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PubMed2006

Factors associated with the length of the latent phase during labor induction.

OBJECTIVE: To evaluate the factors that are associated with the length of the latent phase during labor induction in nulliparous women. STUDY DESIGN: During a 6-month period, all nulliparous women with a viable fetus of at least 36 weeks gestation who underwent induction of labor were identified. Demographic and intrapartum data were abstracted from the medical record. In an effort to understand the association of different factors with the length of the latent phase, both univariable and multivariable analyses were employed. RESULTS: The median length of the latent phase for the women available for analysis (N=397) was 384 min with an interquartile range of 240-604 min. In univariable analysis, a greater maternal age, a medical indication for induction, and unripe cervical status at admission (assessed by either modified Bishop score or use of cervical ripening agents) were significantly associated with a latent phase of at least 12 h. In multivariable analysis, the only variables that continued to be independently associated with a latent phase of at least 12 h were modified Bishop scores of 0-2 (adjusted odds ratio 42.0, 95% confidence interval 9.7, 183.2) and 3-5 (adjusted odds ratio 9.3, 95% confidence interval 2.1, 40.9). CONCLUSION: A woman's modified Bishop score at admission for labor induction, but not other risk factors typically associated with cesarean, is associated with length of the latent phase.

Adult↗
PubMed2006

Effect of sufentanil on minimum local analgesic concentrations of epidural bupivacaine, ropivacaine and levobupivacaine in nullipara in early labour.

BACKGROUND: The aim was to assess the effect of epidural sufentanil on relative analgesic potencies of epidural bupivacaine, ropivacaine and levobupivacaine by determining the minimum local analgesic concentrations during labour. METHODS: In a randomised, double-blind study, 171 parturients were allocated to one of six groups receiving a 10-mL bolus of bupivacaine, ropivacaine or levobupivacaine alone or with sufentanil 0.75 microg/mL. The concentration of local anaesthetic was determined by the response of the previous parturient using up-down sequential allocation starting at a concentration of 0.13% wt/vol with a testing interval of 0.01%. Effective analgesia was defined as a visual analogue pain score < or = 15/100 mm within 30 min and lasting for 30 min. Median effective concentrations were estimated and two-sided P < 0.05 was significant. RESULTS: Local anaesthetic concentration, use of sufentanil and local anaesthetic drug were independent significant predictors of effective and ineffective analgesia. Bupivacaine was significantly more potent than levobupivacaine and ropivacaine. The relative potency ratios without sufentanil of 0.77:0.83:1.00 were reduced to 0.36:0.38:1.00 by the addition of sufentanil. The major factor influencing local anaesthetic requirements was the addition of sufentanil, which reduced overall requirements by a factor of 4.2 (95% CI 3.6-4.8); this effect was proportionately more enhanced for bupivacaine. CONCLUSIONS: Local anaesthetic requirements for bupivacaine, levobupivacaine and ropivacaine follow an analgesic potency hierarchy. Any potency differences are small when compared to the effect of sufentanil, which resulted in a four-fold reduction in local anaesthetic requirements. Sufentanil may also enhance the potency differences between bupivacaine and the two S-enantiomer agents.

Adjuvants, Anesthesia↗
PubMed2006

Continuous monitoring of cervical dilatation and fetal head station during labor.

An ultrasound-based computerized system was developed for monitoring cervix dilatation and fetal head station during labor. The system was designed to provide continuous and accurate assessment of the progression of labor. The computerized labor-monitor (CLM) was tested in the laboratory and was studied in over 95 women during labor. The laboratory test showed that the mean error of measurement is 0.1 mm with standard deviation of 1.14 mm. In the clinical experiments, safety of the various system components was demonstrated and partograms were compared to manual measurements. The systematic error of the fetal head station measurement is estimated as 10-20%, depending on patient's anatomy. In addition, the clinical tests indicated that measurements of the changes of both cervix dilatation and fetal head station are feasible. The CLM is expected to change patient management in the labor room. It will enable timely recognition of abnormal labor patterns such as dysfunctional and precipitous labor. Continuous accurate data will allow earlier diagnosis and intervention that is very likely to improve both mother's and baby's clinical outcome.

Adult↗
PubMed1990

Risk factors for third-degree and fourth-degree perineal lacerations in forceps and vacuum deliveries.

Third- and fourth-degree perineal lacerations occur frequently during operative vaginal deliveries. To identify risk factors for lacerations, 2832 consecutive forceps and vacuum extraction deliveries were analyzed. Third- and fourth-degree lacerations occurred in 30% of deliveries. Multiple logistic regression was used to control for intercorrelation between potential risk factors. Factors associated with increased risk for third- and fourth-degree lacerations were midline episiotomy, nulliparity, second-stage arrest, occipitoposterior position, low or mid station, use of forceps instead of vacuum, use of local anesthesia, and Asian race. When these factors were controlled, there was no effect of birth weight, faculty versus resident operator, gestational age, abnormalities of first-stage labor, or several other factors. Prevention of perineal lacerations requires that the operator identify the patient at risk. Possible options for management of high-risk patients include use of mediolateral episiotomy or no episiotomy, use of vacuum extraction instead of forceps, and use of conduction anesthesia.

Anesthesia, Obstetrical↗
PubMed1986

The preterm cervix and preterm labor: relative risks, predictive values, and change over time.

The accurate prediction and diagnosis of preterm labor continue to frustrate the clinician. This is partly due to a scarcity of cervical data from the early third trimester. A total of 760 prospective, serial, paired, and blinded pelvic examinations were done at 28 to 34 weeks of gestation for 191 patients without a history of preterm labor. If the cervix was dilated greater than or equal to 1 cm (internal os) or effaced greater than 30%, the relative risk of preterm labor was increased to 1.8 to 4.2. Negative predictive values for cervical status were greater than 92%, but positive predictive values were less than or equal to 18%. Change over time was unusual (dilatation increase greater than or equal to 1 cm or effacement increase greater than or equal to 40%), suggesting that a baseline late second-trimester examination could assist in the early but accurate diagnosis of preterm labor should it be suspected later in gestation. These data suggest that even in the low-risk patient, an early cervical examination could be beneficial.

Cervix Uteri↗
PubMed2001

A study of intravaginal misoprostol for induction of labor in toxemia of pregnancy.

OBJECTIVE: To compare the efficacy and complications of intravaginal misoprostol for induction of labor in patients with and without toxemia of pregnancy. METHODS: Forty-two patients with toxemia of pregnancy (group 1) and 59 women at term without toxemia (group 2) with Bishop scores of < or = 6 were treated with 50 microg intravaginal misoprostol given four times at 4-h intervals. Labor and neonatal outcomes, and any complications, were recorded. Mann-Whitney U-, Student's t- and chi(2)-tests were used for statistical analyses. P < or = 0.05 was considered significant. RESULTS: The rates of vaginal delivery were 73.8% and 84.6%, oxytocin augmentation were 4.8% and 5.1% and the mean insertion to delivery times were 12.5 and 13.8 h in group 1 and 2, respectively, with no significant differences between the groups. Neonatal outcomes, rates of uterine contraction abnormalities and gastrointestinal symptoms were similar in both groups. CONCLUSIONS: Intravaginal misoprostol is an equally effective and safe method of induction of labor in patients with toxemia of pregnancy and in normal pregnant women.

Administration, Intravaginal↗
PubMed2001

Active phase labor arrest: revisiting the 2-hour minimum.

OBJECTIVE: To generate contemporary uterine activity and labor progress data for oxytocin-augmented labor, and assess whether 2 hours of active phase labor arrest with at least 200 Montevideo units justifies cesarean delivery. METHODS: Five hundred and one consecutive spontaneously laboring term women with abnormally progressive labor were managed by a standardized protocol: oxytocin and intrauterine pressure catheter with an intent to sustain at least 200 Montevideo units for 4 hours or more before cesarean for labor arrest. Uterine activity was measured, and maternal and neonatal outcomes were evaluated. With a sample of this size, the upper 95% confidence interval limit for an event with an observed rate of 1% is below 3%. RESULTS: During oxytocin augmentation, nulliparas who were delivered vaginally dilated at a median rate of 1.4 cm/hour versus 1.8 cm/hour for parous women. In both groups, the 5th percentile of cervical dilation rate was 0.5 cm/hour. Thirty-eight women experienced labor arrest for over 2 hours despite at least 200 sustained Montevideo units; 23 (61%) achieved a vaginal delivery. Rates of chorioamnionitis and endometritis for the 38 women were 26%. None of their infants sustained a serious complication, including brachial plexus injury, even though three of the 23 vaginal deliveries (13%) were complicated by shoulder dystocia. CONCLUSION: These data demonstrate that oxytocin-augmented labor proceeds at substantially slower rates than spontaneous labor, and support our previous contention that the criteria of labor arrest for 2 hours, despite at least 200 sustained Montevideo units, are insufficiently rigorous for the performance of cesarean.

Adult↗
PubMed1996

Factors predicting successful labor induction.

OBJECTIVE: To evaluate maternal parity, the sonographic measurement of cervical length, and the five components of the Bishop score to determine which factors best predict the length of latent-phase labor in women undergoing labor induction. METHODS: Cervical position, cervical consistency, cervical effacement, cervical dilation, station of fetal presenting part, maternal parity, and sonographic measurement of cervical length were studied prospectively in 109 women undergoing labor induction. A multiple regression model was used to determine which factors best predict the length of latent-phase labor. RESULTS: A model using these seven factors was predictive in determining the number of hours of latent-phase labor (F = 32.1, P < .001). Backward stepwise multiple linear regression indicated that only cervical dilation independently predicted the length of latent-phase labor. There was a significant correlation between the clinical assessment of cervical effacement and the sonographic estimation of cervical length, (r = -0.523, P < .001). CONCLUSION: Only cervical dilation appears to predict the length of latent-phase labor. The sonographic evaluation of cervical length and maternal parity do not add significant independent information.

Cervix Uteri↗
PubMed1996

Association of epidural analgesia with cesarean delivery in nulliparas.

OBJECTIVE: To evaluate whether epidural analgesia during the first stage of labor is associated with an increased risk of cesarean delivery. METHODS: The association of epidural analgesia and cesarean delivery was examined in a retrospective study of 1733 low-risk, term nulliparas with singleton infants in vertex presentations, in which labor began spontaneously. To evaluate the effect of epidural analgesia on cesarean deliveries, independent of other factors influencing the use of epidural analgesia, we used propensity scores to create five subgroups (quintiles) of women who, based on characteristics discernible at admission, appeared equally likely to receive epidural analgesia. Multivariate logistic regression analysis was used to control for confounding. RESULTS: Overall, the cesarean rate among women receiving epidural analgesia was 17% (168 of 991), compared with 4% (30 of 742) among those who did not receive epidural analgesia. An increased cesarean rate among women receiving epidural analgesia was present in all propensity quintiles. In an adjusted logistic regression analysis, women receiving epidural analgesia were 3.7 times more likely to undergo a cesarean (95% confidence interval 2.4, 5.7). The greatest increase in cesarean risk was noted when epidural analgesia was administered earlier in labor, but there was a more than twofold increase regardless of the dilation and station at administration of epidural analgesia. CONCLUSIONS: Epidural analgesia may increase substantially the risk of cesarean delivery. Although the causal nature of this association remains open to debate, prenatal care providers should routinely discuss the risks and benefits of epidural analgesia with women during their pregnancies so that they can make informed decisions about the use of pain relief during labor.

Adult↗
PubMed1987

Birth positions.

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Adolescent↗