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PubMed1995

Cervical assessment.

The relationship between the clinical state of the cervix and spontaneous onset of labor has long been known. The cervix can be characterized by evaluating five parameters: effacement, dilatation, firmness, position, and level of the presenting part. The relative associations between successful labor induction and these factors appears to vary, with the strongest correlation observed with cervical dilation, whereas the association with cervical station and position is less robust. By its nature, cervical examination is somewhat subjective, but the use of objective criteria and numerical scoring of this information has substantially reduced this source of error. The Bishop score and it variations have been used widely and accepted in clinical practice. Its advantage lies in its simplicity, reproducibility, and predictability in successful inductions. Although criticized for the equal weight given to each of the five elements, none of the modifications to the original score has been shown to improve predictability. Although the Bishop score was initially evaluated only in multiparous women, it has been extended to nulliparous women with an equal degree of predictive value. To date, the Bishop score remains as the best and simplest method available to determine the duration and safety of induced labor.

Cervix Uteri↗
PubMed1986

Uterine contraction pressures with oxytocin induction/augmentation.

Uterine contraction pressures were quantified (in Montetevideo units) in 109 women at term gestation who received oxytocin for induction or augmentation of labor and whose labor resulted in a spontaneous vaginal delivery. Newborn five-minute Apgar scores were greater than or equal to 8 in 108 of the 109 neonates, and no immediate neonatal morbidity was attributable to the oxytocin stimulation of labor. Women undergoing oxytocin induction had significantly greater uterine contraction pressures than those with oxytocin augmentation. During oxytocin induction 91% of women achieved at least 200 to 224 Montevideo Units and 40% at least 300 Montevideo units versus 77 and 7.7%, respectively, during augmentation of labor. With concurrent fetal monitoring these levels of uterine activity should be sought before consideration of a cesarean delivery because of presumed cephalopelvic disproportion or failure to progress.

Drug Administration Schedule↗
PubMed1983

Fetal heart rate responses to meperidine alone and in combination with propiomazine.

A study was performed to evaluate the effects of three regimens of intrapartum analgesia upon fetal heart rate characteristics. Either meperidine 50 mg (M50), meperidine 50 mg plus propiomazine 20 mg (M50/P20), or meperidine 25 mg plus propiomazine 10 mg (M25/P10) was given intravenously for intrapartum analgesia to 204 patients in the first stage of labor, and the effects were evaluated upon fetal heart rate variability (FHRV) and fetal heart rate reactivity (FHRR). M25/P10 was found to cause a decrease in FHRV in fewer patients than M50/P20 (13.6% vs 36.5%, P less than .005), while still providing adequate analgesia for most patients. Although M50 also caused a decrease in FHRV in fewer patients than M50/P20 (19.1% vs 36.5%, P less than .05), it produced emesis in 20% of patients. When FHRV was minimal or moderate before the analgesic was given, FHRV became absent in only eight of 222 doses (3.6%). FHRR was lost in fewer patients given M50 than in those given M50/P20 (45% vs 71%, P less than .01); there was no significant difference between M50 and M25/P10. We conclude that the effects of meperidine upon fetal heart rate characteristics are both potentiated by propiomazine, and, when meperidine is given with propiomazine, dose-related. We also conclude that absent FHRV is rarely caused by meperidine; when FHRV becomes absent after meperidine administration, the patient should be fully evaluated for the possibility of fetal distress before the absence of variability is attributed to analgesia.

Dose-Response Relationship, Drug↗
PubMed2004

Ambulatory labor analgesia: what does an obstetrician need to know?

A simple statement that describes the degree of the patient's satisfaction with the pain relief from her labor epidural analgesia has often assessed the quality of labor analgesia as perceived by the patient. Many laboring parturients, midwives, obstetricians and anesthesiologists are increasingly concerned by the limitations of traditional epidural labor analgesia. In general, women dislike the inability to void, the often-dense motor block, the feeling of numbness of the lower body, the total lack of the urge to bear down, and the complete perineal anesthesia. Continuous search for balanced labor analgesia that provides relief from pain, while preserving motor function, has led to the development of an ambulatory labor analgesia technique. This article assesses the validity of various strongly advocated opinions as to whether parturients benefit from ambulation in labor and also reviews the current trends in ambulatory labor analgesia.

Analgesia, Epidural↗
PubMed1995

Biochemical events in cervical ripening dilatation during pregnancy and parturition.

In specimens taken from the posterior lip of the cervix uteri we determined the collagenase activity and the glycosaminoglycan concentration. In biopsies obtained from the lower uterine segment during cesarian section we measured cytokines (IL-8, IL-2, TNF alpha) and matrix metalloproteinases (MMP-8, MMP-9). We found that the release of collagenases is critically involved in the process of cervical dilatation. The glycosaminoglycan concentration increases during pregnancy and shows remarkable changes of the distribution patterns of the different glycosaminoglycans. The parturition is characterized by a dramatic loss of most of the glycosaminoglycans. Furthermore, the IL-8 shows a close correlation to the clinical feature of cervical ripening and is closely associated with the release of MMP-8 and MMP-9. Summarizing the process of cervical maturation and dilatation is a complex enzymatic controlled process with substantial remodelling of the cervical extracellular matrix. The cytokines IL-8 seems to play an essential role in triggering the process of cervical dilatation.

Biopsy↗
PubMed1977

Increase of the prostaglandin precursor, arachidonic acid, in amniotic fluid during spontaneous labour.

Concentrations of free arachidonic acid have been measured by gas liquid chromatography in amniotic fluid obtained during spontaneous labour at term. Levels of arachidonic acid ranged from 0.14 to 2.9 microgram/ml and increased significantly (P less than 0.01) with advancing cervical dilatation. Concentrations of arachidonic acid showed no significant relation to concentrations of either prostaglandin F or 13,14-dihydro-15-keto-prostaglandin F. These findings are discussed with respect to the role of arachidonic acid in the control of prostaglandin biosynthesis during human parturition.

Amniotic Fluid↗
PubMed1982

Intrauterine-pressure studies in African nulliparae: delay, delivery and disproportion.

Uterine activity was measured in 43 African nulliparae who were in the active phase of spontaneous labour and in whom delay in cervical dilatation had occurred. Details of labour were recorded on a partogramme, on which an alert and an action line had been drawn, and which were 2 h apart. Delay was defined as a cervical dilatation rate of less than 1 cm/h. Uterine activity was measured with a fluid-filled intrauterine catheter, an external strain gauge and a pressure-curve integrator. The uterine activity levels which were observed in association with delay are considerably less than those associated with normal labour progress. The uterine activity levels that were associated with pitocin augmentation after the action line and which resulted in vaginal delivery have been analysed. They were similar to the levels observed in normal labour. The uterine activity levels which were associated with 'failure to progress in labour' beyond the action line have also been analysed. It is argued that a minimum uterine activity level of 1800 kPas/15 min is required to fully test the cephalopelvic relation.

Adolescent↗
PubMed1984

The effect of parity on uterine activity in labour.

Uterine activity was studied in 40 multiparous Singapore women of Chinese origin who were in normal labour and had a normal delivery. A catheter tip pressure transducer coupled with a uterine activity integrator was used to quantify uterine activity. Normal labour progress was defined as labour progressing within 2 h to the right of a line drawn on the partogram at 1 cm/h in the active phase of labour. A wide range of activity was observed. The median level of uterine activity rose from 815 kPas/15 min at 3 cm dilatation to 1731 kPas/15 min at 9 cm dilatation with an overall median level of 1130 kPas/15 min. The 10th centile value rose from 430 kPas/15 min at 3 cm dilatation to 923 kPas/15 min at 9 cm dilatation. Profiles of dilatation-specific activity values were constructed. These values were significantly lower than in a comparative group of nulliparous patients. The parous uterus requires to expend significantly less effort to effect normal vaginal delivery than its nulliparous counterpart.

Adult↗
PubMed1987

Uterine artery blood velocities during contractions in pregnancy and labour related to intrauterine pressure.

Doppler recordings from branches of the uterine artery were made simultaneously with intrauterine pressure measurements in eight women in labour. Blood velocities fell and pulsatility index (PI) increased during all 22 contractions studied. Velocities were reduced almost linearly by up to 60% when pressure increased from 0 to 50 mmHg. To study the effect of uterine contractions before labour on uterine blood flow, simultaneous Doppler recordings from branches of the uterine artery and external tocodynamometry were made in seven women during the last trimester. Velocities fell during 18 of the 20 contractions studied (median 35%, range 19-71%). Extrapolating from labour contractions, this corresponds to a pressure increase of 30-40 mmHg. Fetal heart rate (FHR) recordings were normal during all contractions.

Blood Flow Velocity↗
PubMed1988

Screening of the fetal heart rate in early labour.

The fetal heart rates (FHR) of 588 women admitted in labour, or in early labour after induction, were screened for up to 60 min (average 17 min) using computerized numerical analysis. Decelerative records with normal FHR variation occurred in eight (1.4%) and were not associated with acidaemia or depression at birth. Forty women (6.8%) had fetuses with a reduced FHR variation. They were more likely to be in spontaneous labour, to be at an earlier gestational age, and to be delivered operatively for fetal distress of babies that were more hypoxaemic and acidaemic. However, none of the fetuses with the least variable FHR patterns required resuscitation at birth or special care. The results of the screening procedure were not fully concealed and could have influenced clinical management. This is unlikely to have caused the associations that were observed, but could have reduced an association between low FHR variation and poor outcome. We conclude that there is a basis for a randomized controlled trial of FHR screening in early labour, but that this would need to be large (more than 10,000 patients) to test the benefit of detecting the most sinister pattern (decelerations with reduced variation) of which only one example was found in this study.

Female↗
PubMed1991

A randomized controlled trial of early amniotomy.

OBJECTIVE-To determine if a policy of early amniotomy resulted in a reduction in mean labour duration when compared to a policy of conservation of the membranes. DESIGN-A single-centre randomized controlled trial. SETTING-A tertiary care teaching hospital in Alberta, Canada. SUBJECTS-Ninety-seven term nulliparae in spontaneous labour, baby in cephalic presentation. INTERVENTION-Early amniotomy versus intent to keep membranes intact. MAIN OUTCOME MEASURES-Interval from randomization to delivery, rate of abnormalities of fetal heart rate tracings, cord artery blood pH, Apgar scores. RESULTS-The mean interval from randomization to delivery was 390.9 (SE 29.1) min in the amniotomy group and 442.9 (SE 34.1) min in the control group (P = 0.251). There were no differences between groups in the occurrence of fetal heart rate tracing abnormalities, nor was there a difference in the proportion of babies with abnormal Apgar scores, or abnormal cord pH (less than 7.20). CONCLUSION-The results of the study fail to support the long held belief that early amniotomy is an effective method for reducing labour duration.

Amnion↗
PubMed2004

For how long should oxytocin be continued during induction of labour?

OBJECTIVE: To answer the question of whether oxytocin induction of labour should be discontinued when active labour begins. DESIGN: We enrolled patients admitted for induction of labour with oxytocin. Exclusion criteria for induction of labour included non-vertex presentation, past history of more than one caesarean delivery, multiple pregnancies, persistent non-reassuring fetal heart rate before induction of labour and estimated fetal weight of more than 4250 g. SETTING: Department of Obstetrics and Gynecology, Ha'Emek Medical Center, Afula, Israel. POPULATION: Patients who were admitted for induction of labour in Ha'Emek Medical Center from 1st February 1998 to 29th February 2000. METHODS: Patients were randomly divided into two groups. In group A, infusion of oxytocin was incremental until 5 cm dilation and maintained at the same level from that point throughout the labour. In group B, infusion of oxytocin was incremental but was discontinued when cervical dilatation reached 5 cm. Comparison between the two groups was made using Wilcoxon rank-sum test and Fisher's exact test. MAIN OUTCOME MEASURE: Primary outcome variable was duration from induction to delivery. The secondary outcome variables included: duration of labour stages, maximal dosage and total amount of oxytocin used, the use of analgesia, abnormalities in fetal heart rate and episodes of uterine hyperstimulation. We also recorded mode of delivery, together with maternal and neonatal outcome. RESULTS: One hundred and four patients participated in this study. The active phase of labour was shorter in group B compared with group A, but this difference was not statistically significant (2.6 +/- 2 vs 3.3 +/- 2.9, P= 0.07). In group A there were six caesarean deliveries and in group B only three. No significant differences were found when the other outcome parameters were compared. CONCLUSIONS: There is no advantage in continuing oxytocin infusion after the onset of active labour.

Adult↗
PubMed1998

Cervical dilatation: induction by antigestagens via adhesion molecules. An in vitro examination in endothelial cell cultures.

Cervical ripening at term resembles an inflammatory reaction with invasion of activated granulocytes into the cervical stroma. Our objective was to investigate the influence of the antigestagen onapristone alone and in combination with other substances associated with cervical ripening on the expression of the inflammation-associated adhesion molecules ELAM-1, ICAM-1 and VCAM-1. Human endothelial cell cultures were stimulated with onapristone (200 ng/ml), TNF-alpha (100 U/ml), IL-8 (20 ng/ml) and PGE2 (3 ng/ml) separately and in combination (n = 6). The expression of adhesion molecules was determined qualitatively and quantitatively by immunofluorescence staining and flow cytometry with statistical evaluation by Kolmogorov-Smirnov analysis. Onapristone upregulated slightly the expression of ELAM-1 (19%). The costimulation of onapristone and TNF-alpha provoked an additive expression of VCAM-1 (64%) beyond the effect of TNF-alpha alone, while the costimulation of onapristone and PGE2 as well as the combination with IL-8 did not result in an additional stimulatory effect. All results were statistically significant (p < 0.001). This result supports our hypothesis that onapristone may lead to an increased adhesion of granulocytes to the capillary endothelium thereby initiating cervical ripening.

Cell Adhesion Molecules↗
PubMed2002

A diminished intrapartum amniotic fluid index is a predictive marker of possible adverse neonatal outcome when associated with prolonged labor.

OBJECTIVE: To determine whether a diminished intrapartum amniotic fluid volume represents a risk of adverse neonatal outcome when it occurs in conjunction with prolonged labor. METHODS: The intrapartum amniotic fluid index (iAFI) was measured in 242 parturients over 35 weeks of gestation during 1st-stage labor, and the umbilical artery blood gas was analyzed at delivery. The subjects were divided into group A (n = 99), having a diminished amniotic fluid volume (iAFI < or = 8.0 cm) and group B (n = 143), having a normal amniotic fluid volume (iAFI 8.1-20.0 cm), and selected antenatal, delivery, and neonatal variables were compared. In addition, the two groups were subdivided according to the duration of labor. Statistical analysis was performed using independent Student's t test, Mann-Whitney U test, chi-square analysis, and Fisher's exact test where appropriate. p < 0.05 was considered significant. RESULTS: The patient characteristics and pregnancy outcomes were similar in groups A and B, as were the incidences of an umbilical artery blood pH <7.20 and/or an Apgar score <7 (group A 9.5%, group B 10.1%). In group A, however, the incidence of an adverse neonatal outcome was 23.5% in cases in whom the duration of labor was longer than 8 h which was significantly higher than in cases in whom the duration of labor was 8 h or less (2.8%; p < 0.01). In group B, the incidence of an adverse neonatal outcome was similar in the two subgroups. CONCLUSIONS: The risk of an adverse neonatal outcome is higher in patients with diminished amniotic fluid volume if labor is prolonged. Consequently, determination of the iAFI could be a useful admission test.

Adult↗