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PubMed2003

Inaccuracy in cervical dilatation assessment and the progress of labour monitoring.

Cervical dilatation is an essential indicator of the progress of labour and it is assessed several times during every vaginal delivery. For a long period of time, the size of the error in cervical dilatation assessment was considered of no importance and only in the last ten years it was estimated. The hypothesis is that the estimated error of +/-1cm in cervical dilatation assessment and inaccurate values for the rate of cervical dilatation, influence decisions of obstetricians during labour. It is suggested that in labours in which the rate of cervical dilatation is 1 cm/h the possibility of drawing incorrect conclusions upon progress of these labours is 11 and 33% for time intervals between assessments of 4 and 2 h.

Cervix Uteri↗
PubMed2003

[Epidemiology of anal lesions (fissure and thrombosed external hemorroid) during pregnancy and post-partum].

Thrombosed external hemorrhoids (TEH) and anal fissure (AF) are 2 frequent sources of anal pains during childbirth. We are going to define their incidences as available in publications and in our experience in Bichat hospital. Then we will define their risk factors. According to Martin's and Corby's studies, AF was observed in 10% of the delivered women. In Bichat hospital we performed a proctological assessment to 165 pregnant women during the last third of pregnancy and within the 2 months following delivery. We observed 2 AF (1,2%) during the first period and 25 (15,2%) during the second. Rouillon et al. reported an incidence of TEH in 12,2% (20/164), while Pradel and al. reported 34% (18/52) of it. In Bichat hospital, 13 women (7,9%) were presenting with TEH during the last third of pregnancy and 33 (20%) in post-partum period. Two studies looked for a statistical correlation between AF and obstetrical, foetal or maternal factors. Corby et al. only pointed the role of constipation. In our study, terminal constipation was the most important risk factor for AF with 5.7 (2.7-12), odds ratio (95% confidence intervals). Rouillon et al. observed more TEH among women with a prolonged first stage labor and a big baby. In our study, a big baby and mother little lips tears were observed more often among women with TEH (P <0,05). Also, we observed only one TEH among the 25 women with caesarean section (4%). Finally, observation that TEH arise immediately after delivery is another argument to support the role of traumatic delivery. We also demonstrated the role of terminal constipation as risk factor for TEH after delivery. To conclude, 1/3 of pregnant women develop AF or TEH after delivery. These 2 pathologies are strongly correlated to terminal constipation. TEH seems equally furthered by traumatic delivery.

Anus Diseases↗
PubMed2001

The relationship between cervical dilatation, interleukin-6 and interleukin-8 during term labor.

BACKGROUND: To determine interleukin-6 and interleukin-8 levels in amniotic fluid, retroplacental blood and maternal serum and relate these values with cervical dilatation in term labor. METHODS: Prospective study. n=78 healthy women undergoing term cesarean section, divided into four groups: controls, n=42, (elective cesarean section; no contractions, membrane rupture or cervical dilatation); latent labor, n=12, (latent phase labor; cervix <2 cm dilated); established labor, n=12, (active labor, cervix 2-5 cm); advanced labor, n=12, (active labor, cervix >5 cm). Interleukin-6 and interleukin-8 were determined by ELISA (pg/ml), placenta and placental bed biopsy examined histopathologically, and amniotic fluid also microbiologically. Results were expressed as median and ranges or mean and standard deviations, as appropriate. For statistical analysis, Mann-Whitney U-tests or Kruskal-Wallis tests were used as applicable (Statview 4.5). Power and linear regression analyses were performed. p<0.05 was considered significant, p<0.001 highly significant. RESULTS: Compared with controls, IL-6 and IL-8 increased significantly with cervical dilatation in all compartments tested for almost all labor groups (p<0.05 to p<0.0001). Significant changes were also seen between latent and advanced labor groups in some compartments (p<0.05), but not between established and advanced labor groups. Intrauterine infection was excluded in any of the patients clinically and on histopathological or microbiological analysis of placentae and amniotic fluid. CONCLUSIONS: In term labor without intraamniotic infection, interleukin-6 and interleukin-8 at the fetomaternal interface and in maternal serum rise significantly with cervical dilatation. These cytokines could be used as markers of active labor if vaginal examination is not applicable.

Adolescent↗
PubMed1990

Effect of active management on latent phase labor.

The effect of active management on latent phase labor was assessed in 197 consecutive nulliparous women. Active management resulted in a significant shortening of the latent phase but had no effect on active phase labor. Patients undergoing induction of labor had latent phases that were almost identical to the accepted norm. The effect of active management may be due to early diagnosis of labor and early intervention in the form of artificial rupture of membranes and selective high-dose oxytocin infusion.

Extraembryonic Membranes↗
PubMed2001

Amniotic fluid concentrations of matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1 during pregnancy and labor.

OBJECTIVE: This study was undertaken to determine whether obstetric factors affect the concentrations of matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1 in the amniotic fluid. STUDY DESIGN: We prospectively collected amniotic fluid samples from 109 women at various stages of pregnancy and labor and determined matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1 concentrations by means of enzyme-linked immunosorbent sandwich assay systems. With multiple regression analysis we evaluated relationships between amniotic fluid matrix metalloproteinase 9 concentration and tissue inhibitor of metalloproteinase 1 concentration and the following factors: gestational age, presence of labor, cervical dilatation, membrane status, presence of clinical chorioamnionitis, and microbial colonization of the amniotic fluid. RESULTS: The detectable presence of amniotic fluid matrix metalloproteinase 9 was independently associated with intra-amniotic infection, labor, cervical dilatation, and spontaneous rupture of membranes. Chorioamnionitis and amniotic fluid matrix metalloproteinase 9 concentrations were correlated with tissue inhibitor of metalloproteinase 1 levels. CONCLUSIONS: Intra-amniotic infection, advanced labor, and rupture of membranes before the onset of labor were independently associated with the presence of matrix metalloproteinase 9 in the amniotic fluid. Both pathologic and physiologic processes appear to produce shifts in the balance between degradation and synthesis of the extracellular matrix.

Amniotic Fluid↗
PubMed2002

The labor curve of the grand multipara: does progress of labor continue to improve with additional childbearing?

OBJECTIVE: Our purpose was to test the hypothesis that progress of labor slows as parity exceeds 4 by comparing labor curves of grand multiparous women (para 5 and over) (GMs) with those of nulliparous and lower-parity multiparous women. STUDY DESIGN: Retrospective cohorts of spontaneously laboring, vertex-presenting, term GMs who were admitted to two medical centers during the period from January 1990 through June 1995 were randomly computer-matched to a nulliparous and a lower-parity multiparous control subject, matched for age, hospital, and year of delivery. Cervical examination data were graphed retrospectively from the time of full dilatation. Curves were compared by pairwise likelihood ratio tests, by using a random effects model to adjust for obstetric interventions, with significance set at P <.05. RESULTS: Pregnancies in 1095 GMs, 1174 lower-parity multiparous women, and 908 nulliparous women were studied. GMs exhibit a longer initial phase of labor than either nulliparous women or lower-parity multiparous women, begin to dilate rapidly at a greater dilatation than nulliparous women, and experience acceleration of labor at a rate no faster than lower-parity multiparous women. The average labor curve of GMs resembles that of nulliparous women before dilatation of 4 cm is attained, then transitions to the typical curve of the lower-parity multiparous women until dilatation of 6 cm is attained and thereafter is indistinguishable from that of the lower-parity multiparous women (P <.001). CONCLUSIONS: Once parity exceeds 4, progress of labor slows. "Poor progress" beyond dilatation of 4 cm should not be considered abnormal for a GM, because she is likely still in the latent phase until dilatation of 6 cm is attained. Nor should she be expected to progress through her active phase any faster than lower-parity multiparous women.

Adult↗
PubMed2002

Maternal and fetal risks associated with prolonged latent phase of labour.

A pregnancy cohort study was undertaken to assess the fetal, maternal and obstetric risks associated with the prolonged latent phase of labour. One hundred and fifty cases (latent phase >8 hours) were compared with 100 controls (latent phase <8 hours). Data were collected from hospital records. There were more nulliparas in the case group (73% vs. 39%; P<0.0001). Cases required oxytocin augmentation (62% vs. 17%; P<0.0001) and caesarean section (29% vs. 6%; P<0.0001) more frequently than controls. Thick meconium staining of the liquor was more frequent in cases (15% vs. 5%; P<0.05), as were 5-minute Apgar scores less than 7 (17% vs. 3%; P<0.001) and admission to the neonatal unit (22% vs. 1%; P<0.0001). Prolonged latent phase is associated with increased risks for obstetric intervention and poor fetal outcome. The optimal management of prolonged latent phase is still unknown and requires further study by means of randomised controlled trials.

Adult↗
PubMed2004

The multigravid partogram--should it be customised?

Multigravid labour is conducted according to an alert line and an action line derived from primigravid spontaneous labour. Although it is widely recognised that multigravid labour is significantly faster than primigravid labour, the standard of care for both is the 'usual-care' partogram. A series of 1398 partograms of spontaneous multigravid labours resulting in vaginal delivery was audited. Retrospectively, the labours were graphed on a usual-care and on a customised partogram. The customised alert line was built to represent the rate of cervical dilataion of the lower 90 per cent. (after excluding the 10 per cent of very rapid labours.) The effect of putting the action line 2, 3 or 4 hours behind the alert line on the relative distribution of labours was tested. The results indicate that the norms of the usual-care partogram do not reflect the facts of multigravid labour.

Female↗
PubMed2006

A way to lend objectivity to Bishop score.

The aim of this study was to explore the possibility of utilising pre-induction cervical length assessment by trans-vaginal ultrasound to improve the predictive value of the Bishop score. The idea of this paper has evolved following our prospective study, which was designed to compare the pre-induction objective assessment of the cervix by ultrasound with the subjective one by Bishop Score. The Bishop scores of the 104 women included in the study were modified by replacing the digital assessment of the cervical length by ultrasound cervical length measurements. There was a significant statistical difference (p < 0.0001) between the median of the original and the modified Bishop scores. The original Bishop score showed insignificant association (p > 0.05) with the induction-delivery interval (IDI) and the mode of delivery while the modified score showed a significant association (r = 0.31, p < 0.05) with mode of delivery and a highly significant one (r = 0.55, p < 0.0001) with the IDI. The receiver operating characteristic curve showed that the optimised cut-off value for prediction of vaginal delivery was >5 for the original Bishop Score and >3 for the modified one. At those optimised cut-off values, the original Bishop Score predicted vaginal delivery with a sensitivity of 23% (95% CI; 14.6%, 33.2%) and specificity of 88.2% (95% CI; 63.5%, 98.5% while the modified Bishop score predicted vaginal delivery with a sensitivity of 62% [95%; CI 51 - 72.3] and specificity of 82% [95%; CI 56.6 - 96]). In conclusion, the modified Bishop score is better than the original one in predicting the IDI and the success of induction of labour. The sensitivity of the Bishop score in predicting the rate of vaginal delivery has been improved significantly following the modification.

Adolescent↗
PubMed2006

Is misoprostol safe for labor induction in twin gestations?

OBJECTIVE: To compare the safety and efficacy of intravaginal misoprostol to oxytocin for the induction of labor in twin gestations. METHODS: All twin gestations that underwent induction of labor with misoprostol or oxytocin during a 4-year period were identified from the Mount Sinai obstetrical database. Only twins > or = 34 weeks with a vertex presenting twin A were included. Labor and delivery characteristics, maternal complications and neonatal outcomes were compared between the two groups. RESULTS: Of 134 patients with twins, 57 initially received misoprostol and 77 received oxytocin. These groups had similar demographics, but women who received misoprostol had less cervical dilation (0.8 vs. 2.2 cm, p < 0.0001) and were less likely to be multiparous (19% vs. 44%, p = 0.003). There was a shorter length of induction to delivery (7.8 hours vs. 15.1 hours, p = 0.001) and a trend toward a lower cesarean section rate (16.9% vs. 31.6%, p = 0.06) in the oxytocin-only group. There were no cases of uterine rupture or maternal mortality in this series. There were no significant differences in neonatal outcomes between the two groups, but the sample size was underpowered to detect significant differences between the groups. CONCLUSIONS: Misoprostol and oxytocin both appear to be safe and efficacious for use in inductions of labor in twins in this limited retrospective investigation. The safety of these agents with regard to neonatal outcomes should be confirmed by larger studies.

Administration, Intravaginal↗
PubMed1979

25 Hydroxycholecalciferol levels in Beduin women in labor and in cord blood of their infants.

25 Hydroxycholecalciferol levels were measured in eight Beduin mothers in labor and in the cord blood of their infants, and compared with values in 42 Sephardi Israeli women in labor and the cord blood of their offspring. Beduin baby cord blood had a mean 25 hydroxycholecalciferol concentration of 3.78 ng/ml +/- 3.22 (SD) being about half of their mothers' level in labor. Values in Sephardi women and cord blood were 3 times higher. PTH levels were lower and calcium concentrations were higher in cord blood (P less than 0.001) in both groups when compared to their mothers' blood. The relevance of these findings to the high incidence of infantile rickets and hyypocalcemia in Beduin children is discussed.

Calcium↗
PubMed1976

Pethidine compared with pethidine-naloxone administered during labour. A study of analgesic treatment by a sequential method.

In a restricted sequential trial in healthy parturient women, the pain relief from pethidine 100 mg and pethidine 100 mg combined with naloxone 0.4 mg was compared. Pethidine alone gave better relief. The incidence of minor side-effects was high with both treatments but dizziness was reduced slightly by naloxone. It was concluded that naloxone antagonized the analgesia without abolishing the side-effects of pethidine.

Anesthesia, Obstetrical↗
PubMed1979

Effect of maternal position on fetal heart rate during extradural analgesia.

Using continuous cardiotocography, the effect of maternal position on fetal heart rate (FHR) was studied during extradural analgesia (EA) with either 50 or 100 mg of etidocaine without adrenaline for labour and vaginal delivery. Of 70 healthy parturients, 39 were supine and 40 were in the lateral position. FHR was normal in all patients during the control period before EA, and remained normal during EA in 53. Transient abnormal patterns occurred in 26 patients, 22 (56%) in the supine group and four (10%) in the lateral group, a significant difference (P less than 0.001). The decrease in arterial pressure (AP) did not differ between the groups, but the frequency of abnormal FHR associated with a small or moderate decrease in AP (30% or less) was greater in the supine (51%) than in the lateral group (3%).

Adolescent↗
PubMed1981

Epinephrine does not alter human intervillous blood flow during epidural anesthesia.

The effect of epinephrine given epidurally with local anesthetics on uterine blood flow is controversial. Previous work in pregnant ewes demonstrated a transient but significant (14 per cent) decrease in uterine blood flow when 2-chloroprocaine with epinephrine (10 micrograms/l) was used. The authors administered 2-chloroprocaine, 10 ml, with epinephrine (5 micrograms/ml) to 12 healthy women during the first stage of labor. By use of intravenously injected 133Xe, intervillous blood flow was measured before and 15-20 min after epidural anesthesia to a somatic level of at least T10. Intervillous blood flow did not change significantly despite a decrease in mean blood pressure of 11 torr. These conflicting results are probably best explained by methodologic and species differences. It is postulated that human placental vasculature, unlike that of the ewe, undergoes vasodilation when perfusion pressure is decreased to maintain placental blood flow.

Adult↗
PubMed1982

Management of the latent phase of labor.

1. Iatrogenic causes of prolonged latent phase such as sedation, narcotic analgesia, and epidural anesthesia should be avoided during the latent phase. 2. Cesarean delivery is not appropriate management solely for failure to progress in latent phase. 3. Multiparas in latent phase with favorable cervices should be treated with oxytocin stimulation. 4. Multiparas with unfavorable cervices and most nulliparas should be treated with therapeutic rest when they become exhausted during a long latent phase, without regard to an arbitrary time table. 5. Characteristics of latent phase in induced labors are undefined. 6. Management of latent phase in the presence of ruptured membranes should take into consideration the total clinical picture, including gestational age, presentation, and risk of infection and other pertinent factors.

Female↗