Obstetric risk indicators for labour dystocia in nulliparous women: a multi-centre cohort study

Maternal age and body mass index and risk of labor dystocia after spontaneous labor onset among nulliparous women: A clinical prediction model

INTRODUCTION

Obstetrics research has predominantly focused on the management and identification of factors associated with labor dystocia. Despite these efforts, clinicians currently lack the necessary tools to effectively predict a woman's risk of experiencing labor dystocia. Therefore, the objective of this study was to create a predictive model for labor dystocia.

MATERIAL AND METHODS

The study population included nulliparous women with a single baby in the cephalic presentation in spontaneous labor at term. With a cohort-based registry design utilizing data from the Copenhagen Pregnancy Cohort and the Danish Medical Birth Registry, we included women who had given birth from 2014 to 2020 at Copenhagen University Hospital-Rigshospitalet, Denmark. Logistic regression analysis, augmented by a super learner algorithm, was employed to construct the prediction model with candidate predictors pre-selected based on clinical reasoning and existing evidence. These predictors included maternal age, pre-pregnancy body mass index, height, gestational age, physical activity, self-reported medical condition, WHO-5 score, and fertility treatment. Model performance was evaluated using the area under the receiver operating characteristics curve (AUC) for discriminative capacity and Brier score for model calibration.

RESULTS

A total of 12,445 women involving 5,525 events of labor dystocia (44%) were included. All candidate predictors were retained in the final model, which demonstrated discriminative ability with an AUC of 62.3% (95% CI:60.7-64.0) and Brier score of 0.24.

CONCLUSIONS

Our model represents an initial advancement in the prediction of labor dystocia utilizing readily available information obtainable upon admission in active labor. As a next step further model development and external testing across other populations is warranted. With time a well-performing model may be a step towards facilitating risk stratification and the development of a user-friendly online tool for clinicians.

Inconsistent definitions of prolonged labor in international literature: a scoping review

Objective

Prolonged labor is the commonest indication for intrapartum cesarean section, but definitions are inconsistent and some common definitions were recently found to overestimate the speed of physiological labor. The objective of this review is to establish an overview of synonyms and definitions used in the literature for prolonged labor, separated into first and second stages, and establish types of definitions used.

Data sources

A systematic search was conducted in PubMed, Embase, Web of Science, Cochrane Library, Emcare, and Academic Search Premier.

Study eligibility criteria

All articles in English that (1) attempted to define prolonged labor, (2) included a definition of prolonged labor, or (3) included any synonym for prolonged labor, were included.

Methods

Data on study design, year of publication, country or region of origin, synonyms used, definition of prolonged first and/or second stage, and origin of provided definition (if not primarily established by the study) were collected into a database.

Results

In total, 3402 abstracts and 536 full-text papers were screened, and 232 papers were included. Our search established 53 synonyms for prolonged labor. Forty-three studies defined prolonged labor and 189 studies adopted a definition of prolonged labor. Definitions for prolonged first stage of labor were categorized into: time-based (n=14), progress-based (n=12), clinician-based (n=5), or outcome-based (n=4). For the 33 studies defining prolonged second stage, the majority of definitions (n=25) were time-based, either based on total duration or duration of no descent of the presenting part.

Conclusions

Despite efforts to arrive at uniform labor curves, there is still little uniformity in definitions of prolonged labor. Consensus on which definition to use is called for, in order to safely and respectfully allow physiological labor progress, ensure timely management, and assess and compare incidence of prolonged labor between settings.

Variations in the use of oxytocin for augmentation of labour in Sweden: a population-based cohort study

National Swedish data shows substantial variation in the use of oxytocin for augmentation of spontaneous labour between obstetric units. This study aimed to investigate if variations in the use of oxytocin augmentation are associated with maternal and infant characteristics or clinical factors. We used a cohort design including women allocated to Robson group 1 (nulliparous women, gestational week ≥ 37 + 0, with singleton births in cephalic presentation and spontaneous onset of labour) and 3 (parous women, gestational week ≥ 37 + 0, with singleton births in cephalic presentation, spontaneous onset of labour, and no previous caesarean birth). Crude and adjusted logistic regression models with marginal standardisation were used to estimate risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI) for oxytocin use by obstetric unit. An interaction analysis was performed to investigate the potential modifying effect of epidural. The use of oxytocin varied between 47 and 73% in Robson group 1, and 10% and 33% in Robson group 3. Compared to the remainder of Sweden, the risk of oxytocin augmentation ranged from 13% lower (RD - 13.0, 95% CI - 15.5 to - 10.6) to 14% higher (RD 14.0, 95% CI 12.3-15.8) in Robson group 1, and from 6% lower (RD - 5.6, 95% CI - 6.8 to - 4.5) to 18% higher (RD 17.9, 95% CI 16.5-19.4) in Robson group 3. The most notable differences in risk estimates were observed among women in Robson group 3 with epidural. In conclusion, variations in oxytocin use remained despite adjusting for risk factors. This indicates unjustified differences in use of oxytocin in clinical practice.

Maternal factors associated with labor dystocia in low-risk nulliparous women. A systematic review and meta-analysis

OBJECTIVE

To identify maternal factors associated with labor dystocia in low-risk nulliparous women.

METHODS

MEDLINE, Embase, ClinicalTrials.gov, Cochrane, and CINAHL were searched for intervention studies and observational studies published from January 2000 to January 2022. Low-risk was defined as nulliparous women with a singleton, cephalic birth in spontaneous labor at term. Labor dystocia was defined by national or international criteria or treatment. Countries were restricted to OECD members. Two authors independently screened 11,374 titles and abstracts, extracted data, and assessed risk of bias using the Newcastle-Ottawa Scale. Results were presented narratively and by meta-analysis when compatible.

RESULTS

Seven cohort studies were included. Overall, the certainty of the evidence was moderate. Three studies found that higher maternal age was associated with an increased frequency of labor dystocia (relative risk 1.68; 95% CI 1.43-1.98). Further three studies found that higher maternal BMI was associated with increased frequency of labor dystocia (relative risk 1.20; 95% CI 1.01-1.43). Maternal short stature, fear of childbirth, and high caffeine intake were also associated with an increased frequency of labor dystocia, while maternal physical activity was associated with a decreased frequency.

CONCLUSION

Maternal factors associated with an increased frequency of labor dystocia were mainly maternal age, physical characteristics, and fear of childbirth. Maternal physical activity was associated with a decreased frequency. Intervention studies targeting these maternal factors would need to be initiated before or early in pregnancy to test the causality of the identified factors and labor dystocia.

Maternal postures for fetal malposition in labour for improving the health of mothers and their infants

BACKGROUND

Fetal malposition (occipito-posterior and persistent occipito-transverse) in labour is associated with adverse maternal and infant outcomes. Whether use of maternal postures can improve these outcomes is unclear. This Cochrane Review of maternal posture in labour is one of two new reviews replacing a 2007 review of maternal postures in pregnancy and labour.

OBJECTIVES

To assess the effect of specified maternal postures for women with fetal malposition in labour on maternal and infant morbidity compared to other postures.  SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (13 July 2021), and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or cluster-RCTs conducted among labouring women with a fetal malposition confirmed by ultrasound or clinical examination, comparing a specified maternal posture with another posture. Quasi-RCTs and cross-over trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, risk of bias, and performed data extraction. We used mean difference (MD) for continuous variables, and risk ratios (RRs) for dichotomous variables, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included eight eligible studies with 1766 women.  All studies reported some form of random sequence generation but were at high risk of performance bias due to lack of blinding. There was a high risk of selection bias in one study, detection bias in two studies, attrition bias in two studies, and reporting bias in two studies. Hands and knees The use of hands and knees posture may have little to no effect on operative birth (average RR 1.14, 95% CI 0.87 to 1.50; 3 trials, 721 women; low-certainty evidence) and caesarean section (RR 1.34, 95% CI 0.96 to 1.87; 3 trials, 721 women; low-certainty evidence) but the evidence is uncertain; and very uncertain for epidural use (average RR 0.74, 95% CI 0.41 to 1.31; 2 trials, 282 women; very low-certainty evidence), instrumental vaginal birth (average RR 1.04, 95% CI 0.57 to 1.90; 3 trials, 721 women; very low-certainty evidence), severe perineal tears (average RR 0.88, 95% CI 0.03 to 22.30; 2 trials, 586 women; very low-certainty evidence), maternal satisfaction (average RR 1.02, 95% CI 0.68 to 1.54; 3 trials, 350 women; very low-certainty evidence), and Apgar scores less than seven at five minutes (RR 0.71, 95% CI 0.21 to 2.34; 2 trials, 586 babies; very low-certainty evidence).  No data were reported for the hands and knees comparisons for postpartum haemorrhage, serious neonatal morbidity, death (stillbirth or death of liveborn infant), admission to neonatal intensive care, neonatal encephalopathy, need for respiratory support, and neonatal jaundice requiring phototherapy.  Lateral postures The use of lateral postures may have little to no effect on reducing operative birth (average RR 0.72, 95% CI 0.43 to 1.19; 4 trials, 871 women; low-certainty evidence), caesarean section (average RR 0.78, 95% CI 0.44 to 1.39; 4 trials, 871 women; low-certainty evidence), instrumental vaginal birth (average RR 0.73, 95% CI 0.39 to 1.36; 4 trials, 871 women; low-certainty evidence), and maternal satisfaction (RR 0.96, 95% CI 0.84 to 1.09; 2 trials, 451 women; low-certainty evidence), but the evidence is uncertain. The evidence is very uncertain about the effect of lateral postures on severe perineal tears (RR 0.66, 95% CI 0.17 to 2.48; 3 trials, 609 women; very low-certainty evidence), postpartum haemorrhage (RR 0.90, 95% CI 0.48 to 1.70; 1 trial, 322 women; very low-certainty evidence), serious neonatal morbidity (RR 1.41, 95% CI 0.64 to 3.12; 3 trials, 752 babies; very low-certainty evidence), Apgar scores less than seven at five minutes (RR 0.25, 95% CI 0.03 to 2.24; 1 trial, 322 babies; very low-certainty evidence), admissions to neonatal intensive care (RR 1.41, 95% CI 0.64 to 3.12; 2 trials, 542 babies; very low-certainty evidence) and neonatal death (stillbirth or death of liveborn) (1 trial, 210 women and their babies; no events).  For the lateral posture comparisons, no data were reported for epidural use, neonatal encephalopathy, need for respiratory support, and neonatal jaundice requiring phototherapy. We were not able to estimate the outcome death (stillbirth or death of liveborn infant) due to no events (1 trial, 210 participants).  AUTHORS' CONCLUSIONS: We found low- and very low-certainty evidence which indicated that the use of hands and knees posture or lateral postures in women in labour with a fetal malposition may have little or no effect on health outcomes of the mother or her infant. If a woman finds the use of hands and knees or lateral postures in labour comfortable there is no reason why they should not choose to use them. Further research is needed on the use of hands and knees and lateral postures for women with a malposition in labour. Trials should include further assessment of semi-prone postures, same-side-as-fetus lateral postures with or without hip hyperflexion, or both, and consider interventions of longer duration or that involve the early second stage of labour.

Effects of Obstetric Interventions During Labor on Birth Process and Newborn Health

AIM

This study aimed to investigate the effects of the interventions in the delivery room on the delivery process and the newborn health.

METHOD

The analytical-cross-sectional study was carried out with 354 puerperal women who gave birth in hospital between December 2016 and June 2017 in a public hospital. The data were collected by the data collection form developed by the researchers. Data analysis was done by using descriptive statistics and chi-square test in SPSS 21.00 program.

RESULTS

The interventions were determined in continuous electro fetal monitoring (80.5%), oxytocin induction (79.9%), restriction of free movement (56.8%), amniotomy (49.7%), enema (44.1%), and movement restriction (56.8%). The intervention period of the second phase of delivery was longer and the rate of cesarean section was higher, and the need for NICU, suction difficulty, 5th APGAR score less than 7, trauma development, difficulty in suction, and higher trauma rates were found in infants. It was determined that the rate of oxygen need in puerperals admitted to the delivery room with cervical dilatation below five cm, vacuum and episiotomy applications in those who underwent amniotomy, and vacuum application rates in those undergoing oxytocin inductions were found to be high. In addition, the rate of fundal compression and episiotomy was significantly higher in patients who used continuous electro fetal monitoring, fundal compression and vacuum rate in patients who were administered analgesic drugs, and episiotomy rates in patients using analgesic drugs.

CONCLUSION

It has been concluded that interventions in the first phase of labor negatively affect the delivery process and neonatal health and increase the need for intervention in the second phase.

Pre- and during- labour predictors of dystocia in active phase of labour: a case-control study

Background

Labour dystocia (LD) is associated with maternal and foeto-neonatal complications and increased rate of caesarean section. There are scant studies on predictive factors of labour dystocia in Iran, as well as in other countries. Therefore, this study aimed to identify the predictive factors of LD using an integrated and collaborative pre- and during- labour factors to help formulate more effective intervention strategies for prevention and management of LD.

Methods

In this case-control study, 350 women with and 350 women without LD, matched individually in terms of parity and hospital, were compared. The participants were in active labor, had singleton pregnancy, live foetus with a cephalic presentation, gestational age of 37^+ 0–41^+ 6 weeks, and were hospitalized for vaginal birth in two teaching hospitals in Tabriz, Iran. Data related to the socio-demographic characteristics, anxiety status (using the Spielberger State Anxiety Inventory), and woman dehydration were collected at cervical dilatation between 4 and 6 cm (before dystocia detection) and the other data at different phases of labour, and after birth (before discharge). The multivariate logistic regression was used to determine the predictors.

Results

The predictors of LD were severe [OR 58.0 (95% CI 26.9 to 125.1)] and moderate [8.6 (4.2 to 17.4)] anxiety, woman dehydration > 3 h [18.67 (4.0 to 87.3)] and ≤ 3 h [2.8 (1.7 to 4.8], insufficient support by the medical staff in the delivery room [5.8 (1.9 to 17.9)], remifentanil administration [3.1 (1.5 to 6.2)], labour induction [4.2 (2.5 to 7.2], low income [2.0 (1.2 to 3.3)], woman’s height < 160 cm [2.0 (1.1 to 3.3)], and woman age of 16–20 y [0.3 (0.2 to 0.6)]. The proportion of the variance explained by all these factors was 74%.

Conclusion

The controllable predictors, such as woman anxiety and dehydration, and insufficient support from medical staff during labour were strongly associated with the risk of LD. Therefore, it seems that responding to woman physical, psychological, and supportive needs during labour can play a significant role in LD prevention and control.

Ethical code

IR.TBZMED.REC.1397.624.

Labour admission assessment results of index pregnancy as predictors of intrapartum stillbirth in public health facilities of Addis Ababa: A case-control study

BACKGROUND

Approximately one-third of the global stillbirth burden occurs during intrapartum period. The ability to assess obstetric parameters including effacement, dilatation, uterine contraction, decent, rupture of the uterus, and moulding of the foetal head are among the essential competencies required by obstetric service providers admitting women for labour in health facilities. Misdiagnosis of these conditions could result in unnecessary obstetric interventions and unfavourable obstetric outcomes including intrapartum stillbirth. This study aimed to assess associations between missed diagnosis plus complication of labour on admission and intrapartum stillbirth.

METHODS

A case-control study using primary data from chart review of medical records of women who experienced intrapartum stillbirth in 20 public health centres and three public hospitals of Addis Ababa between 01 July 2010 and 30 June 2015 was conducted. Data were collected from charts of all cases meeting the inclusion criteria. Medical records of women with livebirths were randomly selected and reviewed from each public health facilities in two to one (2:1) control to case ratio. Accordingly, 728 cases of stillbirth out of 1,056 charts met the inclusion criteria whereas 1,551 controls out of 1,705 were also considered in the study.

RESULTS

Proportionally, more women in the stillbirth group (39.4%) than in the livebirth group (30.2%) experienced ruptured membrane on admission, with the difference being statistically significant (OR 1.7, 95% CI 1.37-2.03). Significantly higher proportion of women in the intrapartum stillbirth group experienced FRH lower than 110/min, a result suggestive of foetal distress on admission. Proportionally, more women in the intrapartum stillbirth group (14.5%) than in the livebirth group (4.5%) had breech foetal presentation on admission for labour, the difference being statistically significant (aOR 3.26 95% CI 1.93-5.50). Intrapartum stillbirth was slightly higher among women with cervical dilatation 4cm or more on admission (OR 1.2, 95% CI 1.00-1.45). This could be owing to delay in seeking obstetric care or misdiagnosis of the condition, a situation that seeks more rigorous study to determine the underlying causal links. Diagnosis of foetal member was missed among more cases than controls where the difference was statistically significant (aOR 1.51, CI 1.03-2.19).

CONCLUSION

Low FHR, non-vertex foetal presentations and ruptured cervical membrane were predictors of intrapartum stillbirth. Health facilities could avert unnecessary foetal loss by undertaking timely actions to manage obstetric emergencies on admission to labour.

Use of opioids during pregnancy and effects of pregnancy outcomes

PURPOSE

To evaluate the use of opioids in pregnant primiparous women and study the effect of opioid use on maternal and offspring delivery outcomes.

METHODS

The study cohort (N = 6231) consists of all primiparous women with a Finnish background who delivered a singleton between 2009 and 2015 in the city of Vantaa, Finland. Data on births, maternal characteristics, pregnancy outcomes, and purchases of prescription drugs were obtained from National Health Registers.

RESULTS

Of the primiparous women, 5.1% used opioids during pregnancy. Of these, 95.9% used codeine. No differences were observed in purchases of opioids between the different trimesters but more women purchased opioids as pregnancy progressed (.002). Users of opioids more often also purchased other prescription drugs compared with non-users of opioids, 89% versus 58% (P < .001); age, smoking, education, and body mass index adjusted odds ratio 5.66 (95% confidence interval 3.96 to 8.09). Caesarean sections were more common in users of opioids than in non-users, 28.3% versus 21.9% (.007). Before the age of 7 days, the offspring of users of opioids more often needed respirator treatment compared with the offspring of non-users, 3.1% versus 1.6% (.044).

CONCLUSIONS

One out of 20 pregnant women used opioids. Use of opioids during pregnancy was associated with the risk for deliveries by caesarean sections and need for respiratory treatment among the offspring during the first week of life. Further safety evaluations are needed.

Epidural analgesia and its implications in the maternal health in a low parity comunity

Background

In regard to obstetrical analgesia management there are different results related to the use of epidural analgesia versus mechanical adverse outcomes at delivery.

Methods

Cohort study of 23,183 consecutive, term, singleton vaginal deliveries, including spontaneous and induced labours, at a single institution from January 2004 to June 2016 to determine the association between epidural analgesia and different mechanical complications affecting maternal health such as severe perineal tears (SPT), abnormal foetal head position at delivery, instrumental delivery and caesarean section (CS).

Multivariate logistic regression models were constructed to evaluate the risk factors of these mechanical complications with respect to possible cofounders.

Results

Epidural analgesia was used in 15,821 (68.24%) women. The logistic regression model showed a non-significant association between the use of epidural analgesia and SPT (odds ratio [OR], 078; 95% confidence interval [CI], 0.48–1.26; p = 0.310). Instrumental delivery and CSs were more frequently performed in cases than controls (p = < 0.001), with OR of 1.19 (95% CI: 1.10–1.29) for CS and with OR of 3.27 (95% CI: 2.93–4.61) for instrumental delivery. The abnormal foetal position head at delivery were significantly lower in the neonates delivered without epidural analgesia compared with those in which epidural analgesia was used (p < 0.001) with OR of 1.43 (95% CI:1.27–1.72).

Conclusions

Epidural analgesia is not associated with an increase of SPT, but it was an independent risk factor for instrumental delivery, CS and abnormal foetal head position at delivery.

Cervix Stromal Cells and the Progesterone Receptor A Isoform Mediate Effects of Progesterone for Prepartum Remodeling

The prepartum transition from a soft to ripening cervix is an inflammatory process that occurs well before birth when systemic progesterone is near peak concentration. This 2-part study first determined that stromal fibroblasts but not macrophages in the cervix have progesterone receptors (PRs). Neither the number of PR cells in cervix sections nor the relative abundance or ratio of nuclear PR isoforms (PR-A/PR-B) were diminished in mice between day 15 of pregnancy and term. Second in mice lacking PR-B ( Pgr^tm20mc), the number of cells that expressed the PR-A isoform were maintained during this period of prepartum cervix remodeling. Thus, progesterone effects to sustain pregnancy, as well as soften and ripen the cervix, are mediated by a stable stromal cell population that expresses PR-A and, through interactions with resident macrophages, are likely to mediate inflammatory ripening processes in preparation for birth.

Study protocol: the Labor Progression Study, LAPS - does the use of a dynamic progression guideline in labor reduce the rate of intrapartum cesarean sections in nulliparous women? A multicenter, cluster randomized trial in Norway

Background

The increasing rate of intrapartum cesarean sections is subject of attention and concern as it is associated with adverse outcomes. Labor dystocia is one of the most frequent indications for cesarean sections even though there is no consensus on criteria for labor dystocia. Traditionally the progression of labor follows guidelines based on Friedman’s curve from the mid 1950s. In 2010 Zhang presented a new labor curve and a dynamic guideline for labor progression based on contemporary research. The main aim of this trial is to evaluate whether adhering to Zhang’s guideline for labor progression, changes the intrapartum cesarean section rate in nulliparous women without jeopardising maternal and neonatal outcomes compared to a traditional guide line called the 4-h action line based on Friedman’s curve.

Methods/design

A multicenter cluster randomized trial including 14 birth care units in Norway is conducted. Seven units are randomized to use the 4-h action line guideline for labor progression and seven units are randomized to use Zhang’s new dynamic guideline for labor progression, for all nulliparous women with a singleton fetus in a cephalic presentation and spontaneous onset of labor at term. Clinical outcomes are compared between the groups. The determination of the sample size (number of clusters and individuals) is based on a power calculation of intrapartum cesarean section, which is 9.2% in the study population (p1). Further, we expect that the intrapartum cesarean section rate will be 6.7% (p2) which is a 25% reduction, when using the new guideline. With a chosen significance level of 0.05, a power of 80% and p1 = 9.2% and p2 = 6.9%, we should include at least 14 clusters and 6582 individuals.

Discussion

Clinical consequences when using the guideline by Zhang have, to the best of our knowledge, not been investigated earlier. The results will provide a strong basis to make a qualified decision on whether it is beneficial to introduce a dynamic labor progression curve in contemporary obstetrics both nationally and internationally.

Trial registration

Clinicaltrials, NCT02221427

Analysis and evaluation of the effectiveness of epidural analgesia and its relationship with eutocic or dystocic delivery

OBJECTIVE

Numerous studies have demonstrated the difference in the verbal rating scale with regard to obstructed labour and induced labour, so that obstructed labour and foetal macrosomia have been related to a greater sensation of pain during labour, particularly in the first stage. Even the epidural analgesia is linked to the need for instrumented or caesarean section due to foetal obstruction. The goal of the study is to analyze and evaluate the effectiveness of epidural analgesia in normal versus obstructed labour.

PATIENTS AND METHODS

One hundred and eighty pregnant women were included in an observational, analytical, longitudinal and prospective study, that was performed in the Obstetrics Department of the Hospital Universitario Dexeus. All the nulliparous or multiparous over 36 weeks of pregnancy, after 3cm of cervical dilatation in spontaneous or induced labor were included. All the patients were given epidural analgesia according to protocol.

RESULTS

The basic descriptive methods were used for the univariate statistical analysis of the sample and the Mann-Whitney U test was used for the comparison of means between both groups. The correlations between variables were studied by means of the Spearman coefficient of correlation. The differences regarded as statistically significant are those whose P<.05.

CONCLUSION

In our population there were no statistically significant differences in the effectiveness of epidural analgesia in normal versus obstructed labour. Patients who got epidural analgesia and had obstructed labors have the same degree of verbal rating scale as patients that do not had obstructed labors (P>.05).

Factors affecting the rates of caesarean sections in cases with premature rupture of membranes (PROM) at term

The aim of this retrospective study was to investigate the factors affecting the rates of caesarean section in cases with premature rupture of membranes (PROM) in term pregnancies. Eighty-two term PROM patients who presented to Turgut Ozal University and Erzurum Nene Hatun Hospitals between 2012 and 2014 were included. The effects of demographics, nulliparity, active-latent phase durations, presence of meconium and chorioamnionitis, requirement of oxytocin and cervical dilation at the initial examination on C/S rates were assessed. The C/S rates were changed with the duration of active period and the duration of latent period. It was found that the presence of cervical dilation at the initial examination significantly reduced the risk for progress to C/S at a rate of 87.5%. C/S rates did not change with other variables. We conclude that the factors increasing the risk for C/S in PROM at term group are not different from the non-term PROM. Impact statement The aim of this retrospective study was to investigate the factors affecting the rates of caesarean section (C/S) in cases with premature rupture of membranes (PROM) in term pregnancies. The C/S rates were changed with the duration of active period and the duration of latent period. It was found that the presence of cervical dilation at the initial examination significantly reduced the risk for progress to C/S at a rate of 87.5%. We conclude that the factors increasing the risk for C/S in PROM at term group, are not different from the non-term PROM groups. Currently, the PROM is considered the start of a pathological process in both term and preterm pregnancies and also considered to increase the rates of caesarean sections. Studies on the management of PROM at term have concentrated rather on whether to intervene for accelerating the labour or spontaneous monitorisation. As found by the studies like this one in the literature, the factors having an impact on C/S rates in the cases of PROM at term are similar to those of non-PROM patients at term, may prevent clinicians from taking an invasive or aggressive approach towards the cases of PROM at term.

What is normal progress in the first stage of labour? A vignette study of similarities and differences between midwives and obstetricians

OBJECTIVE

intrapartum referrals are high-risk situations. To ensure patient safety, care professionals need to have a shared understanding of a labouring woman's situation. We aimed to gain insight into similarities and differences between midwives and obstetricians in the assessment of a prolonged first stage of labour and the decision to refer a woman to a clinical setting in the Netherlands.

DESIGN

factorial survey.

SETTING

in the Netherlands, the main caregivers for women with low risks of pathology are primary-care midwives working in the locality. Approximately half of all women start labour under supervision of primary-care midwives. Roughly 40% of these women are referred to a hospital during labour, where obstetricians take over responsibility. In 2013, the reason for referral for 5161 women (14.1% of all referrals during labour) was a prolonged first stage of labour.

PARTICIPANTS

respondents consisted of primary-care midwives (N=69), obstetricians (N=47) and hospital based midwives, known as clinical midwives (N=31).

MEASUREMENTS

each respondent assessed seven hypothetical vignettes. The assessment of a prolonged first stage of labour and the decision to refer a woman to a clinical setting based on this indication were used as outcome measures, rated on a 7-point Likert scale (1=very unlikely to 7=very likely). Data were analysed using a linear multilevel model with a two-level hierarchy.

FINDINGS

compared to primary-care midwives, obstetricians were more likely to define a prolonged first stage of labour when progress in cervical dilation was slow (b: 1.11; 95% CI: 0.66 - 1.57). The attributes parity, progress, intensity of uterine contractions and the woman's state of mind, were used by all three groups in the decision to refer a woman to clinical setting based on a prolonged first stage of labour. KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE: we found relevant interprofessional differences and similarities in the assessment of a prolonged first stage of labour and consequent referral. Further interprofessional alignment of clinical assessments, for instance through interprofessional discussions and a review of professional guidelines, might help to improve collaborative care.

Early versus Late Admission to Labor Affects Labor Progression and Risk of Cesarean Section in Nulliparous Women

Background

Rates of cesarean section increase worldwide, and the components of this increase are partially unknown. A strong role is prescribed to dystocia, and at the same time, the diagnosis of dystocia is highly subjective. Previous studies indicated that risk of cesarean is higher when women are admitted to the hospital early in the labor.

Methods

We examined data on 1,202 nulliparous women with singleton, vertex pregnancies and spontaneous labor onset. We selected three groups based on cervical dilatation at admission: early (0.5–1.5 cm, N = 178), intermediate (2.5–3.5 cm, N = 320), and late (4.5–5.5 cm, N = 175). The Kaplan–Meier estimator was used to analyze the risk of delivery by cesarean section at a given dilatation, and thin-plate spline regression with a binary outcome (R library gam) to assess the form of the associations between the cesarean section in either the first or second stage versus vaginal delivery and dilatation at admission.

Results

Women who were admitted to labor early had a higher risk of delivery by cesarean section (18 versus 4% in the late admission group), while the risk of instrumental delivery did not differ (24 versus 24%). Before 4 cm dilatation, the earlier a woman was admitted to labor, the higher was her risk of delivery by cesarean section. After 4 cm dilatation, however, the relationship disappeared. These patterns were true for both first and second stage cesarean deliveries. Oxytocin use was associated with a higher risk of cesarean section only in the middle group (2.5–3.5 cm dilatation at admission).

Conclusion

Early admission to labor was associated with a significantly higher risk of delivery by cesarean section during the first and second stages. Differential effects of oxytocin augmentation depending on dilation at admission may suggest that admission at the early stage of labor is an indicator rather than a risk factor itself, but admission at the intermediate stage (2.5–3.5 cm) becomes a risk factor itself. Further research is needed to study this hypothesis.

Effect of antenatal education in small classes versus standard auditorium-based lectures on use of pain relief during labour and of obstetric interventions: results from the randomised NEWBORN trial

OBJECTIVE

To examine the effect of an antenatal education programme in small classes versus standard auditorium-based lectures.

DESIGN

Randomised trial using random-generated web-based 1:1 allocation.

SETTING

The largest birth site in the Capital Region of Denmark, from August 2012 to May 2014.

PARTICIPANTS

1766 pregnant women. Inclusion criteria ≥18 years, pregnant with a single child, and able to speak and understand Danish. Women were enrolled in the trial from 10+0 to 20+0 weeks of gestation.

INTERVENTIONS

The intervention programme consisted of three times 2.5 hours of antenatal education in small classes (n=6-8 women), and focused on improving information and problem-solving skills for expectant parents in order to ease birth and the transition to parenthood. The control group received standard auditorium-based lectures consisting of two times 2 hours in an auditorium with participation of ∼250 people.

MAIN OUTCOME MEASURES

The primary trial outcome was use of epidural analgesia. Other types of pain relief and obstetric interventions were analysed as explorative outcomes.

RESULTS

There was no statistically significant difference in use of epidural analgesia between participants in the intervention group (30.9%) versus the control group (29.1%), adjusted OR 1.10 (95% CI 0.87 to 1.34). Also, the two groups did not differ regarding other types of pain relief or obstetric interventions. Concomitant birth preparation was common in both groups and highest in the control group, but did not seem to influence our results noticeably.

CONCLUSIONS

Antenatal education in small groups versus standard auditorium-based lectures did not differ regarding use of epidural analgesia, other pain relief, or obstetric interventions.

TRIAL REGISTRATION NUMBER

NCT01672437; Results.

Prevention of primary caesarean delivery: comprehensive management of dystocia in nulliparous patients at term

PURPOSE

Dystocia is the leading indication for primary caesarean sections. Our aim is to compare two approaches in the management of dystocia in labor in nulliparous women with a singleton fetus in cephalic presentation at term in spontaneous or induced labor.

METHODS

Prospective cohort study. Four hundred and nineteen consecutive patients were divided into two groups: the standard management group (SM), in acceleration of labor was commenced at the "action line" in the case of arrested or protracted labor, and the comprehensive management group (CM) in which arrested or protracted labor was considered as a warning sign promoting further diagnostic assessment prior to considering intervention.

RESULTS

Caesarean sections rate was 22.2 % in the SM group (216 patients) and 10.3 % in the CM group (203 patients) (p = 0.001). The rate of oxytocin use decreased from 33.3 % in SM group to 13.8 % in the CM group (p < 0.0005). The rate of amniotomy decreased from 41.7 % in the SM group to 7.4 % in the CM group (p < 0.0005). The percentage of newborns with 5-min Apgar score <7 and/or umbilical cord arterial pH ≤ 7.00 decreased from 2.3 % in SM cohort to 0.5 % in CM cohort (p = ns). The average length of labor did not differ between the two groups of patients (264 vs 277 min; p = ns).

CONCLUSION

Comprehensive management of dystocia enabled us to achieve a reduction in iatrogenic interventions in labor while maintaining good neonatal outcomes.

Epidurals: Do They or Don't They Increase Cesareans?

The controversy over whether epidurals increase the risk of cesarean has raged since the 1970s. This article provides a history of of the early observational research designed to answer this question and an in-depth analysis of the most recent randomized control trials. Based on the research, the author concludes that we cannot assure women that epidurals do not increase the risk of cesarean.

A large head circumference is more strongly associated with unplanned cesarean or instrumental delivery and neonatal complications than high birthweight

OBJECTIVE

Fetal size impacts on perinatal outcomes. We queried whether the fetal head, as the fetal part interfacing with the birth canal, might impact on obstetric outcomes more than birthweight (BW). We examined associations between neonatal head circumference (HC) and delivery mode and risk of perinatal complications as compared to high BW.

STUDY DESIGN

This was an electronic medical records-based study of term singleton births (37-42 weeks' gestation) from January 2010 through December 2012 (N = 24,780, 6343 primiparae). We assessed risks of unplanned cesarean or instrumental delivery and maternal and fetal complications in cases with HC or BW ≥95th centile (large HC, high BW) vs those with parameters <95th centile (normal). Newborns were stratified into 4 subgroups: normal HC/normal BW (reference, n = 22,548, primiparae 5862); normal HC/high BW (n = 817, P = 213); large HC/normal BW (n = 878, P = 265); and large HC/high BW (n = 537, P = 103). Multinomial multivariable regression provided adjusted odds ratio (aOR) while controlling for potential confounders.

RESULTS

Infants with HC ≥95th centile (n = 1415) were delivered vaginally in 62% of cases, unplanned cesarean delivery 16%, and instrumental delivery 11.2%; 78.4% of infants with HC <95th centile were delivered vaginally, 7.8% unplanned cesarean, and 6.7% instrumental delivery. Odds ratio (OR) for unplanned cesarean was 2.58 (95% confidence interval [CI], 2.22-3.01) and for instrumental delivery OR was 2.13 (95% CI, 1.78-2.54). In contrast, in those with BW ≥95th centile (n = 1354) 80.3% delivered vaginally, 10.2% by unplanned cesarean (OR, 1.2; 95% CI, 1.01-1.44), and 3.4% instrumental delivery (OR, 0.46; 95% CI, 0.34-0.62) compared to infants with BW <95th centile: spontaneous vaginal delivery, 77.3%, unplanned cesarean 8.2%, instrumental 7.1%. Multinomial regression with normal HC/normal BW as reference group showed large HC/normal BW infants were more likely to be delivered by unplanned cesarean (aOR, 3.08; 95% CI, 2.52-3.75) and instrumental delivery (aOR, 3.03; 95% CI, 2.46-3.75). Associations were strengthened in primiparae. Normal HC/high BW was not associated with unplanned cesarean (aOR, 1.18; 95% CI, 0.91-1.54), while large HC/high BW was (aOR, 1.93; 95% CI, 1.47-2.52). Analysis of unplanned cesarean indications showed large HC infants had more failure to progress (27.7% vs 14.1%, P < .001), while smaller HC infants had more fetal distress (23.4% vs 16.9%, P < .05).

CONCLUSION

A large HC is more strongly associated with unplanned cesarean and instrumental delivery than high BW. Prospective studies are needed to test fetal HC as a predictive parameter for prelabor counseling of women with "big babies."

Variation in intrapartum referral rates in primary midwifery care in the Netherlands: a discrete choice experiment

OBJECTIVE

in midwife-led care models of maternity care, midwives are responsible for intrapartum referrals to the obstetrician or obstetric unit, in order to give their clients access to secondary obstetric care. This study explores the influence of risk perception, policy on routine labour management, and other midwife related factors on intrapartum referral decisions of Dutch midwives.

DESIGN

a questionnaire was used, in which a referral decision was asked in 14 early labour scenarios (Discrete Choice Experiment or DCE). The scenarios varied in woman characteristics (BMI, gestational age, the preferred birth location, adequate support by a partner, language problems and coping) and in clinical labour characteristics (cervical dilatation, estimated head-to-cervix pressure, and descent of the head).

SETTING

primary care midwives in the Netherlands.

PARTICIPANTS

a systematic random selection of 243 practicing primary care midwives. The response rate was 48 per cent (117/243).

MEASUREMENTS

the Impact Factor of the characteristics in the DCE was calculated using a conjoint analysis. The number of intrapartum referrals to secondary obstetric care in the 14 scenarios of the DCE was calculated as the individual referral score. Risk perception was assessed by respondents׳ estimates of the probability of eight birth outcomes. The associations between midwives׳ policy on management of physiological labour, personal characteristics, workload in the practice, number of midwives in the practice, and referral score were explored.

FINDINGS

the estimated head-to-cervix pressure and descent of the head had the largest impact on referral decisions in the DCE. The median referral score was five (range 0-14). Estimates of probability on birth outcomes were predominantly overestimating actual risks. Factors significantly associated with a high referral score were: a low estimated probability of a spontaneous vaginal birth (p=0.007), adhering to the active management policy Proactive Support of Labour (PSOL) (p=0.047), and a practice situated in a rural area or small city (p=0.016).

KEY CONCLUSIONS

there is considerable variation in referral decisions among midwives that cannot be explained by woman characteristics or clinical factors in early labour. A realistic perception of the possibility of a spontaneous vaginal birth and adhering to expectant management can contribute to the prevention of unwarranted medicalisation of physiological childbirth.

IMPLICATIONS FOR PRACTICE

awareness of variation in referrals and the associated midwife-related factors can stimulate midwives to reflect on their referral behavior. To diminish unwarranted variation, high quality research on the optimal management of a physiological first stage of labour should be performed.

A validation study: assessing the reliability of the hand held StatStripXPress lactate meter to test lactate in amniotic fluid

BACKGROUND

The level of lactate in amniotic fluid may provide useful clinical information when assessing whether a woman in labour is experiencing labour dystocia. If so, a rapid, reliable method to assess the concentration of amniotic fluid lactate at the bedside will be required in order to be clinically relevant. To assess efficacy, we compared the hand held StatStripXPreass lactate meter (Nova Biomedical) to the reference laboratory analyser ABX Pentra 400 (Horiba) in a controlled environment. Baseline biological lactate concentration was measured in triplicate and samples of a known quantity of thawed amniotic fluid spiked with lactate substrate (62 mmol/L) from the LDH12 kit (Roche, SUI) to yield a predetermined lactate concentration above baseline then measured in triplicate. Deming Regression was used to determine the linear agreement and a Bland Altman plot used to determine the paired agreement across the range of values.

FINDINGS

The mean difference with Bland-Altman plot between hand held meter and lab instrument was -1.0 mmol/L (SD 3.0 mmol/L) with 95% CI limits of agreement between -6.9 mmol/L to 4.9 mmol/L. The Deming regression co-efficient or slope of agreement was 0.91 (SD of 0.21).

CONCLUSION

The measurement of amniotic fluid lactate using the StatStripXPress hand held meter was reliable compared to reference laboratory methods for measuring lactate levels in amniotic fluid.

Seasonal variation of dystocia in a large Danish cohort

Background

Dystocia is one of the most frequent causes of cesarean delivery in nulliparous women. Despite this, its causes are largely unknown. Vitamin D receptor (VDR) has been found in the myometrium. Thus, it is possible that vitamin D affects the contractility of the myometrium and may be involved in the pathogenesis of dystocia. Seasonal variation of dystocia in areas with distinct seasonal variation in sunlight exposure, like Denmark, could imply that vitamin D may play a role. This study examined whether there was seasonal variation in the incidence of dystocia in a Danish population.

Method

We used information from a cohort of 34,261 nulliparous women with singleton pregnancies, spontaneous onset of labor between 37 and 42 completed gestational weeks, and vertex fetal presentation. All women gave birth between 1992 and 2010 at the Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby. Logistic regression combined with cubic spline was used to estimate the seasonal variation for each outcome after adjusting for calendar time.

Results

No evidence for seasonal variation was found for any of the outcomes: acute cesarean delivery due to dystocia (p = 0.44); instrumental vaginal delivery due to dystocia (p = 0.69); oxytocin augmentation due to dystocia (p = 0.46); and overall dystocia (p = 0.91).

Conclusion

No seasonal variation in the incidence of dystocia was observed in a large cohort of Danish women. This may reflect no association between vitamin D and dystocia, or alternatively that other factors with seasonal variation and influence on the occurrence of dystocia attenuate such an association.

Titrated oral misoprostol for augmenting labour to improve maternal and neonatal outcomes

BACKGROUND

Labour dystocia is associated with a number of adverse maternal and neonatal outcomes. Augmentation of labour is a commonly used intervention in cases of labour dystocia. Misoprostol is an inexpensive and stable prostaglandin E1 analogue that can be administered orally, vaginally, sublingually or rectally. Misoprostol has proven to be effective at stimulating uterine contractions although it can have serious, and even life-threatening side-effects. Titration refers to the process of adjusting the dose, frequency, or both, of a medication on the basis of frequent review to achieve optimal outcomes. Studies have reported on a range of misoprostol titration regimens used for labour induction and titrated misoprostol may potentially be effective and safe for augmentation of labour.

OBJECTIVES

To examine the effects and safety of titrated oral misoprostol compared with placebo, oxytocin, other interventions, or no active treatment, in women with labour dystocia.

SEARCH METHODS

The Trials Search Co-ordinator of the Cochrane Pregnancy and Childbirth Group searched the Cochrane Pregnancy and Childbirth Group's Trials Register; date of search: 29 May 2013. We also searched the reference lists of retrieved studies

SELECTION CRITERIA

Randomised trials (including quasi-randomised and cluster-randomised trials) comparing titrated oral misoprostol with placebo, other interventions (e.g. oxytocin, other prostaglandins), or no treatment in women requiring augmentation of labour were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility for inclusion, carried out data extraction and assessed risk of bias in included studies. Data were entered by one author and checked for accuracy.

MAIN RESULTS

We included two randomised trials with a total of 581 women each comparing different regimens of titrated oral misoprostol with intravenous oxytocin. One study compared 20 mcg doses of misoprostol dissolved in water (repeated every hour up to four hours, after which the dose was increased to 40 mcg per hour up to a maximum total dose of 1600 mcg), while the second study gave women 75 mcg doses (repeated after four hours provided there were no adverse effects observed).Neither trial reported maternal death, severe maternal morbidity, or fetal/neonatal mortality outcomes, and only a few fetal/neonatal morbidity outcomes were considered, none of which were significantly different between groups. For several outcomes (such as maternal side-effects, instrumental birth, maternal blood transfusion for hypovolaemia and epidural analgesia), the number of events was generally too low for sufficient statistical power to be achieved. Maternal satisfaction was not reported in either trial. One trial reported a slight reduction in the median duration of labour from the start of augmentation to vaginal delivery in the oxytocin group.Neither trial reported significantly higher rates of caesarean section (CS) in the oral misoprostol group. Rates of vaginal delivery within 12 and 24 hours of commencing augmentation were not significantly different in the trial using a 20 mcg misoprostol dose. Neither trial had significantly higher rates of uterine hyperstimulation with fetal heart rate changes in the titrated oral misoprostol group. However, the rates of this outcome varied so greatly between the two studies as to suggest that other factors were at play. The only significant differences between groups related to uterine hyperstimulation (without fetal heart rate changes), and results were not consistent in the two trials. In the trial examining the higher dose of misoprostol, more women in the misoprostol group experienced hyperstimulation of labour measured over a 10-minute period compared with those receiving oxytocin (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.02 to 1.35, 350 women). In the study examining the lower titrated dose of misoprostol, there was a lower incidence of tachysystole when labour was augmented with titrated oral misoprostol than with oxytocin (RR 0.39, 95% CI 0.17 to 0.91, 231 women) with no occurrences of hypertonus in either group of women.

AUTHORS' CONCLUSIONS

Important uncertainties still exist on the safety and acceptability of titrated oral misoprostol compared with intravenous oxytocin regimens in women with dystocia following spontaneous onset of labour. Although in facilities where electronic oxytocin infusion is not available, low-dose titrated misoprostol may offer a better alternative to an uncontrolled oxytocin infusion to avoid hyperstimulation. Further research is needed in both high- and low-resource settings More trials should be conducted to evaluate the effect of a standard titration oral misoprostol regimen, both following spontaneous labour and labour induction. Comparisons with other augmentation methods are also warranted, as are any effects on women's birth experiences.

Oxytocin and dystocia as risk factors for adverse birth outcomes: a cohort of low-risk nulliparous women

OBJECTIVES

augmented and not augmented women without dystocia were compared to investigate associations between oxytocin and adverse birth outcomes. Augmented women with and without dystocia were compared, to investigate associations between dystocia and adverse birth outcomes.

DESIGN

a cohort of low-risk nulliparous women originally included in a randomised controlled trial.

SETTING

the Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Norway.

PARTICIPANTS

the study population consists of 747 well defined low-risk women.

MEASUREMENTS

incidence of oxytocin augmentation, and associations between dystocia and augmentation, and mode of delivery, transfer of newborns to the intensive care unit, episiotomy and postpartum haemorrhage.

FINDINGS

of all participants 327 (43.8%) were augmented with oxytocin of which 139 (42.5%) did not fulfil the criteria for dystocia. Analyses adjusted for possible confounders found that women without dystocia had an increased risk of instrumental vaginal birth (OR 3.73, CI 1.93-7.21) and episiotomy (OR 2.47, CI 1.38-4.39) if augmented with oxytocin. Augmented women had longer active phase if vaginally delivered and longer labours if delivered by caesarean section if having dystocia. Among women without dystocia, those augmented had higher body mass index, gave birth to heavier babies, had longer labours if vaginally delivered and had epidural analgesia more often compared to women not augmented.

KEY CONCLUSION

in low-risk nulliparous without dystocia, we found an association between the use of oxytocin and an increased risk of instrumental vaginal birth and episiotomy.

IMPLICATIONS FOR PRACTICE

careful attention should be paid to criteria for labour progression and guidelines for oxytocin augmentation to avoid unnecessary use.

Impact on caesarean section rates following injections of sterile water (ICARIS): a multicentre randomised controlled trial

BACKGROUND

Sterile water injections have been used as an effective intervention for the management of back pain during labour. The objective of the current research is to determine if sterile water injections, as an intervention for back pain in labour, will reduce the intrapartum caesarean section rate.

METHODS/DESIGN

DESIGN

A double blind randomised placebo controlled trialSetting: Maternity hospitals in AustraliaParticipants: 1866 women in labour, ≥18 years of age who have a singleton pregnancy with a fetus in a cephalic presentation at term (between 37 + 0 and 41 + 6 weeks gestation), who assess their back pain as equal to or greater than seven on a visual analogue scale when requesting analgesia and able to provide informed consent.

INTERVENTION

Participants will be randomised to receive either 0.1 to 0.3 millilitres of sterile water or a normal saline placebo via four intradermal injections into four anatomical points surrounding the Michaelis' rhomboid over the sacral area. Two injections will be administered over the posterior superior iliac spine (PSIS) and the remaining two at two centimetres posterior, and one centimetre medial to the PSIS respectively.

MAIN OUTCOME MEASURE

Proportion of women who have a caesarean section in labour.Randomisation: Permuted blocks stratified by research site.Blinding (masking):Double-blind trial in which participants, clinicians and research staff blinded to group assignment.

FUNDING

Funded by the National Health and Medical Research CouncilTrial registration:Australian New Zealand Clinical Trials Registry (No ACTRN12611000221954).

DISCUSSION

Sterile water injections, which may have a positive effect on reducing the CS rate, have been shown to be a safe and simple analgesic suitable for most maternity settings. A procedure that could reduce intervention rates without adversely affecting safety for mother and baby would benefit Australian families and taxpayers and would reduce requirements for maternal operating theatre time. Results will have external validity, as the technique may be easily applied to maternity populations outside Australia. In summary, the results of this trial will contribute High level evidence on the impact of SWI on intrapartum CS rates and provide evidence of the analgesic effect of SWI on back pain.

A pilot study to determine the feasibility of collecting amniotic fluid samples from women during labour and measuring amniotic fluid lactate at point of care

Background

The level of lactate in amniotic fluid may provide useful clinical information when assessing progress of a woman’s labour and if so, a rapid, reliable method to assess amniotic fluid lactate is required in order to be clinically relevant. However, measuring lactate levels in amniotic fluid, using portable, handheld lactate meters may be less accurate than reference laboratory instruments designed to measure lactate levels in aqueous solutions. Prior to conducting a large study, we assessed recruitment, consent and sampling procedures, and the accuracy of a handheld lactate meter to measure lactate in amniotic fluid. We compared amniotic fluid lactate results obtained using the hand held Lactate Pro (Arkray) to results obtained using reference laboratory methods ABX Pentra 400 (Horiba).

Results

We recruited 35 nulliparous women during their antenatal hospital visits and tested amniotic fluid samples collected from 20 labouring women. The handheld Lactate Pro meter was found accurate from 9–20 mmol/L with a Passing & Bablok regression of y = 0.18 + 0.97x (95% CI 0.76–1.45). Amniotic fluid lactate results remained reliable in the presence of potential contaminants commonly encountered during labour; obstetric lubricant, blood and meconium.

Conclusion

The measurement of amniotic fluid lactate using the Lactate Pro meter was reliable compared to reference laboratory methods for measuring lactate levels in amniotic fluid. The pilot study enabled the refinement of information, recruitment, consenting and sampling procedures prior to commencing a large cohort study.

Indications for operative delivery between 1999-2010 and induction of labor and epidural analgesia on the risk of operative delivery--a population based Swedish register study

OBJECTIVES

The aim of this study was to describe the distribution of indications for vacuum extraction (VE) and emergency cesarean section (EMCS) from 1999 to 2010. Furthermore, we investigated the association of induction of labor and epidural analgesia (EA) on the risk of operative delivery.

STUDY DESIGN

Population based register study with data from the Swedish Medical Birth Register during 1999-2010 including all 415230 primiparous women giving birth in gestational week 37+0 to 41+6.

MAIN OUTCOME MEASURES

Indication for operative delivery as well as VE and EMCS.

RESULTS

Among the VE deliveries the indication "signs of fetal distress" increased while "multiple indications" decreased. For EMCS, "prolonged labor" increased steadily while "multiple indications" decreased. The total rate of induction of labor increased from 8.2% in 1999 to 11.9% in 2010, and was associated with an increased risk of both EMCS (OR 3.37) and VE (OR 1.5). The total rate of EA increased from 43.7% in 1999 to 49.8% in 2010, and was associated with a double risk for VE (OR=2.23) and with an increased risk of EMCS (OR=1.64).

CONCLUSION

There have been changes in the distribution of indications for VE and EMCS during the study period. A growing number of mothers are being induced and more mothers receive EA. These factors seem to have influenced the rate of operative deliveries. Our findings underline the importance of carefully considering the advantages, disadvantages and risks with EA and induction of labor.

Labour augmentation and fetal outcomes in relation to birth positions: a secondary analysis of an RCT evaluating birth seat births

OBJECTIVE

the aim of this study was to compare the use of synthetic oxytocin for augmentation, duration of labour and birth and infant outcomes in nulliparous women randomised to birth on a birth seat or any other position.

STUDY DESIGN

a randomised controlled trial in Sweden where 1002 women were randomised to birth on a birth seat (experimental group) or birth in any other position (control group). Data were collected between November 2006 and July 2009. The outcome measurements included synthetic oxytocin augmentation, duration of the second stage of labour and fetal outcome. Analysis was by intention to treat.

SETTING

southern Sweden.

FINDINGS

the main findings of this study were that women randomised to the experimental group had a statistically significant shorter second stage of labour than women randomised to the control group. There were no differences between the groups for use of synthetic oxytocin augmentation or for neonatal outcomes.

CONCLUSIONS

women allocated to the birth seat had a significantly shorter second stage of labour despite similar numbers of women subjected to synthetic oxytocin augmentation in the study groups. The adverse neonatal outcomes did not differ between groups. The birth seat can be suggested as non-medical intervention used to reduce duration of second stage labour and birth. The birth seat can be suggested as a non-medical intervention that may facilitate reduced duration of the second stage of labour. Furthermore it is recommended that caregivers, both midwives and midwifery students, should learn skills to assist women in using a variety of birth positions.

TRIAL REGISTRATION

unique Protocol ID: Dnr 2009/739 (register.clinicaltrials.gov).

[Obstetric and neonatal outcomes in a home-like birth centre: a case-control study]

OBJECTIVES

To compare intervention rates associated with labor in low-risk women who began their labor in the "home-like birth centre" and the traditional delivery room.

PATIENTS AND METHODS

This retrospective study used data that were collected from January 2005 through June 2008, from women admitted to the "home-like birth centre" (n=316) and compared to a group of randomly selected low-risk women admitted to the traditional labor ward (n=890) using the Baysian Information Criterion to select the best predictive model.

RESULTS

Women in the "home-like birth centre" had spontaneous vaginal deliveries more often (88.6% versus 82.8%, P value 0.034) and perineal lesions less often (60.1% versus 62.5%, P value 0.013). The frequency of adverse neonatal outcomes did not differ statistically between the two groups, although mean clamped at birth umbilical arterial pH level was higher in the "home-like birth centre" group. The transfer rate from "home-like birth centre" to traditional labor ward was 31.3%.

DISCUSSION AND CONCLUSIONS

It appears that women could benefit from "home-like birth centre" care in settings such as the one studied. Larger observational studies are warranted to validate these results.

"Every case of asphyxia can be used as a learning example". Conclusions from an analysis of substandard obstetrical care

AIM

To propose suggestions for improvements in care based on conclusions from studies on low Apgar scores and substandard care during labor.

SETTING AND PATIENTS

Studies on infants with low Apgar scores in a general obstetric population 2004-2006 and claims for financial compensation on the behalf of infants, based on the suspicion that substandard care in conjunction with childbirth has caused severe asphyxia or neonatal death in Sweden 1990-2005.

RESULTS

The most common flaws were related to insufficient fetal surveillance, defective interpretation of cardiotocography (CTG) tracings, not acting in a timely fashion on abnormal CTG, and the incautious use of oxytocin. Besides, in half of the infants a suboptimal mode of delivery added further trauma to the already asphyxiated infant. Additionally, resuscitation was unsatisfactory in many of these infants. The most critical flaw was defective compliance with the guidelines concerning ventilation and the early paging of skilled personnel in cases of imminent asphyxia or known complications during labor. In many case reports, the documentation of the neonatal resuscitation was insufficient to enable accurate and reliable evaluation.

CONCLUSIONS

Examples of proposed improvements in care during labor are the introduction of a permanent educational atmosphere with aside time for daily educational rounds and discussion, cooperation around the use of standardized terminology in CTG interpretation, the cautious use of oxytocin, and the routine paging of a pediatrician before birth in cases of complicated delivery or imminent asphyxia. The proposed interventions need to be evaluated in clinical trials in the future.

Limited midwifery care for undocumented women in the Netherlands

BACKGROUND

Ethnic minority women in Western countries have poorer pregnancy outcomes compared to majority populations, and undocumented women are particularly vulnerable. We intended to assess whether midwives adjust their care if women are undocumented and have no health insurance.

METHODS

A retrospective matched cohort study in primary midwifery care practices in Amsterdam and Rotterdam, the Netherlands. Undocumented, uninsured women (N?=?141) were matched with documented, insured ethnic minority women (N?=?141). Information was extracted from patient records.

RESULTS

Undocumented women attended their first prenatal visit 5 weeks later in their pregnancy and received care elsewhere or disappeared from care more frequently (59.6 versus 34.3%). They frequently have an excess of 110% of the number of expected antenatal visits (32.4% versus 16.9%) and had a preterm birth more frequently (OR 4.59, 95% CI 1.43 to 14.72). Midwives were equally likely to follow referral guidelines in both groups. Undocumented women were more likely to give birth at home (OR 2.14, 95% CI 1.07?4.28) and less likely to receive maternity home care assistance (56.0 versus 79.7%).

CONCLUSION

Although referral guidelines are generally followed by midwives, undocumented women are more at risk of adverse perinatal outcomes and inadequate care than documented ethnic minority women.

Effects of codeine on pregnancy outcome: results from a large population-based cohort study

Background

Guidelines on codeine safety during pregnancy rely on small studies with inconsistent results, and associations between codeine use during pregnancy and increased risk of congenital malformations remain unsubstantiated.

Objectives

Our objective was to analyze the effect of codeine on pregnancy outcome.

Methods

Pregnancy outcomes of 2,666 women who used codeine during pregnancy were compared with 65,316 women who used no opioids during pregnancy. Information on maternal sociodemographic and medical characteristics, potential confounders, and pregnancy outcome was obtained from The Norwegian Mother and Child Cohort Study [den norske Mor & barn-undersøkelsen (MoBa)] data set and the Medical Birth Registry of Norway (MBRN) data set. The data sets were linked via the maternal personal identification number. Associations between codeine therapy and pregnancy outcomes were identified using logistic regression analyses.

Results

No significant differences were found in the survival rate [adjusted odds ratio (OR) 0.9, 95% confidence interval (CI) 0.6–1.5] or the congenital malformation rate (adjusted OR 0.9, 95% CI 0.8–1.1) between codeine-exposed and unexposed infants. Codeine use anytime during pregnancy was associated with planned Cesarean delivery (adjusted OR 1.4, 95% CI 1.2–1.7; P < 0.0001). Third-trimester use was associated with acute Cesarean delivery (adjusted OR 1.5, 95% CI 1.3–1.8; P < 0.0001) and postpartum hemorrhage (adjusted OR 1.3, 95% CI 1.1–1.5; P < 0.0001). No significant associations with other adverse pregnancy outcomes were found.

Conclusions

No effects of maternal codeine intake during pregnancy were observed on infant survival or congenital malformation rate. Our findings are reassuring; however, the association with acute Cesarean delivery and postpartum hemorrhage may justify a certain level of caution when administering codeine toward the end of pregnancy.

Electronic supplementary material

The online version of this article (doi:10.1007/s00228-011-1069-5) contains supplementary material, which is available to authorized users.

In-hospital birth center with the same medical guidelines as standard care: a comparative study of obstetric interventions and outcomes

BACKGROUND

A challenge of obstetric care is to optimize maternal and infant health outcomes and the mother's experience of childbirth with the least possible intervention in the normal process. The aim of this study was to investigate the effects of modified birth center care on obstetric procedures during delivery and on maternal and neonatal outcomes.

METHODS

In a cohort study 2,555 women who signed in for birth center care during pregnancy were compared with all 9,382 low-risk women who gave birth in the standard delivery ward in the same hospital from March 2004 to July 2008. Odds ratios (OR) were calculated with 95% confidence interval (CI) and adjusted for maternal background characteristics, elective cesarean section, and gestational age.

RESULTS

The modified birth center group included fewer emergency cesarean sections (primiparas: OR: 0.69, 95% CI: 0.58-0.83; multiparas: OR: 0.34, 95% CI: 0.23-0.51), and in multiparas the vacuum extraction rate was reduced (OR: 0.42, 95% CI: 0.26-0.67). In addition, epidural analgesia was used less frequently (primiparas: OR: 0.47, 95% CI: 0.41-0.53; multiparas: OR: 0.25, 95% CI: 0.20-0.32). Fetal distress was less frequently diagnosed in the modified birth center group (primiparas: OR: 0.72, 95% CI: 0.59-0.87; multiparas: OR: 0.45, 95% CI: 0.29-0.69), but no statistically significant differences were found in neonatal hypoxia, low Apgar score less than 7 at 5 minutes, or proportion of perinatal deaths (OR: 0.40, 95% CI: 0.14-1.13). Anal sphincter tears were reduced (primiparas: OR: 0.73, 95% CI: 0.55-0.98; multiparas: OR: 0.41, 95% CI: 0.20-0.83).

CONCLUSION

Midwife-led comprehensive care with the same medical guidelines as in standard care reduced medical interventions without jeopardizing maternal and infant health.

A multi-centre cohort study shows no association between experienced violence and labour dystocia in nulliparous women at term

BACKGROUND

Although both labour dystocia and domestic violence during pregnancy are associated with adverse maternal and fetal outcome, evidence in support of a possible association between experiences of domestic violence and labour dystocia is sparse. The aim of this study was to investigate whether self-reported history of violence or experienced violence during pregnancy is associated with increased risk of labour dystocia in nulliparous women at term.

METHODS

A population-based multi-centre cohort study. A self-administrated questionnaire collected at 37 weeks of gestation from nine obstetric departments in Denmark. The total cohort comprised 2652 nulliparous women, among whom 985 (37.1%) met the protocol criteria for dystocia.

RESULTS

Among the total cohort, 940 (35.4%) women reported experience of violence, and among these, 66 (2.5%) women reported exposure to violence during their first pregnancy. Further, 39.5% (n = 26) of those had never been exposed to violence before. Univariate logistic regression analysis showed no association between history of violence or experienced violence during pregnancy and labour dystocia at term, crude OR 0.91, 95% CI (0.77-1.08), OR 0.90, 95% CI (0.54-1.50), respectively. However, violence exposed women consuming alcoholic beverages during late pregnancy had increased odds of labour dystocia, crude OR 1.45, 95% CI (1.07-1.96).

CONCLUSIONS

Our findings indicate that nulliparous women who have a history of violence or experienced violence during pregnancy do not appear to have a higher risk of labour dystocia at term, according to the definition of labour dystocia in this study. Additional research on this topic would be beneficial, including further evaluation of the criteria for labour dystocia.