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PubMed1988

Intrauterine pressure studies in multigravid patients in spontaneous labour: effect of oxytocin augmentation in delayed first stage.

Uterine activity was assessed by measuring the uterine activity integral (UAI) in 116 black multigravid patients in spontaneous active labour at term. Although individual patients showed a wide range of mean UAI levels, normal labour (group I, n = 54) was associated with a mean UAI level of 1640 kPas/15 min which was higher than the mean level observed in patients in whom delay in cervical dilatation occurred in active labour. The patients who failed to progress in labour were treated with oxytocin infusion and 32 of them made good progress in labour and achieved vaginal delivery (group IIa: mean UAI pre-oxytocin treatment 1040 (SD 424) kPas/15 min, post-oxytocin 1890 (SD 559) kPas/15 min). The other 23 patients required operative delivery (group IIb) despite correction of uterine activity after oxytocin treatment (pre-oxytocin mean UAI 1230 (SD 570) kPas/15 min, post-oxytocin 1815 (SD 650) kPas/15 min). The rate of oxytocin infusion varied between patients from 2 to 16 mU/min but in 75% uterine activity was corrected to normal levels by a dose of less than or equal to 8 mU/min. It is concluded that delay in progress in labour is associated with lower intrauterine pressures than are present in normal labour, and that management of patients presenting with inefficient uterine action may benefit from the use of uterine activity integral measurements.

Female↗
PubMed1994

Comparing routine versus delayed amniotomy in spontaneous first labor at term. A multicenter randomized trial. UK Amniotomy Group.

OBJECTIVE: To measure the effect of a policy of routine amniotomy on nulliparous labor. DESIGN: A multicenter randomized controlled trial. SUBJECTS: Nulliparous women (1463) in spontaneous labor at term with intact membranes and a single cephalic fetus. INTERVENTIONS: Rupturing membranes routinely early in labor or leaving them intact for as long as possible. MAIN OUTCOME MEASURES: Duration of labor, operative and instrumental delivery rates, use of analgesia, perinatal death, neonatal convulsions, and admission to special care. RESULTS: Median duration of labor was 8.4 hours in the early rupture group and 9.4 hours in the late group. No clear trend for this difference emerged at any particular cervical dilatation at randomization. We found no difference in cesarean section, typical odds ratio (OR) 1.1 (95% CI, 0.65 to 1.8); operative vaginal delivery, OR 1.1 (95% CI, 0.83 to 1.5); use of epidural/spinal, OR 0.92 (95% CI, 0.72 to 1.2); use of pethidine, OR 1.0 (95% CI, 0.79 to 1.4); either method of analgesia, OR 0.96 (95% CI, 0.68 to 1.3); blood transfusion, OR 0.71 (95% CI, 0.28 to 1.8. We found no effect on fetal intubation, OR 1.40 (95% CI, 0.78 to 2.5), or on admission to special care, OR 1.28 (95% CI, 0.65 to 2.5). One fetus in the early amniotomy group had care, Or 1.28 (95% CI, 0.65 to 2.5). One fetus in the early amniotomy group had neonatal convulsions, but there were no perinatal deaths. CONCLUSIONS: Beyond a modest shortening of labor, a policy of routine amniotomy has little effect on important outcomes and should not be recommended.

Amnion↗
PubMed1987

Cardiac output during labour.

Serial measurements of cardiac output and mean arterial pressure were performed in 15 women during the first stage of labour and at one and 24 hours after delivery. Cardiac output was measured by Doppler and cross sectional echocardiography at the pulmonary valve. Basal cardiac output (between uterine contractions) increased from a prelabour mean of 6.99 l/min to 7.88 l/min at greater than or equal to 8 cm of cervical dilatation as a result of an increase in stroke volume. Over the same period basal mean arterial pressure also increased. During uterine contractions there was a further increase in cardiac output as a result of increases in both stroke volume and heart rate. The increment in cardiac output during contractions became progressively greater as labour advanced. At greater than or equal to 8 cm of dilatation cardiac output increased from a basal mean of 7.88 l/min to 10.57 l/min during contractions. There were also further increases in mean blood pressure during contractions. One hour after delivery heart rate and cardiac output had returned to prelabour values, though mean arterial pressure and stroke volume remained raised. By 24 hours after delivery all haemodynamic variables had returned to prelabour values. Haemodynamic changes of the magnitude found in this series are of considerable clinical relevance in managing mothers with complicated cardiovascular function.

Adult↗
PubMed2006

Clinical triggers to initiate intrapartum penicillin therapy for prevention of group B streptococcus infection.

Despite national recommendations for prophylactic group B streptococci intrapartum penicillin therapy (GBS-IPT), there is little guidance for clinicians regarding to how to achieve the recommended 4 hours of therapy. We sought to identify clinical triggers for effective temporal prompts to initiate GBS-IPT to achieve the recommended duration of therapy. GBS-colonized women who delivered between 37 and 42 weeks were analyzed retrospectively. The clinical record was reviewed for clinical events including rupture of membranes, oxytocin therapy, 4-cm dilation, active labor, narcotic analgesia, epidural analgesia. In addition, combinations of these triggers were evaluated using the first appearance of 4-cm dilation or active labor, narcotic analgesia or epidural, and a composite indicator of each of these four triggers. Antibiotic duration and proportion receiving 4 hours of GBS-IPT for each trigger were compared with the conventional penicillin management the patient actually received (CM). Data were analyzed with Z-test for proportions with Bonferroni correction and one-way analysis of variance. Two hundred thirteen women met study criteria and were reviewed. Using CM, 90.8% of nulliparas and 68.7% of parous women achieved adequate GBS-IPT. In nulliparas, each clinical trigger resulted in equivalent rates of adequate GBS-IPT compared with CM. The duration of therapy was less for 4-cm dilation, epidural, epidural or narcotic analgesia, and 4-cm dilation or active labor triggers in nulliparas, suggesting better identification of the period 4 hours prior to delivery. In parous women, clinical triggers did not perform better than CM. In nulliparous women, clinical triggers to initiate therapy may achieve high rates of GBS-IPT, with a significant decrease in the duration of antibiotic therapy. In nulliparous women, clinical triggers better identify the 4-hour window prior to delivery than CM.

Adult↗
PubMed1986

Correlation between subjective labour pain and uterine contractions: a clinical study.

Fifteen primiparous women underwent tocography during the second phase of the first stage of labour in order to evaluate the main characteristics of their uterine contractions (intensity, duration and pattern). At the end of each contraction, for a total of about 8 contractions per woman and an overall total of 125 tocographic curves, each woman was asked to make a subjective evaluation of the pain felt during that contraction using a 10 cm visual analogue scale (VAS). All the tocographic curves corresponding to the contractions studied were elaborated mathematically to determine the peak (intensity), base (duration) and area under the curve (AUC). Lastly, correlations between the mathematical parameters of the curves and corresponding VAS scores were sought. In the population a general positive correlation between the 3 main parameters of tocographic curves and the VAS score was demonstrated; the AUC and the peak tended to be better correlated with VAS than duration. Within-subject comparison showed the existence of a significant correlation with VAS score in 12/15 women as far as peaks are concerned, in 10/15 as far as AUC is concerned and in 0/15 women as regards duration. The findings support the concept that perceived labour pain depends in most of the women on the intensity and pattern of the uterine contractions. The possible clinical and experimental applications of this finding are discussed.

Adult↗
PubMed1998

[The obstetrical management of pregnant patients with spontaneous rupture of the fetal membranes after 37 weeks' gestation].

The purpose of the study was to analyze the obstetric management in pregnancies with spontaneous rupture of membranes (RM) after 37 w.g. and to find out is there a correlation between the cervical status and the pregnancy outcome. The study includes 66 primiparous women divided into two groups depending on the cervical status(CS) at admission: Group 1-44 patients with unfavourable cervix (PS < 4) according to the Bishop's original scoring system and Group 2-22 patients with favourable cervix (PS > 4). The delivery started spontaneously within the first 8 hours after the RM in 59% of the pregnant women with favourable cervix compared to 50% of women with PS < 4. There is no significant difference in the mean duration of the latent period between group 1 and 2-6.3 and 6.2 hours, respectively. The mean duration of delivery was 14.08 hours in Group 1 compared to 14.03 hours in Group 2. 72.7% of the pregnant women in Group 1 had normal vaginal delivery compared to 86.44% of the patients in Group 2. There were 3 newborn (one in Group 1 and 2 in Group 2) with signs of infection. There were no perinatal deaths. Postpartal endometritis was diagnosed in 2 of the patients with unfavourable cervix. There is no motivation to fear the development of ascendant infection in pregnancies with RM after 37 w.g. even if the time elapsed from the very beginning of the RM to the start of delivery is more than 24 hours. We favour both active and passive management of delivery in pregnancies with favourable cervix at the time of RM. We have to reevaluate the active approach in pregnancies with unfavourable cervix and ruptured membranes because of the higher incidence of operative deliveries because of non-progress of labour in these cases.

Adult↗
PubMed1983

Cervical ripening.

When induction of labour is being considered the first step should be to assess the cervical score. If this is low, the gestational age should be confirmed since an unripe cervix is normal in earlier pregnancy and there may be a mistake in the patient's dates. If the maturity is confirmed, the choice lies between delivering the baby and waiting. Few genuine indications for induction change by waiting and increased risks may occur by postponing the date of delivery. The choice may then lie between elective caesarean section or amniotomy and intravenous oxytocin with an unripe cervix on the one hand, and cervical ripening before induction of labour on the other (Lancet, 1979). The last course has many advantages to commend it. There is still much to be learnt about cervical ripening. The success of the prostaglandins suggests that they may be the agents of choice at present. The ideal preparation would be one that could be administered vaginally to ripen the cervix without inducing uterine contractions. A major problem to date has been the absence of a commercially available PGE2 preparation for local use and this has necessitated the formulation of home-made gels and pessaries by individual hospital pharmacies. However, recently Prostin E2 vaginal tablets (each containing dinoprostone 3 mg) have been marketed and initial studies (Stewart et al, 1983) have shown promising results.

Administration, Oral↗
PubMed2004

Vaginal birth after Cesarean delivery: predicting success, risks of failure.

OBJECTIVES: To identify predictors of successful trial of labor in women after one low transverse Cesarean delivery and no prior deliveries, and to assess perinatal morbidity associated with a failed vaginal birth after Cesarean delivery (VBAC). METHODS: Retrospective chart review of women with one low transverse Cesarean delivery in their first pregnancy who delivered their next pregnancy at our institution. Clinical characteristics and intrapartum data were reviewed to identify predictors of successful VBAC. Perinatal outcomes were reviewed to assess morbidity associated with VBAC attempt and failed VBAC. RESULTS: Of 768 women studied, 522 (68%) attempted VBAC and 344 (66%) of these were successful. Uterine rupture occurred in 0.8% of the VBAC group. On initial examination, women with cervical dilation >1 cm, effacement > 50% and station lower than -1 were more likely to deliver vaginally. Women with successful VBAC had more spontaneous labor (85.2 vs. 76.4%, p=0.02) and less oxytocin use (49.7 vs. 70.8%, p < 0.0001). There were no differences in outcomes between failed and successful VBAC, except more frequent 1-min Apgar scores < 5 (10.1 vs. 4.1%, p=0.01) and increased endometritis (9.6 vs. 2%, p=0.0002) with failed VBAC. Compared with elective repeat Cesarean delivery, VBAC attempt was associated with amnionitis (5.9 vs. 0%, p < 0.0001) and low 1- and 5-min Apgar scores (6.1 vs. 2.4%, p=0.03 and 2.3 vs. 0%, p=0.01, respectively), but not endometritis, admission to a neonatal intensive care unit (NICU), ventilation, intraventricular hemorrhage (IVH) or seizures. Failed VBAC had more amnionitis (7.3 vs. 0%, p < 0.0001), postpartum fever (11.2 vs. 2.4%, p=0.0003) and endometritis (9.6 vs. 2.0, p=0.0007) than elective repeat Cesarean delivery and was associated with low 1- and 5-min Apgar scores (10.1 vs 2.4%, p < 0.001 and 2.8 vs. 0%, p=0.01, respectively), but not NICU admission, ventilation, IVH or seizures. CONCLUSIONS: Favorable initial pelvic examination, spontaneous labor and a lack of oxytocin use are associated with successful VBAC in women with a single prior low transverse Cesarean delivery and no prior vaginal deliveries. While attempted VBAC and failed VBAC have more maternal infectious morbidity and lower Apgar scores, infant outcomes are similar to those of elective repeat Cesarean delivery.

Adult↗
PubMed2005

A double blind, randomized trial on augmentation of labour with a combination of intravenous propranolol and oxytocin versus oxytocin only.

OBJECTIVE: To compare the combination of intravenous propranolol and oxytocin with oxytocin only in augmentation of labour. STUDY DESIGN: A prospective randomized double-blind study in an obstetric department of a large university hospital in Finland. A total of 107 parturients with arrested first stage of labour owing to inadequate uterine contractility were randomized to receive intravenously once or twice a 2 mg dose of propranolol or placebo combined with oxytocin infusion. The main outcome measure was the effect of intravenous propranolol on the frequency of Caesarean section among parturients with arrested labour. The secondary outcome measures were the duration of labour, the required dosage of oxytocin, CTG readings, neonatal outcome and maternal and cord plasma levels of beta-adrenoceptor-binding component of propranolol. Categorial variables between the groups were compared using Chi square and Fisher's exact tests. Continuous variables were compared using the Mann-Whitney U-test and Student's t-test. RESULTS: No reduction in Caesarean section rate was found in the propranolol group. Seventy-three percent of the parturients in the propranolol group and 85% in the placebo group had spontaneous vaginal delivery, RR=0.86 (95% CI 0.70-1.05). The percentage proportion of the augmented part of labour was significantly shorter in the propranolol group than in the placebo group. No differences in the required oxytocin dosage or CTG pathology were found between the groups. Propranolol was found to be safe for the neonates. The concentrations of its beta-adrenoceptor-binding component after a 2mg intravenous dose were quite similar in parturients and neonates at the time of delivery. The active drug component crossed placental barriers with an average neonate umbilical artery/parturient venous plasma ratio of 0.7. After a 4 mg dose the active drug concentrations in parturients were rather similar to those measured after 2 mg dose, whereas in neonates there were signs of drug accumulation. No picture could be obtained from the kinetics of the beta-adrenoceptor-binding component of propranolol from the data. CONCLUSIONS: Propranolol (2 or 4 mg i.v.) combined with oxytocin, as treatment for arrested labour did not affect the Caesarean section rate compared with placebo plus oxytocin. The percentage proportion of the augmented part of labour was significantly shorter after propranolol. Propranolol was safe for the neonates and can be used as an additional medication among parturients with arrested labour.

Adult↗
PubMed1998

Cervical ripening with prostaglandin gel and hygroscopic dilators.

OBJECTIVE: To study the effectiveness and morbidity of adding hygroscopic cervical dilators to prostaglandin gel for cervical ripening and labor induction. STUDY DESIGN: Patients of at least 34 weeks' gestation with a medical indication for induction of labor and with a modified Bishop score of 5 or less were randomized to receive either prostaglandin gel or prostaglandin gel with hygroscopic cervical dilators. Primary outcomes were time to delivery, change in cervical score, and infection. Secondary outcomes included cesarean delivery rate and deliveries before 24 hours of induction. Continuous variables were analyzed by Wilcoxon sum rank test and categorical data by chi-square or Fisher exact test, with P < 0.05 being significant. RESULTS: Seventeen patients were randomized to intracervical prostaglandin alone and 23 patients received intracervical prostaglandin plus hygroscopic dilators. No demographic differences were noted between the groups. After six hours of ripening, the combined group achieved a greater change in Bishop score (3.6 vs. 2.1, P = 0.007) and tended to have a shorter induction time (21.7 vs. 26.4 hours, P = 0.085). The combined therapy group had a higher infection rate than the prostaglandin-only group (59% vs. 12%, P = 0.003). CONCLUSION: Combining cervical dilators with prostaglandin gel provides more effective cervical ripening and a more rapid induction to delivery interval than prostaglandin alone but with a significant and prohibitive rate of infection.

Cervix Uteri↗
PubMed2004

Does ultrasound examination when the cervix is unfavorable improve the prediction of failed labor induction?

OBJECTIVE: To compare the Bishop score, ultrasound cervical parameters and fetal fibronectin assessment for predicting failed labor induction when the cervix is unfavorable. METHOD: A prospective observational study was performed in 106 consecutive pregnant women with a Bishop score < or =5 undergoing labor induction. Assessment of fetal fibronectin and ultrasound measurement of cervical length, cervical wedging and cervical lip areas were performed. The relationship between these parameters and failure of labor induction was determined. RESULTS: Failure of labor induction was defined as failure to reach a cervical dilatation of > or =5 cm, and it occurred in 16 patients (15.1%). Induction failure was associated with low Bishop scores before (P = 0.004) and 6 h after the start of induction (P = 0.007), increased clinical cervical length (P = 0.02) and increased ultrasound anterior cervical lip area (P = 0.04). The logistic regression model identified the Bishop score before induction (odds ratio = 2.25; 95% CI, 1.30-3.91; P = 0.003) and the clinical cervical length (odds ratio = 3.95; 95% CI, 1.3-11.7; P = 0.01) as being independent predictors of failed induction. To predict an induction failure, the best Bishop score cut-off value was 4, with a sensitivity of 87.5%, a specificity of 45.6%, a likelihood ratio of 1.58, a positive predictive value of 22.2% and a negative predictive value of 95.4%. CONCLUSION: Compared with the Bishop score, cervical length by ultrasound is not a better predictor for the outcome of labor induction in an unfavorable cervix. Nevertheless, the Bishop score appears to be of poor predictive value for failed induction of labor.

Adult↗
PubMed2004

The role of ultrasound and fetal fibronectin in predicting the length of induced labor when the cervix is unfavorable.

OBJECTIVE: To compare cervical clinical data, ultrasound parameters and fetal fibronectin assessment in the prediction of the duration of induced labor when the cervix is unfavorable. METHODS: This was a prospective study of 90 pregnant women with a Bishop score </= 5 undergoing labor induction. The Bishop score and its components, parity, cervical ultrasound parameters and fetal fibronectin level were analyzed using Cox's model in order to determine the most predictive factors for the duration of the latent and active phases of labor as well as its total duration. RESULTS: There was a significant correlation between duration of the latent phase and the whole of labor, and digitally assessed cervical dilatation (P = 0.003 and P < 0.001, respectively), parity (P = 0.006 and P < 0.001), the Bishop score (P = 0.019 and P = 0.003) and ultrasound-determined cervical length (P = 0.035 and P = 0.003). The length of the active phase of labor did not correlate with the cervical status. Funneling did not appear to be predictive of the duration of labor and it had a poor correlation with digital cervical dilatation. The length of the latent phase and that of the whole of labor was significantly longer when cervical dilatation was </= 2 cm (P < 0.001 in each case), when women were nulliparous (P = 0.002 and P < 0.001) and when ultrasound cervical length was >/= 27 mm (P = 0.002 and P = 0.005). CONCLUSION: Cervical dilatation as assessed by digital examination is the best predictor of the duration of the latent phase and of that of the whole of labor. Ultrasound measurement of cervical length is not more accurate at predicting the duration of labor than are clinical data.

Biomarkers↗
PubMed2000

Can magnetic resonance imaging predict the success of parturition in oxytocin-induced pregnant women?

The aim of this study was to assess whether magnetic resonance imaging could predict the outcome of attempted vaginal delivery in a group of pregnant women whose parturition had to be induced by oxytocin. The signal intensity and morphology alterations in the cervix of 21 full-term pregnant women were analyzed before the induction of parturition. T2-weighted gradient echo sequences were utilized and signal intensity in the cervix was measured from the anterior and posterior lips of the cervix. An index indicating the brightness range of the cervix was formulated to overcome the effects of the individual intensity changes. Imaging features including the signal intensity and the evidence of effacement were correlated with the actual type of delivery performed. Images were also assessed visually by two independent radiologists. Statistical analysis of brightness indexes that were considered to have a predictive value as an indicator for possible delivery was not significant. However, visually assessed signal intensity of the cervix correlated strongly with the type of delivery. Effacement itself was the most reliable parameter in predicting the progress of the delivery. In conclusion, MR imaging seems to be useful for predicting normal parturition in full-term pregnant women who need oxytocin induction. However, the presence of effacement seems to be a more reliable and practical parameter that will be preferred in that prediction.

Adult↗
PubMed1979

Changes in the glycosaminoglycans distribution pattern in the human uterine cervix during pregnancy and labor.

The glycosaminoglycans distribution pattern of uterine cervix samples obtained from 42 women of reproductive age was determined by means of proteolytic digestion and subsequent chromatographic separation. The following glycosaminoglycans were detected: chondroitin 4- and 6-sulfates, dermatan sulfate, hyaluronate, chondroitin, and keratan sulfate. The connective tissue of the uterine cervix shows a characteristic distribution pattern with regard to glycosaminoglycans which does not correspond to that found in any other tissue studied so far. Based on dry weight, the content of keratan sulfate increases during pregnancy while the concentration of chondroitin remains unchanged. The chondroitin sulfates and dermatan sulfate drop simultaneously. During labor chondroitin increases threefold. The hyaluronate content of the postpartum cervix is higher than that of the cervix in nonpregnant women. Both changes in the solubility of collagen as well as in the distribution pattern of the glycosaminoglycans seem to be related to cervical dilatation.

Adult↗
PubMed1984

Amniotic fluid 6-keto-prostaglandin F1 alpha and thromboxane B2 during labor.

Production of the antiaggregatory and vasodilatory prostacyclin (prostaglandin I2) and the proaggregatory and vasoconstrictory thromboxane A2 during human labor was studied by measuring serial concentrations of the stable metabolites of these prostanoids, 6-keto-prostaglandin F1 alpha and thromboxane B2, respectively, in the amniotic fluid of 43 parturients whose labor was induced by amniotomy. The concentration of 6-keto-prostaglandin F1 alpha at amniotomy in 28 healthy parturients (92.7 +/- 12.1 pg/ml, mean +/- SE) was higher (p less than 0.02) than that in 15 preeclamptic women (48.6 +/- 5.5 pg/ml). The concentration of thromboxane B2 at amniotomy was 292.4 +/- 56.1 pg/ml, with no difference between the healthy and preeclamptic parturients. Both prostanoid levels rose consistently during labor, reaching peak levels when the cervix was fully dilated, but this rise started only after the established uterine contractility. Epidural anesthesia and paracervical blockade had no effect on 6-keto-prostaglandin F1 alpha and thromboxane B2 in the amniotic fluid, whereas oxytocin infusion was accompanied by reduced levels of thromboxane B2. The rise in amniotic fluid 6-keto-prostaglandin F1 alpha was reduced at every stage of labor in the preeclamptic women (n = 15), and its maximal increase (112.4 +/- 28.3 pg/ml) was smaller (p less than 0.005) than in the healthy women (n = 28, 240.8 +/- 21.4 pg/ml). The ratio of 6-keto-prostaglandin F1 alpha to thromboxane B2 also shifted to thromboxane B2 dominance in the preeclamptic parturients. It is concluded that a relative prostacyclin deficiency deteriorates in preeclamptic women during labor.

6-Ketoprostaglandin F1 alpha↗