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Prolonged labor is a common occurrence, but proper diagnosis is difficult, and the management is controversial. Prolonged labor can be prevented by providing the laboring woman with proper emotional support and by encouraging ambulation and position changes. The indication for and proper use of oxytocin and other measures to correct prolonged labor are discussed.
"The objective of this paper is to better understand the manner in which the supply of labor in a regional economy adjusts to changing labor demand. The principal response mechanisms include changed rates of labor force participation, changed unemployment rates, and migration....[Following a review of] the relevant literature...the simultaneous relationships among participation, unemployment, employment, and migration are formally recognized in a 10-equation model of the regional labor market adjustment process. The model is estimated for a sample of about 350 U.S. counties over the period 1960 to 1970."
The purpose of this study was to establish the prevalence, microbiology, and outcome of microbial invasion of the amniotic cavity in twin gestation presenting with preterm labor and intact membranes. Amniocenteses were performed on both sacs of 46 women with twin gestations, preterm labor, and intact membranes. Indigo carmine was injected to ensure sampling of both amniotic sacs. Amniotic fluid was cultured for aerobic and anaerobic bacteria, Mycoplasma hominis, and Ureaplasma urealyticum. A positive amniotic fluid culture of at least one sac was noted in 10.8% (5/46) of patients admitted in preterm labor and in 11.9% (5/42) of women delivered of preterm neonates. Of the five patients with microbial invasion of the amniotic cavity, three had microorganisms isolated from both sacs. The presenting sac was involved in all cases, supporting an ascending route for microbial invasion of the amniotic cavity in twin gestation. Polymicrobial infection was found in three of the eight amniotic sacs with positive cultures. In two cases different organisms were isolated from each sac. All patients with positive amniotic fluid cultures were delivered of preterm infants within 48 hours of amniocentesis. Patients with positive amniotic fluid cultures presented with preterm labor at an earlier gestational age and with more advanced cervical dilatation than did women with negative amniotic fluid cultures. Clinical evidence of chorioamnionitis subsequently developed in two of five women with positive amniotic fluid cultures. The interval between amniocentesis and delivery was shorter in women with positive amniotic fluid cultures than in women with negative amniotic fluid cultures (median: 3.5 vs 168 hours, p less than 0.0001). Infants born to women with microbial invasion of the amniotic cavity had a lower median birth weight and a higher incidence of respiratory distress syndrome than those born to women with negative amniotic fluid cultures (birth weight: 1085 vs 1975 gm, p = 0.024; respiratory distress syndrome: 37.5% vs 8.3%, p = 0.04).
Epidural analgesia (bupivacaine) was administered during labor after amniotomy, in some cases supplemented by intravenous oxytocin. A higher incidence of transient uterine hypertonus was seen after blocking. Fetal heart rate changes mainly took the form of bradycardia (in association with uterine hypertonus). At birth, the maternal biochemical condition was characterized by a lower degree of metabolic acidosis, compared to normal unanesthetized controls. The fetuses displayed a slight degree of hypoxia and hypercapnia. The mechanisms underlying these modifications are discussed. Epidural blockade in combination with elective induction of labor, whether or not supplemented by intravenous oxytocin, may carry a risk. Its magnitude is considered acceptable for both mother and fetus provided they are constantly under close surveillance, limited amounts of bupivacaine are administered and the second stage of labor is kept short. However, some warnings against epidural analgesia apply to patients with placental insufficiency and very active labor.
The objective was to evaluate the influence of patient-controlled epidural analgesia (PCEA) using low doses of bupivacaine vs. ropivacaine, on labor pain, motor blockade, progression of labor, delivery and neonatal outcome. This randomized double blind study included 565 parturients. All received a 5-mL/h infusion and PCEA (5-mL boluses with a 20-min lockout, maximum volume 20 mL/h) of either 0.125% bupivacaine (n = 313: 165 nulliparous, 148 parous) or 0.2% ropivacaine (n = 252: 113 nulliparous, 139 parous). Pain score, lower limb motor block, sensory levels, local analgesic doses required, hemodynamic parameters, side effects and complications were assessed. Obstetric variables included cervical dilation at epidural insertion, incidence of ruptured membranes and their duration, use of oxytocin, fetal heart rate changes, duration of labor, mode and outcome of delivery, and use of invasive and non-invasive fetal monitoring. Neonatal characteristics included birth weight, Apgar scores, umbilical artery pH, serum bilirubin, hypoglycemia, need for assisted ventilation, sepsis or sepsis study, feeding difficulties and respiratory distress syndrome. Ropivacaine 0.2% was equianalgesic with 0.125% bupivacaine, but produced less motor block (P < 0.0001). There were no significant differences, however, in duration of labor, delivery type or neonatal outcome.
Labor-onset hypertension is a poorly documented category, and there is scanty information concerning the outcome of pregnancy in this condition. A retrospective study was performed to compare the pregnancy outcome of 36 patients with labor-onset hypertension (group A) with 36 patients with classical preeclampsia diagnosed before labor (group B) who were matched for parity and age. There was no difference in age, past history of hypertensive pregnancies or family history of hypertension between the two groups. The need for intrapartum hypertensive and anticonvulsant treatment as well as the outcome of pregnancy were similar in both groups. The only significant difference was that group A patients had lower maximum and booking systolic and diastolic pressures. The results indicate that labor-onset hypertension represents a late manifestation of the preeclampsia process, because these patients had lower blood pressure in pregnancy and would not be identified until intrapartum elevation of blood pressure satisfied the diagnostic criteria of preeclampsia.
Organized labor has been largely responsible for the health and safety protections many U.S. workers take for granted. This article provides a brief history of labor's influence on California's health and safety policies--sometimes with ripple effects beyond its borders. Six cases where various successful strategies were used are examined. These gains were achieved with strong support from international health and safety staff, and, on some issues, support from the state labor federation. But in most cases local union staff involvement was key. Now that labor mobilizes to build its shrinking membership--with only 1 out of 12 workers in the private sector organized--resources are being re-directed toward organizing. Understandably, health and safety advocates have expressed concern that worker protections may suffer. Time will tell, but there is evidence that health and safety demands are front and center in a number of current and upcoming organizing campaigns. Now more than ever, it is in health and safety professionals' interest to tie their research and clinical work into these emerging campaigns.
Instead of continuous CTG monitoring lasting from the onset of labor to delivery, various obstetricians recommend interval monitoring in cases designated "likely to be free of complications". This enables the mother to move freely from time to time without being permanently confronted by technological apparatus. In the study reported here the authors therefore investigated whether-and if so what-risks interval monitoring involves. In order to answer this question 436 cardiotokograms recorded during labor with externally and internally attached leads were analyzed, evaluated 30 CTG minutes after the Hammacher Score in each case, and the number of points thus obtained was assigned to the corresponding cervical widths. As labor progressed from 3 to 10 cm cervix dilatation, there was a fourfold increase (p less than 0.0001) in particular in tentatively pathologic and prepathologic CTG patterns. No statistically significant difference was found between no-risk and risk patients. A check was also made as to whether the results of interval monitoring are as good as those of continuous monitoring. On the basis of two patient populations with different interval monitoring frequencies (17% versus 6.4%) it was established that with high interval monitoring frequencies the perinatal results were poorer: early morbidity of the newborns was twice as high when interval monitoring was used more often (21.4% versus 10.8%) (p less than 0.0001). From this the authors conclude that for the sake of the child, continuous monitoring during labor ought not to be dispensed with.
In 1984 the Tobacco Institute and the Bakery, Confectionary and Tobacco Workers Union formed a Labor Management Committee. From the mid-1980s to the mid-1990s, this LMC worked to elicit labor support in New York by framing issues in terms that made them salient to unions: tobacco excise taxes as regressive taxation, workplace smoking restrictions as an intrusion into collective bargaining. By the late 1990s, however, most of labor in New York had shifted to support for anti-tobacco policies. The reasons for this shift include the growing size and influence of public-sector unions, and their generally favorable stances on tobacco control issues; the policy-making autonomy of the unions; the growing body of scientific knowledge concerning the dangers of tobacco use; and the rise in public awareness of such dangers. Nevertheless, for two decades, the LMC contributed to mutual suspicion between labor and tobacco control advocates that prevented collaboration between them.
An analysis of the subjects of the controversy of energy theory, which was discussed over the various fields of labor science at 1930s-50s in Japan is as follows: (1) This theory was to re-arrange rationally, work in order to reduce the consumption of energy in human actions. It, moreover, was considered to be the standard of the wage adjustment. (2) It became popular since the working powers were terribly wasted by the industrial mobilization during WWII, and when the starvation wages spread throughout the country after the defeat. (3) This theory played an important role to synthesize the academic achievements of various fields such as labor economic, labor physiology, labor psychology and others.
An outbreak of pulmonary tuberculosis (TB) in a dormitory of construction laborers took place, and this outbreak was presumed to be caused by the same sourse of infection, based on the results of restriction fragment length polymorphism (RFLP) analysis and other findings. After the first patient was admitted to the hospital with active TB, 18 new other TB patients were discovered by repeated contacts examinations. They were all male and single, and were aged from 41 to 67 years old (mean age 51.7). Among 19 patients, only 4 patients had a health insurance. As these patients lived together in the same dormitory, to prevent infection through close contact in the dormitory, repeated contacts examinations were further performed. In addition, several medical, social, and economical interventions were needed for these patients. It was also required to improve labor conditions in this construction company. It was concluded that comprehensive approaches including public health, medical treatment, social welfare, and labor management aspects were indispensable to prevent TB among relatively poor laborers.
The fetal-pelvic index, which compares fetal head and abdomen circumferences with respective maternal inlet and midpelvic circumferences, was introduced in 1986 as a means of identifying the presence or absence of fetal-pelvic disproportion. In this study the efficacy of the fetal-pelvic index was evaluated in 46 patients with abnormal labor patterns that required labor augmentations and was compared with that of two other means (Colcher-Sussman x-ray pelvimetry and ultrasonographically derived estimated fetal weight greater than or equal to 4000 gm). Of the 24 women who required operative intervention (19 cesarean sections and five operative vaginal procedures), 17 had positive fetal-pelvic index values (sensitivity = 0.71). Six of the seven fetuses of patients with false-negative fetal-pelvic index values persisted in an occipitoposterior presentation, and these patients failed to progress in labor. Of the 22 patients in whom vaginal deliveries were spontaneous, 21 had negative fetal-pelvic index values (specificity = 0.95). Of the 18 women with positive fetal-pelvic index values, 17 required operative intervention (positive predictability = 0.94). In contrast, when used alone, neither x-ray pelvimetry nor ultrasonographically derived estimated fetal weight greater than or equal to 4000 gm provided accurate identification of fetal-pelvic disproportion.
OBJECTIVE: To determine if fetal growth restriction and prematurity are observed with subclinical shedding of herpes simplex virus (HSV) at the onset of labor. METHODS: Within 48 hours of delivery, cultures were taken from the cervix and external genitalia of 15,923 asymptomatic pregnant women without symptoms or signs of genital HSV infection; results were positive for HSV in 57. Each of these 57 women were compared with a control group composed of the three culture-negative women delivering immediately before and the three delivering immediately after each woman shedding HSV. RESULTS: The median birth weight for infants born to the 57 women with asymptomatic shedding was 3050 g, compared with 3360 g among the 342 women without asymptomatic shedding, a statistically significant difference (P < .002). These differences were due to very low birth weight (LBW) among the five infants of women with subclinical viral shedding secondary to recently acquired primary genital herpes; these five infants had a median gestational age of 33 weeks, compared with 37 weeks for the 14 infants of mothers with nonprimary, first-episode disease and 39 weeks for the 33 infants of women with reactivation disease, also a significant difference (P = .018). CONCLUSIONS: Asymptomatic genital shedding of HSV at the onset of labor because of subclinical primary genital HSV infection is associated with preterm delivery. Women who acquire genital HSV-2 before pregnancy and are shedding subclinically at the onset of labor experience no increase in adverse outcome. Thus, prevention of the prematurity and LBW associated with genital herpes means that acquisition of the infection in late pregnancy must be prevented.
Labor induction in impending premature delivery complicated by premature rupture of the membranes is controversial. Problems arise both with choice of a mode of delivery and induction manoeuvres to be used in biologically premature delivery. The paper addresses the results with a reflex method of labor induction based on transcutaneous electroneurostimulation (TENS). An appropriate TENS regimen was found to be a highly efficient method of labor induction allowing one to reduce the incidence of perinatal complications.
We have previously reported the detection of endotoxin in the amniotic fluid of patients with gram-negative intraamniotic infection. Endotoxin or lipopolysaccharide is a potent biologic product capable of inducing prostaglandin release from several cell types and, therefore, may be involved in the onset of human parturition in the presence of intraamniotic infection. This article describes a technique for the quantification of endotoxin in amniotic fluid. The method uses a computer-assisted quantification of the turbidimetric reaction between the Limulus amebocyte lysate and endotoxin. Serial dilutions of Escherichia coli endotoxin in culture-negative amniotic fluid were prepared, and the samples were run in the assay. Amniotic fluid was found to enhance the reaction, and a dilution of 1:20 was required for this biologic fluid to behave similarly to pyrogen-free water. The sensitivity of this kinetic turbidimetric technique in the detection of endotoxin in amniotic fluid was 40 pg/ml. This method was applied to the quantification of endotoxin concentration in amniotic fluid in 26 patients with intraamniotic infection and premature rupture of membranes. Patients in active labor had higher concentrations of endotoxin (median = 47,514 pg/ml) than nonlaboring patients (median = 635 pg/ml) (p less than 0.025). Therefore, women with preterm labor had a higher median concentration of endotoxin in amniotic fluid than patients who were not in labor.
Amniotic fluid was retrieved by amniocentesis from 264 patients with preterm labor and intact membranes admitted to Yale-New Haven Hospital from Jan. 1, 1985, to July 31, 1988. The prevalence of a positive amniotic fluid culture was 9.1% (24/264). A total of 111 patients (42%) delivered preterm neonates, and 24 (21.6%) of those had positive amniotic fluid cultures. The diagnostic indexes of the Gram stain of amniotic fluid in the prediction of a positive amniotic fluid culture were as follows: sensitivity, 79.1%; specificity, 99.6%; positive predictive value, 95%; and negative predictive value, 98%. Endotoxin was detected with the limulus amebocyte lysate assay in 4.9% (13/264) of patients with preterm labor. All patients with endotoxin in the amniotic fluid delivered preterm neonates. The three most frequently isolated organisms were Ureaplasma urealyticum (n = 6), Fusobacterium species (n = 5), and Mycoplasma hominis (n = 4). Clinical chorioamnionitis was present in only 12.5% of the patients with positive amniotic fluid cultures. Women with positive amniotic fluid cultures had lower gestational ages and more advanced cervical dilatation on admission than women with negative cultures. Preterm infants born to mothers with positive amniotic fluid cultures had a higher incidence of respiratory distress syndrome and infectious complications than preterm neonates born after negative amniotic fluid cultures. These data underscore the frequency and importance of intraamniotic infections in women with preterm labor.
Myometrial contractions of labor result from an increase in myometrial activation and stimulation. Activation develops through the expression of contraction associated proteins (CAPs), including oxytocin receptors (OTR), connexin-43 (Cx-43), and prostaglandin F2 alpha, receptors (FP). Stimulation involves increases in contractile agonists including prostaglandin E2 (PGE2) and prostaglandin F2 alpha. (PGF2 alpha) that may result from increases in prostaglandin endoperoxide H synthase (PGHS)-2. A mouse model of preterm birth was used to study gene expression involved in myometrial activation and stimulation. To induce preterm birth, pregnant C57BL/6J mice were intubated with 6 g/kg ethanol on gestational day 16 and were killed every 6 h from treatment until birth. RIA was used to measure uterine PGE2 and PGF2 alpha, while PGHS-2, OTR, Cx-43, and FP messenger RNA levels were measured by ribonuclease protection assay. Increases in CAP mRNA were associated with term and preterm birth. There were differences in stimulation effectors associated with preterm and term birth. Uterine PGF2 alpha values were increased only at the time of term birth, but PGE2 was elevated during both preterm and term labor. These data suggest that existing levels of PGF2 alpha are sufficient for preterm birth when CAP expression is increased, but term labor requires increases in PGE2, PGF2alpha, and CAPs. The PGHS-2 messenger RNA expression pattern suggests that it is a CAP.
A health care program may influence both costs and health effects. We developed the Health and Labor Questionnaire (HLQ), which consists of four modules, to collect data on absence from work, reduced productivity, unpaid labor production, and labor-related problems. We applied the HLQ in several studies, and the results are encouraging.