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PubMed2005

Normal labor: mechanism and duration.

Labor is refers to the chain of physiologic events that allows a fetus to undertake its journey from the uterus to the outside world. The mean duration of a singleton preganancy is 40.0 weeks (280 days), which is dated from the first day of the last normal menstrual period. The period from 37.0 weeks (259 days) to 42.0 weeks (294 days) of gestation is regarded as "term". This article focuses on the onset progress, and mechanics of normal labor term. Topics such as preterm labor (labor before 37 weeks), postterm labor (labor after 42 weeks), and abnormal labor and delivery have not been addressed and are discussed in detail elsewhere in this issue.

Female↗

PubMed1985

Extradural analgesia in the management of singleton breech delivery.

Ninety-four singleton vaginal breech deliveries conducted under extradural analgesia were compared with 277 singleton vaginal breech deliveries conducted without extradural analgesia. Mean duration of the first stage of labour was similar in both groups. Mean duration of the second stage of labour was prolonged and mean 1-min Apgar scores were less in fetuses weighing more than 2500 g in the extradural group. Mean 5-min Apgar scores, perinatal morbidity and maternal complications were similar in both groups.

Anesthesia, Epidural↗

PubMed1977

Cyclic AMP and segmental epidural analgesia during labour.

The blood cyclic AMP level was determined just before, during and after induced labour in 27 healthy women. To achieve complete pain relief during the first stage of labour, 14 of them were given segmental epidural analgesia at the height of Th 10-12. The remaining parturients served as controls. Cyclic AMP was above the normal non-gravid level before induction in both groups. In the control group the cyclic AMP content decreased during the first stage of labour, then it increased and reached a peak at the moment of delivery. These changes were, however, not significant. In the epidural group the cyclic AMP level rose significantly during the first stage, and also reached its peak at the moment of delivery. There was a statistically significant difference between the groups at a cervical dilatation of 6-8 cm. After delivery the cyclic AMP rapidly declined to its initial value in both groups. The possible role of the decreased uterine contractions after the block in the increase of the cyclic AMP is discussed.

Adolescent↗

PubMed1975

Characteristics of normal labour in different racial groups.

The characteristics of normal labour in 1306 white, Asian and black parturients have been established following a prospective study of 3217 consecutive labours. Asian patients were found to be of significantly shorter stature than white or black women (p less than 0-001) and their infants significantly lighter than those of white (p less than 0-001) and of black (p less than 0-05) women, and a low positive correlation was found between maternal height and infant birth weight. The mean duration of the first stage of labour, taken from the time of admission to the labour ward, was 5-6 hours in primiparae and 3-7 hours in multiparae. The mean durations of the second stage of labour were 41-5 and 17-4 minutes respectively. The correlations between the duration of the first and second stages of labour were too low to be of value in patient management. Similar low correlations were found between the duration of the second stage of labour and both infant birth weight and the Apgar score at one minute. Cervical dilatation-time curves, constructed with reference to the cervical dilatation found on admission to the labour ward, revealed no significant differences in the progress of normal labour in the different racial groups.

Apgar Score↗

PubMed2006

The impact of parity on course of labor in a contemporary population.

BACKGROUND: Few studies have examined in depth the labor progression of multiparas to determine if there is any additional impact of being parous beyond the first birth. The objective of this study was to determine the effect of parity on labor progression in contemporary obstetric practice. METHODS: Our sample consisted of all low-risk women who delivered a term, live-born infant from January 2002 to March 2004 at a single institution in Delaware, United States (n = 5,589). The median duration of labor by each centimeter of cervical dilation was computed for parity = 0 (n = 2,645); parity = 1 (n = 1,839); parity = 2 (n = 750); and parity = 3 + (n = 355). RESULTS: Multiparas had a significantly faster labor progression from 4 to 10 cm (293, 300, and 313 min, respectively, for parity = 1, parity = 2, and parity = 3 +), compared with nulliparas (383 min for parity = 0), as well as a shorter second stage of labor. However, no significant differences were found in duration of the active phase or the second stage of labor among multiparas. CONCLUSIONS: Additional childbearing appears to have no effect of on the progression of labor among multiparous subgroups. The difference in duration of the active phase between nulliparas and multiparas is substantially smaller in a contemporary population.

Adult↗

PubMed1978

Maternal and foetal plasma bupivacaine concentrations in labour with segmental epidural analgesia.

Maternal and foetal plasma bupivacaine concentrations were assayed following segmental epidural analgesia during the first stage of 14 normal labours. Analgesia was accomplished with 20 mg of 0.5% bupivacaine. 10 mothers received only one dose and four mothers two doses. The maternal and foetal plasma bupivacaine levels remained very low and the foetomaternal ratios were about 1:4 during the labour. At delivery, the foeto-maternal ratio increased, showing that the decline of bupivacaine concentrations is slower in foetal than in maternal plasma.

Adult↗

PubMedDate not supplied

Comparative evaluation of four different infusion rates of ropivacaine (2 mg/mL) for epidural labor analgesia.

BACKGROUND AND OBJECTIVES: Previous studies have reported comparable efficacy for ropivacaine and bupivacaine when used for labor analgesia at concentrations of 2.5 mg/mL. In this multicenter study, we assessed ropivacaine at the commercially available concentration of 2 mg/mL (0.2%) for labor pain management. METHODS: After Institutional Review Board approval and informed consent, 128 women at term were randomly assigned to receive ropivacaine at one of the four infusion rates via a lumbar epidural catheter. Analgesia was initiated with a 5-mL test dose, followed by injections of 5-15 mL of 2 mg/mL ropivacaine. The continuous infusion was then started at 4, 6, 8, or 10 rmL/hour. Rescue analgesia was provided with 5-mL "top-up" injections as necessary to provide maternal comfort. Pain relief was assessed by using a visual analog pain scale (VAPS) and motor block was assessed by using a modified Bromage scale. RESULTS: All infusion regimens effectively decreased VAPS, and most patients in all groups had minimal or no motor block at the end of the first stage of labor. Mean total number of the top-up injections required per patient were 3, 2, 1.5, and 1.4, respectively, in the 4, 6, 8, and 10-mL/hour groups (P < .05, 4 mL/hour vs. all other groups). Despite receiving more total bolus dosages, the 4-mL/hour group had less motor block in the lower extremities (P < .05). Apgar scores and neurological adaptive capacity scores were similar for all groups. CONCLUSIONS: The 2 mg/mL of ropivacaine produces satisfactory labor analgesia at epidural infusion rates of 4, 6, 8, and 10 mL/hour, provided supplemental bolus dosages are available. Clinically, a rate of 6 mL/hour may be the lowest effective rate that provides the best combination of pain relief, motor block, and rebolusing, although rates of 8 and 10 mL/hour produced similar results.

Adult↗

PubMed1992

Plasma oxytocin during the first and second stages of spontaneous human labour.

A technique for complete oxytocinase inhibition has been combined with a rapid serial sampling strategy to determine plasma oxytocin concentrations in twelve women during the early and late first stage and in eight women throughout the second stage of labour. The progress of labour is not related to an increase in oxytocin concentration, uterine contractions are not associated with changes in plasma oxytocin concentration and hypocontractile labour does not appear to be the result of a deficit of oxytocin. The majority of patients do not demonstrate an increase in plasma oxytocin concentration during the second stage of labour; however, a minority produce a large surge immediately before delivery. The results do not support a role for oxytocin during spontaneous labour unless uterine activity is controlled by extremely low plasma hormone concentrations or the uterus becomes sensitive to a constant oxytocin concentration.

Adult↗

PubMed1992

Is fetal heart rate monitoring sufficiently sensitive to detect changes during labour?

Although fetal monitoring is a common clinical procedure, there is little quantitative evidence that it can detect changes occurring during labour. We present quantitative data comparing the first and second stage of labour, from 21 labours resulting in a normal fetal outcome. A range of fetal heart rate variables was calculated from the output of a fetal heart rate monitor. Significant changes were detected in baseline fetal heart rate (P less than 0.005), heart rate variability (P less than 0.05), number of dips (P less than 0.01) and their depth (P less than 0.01). The results encourage confidence in the sensitivity of fetal monitoring for the detection of changes in a number of fetal heart rate variables during the course of labour.

Electrocardiography↗

PubMed2006

Occurrence of ST-changes recorded with the STAN S21-monitor during normal and abnormal fetal heart rate patterns during labour.

OBJECTIVE: To determine the frequency of ST-changes in the fetal electrocardiogram (ECG) both during normal and abnormal fetal heart (FHR) traces and to study relations with characteristics of pregnancy and delivery. STUDY DESIGN: Retrospective analysis of 563 FHR+ECG-recordings. ST-changes were counted for all recordings with respect to their FHR pattern. Relationships between the occurrence of ST-events and characteristics of pregnancy and delivery were determined for the recordings with a completely normal FHR tracing during the first stage. RESULTS: ST-events were present during 51.7% of recordings in the first stage of labour and during 24.3% of the recordings in the second stage. Surprisingly, events occurred during the first stage at a similar incidence during normal and abnormal FHR-patterns. During the second stage of labour events also occurred in a similar percentage of normal, intermediary and abnormal recordings, but - if present - events were more numerous during the abnormal FHR traces. In the subgroup of cases with a normal FHR pattern more events per hour occurred in babies born at 36-37 weeks of gestation and in boys. CONCLUSION: ST-events are a frequent finding during normal FHR tracings.

Birth Weight↗

PubMed1993

Hypnosis: practical applications and theoretical considerations in normal labour.

OBJECTIVE: To assess the effects of hypnotherapy on the first and second stages of labour in a large group of pregnant women. DESIGN: A semi-prospective case control study in which women attending antenatal clinics were invited to undergo hypnotherapy. SUBJECTS: One hundred twenty-six primigravid women with 300 age matched controls, and 136 parous women having their second baby with 300 age matched controls. Only women who had spontaneous deliveries were included. SETTING: Aberdare District Maternity Unit, Mid Glamorgan, Wales. INTERVENTION: Six sessions of hypnotherapy given by a trained medical hypnotherapist during pregnancy. OUTCOME MEASURES: Analgesic requirements, duration of first and second stages of labour. RESULTS: The mean lengths of the first stage of labour in the primigravid women was 6.4 h after hypnosis and 9.3 h in the control group (P < 0.0001); the mean lengths of the second stage were 37 min and 50 min, respectively (P < 0.001). In the parous women the corresponding values were 5.3 h and 6.2 h (P < 0.01); and 24 and 22 min (ns). The use of analgesic agents was significantly reduced (P < 0.001) in both hypnotised groups compared with their controls. CONCLUSION: In addition to demonstrating the benefits of hypnotherapy, the study gives some insight into the relative proportions of mechanical and psychological components involved in the longer duration of labour in primigravid women.

Adult↗

PubMed1979

Duration of labour with spontaneous onset.

Among 2242 women with spontaneous onset of labour, the median duration of labour for those delivered vaginally was 8 1/4 hours in para 0, 5 1/2 hours in para 1 and 4 3/4 hours in para 2+ mothers. In the parity groups 0, 1 and 2+ 90% had delivered within 16 1/4 hours, 10 1/2 hours and 10 3/4 hours, respectively, while 10% of para 0 labours lasted less than 4 hours, 10% of para 1 labours less than 2 1/4 hours and finally 10% of para 2+ labours less than 2 hours. In the first stage of labour the latent phase (cervical dilatation less than 4 cm), was nearly 2.5 times as long as the active phase (cervical dilatation 4-10 cm). The second stage (cervical dilatation 10 cm-birth) had a median duration of 16 min in para 0 and approximately 10 min in para 1+ mothers. The length of the latent and active phases and the second stage for para 1+ mothers was 60-70% of that of para 0 mothers. In individual mothers there were weak correlations between the length of the phases and stages. For example, the length of the latent phase appeared to be a relatively poor predictor of the length of the active phase of labour. However, selection bias may have weakened these correlations somewhat.

Delivery, Obstetric↗

PubMed1976

Extradural analgesia in labour when the breech presents.

A retrospective study was made of the course and outcome of labour in 226 patients in whom a singleton fetus presented by the breech. Patients with macerated stillbirths or who were delivered before the 28th week of gestation had been excluded. Of the 226 patients, 101 received extradural analgesia, 79 received parenteral analgesia and 46 underwent elective Caesarean section. There was no difference in the incidence of breech extraction or emergency Caesarean section in the first two groups of patients. The length of both first and second stages of labour in multiparae was prolonged in the extradural group, but not markedly so. The Apgar scores of the infants delivered vaginally were not significantly different at one minute in both groups but the five minute Apgar score in the infants of primiparae was significantly higher in the extradural group. The Apgar score at one minute in the group delivered by emergency Caesarean section was significantly lower after extradural block but the difference was not significant at five minutes. This study suggests that the management and outcome of labour when the breech presents is not adversely affected by the provision of extradural analgesia.

Adult↗

PubMedDate not supplied

[Concentration of estrogen and progesterone receptors in the lower uterine segment at term labor].

BACKGROUND: To determine cytosol estrogen and progesterone receptor concentrations in the human lower uterine segment in different stages of cervical dilatation during parturition at term. PATIENTS AND METHODS: Biopsy specimens of the lower uterine segment were obtained from 51 women undergoing non-elective cesarean section at term. The stage of cervical dilatation at the time of cesarean section was < 2 cm (N = 14), 2 to < 4 cm (N = 13), 4 to 6 cm (N = 11) or > 6 cm (N = 13). The cytosolic estrogen and progesterone receptor concentrations were determined by enzyme immunoassays. RESULTS: Median estrogen receptor concentrations at < 2 cm and at 2-< 4 cm cervical dilatation were 2.12 fmol/mg protein and 2.03 fmol/mg protein, respectively. After a significant drop at 4-6 cm cervical dilatation (median: 1.08 fmol/mg protein), estrogen receptor concentrations raised again at > 6 cm cervical dilatation (median: 2.00 fmol/mg protein). Median progesterone receptor concentration was 84.7 fmol/mg protein at < 2 cm cervical dilatation, diminished significantly at 2-< 4 cm cervical dilatation (36.6 fmol/mg protein) and increased at further cervical dilatation (4-6 cm: 75.7 fmol/mg protein; > 6 cm: 83.7 fmol/mg protein). CONCLUSIONS: These data suggest that predominantly a decrease in cytosolic concentration of the progesterone receptor at the beginning of the active phase of first stage labor may play a crucial role in the hormonal control of cervical dilatation during parturition at term.

Adult↗

PubMed1982

Predictive value of cervimetric labour patterns in primigravidae.

From a study of 2000 consecutive labours the outcome of the 684 primigravid patients admitted in spontaneous labour has been examined according to their cervimetric progress during the first stage of labour. A partogram and labour stencil were used to identify dysfunctional labour which was treated with a standard protocol of augmentation by oxytocin. This policy achieved labours with a mean 'observed first stage' of 6.3 h and a caesarean section rate of 8.7%. There was one stillbirth due to multiple congenital abnormalities and no increase in perinatal morbidity. Our data show that the type of first stage cervimetric pattern is helpful in predicting the outcome of labour. A normal cervimetric pattern resulted in a vaginal delivery rate of 98.4%; primary dysfunctional labour, which could be improved by oxytocin, had a 93.8% incidence of vaginal delivery, but if there was no improvement in the rate of cervical dilatation when this was administered the vaginal delivery rate was only 22.7% . A prolonged latent phase was associated with a caesarean section rate of 16.7% and the incidence of neonatal intubation was nearly as high as that found in uncorrected primary dysfunctional labour. The neonatal asphyxia in secondary arrest was minimal with an overall caesarean section rate of 28.4%; there was no increased incidence of neonatal morbidity with this cervimetric type.

Cervix Uteri↗

PubMed1995

Postoperative morbidity following Caesarean delivery.

The current study was designed to determine the postoperative morbidity associated with Caesarean section and to compare the morbidity with the timing of the operation: elective versus emergency Caesarean section; subgroups of women delivered by emergency Caesarean section; women delivered during the first stage of labour versus those delivered during the course of the second stage. A retrospective review was conducted of the obstetric case record and the midwifery notes of all women delivered by Caesarean section over a 1-year period in a university teaching hospital (n = 619). The variables used to measure postoperative morbidity included: wound infection, intrauterine infection, urinary tract infection, chest infection, pyrexia, urinary catherization and postnatal blood transfusion. Only 9.5% of the women had no recorded morbidity in the postnatal period. Women delivered by emergency Caesarean section experienced a greater number of postnatal problems, an increased incidence of febrile morbidity, more blood transfusions in the postnatal period and a higher proportion had a urinary catheter left in situ after surgery. The incidence of wound infection, intrauterine infection and chest infection was higher in the emergency group and this resulted in an increased proportion of the women requiring antibiotic therapy in the postnatal period. The study found that there was considerable postoperative morbidity associated with Caesarean delivery, particularly if the operation was carried out as an emergency procedure.

Antibiotic Prophylaxis↗

PubMed1994

A re-evaluation of the effect of pethidine on the length of labour.

In a pilot study of a randomized controlled trial comparing pushing techniques in the second stage of labour, a surprise finding was that there was a positive correlation between the amount of pethidine used for analgesia in the first stage of labour and an increasing length of both the first (r = 0.5687, P = 0.0001, CI = 0.33 to 0.74) and second stages (r = 0.3204, P = 0.037, CI = 0.03 to 0.56). In order to investigate this further a review of the literature on the effect of pethidine on the length of labour was undertaken. The literature searched was the English-language literature, and MEDLINE and Index Medicus were used to identify pertinent papers. Studies selected were randomized controlled trials of pethidine given for pain relief in labour compared with placebo. As only five studies were identified other pertinent studies using the drug were scrutinized. The findings of this review are that, due to methodological flaws and studies with small sample sizes, the effect of pethidine on the length of labour in women has not been adequately assessed. However, there is a strong suggestion in the literature that the use of this drug is associated with a lengthening of labour and this association is dose-related. Studies in animals support this view. Those caring for women in labour should be aware of this side-effect of the analgesic most frequently given in labour in North America and the United Kingdom. As pethidine frequently does not provide adequate analgesia and has other side-effects, the search for an alternative analgesia should continue.

Animals↗

PubMed2004

[Gentle obstetrical management for very early preterm deliveries].

OBJECTIVE: In view of the general improvement in survival of very early preterm newborns the contribution of the obstetrical management to this development has been studied. METHODS: A comprehensive literature search was performed concentrating on prospective randomised clinical trials, meta-analyses and review articles dealing with different aspects of the obstetrical management of very early preterm deliveries which were published during the last 10 years. RESULTS: The benefit of antepartal administration of glucocorticoids to the mother for stimulation of pulmonary maturity of the fetus and the overall clinical condition of the preterm newborn at birth has been proven by several prospective randomised studies. In contrast, there is only indirect evidence for the benefit of an early transfer of these pregnancies to a perinatal centre. The benefit of a short-term prolongation of pregnancy by the administration of tocolytics is evident in the context of glucocorticoid administration for pulmonary maturity. There is no clear evidence for the benefit of long-term tocolytic treatment of preterm labour. Various prospective randomised trials comparing delivery by primary or elective caesarean section with vaginal birth combined with selective section as indicated by a deterioration of the condition of the fetus or the mother during the first or second stage of labour have clearly shown increased maternal morbidity in the elective caesarean section group. The expected advantage for the condition of the newborn could not be shown. In a meta-analysis of 6 such trials, the problem of recruiting participants was stressed. All 6 trials had to be terminated before the calculated number of study participants had been recruited. CONCLUSION: For planned early preterm delivery a transfer of the mother into perinatal centre is recommended for pregnancies beyond 22 0/7 weeks. Starting at 24 0/7 weeks, glucocorticoids should be administered. Between 24 0/7 and 24 6/7 weeks, survival chances remain clearly at less than 50%, and up to 50% of those surviving develop moderate to severe handicaps. Obstetrical management, in particular a decision for caesarean section due to fetal indication, must be individualised taking into account the wishes of the parents. Beyond 25 0/7 weeks, newborn survival should be given priority, and although clear evidence for the optimal mode of delivery is missing in cases of spontaneous labour leading to rapid dilatation of the cervix, with a normal singleton cephalic fetus, a vaginal delivery may be attempted. If under close supervision of labour there are signs of fetal or maternal deterioration, a caesarean section should be performed without delay. With breech presentation as well as twins or multiple fetuses there is a general trend towards primary caesarean section. In the absence of spontaneous labour and with an unripe cervix, elective caesarean section is considered as the method of choice for the delivery of the early preterm fetus.

Cesarean Section↗