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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↗
PubMed1993

A multicenter, multiyear study of the safety and clinical utility of esophagogastroduodenoscopy in 20 consecutive pregnant females with follow-up of fetal outcome.

OBJECTIVES: To analyze the risks versus benefits of panendoscopy to the pregnant female and fetus. METHODS: Retrospective study of 20 consecutive pregnant patients admitted to three university teaching hospitals during 7 1/2 yr who underwent panendoscopy. RESULTS: Indications for panendoscopy included hematemesis in eight, vomiting and abdominal pain in five, vomiting in four, abdominal pain in two, and melena without hematemesis in one. Six patients were in the first trimester of pregnancy, eight were in the second trimester, and six were in the third trimester. Fourteen patients (70%) had a lesion diagnosed by panendoscopy, including esophagitis in seven, duodenal ulcer in two, gastritis in three, and Mallory-Weiss tear in two. In particular, all nine patients (100%) with gastrointestinal bleeding had a lesion identified by esophagogastroduodenoscopy. No significant endoscopic complications occurred. Panendoscopy did not induce labor in any patient. Fetal outcome was ascertained in 19 (95%) of the pregnancies. Seventeen infants were delivered at full term. Two were delivered at 33 and 35 weeks of gestation. No infant had a congenital malformation noted in the neonatal nursery. The mean infant Apgar scores were 8.2 +/- 1.3 (SD) at 1 min, and 9.1 +/- 0.3 (SD) at 5 min. CONCLUSIONS: In this study of 20 pregnancies, panendoscopy did not induce labor or result in congenital malformations. Panendoscopy is not absolutely contraindicated during pregnancy. Panendoscopy appears to be beneficial in medically stable pregnant patients with significant gastrointestinal bleeding. Panendoscopy should be performed with monitoring by electrocardiography and pulse oximetry after stabilization of vital signs, which may require transfusion of blood products and supplemental oxygen administration.

Endoscopy, Digestive System↗
PubMed1995

Evaluation of breast stimulation for induction of labor in women with a prior cesarean section and in grandmultiparas.

BACKGROUND: Information on the efficacy of breast stimulation for inducing labor in grandmultiparas and in women with a previous cesarean section with or without premature rupture of membranes is limited. METHODS: Retrospective study of labor data from 135 women of grand multiparity or those with a previous section with or without premature rupture of the membranes in whom labor was induced by breast stimulation. RESULTS: The success rate in achieving vaginal delivery was 84%. The duration of breast stimulation, length of labor, vaginal delivery rate, and Apgar score did not differ significantly among the four groups studied. CONCLUSION: Breast stimulation in grandmultiparas and in women with a previous cesarean section is efficacious and safe.

Adult↗
PubMed1985

Fetal breathing movements and the diagnosis of labor: a prospective analysis of 100 cases.

One hundred patients self-admitted to the hospital with a diagnosis of labor, were observed for up to 45 minutes with real-time ultrasonography to determine if the presence or absence of fetal breathing movements was helpful in separating false labor from true labor. Fetal breathing movements were not detected in 31 patients, and 30 of these delivered spontaneously within 48 hours; fetal breathing movements were present in 69 cases, and pregnancy continued for at least 48 hours in 56; of the remaining 13, labor occurred spontaneously within 48 hours in eight, whereas five had labor induced. Assessment of the cervix by Bishop score after ultrasound further improved diagnostic precision; none of 13 patients with a score greater than 9 exhibited fetal breathing movements, and all delivered within 48 hours. Gestational age did not influence outcome; 25 patients were preterm, and all 22 in whom fetal breathing movements were present continued for more than 48 hours. The results suggest that the absence of fetal breathing movements differentiates true labor from false labor.

Cervix Uteri↗
PubMedDate not supplied

An automatic infusion system for the measurement and control of uterine activity.

A system for the online quantitation of uterine activity has been used to define the optimum levels and patterns of uterine activity in spontaneous labors and labors induced by oxytocin infusion. Using these parameters, the system automatically adjusts oxytocin infusion to suit the individual requirements of the patient. The infusion rate is subsequently automatically adjusted to take account of any increase or decrease in the uterine activity.

Feedback↗
PubMed1995

Practice variations between family physicians and obstetricians in the management of low-risk pregnancies.

BACKGROUND: Studies suggest that family physicians and other generalist physicians practice differently than specialists. This study was performed to determine whether practice patterns and outcomes differ for women with low-risk pregnancies who obtain maternity care from family physicians as compared with those who are cared for by obstetricians. METHODS: A retrospective chart review was performed at five sites across the United States. Women who presented for elective repeat cesarean section or who had any one of 14 high-risk conditions were excluded from the analysis. The final sample analyzed included 4865 women. Family physicians managed the labor of 2000 of these women, and obstetricians managed 2865. RESULTS: During intrapartum care, women managed by family physicians were less likely to have their labor induced (8.6% vs 10.4%, P = .03), receive oxytocin augmentation (14.9% vs 17.8%, P = .006), or receive epidural anesthesia (5.4% vs 17.0%, P < .001) as compared with those managed by obstetricians. Delivery outcomes showed that patients of family physicians were less likely to have an episiotomy during vaginal delivery (53.7% vs 74.5%, P < .001) and a lower frequency of cesarean section deliveries (9.3% vs 16.0%, P < .001), especially for cephalopelvic disproportion. When adjusted for potential confounders, rates for cesarean section and episiotomy for obstetricians were still significantly higher than those of family physicians. For neonatal outcomes (low 1-minute Apgar score, neonatal intensive care unit admission, birth trauma, or neonatal infection), no significant differences were found between the care delivered by obstetricians and family physicians. CONCLUSIONS: Women obtaining maternity care from family physicians were less likely to receive epidural anesthesia during labor or an episiotomy after vaginal births, and had a lower rate of cesarean section delivery rates, primarily because of a decreased frequency in the diagnosis of cephalopelvic disproportion. Differences between outcomes persisted after adjustment for potential confounders such as parity, previous cesarean delivery, and use of epidural anesthesia during labor. No differences between the two physician groups with respect to neonatal outcomes were found.

Anesthesia, Epidural↗
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↗
PubMed1996

A study of eight medical centers of the safety and clinical efficacy of esophagogastroduodenoscopy in 83 pregnant females with follow-up of fetal outcome with comparison control groups.

OBJECTIVES: To analyze risks versus benefits of esophagogastroduodenoscopy (EGD) during pregnancy to the fetus and pregnant female. METHODS: Retrospective study of 83 consecutive pregnant patients who underwent EGD admitted to eight university teaching hospitals during a study period of up to 14 yr, with follow-up of fetal outcome. Controls included: 48 pregnant females matched for EGD indications who did not undergo EGD (pregnant controls), 83 nonpregnant females undergoing EGD matched for age and EGD indication (EGD controls), and national pregnancy outcome rates (national controls). RESULTS: EGD indications included acute GI bleeding in 37, vomiting and abdominal pain in 17, vomiting in 14, abdominal pain in 11, and other in four. The mean week of gestation was 19.8 +/ 8.9 EGD was diagnostic in 65 patients. The diagnostic yield of EGD was 95% for acute GI bleeding and ranged from 50 to 82% for the other indications (significantly different rates, odds ratio = 9.3, p < 0.001, odds ratio confidence interval = 2.22-45.5). Esophagitis was found in 62+ of patients with a diagnostic EGD. No significant endoscopic complications occurred. EGD did not induce labor. Excluding six voluntary abortions and three unknown pregnancy outcomes, 70 (95%) of 74 patients delivered healthy babies (pregnant control rate = 94%, national control rate = 98.4%, all not significant, Fisher's exact test). Moreover, the four poor outcomes (three stillbirths and one involuntary abortion) occurred in high risk pregnancies and were unrelated to EGD temporally or etiologically. No other infant had a congenital malformation noted in the neonatal nursery. Nine (12.7%) of the live born infants had a low birth weight (pregnant control rate = 8.5%, national control rate = 7.0%, all not significant, kappa 2). Mean Apgar scores of live born infants were 7.7 +/ 1.6 at 1 min and 9.0 +/ 0.6 at 5 min (pregnant control scores = 7.6 +/ 2.0 at 1 min and 8.5 +/ 1.1 at 5 min; national control mean scores = 8.0 +/ 1.4 at 1 min and 9.0 +/ 0.9 at 5 min; all not significant, Student's t test). In three cases with fetal cardiac monitoring, EGD did not induce abnormal fetal heart rates (preendoscopy rate = 143.3 +/ 5.8 beats/min, postendoscopy rate = 148.0 +/ 10.6 beats/min). CONCLUSIONS: In this study, EGD did not induce labor or result in congenital malformations. EGD is not contraindicated during pregnancy. EGD is beneficial in pregnant patients with upper GI bleeding.

Abdominal Pain↗
PubMed1992

Amnion cell biosynthesis of interleukin-8: regulation by inflammatory cytokines.

The cellular constituents of the placenta are important participants in the recruitment and trafficking of inflammatory cells within the placenta. In infection-induced labor, gestational tissues synthesize and release a variety of inflammatory cytokines whose effects include increased prostaglandin biosynthesis and the initiation of uterine contractions. Interleukin-8 (IL-8), a potent neutrophil chemoattractant, has been recently described as being elevated in the amniotic fluid of mothers with chorioamnionitis. We investigated the biosynthesis of IL-8 by human amnion cells and its regulation by other inflammatory cytokines. Cultured amnion cells obtained from normal term placentae were found to produce IL-8 in response to pathophysiologic concentrations of interleukin 1 beta (IL-1 beta) and tumor necrosis factor alpha (TNF-alpha). Treatment of amnion cells stimulated by IL-1 beta with cycloheximide resulted in increased IL-8 production, while incubation of IL-1 beta treated amnion cells with actinomycin D resulted in a concentration-dependent decrease in detectable amounts of IL-8. Northern blot analysis of cultured amnion cells stimulated with IL-1 beta demonstrated a rapid increase in IL-8 mRNA which peaked at 2-4 hr. These in vitro results suggest inflammation of gestational tissues in vivo may result in locally produced IL-8 and, in association with other inflammatory mediators, may be important in the pathophysiology of infection-induced labor.

Amnion↗
PubMed1993

[The computer assessment of cardiotocograms during labor induction].

IBC-3 computer-based automated system was used to analyze the cardiotocograms obtained in the course of 40 induced labors. Labor was induced by amniotomy in Group 1 parturients, by a combined method (amniotomy followed by i.v. droplet infusions of oxytocin and enzaprost) in Group 2 patients. No significant differences between the two groups were observed. Uterine contractility parameters were higher in Group 2. Clinical and computer-aided cardiotocographic investigations revealed no unfavorable effects of the before methods of labor induction on the mother, fetus, and newborn.

Amnion↗
PubMed1976

Mammary blood flow and endocrine changes during parturition in the ewe.

The temporal relationship between changes in mammary blood flow (MBF) and changes in the concentration of plasma prolactin, progesterone, estradiol-17beta, and cortisol, was examined in chronic sheep preparations undergoing spontaneous labor (Group I) or labor induced by an infusion of dexamethasone (1 mg/24 h) to the fetus (Group II). In Group I, an increase in prolactin (45 to 489 ng/ml), a decrease in progesterone (15 to 4 ng/ml), and an increase in MBF (97 to 365 ml/min) occurred at about the same time, whereas increases in estradiol-17beta (80 to 211 pg/ml) and cortisol (9 to 39 ng/ml) followed the change in MBF. A similar pattern of changes in MBF and hormonal concentrations occurred over a shorter period when premature labor was induced in the animals in Group II. These findings suggest that changes in plasma prolactin and progesterone concentrations play an important role in the regulation of MBF at the time of parturition.

Animals↗
PubMedDate not supplied

[Efficacy and safety of misoprostol in obstetrics].

OBJECTIVE: To review the efficacy and safety of misoprostol for indications not included in the prescription information given for the product, including abortion, labor induction, treatment and prevention of postpartum bleeding, and hysteroscopy preparation. METHOD: Pubmed was searched for controlled, randomized, blinded clinical trials of misoprostol in obstetrics from 1999 through 2004. RESULTS: Nineteen clinical trials were found. The efficacy for abortion in association with mifepristone at a dosage of 400 microg/6 h is superior versus both placebo and gemeprost, but misoprostol is more painful and less effective than dilation and subsequent evacuation. Regarding the administration route, trials show similar efficacy for the vaginal and oral approaches. In the prevention and treatment of postpartum hemorrhage, misoprostol was not any better than oxytocin. When used as a labor inducing agent, results are best with doses of 50 microg/3-8 h, but no controlled clinical trials were found. Although its use for hysteroscopy facilitates the procedure versus placebo, it entails a higher frequency of adverse events. No controlled clinical trials were found for other options. CONCLUSIONS: The efficacy of misoprostol for indications reviewed in this paper is controversial, and studies found are heterogeneous. Designing and conducting further clinical trials to investigate appropriate dosage and administration routes, as well as the drug s adverse effect profile under such circumstances is essential, and would potentially allow an application for approval to be filed with health authorities regarding its use in obstetric practice.

Abortifacient Agents, Nonsteroidal↗
PubMed2001

Do very sick neonates born at term have antenatal risks? 1. Infants ventilated primarily for problems of adaptation to extra-uterine life.

AIMS: 1. Ascertain antenatal and intrapartum risk factors for term neonates ventilated primarily for 'perinatal asphyxia'. 2. Describe the neonatal morbidity and mortality. METHODS: Population-based case control cohort study. SETTING: Sydney and four large rural/urban health areas in New South Wales. SUBJECTS: Singleton term infants, no major congenital anomaly: subset of 83 infants ventilated primarily for 'asphyxia' from 182 cases admitted to a tertiary neonatal intensive care unit (NICU) for mechanical ventilation, 550 randomly selected controls. Outcome. Risk factors for case status by maternal, antenatal, labor, delivery, and combined epochs, adjusted odds ratios (OR), 95 per cent confidence intervals (CI), p < 0.05. RESULTS: Predictors of case status by multivariate epochs: Primigravida (1.8 [1.1, 2.8]), thyroid disease (7.8 [1.1, 57.0]), any antenatal complication (5.1 [3.0, 8.6]), growth restriction (4.2 [1.7, 10.4]), male gender (2.1 [1.3, 3.5]), gestational age >40 weeks (1.9 (1.1, 3.3)), prolonged rupture of membranes (9.7 [1.3, 72.5]), complicated labor (6.6 [3.7, 11.9]), induced labor (2.2 [1.3, 3.9]), prostaglandins 2.46 [1.23, 4.91]), maternal pyrexia (10.8 [2.8, 42.7]), placental hemorrhage in labor (OR 4.24 [1.45, 12.42]), forceps delivery (4.1 [1.9, 8.5]), emergency cesarean section (4.7 [2.6, 8.7]). Twenty case infants (24%) and no control infants died. CONCLUSIONS: This study has shown maternal and antepartum risk factors for severe neonatal morbidity in term infants. More centers need to become interested in the term baby, so that a larger multicenter study can further elucidate the heterogeneous causal pathways to term neonatal morbidity.

Adaptation, Biological↗
PubMed2002

Suspected big baby: a difficult clinical problem in obstetrics.

BACKGROUND: Large for gestational age fetuses, also called macrosomic fetuses, represent a continuing challenge in obstetrics. METHODS: We review various problems with large for gestational age fetuses. We have performed a literature search, mainly through the database PubMed (includes the Medline database). The clinical problem is discussed from the primary care provider's, the patient's and the obstetrician's point of view. RESULTS: Macrosomia is arbitrarily defined as having a fetal weight of above the 90th percentile, a birth weight of above 4000 g or 4500 g, or a birth weight of over +2 standard deviation of the mean birth weight by gestational age. The diagnosis of macrosomia is difficult, both by palpation and symphysis fundus measurement; even with sophisticated sonographic measures. The combination of biparietal diameter, femur length and abdominal circumference appears to be no better than abdominal circumference alone. INTERPRETATION: Based on the literature, labor should not be induced in nondiabetic pregnancies. The best policy is to await spontaneous birth or to induce labor after 42 weeks completion. A great number of cesarean sections have to be performed to avoid a single case of plexus brachialis paresis resulting from a difficult shoulder delivery. Cesarean section should not be considered in nondiabetic pregnancies unless the estimated fetal weight is above 5000 g. In pregnancies complicated by diabetes mellitus there are reasons for selective induction of labor if macrosomia is suspected and for cesarean section if the calculated birth weight is above 4000 g. Each department should have a strategy to handle such a situation because the problem with the difficult shoulder delivery cannot be completely avoided. Different procedures of managing difficult shoulder delivery are described.

Female↗
PubMed1989

Cachectin/tumor necrosis factor-alpha formation in human decidua. Potential role of cytokines in infection-induced preterm labor.

This study was conducted as part of an investigation to evaluate the hypothesis that bacterial toxins (LPS or lipoteichoic acid), acting on macrophage-like uterine decidua to cause increased formation of cytokines, may be involved in the pathogenesis of infection-associated preterm labor. We found that cachectin/tumor necrosis factor-alpha (TNF-alpha) was synthesized and secreted into the culture medium by human decidual cells and explants in response to treatment with LPS. LPS treatment also caused an increase in PGF2 alpha production by decidual cells and explants. In amnion cells in monolayer culture, TNF-alpha stimulated PGE2 formation, and TNF-alpha was cytostatic (inhibited [3H]thymidine incorporation into DNA) but not cytolytic in amnion cells. TNF-alpha was not detectable (less than 0.34 ng/ml) in the amniotic fluid of normal pregnancies at midtrimester or at term before or after the onset of labor (n = 44); but TNF-alpha was present at concentrations between 2.8 and 22.3 ng/ml in amniotic fluids of 4 of 20 pregnancies with intact membranes complicated by preterm labor (less than 34 wk gestational age). LPS was present in 10 of the 20 amniotic fluids of preterm labor pregnancies, including all four in which TNF-alpha was present. Bacteria were identified in only one of the four LPS-positive, TNF-alpha-positive fluids. Cytokine formation in macrophage-like decidua may serve a fundamental role in the pathogenesis of preterm labor, including increased prostaglandin formation and premature rupture of the membranes.

Amniotic Fluid↗
PubMedDate not supplied

Bilateral orbital hemorrhage induced by labor.

We describe a woman in whom bilateral orbital hemorrhage occurred during labor. She developed sudden proptosis and complete loss of vision bilaterally. After a stillbirth, she underwent total hysterectomy because of atonic uterus and postpartum hemorrhage. The location of the hematomas was confirmed by magnetic resonance imaging. Clinical resolution occurred in one month but both eyes remained blind. Fundoscopy revealed bilateral atrophy of the optic discs.

Adult↗