODS: The study was conducted over 1 year with institutional review board approval. Parturients were recruited in early labor and self-selected to either the study (with epidural) or control (without epidural) group. Post-void residual volume was compared between groups, using transabdominal ultrasound during labor, and on postpartum day 1 and 2. Main outcome measure was intrapartum residual bladder volume. RESULTS: Thirty patients were recruited to each group. During labor, residual bladder volume was significantly larger in the epidural group compared with the non-epidural group [median (range)] 240 (12-640), ml vs. 45 (13-250) ml, respectively, P < 0.001], but was similar on postpartum day 1 and 2. Twenty-five (83%) women with epidural analgesia required bladder catheterization during labor vs. one (3.3%) without (P < 0.0001). CONCLUSION: The greater post-void residual volume and increased inability to void in parturients with epidurals suggests that epidural analgesia plays a role in intrapartum urinary retention.

Anesthesia, Epidural↗
PubMed1999

Elective induction of labor at 39 weeks of gestation: a prospective randomized trial.

OBJECTIVE: To clarify the safety of elective induction of labor at 39 weeks of gestation. STUDY DESIGN: Prospective randomized study. SUBJECTS AND METHODS: Uncomplicated nulliparas (N = 194) were randomly assigned at 36 weeks of gestation. Labor was electively induced in 63 women at 39 weeks of gestation in the active management group (I group, N = 98). Spontaneous labor onset was expected with semi-weekly nonstress test (NST) and amniotic fluid index (AFI) by 42 weeks of gestation in the expectant group (E group, N = 96). Perinatal events were compared between the 2 groups. RESULTS: A significantly higher incidence of meconium-stained amnios (19.4% vs 3.2%) and fetal resuscitation (16.7% vs 4.8%) was found in the E group than in the I group. Also, although a significantly higher incidence of epidural analgesia was noted in the I group (89%) than in the E group (54%) (labor onset > or = 39 weeks, N = 72), the duration of the 1st stage was shorter in I group and the duration of the 2nd stage was not significantly different. No other significant difference was noted between the 2 groups in terms of the rate of C-section, blood loss, incidence of pathological FHR, birth weight, Apgar score, umbilical arterial pH, or admission to NICU. CONCLUSION: Active management of labor at 39 weeks could be made as safely as expectant management with modified biophysical profile monitoring.

Adult↗
PubMed2005

Labor epidural analgesia in pre-eclampsia: a prospective study.

AIM: To assess the safety of labor epidural analgesia in subjects with pre-eclampsia. METHODS: Nulliparous laboring women were included in the prospective study. One hundred pre-eclamptic nullipara who were given epidural analgesia (group I) were compared with 100 nullipara with pre-eclampsia who were not given epidural analgesia (group II). The outcome was further compared with 200 women who were not pre-eclamptic, but who were given epidural analgesia (group III), and also with 200 women who were normotensive and who were not given epidural analgesia (group IV). RESULTS: In group I, 58% of subjects delivered normally compared with 60% in group II. The operative vaginal delivery rate was 28% in group I compared with 24% in group II (P = 0.62), and the cesarean section rate was 14% and 16% in groups I and II, respectively, (P = 0.8). The difference was not statistically significant. The incidence of a prolonged second stage of labor was also not increased in pre-eclamptic women who received epidural analgesia. Five of the neonates in group I had a 5-min APGAR score <6 compared with seven neonates in group II. The necessity of neonatal resuscitation was also not significantly increased in group I (P = 1.0). The incidences of fetal distress (P = 0.71), non-progressive second stage of labor (P = 0.66) and cephalopelvic disproportion (P = 0.90) were not statistically different in the pre-eclampsia group compared with the non-pre-eclampsia group. Similar results were noted when these outcome measures were compared with the other two groups. With regard to hypotension and tachycardia in the pre-eclamptic subjects who were given epidural analgesia, no statistical difference (P = 0.72) was seen when compared with the normotensive subjects. CONCLUSION: In the absence of coagulopathy, epidural analgesia is a safe and effective method for labor pain relief, even for subjects with pre-eclampsia.

Adult↗
PubMed1996

The experience of precipitate labor.

BACKGROUND: Despite abundant research on psychosocial factors related to childbirth, no studies have focused on the specific phenomenon of a precipitate labor. A descriptive exploratory study was conducted to investigate this experience. METHOD: Semistructured interviews were conducted in 1992 with 11 women 3 to 4 months after they gave birth. Transcribed interviews were then analyzed using latent content analysis. RESULTS: The experience of precipitate labor was categorized in terms of physical experience (perception of labor length and contractions), psychological experience (relationship of how women perceived birth to their prenatal expectations, and emotional trajectory of disbelief, alarm panic, and relief), and external factors (support persons and hospital system). CONCLUSIONS: Understanding the experience of precipitate labor is essential before caregivers can offer appropriate support to clients. Perinatal caregivers gain valuable insight into a woman's experience by comprehending the speed, intensity, and emotional impact specific to precipitate labor.

Adult↗
PubMedDate not supplied

Maternal confidence in coping with labor. A self-efficacy concept.

The clinical study of labor pain suggests that a woman's confidence in her ability to cope with labor contributes significantly to her perception of pain during labor. Self-efficacy theory is examined as a framework for evaluating women's confidence in their ability to cope with labor. The major propositions of self-efficacy theory are described and related to the experience of women approaching labor. The implications for nursing practice are presented, and directions for the study of maternal confidence are proposed.

Adaptation, Psychological↗
PubMed1996

The pain and discomfort of labor and birth.

One unique aspect of childbirth is the association of this physiologic process with pain and discomfort. However, the experience of pain during labor is not a simple reflection of the physiologic processes of parturition. Instead, labor pain is the result of a complex and subjective interaction of multiple physiologic and psychological factors on a woman's individual interpretation of labor stimuli. An understanding of labor pain in a multidimensional framework provides the basis for a woman-centered approach to labor pain management that includes a broad range of pharmacologic and nonpharmacologic intervention strategies.

Analgesia, Obstetrical↗
PubMedDate not supplied

Responses of pregnant women to potential preterm labor symptoms.

OBJECTIVE: To examine the knowledge that healthy pregnant women have of appropriate actions to take in response to hypothetical symptoms of preterm labor. DESIGN: This was a descriptive, correlational study using a convenience sample. SETTING: Subjects were recruited from the private practices of obstetricians and nurse-midwives. PARTICIPANTS: Three hundred twenty pregnant women who were between 20 and 32 weeks gestation were asked to complete a 17-item demographic information sheet and an 18-item Health Pregnancy Questionnaire while waiting for prenatal visits. Questionnaires from 269 women were appropriate for analysis. RESULTS: Most respondents could select appropriate action responses to items that identified obvious symptoms of being in preterm labor. In response to three questions that posed hypothetical preterm labor symptoms that were more subtle or were similar to normally occurring discomforts of pregnancy, between 26% and 35% of the women selected a choice that would have delayed entry into care. With a 95% confidence interval, significant positive relationships were found between selecting best responses and having experienced a previous preterm labor and maternal age. CONCLUSION: This study supports the need for all pregnant women to receive information on identification of preterm labor symptoms and appropriate actions to take with regard to these symptoms.

Adolescent↗
PubMedDate not supplied

The effect of relaxation therapy on preterm labor outcomes.

OBJECTIVE: To examine the effect of relaxation on preterm labor outcome. DESIGN: Quasi-experimental, with women who experienced preterm labor randomly assigned to a control or experimental group. The experimental group was to do a daily relaxation exercise. A third group was added to the study: women who were originally assigned to the relaxation group but were unable to adhere to the daily practice. Final data were analyzed for three groups: control (n = 40), experimental (n = 44), and nonadherent (n = 23) participants. SETTING: Women were referred to the study from physician offices and a hospital-based obstetric triage clinic in the Northwest. PARTICIPANTS: Total sample was comprised of 107 women with singleton gestations, documented contractions with cervical change, and intact membranes. INTERVENTIONS: The experimental group was instructed in a progressive relaxation exercise. The participants were given tapes of the exercise and instructed to do it daily. OUTCOME MEASURES: Study outcomes included gestational age at birth, rate of pregnancy prolongation, and birth weight. RESULTS: The outcome variables were analyzed using analysis of covariance, with the preterm labor risk score entered as a covariate to compensate statistically for group differences. A positive response to the relaxation intervention was found: The experimental group had significantly longer gestations and larger newborns when compared to the control and nonadherent groups. CONCLUSIONS: Relaxation therapy made a difference in preterm labor outcome. Women who practiced relaxation had larger newborns, longer gestations, and higher rates of pregnancy prolongation. Given the low cost of the intervention, it should be offered to all women at risk for preterm labor.

Adult↗
PubMedDate not supplied

Current practice in oxytocin dilution and fluid administration for induction of labor.

OBJECTIVE: To determine the types of intravenous fluids used to dilute oxytocin for labor induction in a national sample of obstetric units, as well as the extent to which these fluids reflect current published guidelines. DESIGN: A descriptive design. SETTING: Questionnaires were mailed to nurse managers at 700 obstetric units chosen via systematic random sampling from eligible hospitals listed in The AHA Guide (1998). PARTICIPANTS: Two hundred fifty-six usable questionnaires were included in data analysis. MAIN OUTCOME MEASURES: The Labor Induction Protocol Survey, consisting of eight questions relating to number of births per year, percentage of women whose labor is induced or augmented, methods used for induction of labor, intravenous fluids used to dilute oxytocin for induction of labor, the level of perinatal care of the unit, and the protocols units used to guide their practice in the use of oxytocin, was developed for this study. RESULTS: Approximately 98% of the responding sites follow the current recommendations for oxytocin dilution and mainline fluid delivery. However, 5 or 2% of the sites reported the use of 5% dextrose in water for both oxytocin dilution and the mainline intravenous solution. CONCLUSIONS: Although only 5 (2%) of the responding facilities indicated the use of 5% dextrose in water for both oxytocin dilution and the mainline intravenous solution, this may be clinically significant because of the serious nature of hyponatremia and the ease of its prevention. Nurses should be aware of the extent to which protocols for the infusion of oxytocin vary, despite what is documented as best practice and the potential consequences for their patients of implementing those protocols. Nurses who advocate for and participate in writing protocols that reflect the best-recommended practice for their patients will assist in ensuring that what is documented as best practice is actually implemented.

Benchmarking↗