Progression of the first stage of spontaneous labour: A prospective cohort study in two sub-Saharan African countries

Labour monitoring and decision support: a machine-learning-based paradigm

Introduction

A machine-learning-based paradigm, combining unsupervised and supervised components, is proposed for the problem of real-time monitoring and decision support during labour, addressing the limitations of current state-of-the-art approaches, such as the partograph or purely supervised models.

Methods

The proposed approach is illustrated with World Health Organisation's Better Outcomes in Labour Difficulty (BOLD) prospective cohort study data, including 9,995 women admitted for labour in 2014-2015 in thirteen major regional health care facilities across Nigeria and Uganda. Unsupervised dimensionality reduction is used to map complex labour data to a visually intuitive space. In this space, an ongoing labour trajectory can be compared to those of a historical cohort of women with similar characteristics and known outcomes-this information can be used to estimate personalised "healthy" trajectory references (and alert the healthcare provider to significant deviations), as well as draw attention to high incidences of different interventions/adverse outcomes among similar labours. To evaluate the proposed approach, the predictive value of simple risk scores quantifying deviation from normal progress and incidence of complications among similar labours is assessed in a caesarean section prediction context and compared to that of the partograph and state-of-the-art supervised machine-learning models.

Results

Considering all women, our predictors yielded sensitivity and specificity of ∼0.70. It was observed that this predictive performance could increase or decrease when looking at different subgroups.

Discussion

With a simple implementation, our approach outperforms the partograph and matches the performance of state-of-the-art supervised models, while offering superior flexibility and interpretability as a real-time monitoring and decision-support solution.

Can the use of a next generation partograph based on WHO's latest intrapartum care recommendations improve neonatal outcomes? (PICRINO) Study protocol for a stepped-wedge cluster randomized trial

BACKGROUND

Monitoring labor and childbirth, early recognition, and treatment of complications are critical for preventing adverse birth outcomes. However excessive use of interventions during labor has not been demonstrated to enhance subsequent birth outcomes and may, in fact, pose a risk of harm. The World Health Organization has recently synthesized research from the last decade concerning labor progress and patient-centered care into a new recommendation: the Labour Care Guide (LCG). No trial has, however, compared the LCG with standard care regarding adverse neonatal outcomes or the degree of safety associated with implementing this recommendation within a high-resource setting, and its potential to enhance birth outcomes remains undetermined.

AIM AND HYPOTHESIS

This trial aims to evaluate the impacts of using two different guidelines for monitoring labor with respect to neonatal and maternal outcomes, the LCG and the currently used standard care guideline. The hypothesis is that use of the LCG will reduce the number of adverse neonatal outcomes and decrease the rate of intrapartum cesarean sections, as compared with standard care.

MATERIALS AND METHODS

A national, multicenter, stepped-wedge cluster randomized controlled trial that includes 24 Swedish maternity wards randomized to six clusters. The trial is planned to run during a 22 month period in 2023-2025 and the intervention LCG will be implemented in the six clusters, with three months intervals. The recruited wards will together have approximatively 100,000 births during the study period. Outcome data will be extracted from the Swedish national pregnancy, neonatal, and patient registers. Two safety analyses will be performed at one-third and two-thirds of the way through the trial.

DISCUSSION

The LCG offers a promising new approach, but its effectiveness and safety in high resource settings remain unexplored and must be studied further before LCG can be fully implemented in settings with similar health care.

TRIAL REGISTRATION

The trial has been registered at www.clinicaltrials.gov: NCT05560802.

How does place impact intrapartum practice for midwives and obstetricians?

BACKGROUND

Rising rates of labour and birth interventions are causing concern, having the potential to cause harm if used inappropriately. International evidence demonstrates that place itself influences birth outcomes, but evidence is limited as to how. In New Zealand there are differences in the rates of spontaneous vaginal births by place, along with differences when benchmarking uncomplicated primiparae birthing in hospital maternity facilities throughout the country.

AIM

To develop understanding of how place influenced midwives' and obstetricians' practice in relation to supporting physiological birth.

METHOD

For this Hermeneutic Phenomenological study participants were purposively selected and consisted of nine midwives (employed and self-employed) and three obstetricians, all practising in midwifery led units or hospital maternity facilities. Data was collected using semi-structured interviews. The method of analysis involved writing and rewriting to surface interpretive insights, drawing on philosophical notions from Heidegger and Gadamer.

FINDINGS

The findings revealed that place influences what practitioners are attuned to, what is easier for them to achieve, and their ability to provide woman-centred care. Competing tensions and pressures within place can blur the perceived relationship between normality and risk, influencing what is considered to be safe.

SUMMARY

Place is not neutral; it influences how midwives and obstetricians practise and shapes how they support physiological labour and birth. The findings of this research contribute to a deeper understanding of the barriers and enablers to supporting physiological birth within place.

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.

Improving management of first and second stages of labour in low- and middle-income countries

Labour care must balance aspirations of parents with vigilance for unanticipated calamities. The 'on-site midwife-led primary care birth unit' facilitates this. The World Health Organization have replaced the traditional partograph with the 'Labour Care Guide'. An implementation project in Botswana included the mnemonic COPE: Companion, Oral fluids, Pain relief and Eliminate the supine position. The Parto-Ma project in Tanzania used guidelines, training and support to improve childbirth outcomes. We list labour practices supported by recent evidence, and highlight new developments. Foetal macrosomia increases risk but mistaken diagnosis increases caesarean births. Obstructed labour is a complex clinical diagnosis, and is difficult to predict. For shoulder dystocia prioritise delivery of the posterior shoulder, facilitated if needed by posterior axilla sling traction. 'Extended balloon labour induction' with two or three Foley catheters side by side, may reduce risks associated with uterine stimulants. Bedside ultrasound may facilitate the diagnosis of cephalic malpositions and malpresentations.

New labor curves of dilation and station to improve the accuracy of predicting labor progress

BACKGROUND

The diagnosis of failure to progress, the most common indication for intrapartum cesarean delivery, is based on the assessment of cervical dilation and station over time. Labor curves serve as references for expected changes in dilation and fetal descent. The labor curves of Friedman, Zhang et al, and others are based on time alone and derived from mothers with spontaneous labor onset. However, labor induction is now common, and clinicians also consider other factors when assessing labor progress. Labor curves that consider the use of labor induction and other factors that influence labor progress have the potential to be more accurate and closer to clinical decision-making.

OBJECTIVE

This study aimed to compare the prediction errors of labor curves based on a single factor (time) or multiple clinically relevant factors using two modeling methods: mixed-effects regression, a standard statistical method, and Gaussian processes, a machine learning method.

STUDY DESIGN

This was a longitudinal cohort study of changes in dilation and station based on data from 8022 births in nulliparous women with a live, singleton, vertex-presenting fetus ≥35 weeks of gestation with a vaginal delivery. New labor curves of dilation and station were generated with 10-fold cross-validation. External validation was performed using a geographically independent group. Model variables included time from the first examination in the 20 hours before delivery; dilation, effacement, and station recorded at the previous examination; cumulative contraction counts; and use of epidural anesthesia and labor induction. To assess model accuracy, differences between each model's predicted value and its corresponding observed value were calculated. These prediction errors were summarized using mean absolute error and root mean squared error statistics.

RESULTS

Dilation curves based on multiple parameters were more accurate than those derived from time alone. The mean absolute error of the multifactor methods was better (lower) than those of the single-factor methods (0.826 cm [95% confidence interval, 0.820-0.832] for the multifactor machine learning and 0.893 cm [95% confidence interval, 0.885-0.901] for the multifactor mixed-effects method and 2.122 cm [95% confidence interval, 2.108-2.136] for the single-factor methods; P<.0001 for both comparisons). The root mean squared errors of the multifactor methods were also better (lower) than those of the single-factor methods (1.126 cm [95% confidence interval, 1.118-1.133] for the machine learning [P<.0001] and 1.172 cm [95% confidence interval, 1.164-1.181] for the mixed-effects methods and 2.504 cm [95% confidence interval, 2.487-2.521] for the single-factor [P<.0001 for both comparisons]). The multifactor machine learning dilation models showed small but statistically significant improvements in accuracy compared to the mixed-effects regression models (P<.0001). The multifactor machine learning method produced a curve of descent with a mean absolute error of 0.512 cm (95% confidence interval, 0.509-0.515) and a root mean squared error of 0.660 cm (95% confidence interval, 0.655-0.666). External validation using independent data produced similar findings.

CONCLUSION

Cervical dilation models based on multiple clinically relevant parameters showed improved (lower) prediction errors compared to models based on time alone. The mean prediction errors were reduced by more than 50%. A more accurate assessment of departure from expected dilation and station may help clinicians optimize intrapartum management.

A model to predict delivery time following induction of labor at term with a dinoprostone vaginal insert: a retrospective study

BACKGROUND

Dinoprostone vaginal insert is the most common pharmacological method for induction of labor (IOL); however, studies on assessing the time to vaginal delivery (DT) following dinoprostone administration are limited.

AIMS

We sought to identify the primary factors influencing DT in women from central China, at or beyond term, who underwent IOL with dinoprostone vaginal inserts.

METHODS

In this retrospective observational study, we analyzed the data of 1562 women at 37 weeks 0 days to 41 weeks 6 days of gestation who underwent dinoprostone-induced labor between January 1st, 2019, and December 31st, 2021. The outcomes of interest were vaginal or cesarean delivery and factors influencing DT, including maternal complications and neonatal characteristics.

RESULTS

Among the enrolled women, 71% (1109/1562) delivered vaginally, with median DT of 740.50 min (interquartile range 443.25 to 1264.50 min). Of the remaining 29% (453/1562), who delivered by cesarean section, 11.9% (54/453) were multiparous. Multiple linear regression analysis showed that multiparity, advanced maternal age, fetal macrosomia, premature rupture of membranes (PROM), and daytime insertion of dinoprostone were the factors that significantly influenced DT. Time to vaginal delivery increased with advanced maternal age and fetal macrosomia and decreased with multiparity, PROM, and daytime insertion of dinoprostone. A mathematical model was developed to integrate these factors for predicting DT: Y = 804.478 - 125.284 × multiparity + 765.637 × advanced maternal age + 411.511 × fetal macrosomia-593.358 × daytime insertion of dinoprostone - 125.284 × PROM.

CONCLUSIONS

Our findings may help obstetricians estimate the DT before placing a dinoprostone insert, which may improve patient management in busy maternity wards and minimize potential risks.

Duration of the active first stage of labour and severe perineal lacerations and maternal postpartum complications: a population-based cohort study

OBJECTIVE

The impact of first stage labour duration on maternal outcomes is sparsely investigated. We aimed to study the association between a longer active first stage and maternal complications in the early postpartum period.

DESIGN

A population-based cohort study.

SETTING

Regions of Stockholm and Gotland, Sweden, 2008-2020.

POPULATION

A cohort of 159 459 term, singleton, vertex pregnancies, stratified by parity groups.

METHODS

The exposure was active first stage duration, categorised in percentiles. Poisson regression analysis was performed to estimate the adjusted relative risk (aRR) and the 95% confidence interval (95% CI). To investigate the effect of second stage duration on the outcome, mediation analysis was performed.

MAIN OUTCOME MEASURES

Severe perineal lacerations (third or fourth degree), postpartum infection, urinary retention and haematoma in the birth canal or ruptured sutures.

RESULTS

The risks of severe perineal laceration, postpartum infection and urinary retention increased with a longer active first stage, both overall and stratified by parity group. The aRR increased with a longer active first stage, using duration of <50th percentile as the reference. In the ≥90th percentile category, the aRR for postpartum infection was 1.64 (95% CI 1.46-1.84) in primiparous women, 2.43 (95% CI 1.98-2.98) in parous women with no previous caesarean delivery (CD) and 2.33 (95% CI 1.65-3.28) in parous women with a previous CD. The proportion mediated by second stage duration was 33.4% to 36.9% for the different outcomes in primiparous women. The risk of haematoma or ruptured sutures did not increased with a longer active first stage.

CONCLUSIONS

Increasing active first stage duration is associated with maternal complications in the early postpartum period.

Effect of implementation of the WHO intrapartum care model on maternal and neonatal outcomes: a randomized control trial

BACKGROUND

In 2018, the World Health Organization published a set of recommendations for further emphasis on the quality of intrapartum care to improve the childbirth experience. This study aimed to determine the effects of the WHO intrapartum care model on the childbirth experience, fear of childbirth, the quality of intrapartum care (primary outcomes), as well as post-traumatic stress disorder symptoms, postpartum depression, the duration of childbirth stages, the frequency of vaginal childbirth, Apgar score less than 7, desire for subsequent childbearing, and exclusive breastfeeding in the 4 to 6 weeks postpartum period (secondary outcomes).

METHODS

This study was a randomized controlled trial involving 108 pregnant women admitted to the maternity units of Al-Zahra and Taleghani hospitals in Tabriz-Iran. Participants were allocated to either the intervention group, which received care according to the ' 'intrapartum care model, or the control group, which received the' 'hospital's routine care, using the blocked randomization method. A Partograph chart was drawn for each participant during pregnancy. A delivery fear scale was completed by all participants both before the beginning of the active phase (pre-intervention) and during 7 to 8 cm dilation (post-intervention). Participants in both groups were followed up for 4 to 6 weeks after childbirth and were asked to complete questionnaires on childbirth experience, postpartum depression, and post-traumatic stress disorder symptoms, as well as the pregnancy and childbirth questionnaire and checklists on the desire to have children again and exclusive breastfeeding. The data were analyzed using independent T and Mann-Whitney U tests and analysis of covariance ANCOVA with adjustments for the parity variable and the baseline scores or childbirth fear.

RESULTS

The average score for the childbirth experience total was notably higher in the intervention group (Adjusted Mean Difference (AMD) (95% Confidence Interval (CI)): 7.0 (0.6 to 0.8), p < 0.001). Similarly, the intrapartum care quality score exhibited a significant increase in the intervention group (AMD (95% CI): 7.0 (4.0 to 10), p < 0.001). Furthermore, the post-intervention fear of childbirth score demonstrated a substantial decrease in the intervention group (AMD (95% CI): -16.0 (-22.0 to -10.0), p < 0.001). No statistically significant differences were observed between the two groups in terms of mean scores for depression, PTSD symptoms, duration of childbirth stages, frequency of vaginal childbirth, Apgar score less than 7, and exclusive breastfeeding in the 4 to 6 weeks postpartum (p > 0.05).

CONCLUSION

The intrapartum care model endorsed by the World Health Organization (WHO) has demonstrated effectiveness in enhancing childbirth experiences and increasing maternal satisfaction with the quality of obstetric care. Additionally, it contributes to the reduction of fear associated with labor and childbirth. Future research endeavors should explore strategies to prioritize and integrate respectful, high-quality care during labor and childbirth alongside clinical measures.

Intrapartum time intervals and transfer of nulliparae from community births to maternity care units in Germany

BACKGROUND

Over one-third of nulliparae planning births either at home or in freestanding midwife-led birthing centers (community births) in high-income countries are transferred during labor. Perinatal data are reported each year in Germany for women planning community birth. So far, data sets have not been linked to describe time-related factors associated with nulliparous transfer to hospital.

OBJECTIVES

To describe the prevalence of referral for nulliparae and assess maternal and labor characteristics associated with intrapartum transfer.

METHODS

Perinatal data from 2010 to 2015 were linked (n = 26,115). Women were reviewed with respect to international eligibility criteria for community birth; 1997 women were excluded (7.6%). Descriptive statistics were reported; unadjusted and adjusted odds ratios with 95% confidence intervals (CI) tested the predictive effect of demographic and labor factors on rates of intrapartum transfer.

RESULTS

One in three nulliparous women (30.6%) were transferred to hospital. Compared with community births, transferred women were significantly more likely to experience longer time intervals during labor: from rupture of membranes (ROM) until birth lasting 5 to 18 h (OR 6.05, CI 5.53-6.61) and 19 to 24 h (OR 10.83, CI 9.45-12.41) compared to one to 4 h; and from onset of labor until birth 11 to 24 h (OR 6.72, CI 6.24-7.23) and 25 to 29 h (OR 26.62, CI 22.77-31.11) compared to one to 10 h. When entering all factors into the model, we found the strongest predictors of transfer to be fetal distress, longer time intervals between ROM until birth and onset of labor until birth.

CONCLUSIONS

Nulliparous transfer rates were similar to rates in other high-income countries; 94% of referrals were non-urgent. Time was found to be an independent risk factor for the transfer of nulliparae planning community birth.

Efficacy of midwife-led role orientation of birth companions on maternal satisfaction and birth outcomes: a randomized control trial in Uganda

BACKGROUND

The World Health Organization recommends birth companionship for all women in labor. There is insufficient evidence on birth companionship in low-income settings and it is not clear if role orientation impacts effectiveness. The aim of this study was to assess the efficacy of midwife-led role orientation of birth companions of on maternal satisfaction and birth outcomes in a sub-region in Uganda.

METHODS

A stepped wedge cluster randomized trial conducted (control n = 240), intervention n = 235) from 4 clusters. Women who had a birth companion, in spontaneously established labor and, expecting a vaginal delivery were eligible. The intervention was "midwife-provided orientation of birth companions". The admitting midwife provided an orientation session for the birth companion on supportive labor techniques. The primary outcome was the chance of having a spontaneous vaginal delivery. Assessors were not blinded. Independent t-test and Chi-Square tests were used to assess the differences by study period.

RESULTS

Mean maternal satisfaction rate was significantly higher in the intervention period compared to the control period (P > 0.001). High maternal satisfaction levels were noted among the women who were; at the regional referral hospital, younger, first-time mothers, and unmarried (P < 0.001). Satisfaction with pain management was rated lowest across study periods. Satisfaction with humaneness was rated highest with a higher score in the intervention period (93%) than the control (79.5%). There were no statistically significant differences in the mode of delivery, need to augment labor, length of labor and Apgar scores.

CONCLUSION

Midwife-led role orientation of birth companions increased maternal satisfaction. Nevertheless, no significant effect was noted in the mode of delivery, length of labor, Apgar score, and need to augment labor. Findings could inform the integration of birth companions in the admission process of the woman in labor in similar settings.

TRIAL REGISTRATION NUMBER

NCT04771325.

Association between Parity and Preterm Birth-Retrospective Analysis from a Single Center in Poland

Preterm births and parity are two medical areas that seem to be entirely different from each other. The aim of this study was to analyze the relationships between parity and maternal and neonatal outcomes associated with preterm birth. This study involved a retrospective analysis of electronic medical records from St. Sophia Hospital in Warsaw (Poland). This study was conducted among women who gave birth to preterm infants between 1 January 2017 and 31 December 2021. A total of 2043 cases of preterm births were included in the final analysis. A higher odds ratio of preterm birth in primiparas was found in women living in a city/town (OR = 1.56) and having secondary (OR = 1.46) and higher education (OR = 1.82). Multiparas who gave birth to preterm infants were more frequently diagnosed with gestational diabetes (19.69%) than primiparas. Multiparas were more likely to give birth to preterm infants who received an Apgar score of ≤7 both at 1 and 5 min after birth (25.80% and 15.34%). The results of our study emphasize the differences between primiparas and multiparas who give birth to preterm infants. Knowledge of these differences is essential to improve the perinatal care provided to mothers and their infants.

New insights on labor progression: a systematic review

The past 20 years witnessed an invigoration of research on labor progression and a change of thinking regarding normal labor. New evidence is emerging, and more advanced statistical methods are applied to labor progression analyses. Given the wide variations in the onset of active labor and the pattern of labor progression, there is an emerging consensus that the definition of abnormal labor may not be related to an idealized or average labor curve. Alternative approaches to guide labor management have been proposed; for example, using an upper limit of a distribution of labor duration to define abnormally slow labor. Nonetheless, the methods of labor assessment are still primitive and subject to error; more objective measures and more advanced instruments are needed to identify the onset of active labor, monitor labor progression, and define when labor duration is associated with maternal/child risk. Cervical dilation alone may be insufficient to define active labor, and incorporating more physical and biochemical measures may improve accuracy of diagnosing active labor onset and progression. Because the association between duration of labor and perinatal outcomes is rather complex and influenced by various underlying and iatrogenic conditions, future research must carefully explore how to integrate statistical cut-points with clinical outcomes to reach a practical definition of labor abnormalities. Finally, research regarding the complex labor process may benefit from new approaches, such as machine learning technologies and artificial intelligence to improve the predictability of successful vaginal delivery with normal perinatal outcomes.

The evolution of the labor curve and its implications for clinical practice: the relationship between cervical dilation, station, and time during labor

The assessment of labor progress is germane to every woman in labor. Two labor disorders-arrest of dilation and arrest of descent-are the primary indications for surgery in close to 50% of all intrapartum cesarean deliveries and are often contributing indications for cesarean deliveries for fetal heart rate abnormalities. Beginning in 1954, the assessment of labor progress was transformed by Friedman. He published a series of seminal works describing the relationship between cervical dilation, station of the presenting part, and time. He proposed nomenclature for the classification of labor disorders. Generations of obstetricians used this terminology and normal labor curves to determine expected rates of dilation and fetal descent and to decide when intervention was required. The analysis of labor progress presents many mathematical challenges. Clinical measurements of dilation and station are imprecise and prone to variation, especially for inexperienced observers. Many interrelated factors influence how the cervix dilates and how the fetus descends. There is substantial variability in when data collection begins and in the frequency of examinations. Statistical methods to account for these issues have advanced considerably in recent decades. In parallel, there is growing recognition among clinicians of the limitations of using time alone to assess progress in cervical dilation in labor. There is wide variation in the patterns of dilation over time and most labors do not follow an average dilation curve. Reliable assessment of labor progression is important because uncertainty leads to both over-use and under-use of cesarean delivery and neither of these extremes are desirable. This review traces the evolution of labor curves, describes how limitations are being addressed to reduce uncertainty and to improve the assessment of labor progression using modern statistical techniques and multi-dimensional data, and discusses the implications for obstetrical practice.

The sonopartogram

The assessment of labor progress from digital vaginal examination has remained largely unchanged for at least a century, despite the current major advances in maternal and perinatal care. Although inconsistently reproducible, the findings from digital vaginal examination are customarily plotted manually on a partogram, which is composed of a graphical representation of labor, together with maternal and fetal observations. The partogram has been developed to aid recognition of failure to labor progress and guide management-specific obstetrical intervention. In the last decade, the use of ultrasound in the delivery room has increased with the advent of more powerful, portable ultrasound machines that have become more readily available for use. Although ultrasound in intrapartum practice is predominantly used for acute management, an ultrasound-based partogram, a sonopartogram, might represent an objective tool for the graphical representation of labor. Demonstrating greater accuracy for fetal head position and more objectivity in the assessment of fetal head station, it could be considered complementary to traditional clinical assessment. The development of the sonopartogram concept would require further undertaking of serial measurements. Advocates of ultrasound will concede that its use has yet to demonstrate a difference in obstetrical and neonatal morbidity in the context of the management of labor and delivery. Taking a step beyond the descriptive graphical representation of labor progress is the question of whether a specific combination of clinical and demographic parameters might be used to inform knowledge of labor outcomes. Intrapartum cesarean deliveries and deliveries assisted by forceps and vacuum are all associated with a heightened risk of maternal and perinatal adverse outcomes. Although these outcomes cannot be precisely predicted, many known risk factors exist. Malposition and high station of the fetal head, short maternal stature, and other factors, such as caput succedaneum, are all implicated in operative delivery; however, the contribution of individual parameters based on clinical and ultrasound assessments has not been quantified. Individualized risk prediction models, including maternal characteristics and ultrasound findings, are increasingly used in women's health-for example, in preeclampsia or trisomy screening. Similarly, intrapartum cesarean delivery models have been developed with good prognostic ability in specifically selected populations. For intrapartum ultrasound to be of prognostic value, robust, externally validated prediction models for labor outcome would inform delivery management and allow shared decision-making with parents.

Comparing compliance with commencement and use of two partograph designs for women in active labour: A randomised controlled trial

BACKGROUND

Documentation and assessment of progress in labour using a partograph is recommended by the World Health Organisation to assist in the timely recognition of labour dystocia. Recent studies have tested new designs of partographs that aim to account for more variable rates of labour progress. However, other studies have suggested that poor compliance in the completion of partographs affects utility. The objective of this study was to compare two types of partographs for compliance in documentation and use for managing labour.

METHODS

Low-risk nulliparous women in spontaneous labour (n = 228) were randomised to either an Action Line (control) (n = 114) or Dystocia Line partograph (intervention) (n = 114). Primary outcome was compliance with instructions for commencement of the partograph following a multifaceted training strategy. Secondary outcomes included compliance with the accompanying clinical management protocol for each partograph; and labour and birth outcomes.

RESULTS

The compliance rate for commencing the Action line partograph was 43.2% compared to 67.0% (p = 0.02) for the Dystocia line partograph. Other than a reduction in artificial rupture of membranes in the Dystocia Line group there were no other differences in labour management or birth outcomes. The use of centralised electronic display of labour progress may be a contributing factor.

CONCLUSIONS

Compliance with the commencement and use of either partograph was low. There was little indication that the partograph was being utilized in the assessment and management of prolonged labour. Further studies are needed to explore the current utility of partographs in labour management and the effect of centralised monitoring of progress in high resource settings.

Cervical change times during induction in nulliparas using vaginal or buccal misoprostol

AIM

To determine if the time to cervical change and time to active labor were different when misoprostol was administered by a vaginal or buccal route for cervical ripening in nulliparas undergoing labor induction at term.

METHODS

This was a secondary analysis of nulliparous participants in the IMPROVE Study-A comparison of vaginal versus buccal misoprostol for cervical ripening for labor induction at term: a triple-masked randomized controlled trial (NCT02408315). The parent study was a non-inferiority randomized controlled trial in which patients beginning induction with a modified Bishop score ≤6 received either vaginal or buccal misoprostol and simultaneous placebo via the opposite route. The primary outcome of the parent study was time to delivery. Primary outcomes for this secondary analysis were the time to active labor (at least 6 cm dilated) and time to change in cervical dilation. Kaplan-Meier analysis was used to compare routes for time to active labor and multistate Markov modeling was used to compare sojourn times at each cervical dilation.

RESULTS

Of the 300 participants enrolled in the parent trial, 124 (41.3%) were nulliparous; 59 (47.6%) nulliparous participants underwent induction with vaginal misoprostol and 65 (52.4%) received buccal dosing. Nulliparas receiving vaginal dosing required fewer doses of misoprostol to reach active labor (median 2 vs 3, p = .003). However, this did not result in shorter time to active labor (median vaginal 23.1 h, 95% CI = [21.6, 27.2 h]; buccal 25.6 h [21.5, 29.3 h], p = .45) or higher rate of vaginal delivery within 24 h; (33.9% vs 35.4%, p = .86). There was also no significant difference in time to active labor after adjusting for covariates (adjusted HR for dose route (buccal vs vaginal) = 0.91 [0.61, 1.36], p = .649). Among people that delivered vaginally, the mean sojourn times, measuring cervical dilation state change, were not significantly different, with mean duration to active labor of 20.5 [17.6, 24.5] h for buccal and 21.8 [17.7, 28.2] h for vaginal dosing (p = .092). Satisfaction and preference for dosing routes were not different between groups.

CONCLUSION

Buccal and vaginal dosing of misoprostol for cervical ripening in nulliparas appear to have similar times to active labor and progression of cervical change during ripening.

Advancement in Partograph: WHO's Labor Care Guide

Worldwide, the partograph, also known as a partogram, is used as a labor monitoring tool to detect difficulties early, allowing for referral, intervention, or closer observations to follow. Despite widespread support from health experts, there are worries that the partograph has not yet fully realized its potential for enhancing therapeutic results. As a result, the instrument has undergone several changes, and numerous studies have been conducted to examine the obstacles and enablers to its use. Nevertheless, the partograph was widely embraced and has been a component of evaluating labor progress. Earlier it was also used as a standard method for monitoring labor progress. Even though it is widely used, there have been reports of usage and accurate execution rates. The WHO Labor Care Guide (LCG) was created so that medical professionals could keep an eye on the health of pregnant women and their unborn children during labor by conducting routine evaluations to spot any abnormalities. The tool intends to enhance women-centered care and encourage collaborative decision-making between women and healthcare professionals. The LCG is designed to be a tool for ensuring high-quality research centered on health, reducing pointless measures, and offering comfort measures.

Prevalence of amniotomy in Sweden: a nationwide register study

BACKGROUND

Amniotomy is a commonly used labor intervention with uncertain evidence, and there are complications connected to the intervention. Yet, the Swedish prevalence of amniotomy is unknown. The aim of the study was therefore to describe the prevalence of amniotomy in Sweden.

METHODS

This nationwide register-based study included 330,913 women giving birth in 2017-2020. Data were collected from the Swedish Pregnancy Register in which the majority of data is collected via direct transfer from medical records. Prevalence of amniotomy was described for all births, for nulliparous and multiparous women with spontaneous onset of labour, and at the hospital level. Descriptive statistics and chi-square test were used to analyse the data.

RESULTS

For all births, the prevalence of amniotomy was 40.6%. More amniotomies were performed in Robson group 1 compared to Robson group 3; 41.1% vs 32.3% (p < 0.001). The prevalence for all births remained the same during the study period; however, a decrease from 37.5 to 34.1%, was seen in Robson group 1 and Robson group 3 (p < 0.001). Variations in the prevalence between hospitals were reported. The hospitals with the fewest number of births annually had the highest prevalence of amniotomy (45.0%), and the lowest prevalence was reported at the University hospitals (40.4%) (p < 0.001).

CONCLUSIONS

Amniotomy is a common labor intervention in Sweden, given that almost half of the laboring women underwent the intervention. Our results, regarding variations in the prevalence between hospitals, could imply a potential for fewer amniotomies in Swedish childbirth care.

The duration of spontaneous active and pushing phases of labour among 75,243 US women when intervention is minimal: A prospective, observational cohort study

BACKGROUND

Friedman's curve, despite acknowledged limitations, has greatly influenced labour management. Interventions to hasten birth are now ubiquitous, challenging the contemporary study of normal labour. Our primary purpose was to characterise normal active labour and pushing durations in a large, contemporary sample experiencing minimal intervention, stratified by parity, age, and body mass index (BMI).

METHODS

This is a secondary analysis of the national, validated Midwives Alliance of North America 4·0 (MANA Stats) data registry (n = 75,243), prospectively collected between Jan 1, 2012 and Dec 31, 2018 to describe labour and birth in home and birth center settings where common obstetric interventions [i.e., oxytocin, planned cesarean] are not available. The MANA Stats cohort includes pregnant people who intended birth in these settings and prospectively collects labour and birth processes and outcomes regardless of where birth or postpartum care ultimately occurs. Survival curves were calculated to estimate labour duration percentiles (e.g. 10th, 50th, 90th, and others of interest), by parity and sub-stratified by age and BMI.

FINDINGS

Compared to multiparous women (n = 32,882), nulliparous women (n = 15,331) had significantly longer active labour [e.g., median 7.5 vs. 3.3 h; 95th percentile 34.8 vs. 12.0 h] and significantly longer pushing phase [e.g., median 1.1 vs. 0.2 h; 95th percentile 5.5 vs. 1.1 h]. Among nulliparous women, maternal age >35 was associated with longer active first stage of labour and longer pushing phase, and BMI >30 kg/m² was associated with a longer active first stage of labour but a shorter pushing phase. Patterns among multiparous women were different, with those >35 years of age experiencing a slightly more rapid active labour and no difference in pushing duration, and those with BMI >30 kg/m² experiencing a slightly longer active labour but, similarly, no difference in pushing duration.

INTERPRETATION

Nulliparous women had significantly longer active first stage and pushing phase durations than multiparous women, with further variation noted by age and by BMI. Contemporary US women with low-risk pregnancies who intended birth in settings absent common obstetric interventions and in spontaneous labour with a live, vertex, term, singleton, non-anomalous fetus experienced labour durations that were often longer than prior characterizations, particularly among nulliparous women. Results overcome prior and current sampling limitations to refine understanding of normal labour durations and time thresholds signaling 'labour dystocia'.

FUNDING

OHSU Nursing Innovation and OHSU University Shared Resources.

Association between first and second stage of labour duration and mode of delivery: A population-based cohort study

BACKGROUND

Active first stage of labour duration can widely vary between women. However, the nature of the relationship between the active first stage and second stage of labour duration is sparsely studied.

OBJECTIVES

To determine whether active first stage of labour duration (i) influences second stage of labour duration; and (ii) is associated with mode of delivery.

METHODS

A population-based cohort study of 13,379 women primiparous women, with spontaneous start in Stockholm-Gotland Region, Sweden, between 2008 and 2014. Duration of the active first stage of labour was examined in relation to second-stage duration using univariate and multivariable quantile regressions, with the first quartile (first stage duration) as the reference. Nonlinearity of associations was tested by restricted cubic splines. Association between active first-stage duration with mode of delivery was estimated using a multinomial logistic regression based on adjusted odds ratios.

RESULTS

Longer active first stage of labour duration was linearly associated with longer second stage of labour duration until approximately 12 h of active first stage of labour duration. After 12 h, a non-linear trend is seen, demonstrated by a plateau in the second-stage duration. In addition, longer active first stage of labour duration was associated with increased occurrence of operative vaginal delivery (adjusted odds ratio 3.36, 95% confidence interval [CI] 2.89, 3.89) and caesarean delivery (adjusted odds ratio 4.75, 95% CI 3.85, 5.80).

CONCLUSIONS

Among primiparous women with spontaneous onset of labour, longer active first stage of labour duration was associated with both longer second stage of labour duration and higher odds of operative delivery. This study contributes with findings, which may inform future discussions regarding how to properly account for second-stage duration, with applications in obstetric and perinatal epidemiology.

Routine vaginal examinations compared to other methods for assessing progress of labour to improve outcomes for women and babies at term

BACKGROUND

Routine vaginal examinations are undertaken at regular time intervals during labour to assess whether labour is progressing as expected. Unusually slow progress can be due to underlying problems, described as labour dystocia, or can be a normal variation of progress. Evidence suggests that if mother and baby are well, length of labour alone should not be used to decide whether labour is progressing normally. Other methods to assess labour progress include intrapartum ultrasound and monitoring external physical and behavioural cues. Vaginal examinations can be distressing for women, and overdiagnosis of dystocia can result in iatrogenic morbidity due to unnecessary intervention. It is important to establish whether routine vaginal examinations are effective, both as an accurate measure of physiological labour progress and to distinguish true labour dystocia, or whether other methods for assessing labour progress are more effective. This Cochrane Review is an update of a review first published in 2013.

OBJECTIVES

To compare the effectiveness, acceptability, and consequences of routine vaginal examinations compared with other methods, or different timings, to assess labour progress at term.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, and conference proceedings) and ClinicalTrials.gov (28 February 2021). We also searched the reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of vaginal examinations compared with other methods of assessing labour progress and studies assessing different timings of vaginal examinations. Quasi-RCTs and cluster-RCTs were eligible for inclusion. We excluded cross-over trials and conference abstracts.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all studies identified by the search for inclusion in the review. Four review authors independently extracted data. Two review authors assessed risk of bias and certainty of the evidence using GRADE.

MAIN RESULTS

We included four studies that randomised a total of 755 women, with data analysed for 744 women and their babies. Interventions used to assess labour progress were routine vaginal examinations, routine ultrasound assessments, routine rectal examinations, routine vaginal examinations at different frequencies, and vaginal examinations as indicated. We were unable to conduct meta-analysis as there was only one study for each comparison.  All studies were at high risk of performance bias due to difficulties with blinding. We assessed two studies as high risk of bias and two as low or unclear risk of bias for other domains. The overall certainty of the evidence assessed using GRADE was low or very low.  Routine vaginal examinations versus routine ultrasound to assess labour progress (one study, 83 women and babies) Study in Turkey involving multiparous women with spontaneous onset of labour. Routine vaginal examinations may result in a slight increase in pain compared to routine ultrasound (mean difference -1.29, 95% confidence interval (CI) -2.10 to -0.48; one study, 83 women, low certainty evidence) (pain measured using a visual analogue scale (VAS) in reverse: zero indicating 'worst pain', 10 indicating no pain). The study did not assess our other primary outcomes: positive birth experience; augmentation of labour; spontaneous vaginal birth; chorioamnionitis; neonatal infection; admission to neonatal intensive care unit (NICU). Routine vaginal examinations versus routine rectal examinations to assess labour progress (one study, 307 women and babies) Study in Ireland involving women in labour at term. We assessed the certainty of the evidence as very low. Compared with routine rectal examinations, routine vaginal examinations may have little or no effect on: augmentation of labour (risk ratio (RR) 1.03, 95% CI 0.63 to 1.68; one study, 307 women); and spontaneous vaginal birth (RR 0.98, 95% CI 0.90 to 1.06; one study, 307 women). We found insufficient data to fully assess: neonatal infections (RR 0.33, 95% CI 0.01 to 8.07; one study, 307 babies); and admission to NICU (RR 1.32, 95% CI 0.47 to 3.73; one study, 307 babies). The study did not assess our other primary outcomes: positive birth experience; chorioamnionitis; maternal pain. Routine four-hourly vaginal examinations versus routine two-hourly examinations (one study, 150 women and babies) UK study involving primiparous women in labour at term. We assessed the certainty of the evidence as very low. Compared with routine two-hourly vaginal examinations, routine four-hourly vaginal examinations may have little or no effect, with data compatible with both benefit and harm, on: augmentation of labour (RR 0.97, 95% CI 0.60 to 1.57; one study, 109 women); and spontaneous vaginal birth (RR 1.02, 95% CI 0.83 to 1.26; one study, 150 women). The study did not assess our other primary outcomes: positive birth experience; chorioamnionitis; neonatal infection; admission to NICU; maternal pain. Routine vaginal examinations versus vaginal examinations as indicated (one study, 204 women and babies)  Study in Malaysia involving primiparous women being induced at term. We assessed the certainty of the evidence as low. Compared with vaginal examinations as indicated, routine four-hourly vaginal examinations may result in more women having their labour augmented (RR 2.55, 95% CI 1.03 to 6.31; one study, 204 women). There may be little or no effect on: • spontaneous vaginal birth (RR 1.08, 95% CI 0.73 to 1.59; one study, 204 women); • chorioamnionitis (RR 3.06, 95% CI 0.13 to 74.21; one study, 204 women); • neonatal infection (RR 4.08, 95% CI 0.46 to 35.87; one study, 204 babies); • admission to NICU (RR 2.04, 95% CI 0.63 to 6.56; one study, 204 babies). The study did not assess our other primary outcomes of positive birth experience or maternal pain.

AUTHORS' CONCLUSIONS

Based on these findings, we cannot be certain which method is most effective or acceptable for assessing labour progress. Further large-scale RCT trials are required. These should include essential clinical and experiential outcomes. This may be facilitated through the development of a tool to measure positive birth experiences. Data from qualitative studies are also needed to fully assess whether methods to evaluate labour progress meet women's needs for a safe and positive labour and birth, and if not, to develop an approach that does.

Shaping birth: variation in the birth canal and the importance of inclusive obstetric care

Regional variation in pelvic morphology and childbirth has long occurred alongside traditional labour support and an understanding of possible normal courses of childbirth for each population. The process of migration and globalization has broken down these links, while a European model of 'normal' labour has become widespread. The description of 'normal' childbirth provided within obstetrics and midwifery textbooks, in fact, is modelled on a specific pelvic morphology that is common in European women. There is mounting evidence, however, that this model is not representative of women's diversity, especially for women of non-white ethnicities. The human birth canal is very variable in shape, both within and among human populations, and differences in pelvic shapes have been associated with differences in the mechanism of labour. Normalizing a white-centred model of female anatomy and of childbirth can disadvantage women of non-European ancestry. Because they are less likely to fit within this model, pelvic shape and labour pattern in non-white women are more likely to be considered 'abnormal', potentially leading to increased rates of labour intervention. To ensure that maternal care is inclusive and as safe as possible for all women, obstetric and midwifery training need to incorporate women's diversity. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

An Algorithm (LaD) for Monitoring Childbirth in Settings Where Tracking All Parameters in the World Health Organization Partograph Is Not Feasible: Design and Expert Validation

Background

After determining the key childbirth monitoring items from experts, we designed an algorithm (LaD) to represent the experts’ suggestions and validated it. In this paper we describe an abridged algorithm for labor and delivery management and use theoretical case to compare its performance with human childbirth experts.

Objective

The objective of this study was to describe the LaD algorithm, its development, and its validation. In addition, in the validation phase we wanted to assess if the algorithm was inferior, equivalent, or superior to human experts in recommending the necessary clinical actions during childbirth decision making.

Methods

The LaD algorithm encompasses the tracking of 6 of the 12 childbirth parameters monitored using the World Health Organization (WHO) partograph. It has recommendations on how to manage a patient when parameters are outside the normal ranges. We validated the algorithm with purposively selected experts selecting actions for a stratified sample of patient case scenarios. The experts’ selections were compared to obtain pairwise sensitivity and false-positive rates (FPRs) between them and the algorithm.

Results

The mean weighted pairwise sensitivity among experts was 68.2% (SD 6.95; 95% CI 59.6-76.8), whereas that between experts and the LaD algorithm was 69.4% (SD 17.95; 95% CI 47.1-91.7). The pairwise FPR among the experts ranged from 12% to 33% with a mean of 23.9% (SD 9.14; 95% CI 12.6-35.2), whereas that between experts and the algorithm ranged from 18% to 43% (mean 26.3%; SD 10.4; 95% CI 13.3-39.3). The was a correlation (mean 0.67 [SD 0.06]) in the actions selected by the expert pairs for the different patient cases with a reliability coefficient (α) of .91.

Conclusions

The LaD algorithm was more sensitive, but had a higher FPR than the childbirth experts, although the differences were not statistically significant. An electronic tool for childbirth monitoring with fewer WHO-recommended parameters may not be inferior to human experts in labor and delivery clinical decision support.

Progression of the first stage of labour, in low risk nulliparas in a South Asian population: a prospective observational study

We compared the labour pattern in the active phase of labour, defined at 4 cm versus 6 cm cervical dilatation, in a South Asian population. This was a prospective observational study where 500 low risk nulliparous women were recruited. Our aim was to study, the average labour pattern curve of all parturients. Mean duration of the active phase from 4 to 10 cm was 5.12 ± 2.10 hours and from 6 to 10 cm was 2.79 ± 1.72 hours. The 95th percentile values suggests that it takes 5-6 hours to progress from 4 to 6 cm and again 5-6 hours from 6 to 10 cm. The minimum labour progression rate can be as low as 0.5 cm/hour with vaginal delivery (VD) still being achieved. The slope of labour curve steepens after 6 cm, suggesting 6 cm as the onset of the active phase. Allowing labour to continue for a longer period before 6 cm of cervical dilation may reduce the rate of unnecessary intrapartum intervention and caesarean section (CS) for labour dystocia.Impact StatementWhat is already known on this subject? Friedman's definitions of normal labour and abnormal labour are widely accepted in current obstetric practises. Friedman's normal dilatation rate of 1 cm/h that is universally accepted is becoming questionable in our current obstetric population because of escalating rates of unnecessary labour interventions like oxytocin augmentation and CS.What the results of this study add? The rule of 1 cm/hour of labour progression cannot be applied to every woman and inappropriate interventions should be withheld until labour progression does falls below 0.5 cm/hour.What the implications are of these findings for clinical practice and/or further research? Six centimetres rather than 4 cm of cervical dilatation is a more appropriate landmark for the start of the active phase. Allowing labour to continue for a longer period before 6 cm of cervical dilation may reduce the rate of unnecessary intrapartum interventions and CS for labour dystocia.

Impact of analysis technique on our understanding of the natural history of labour: a simulation study

OBJECTIVE

To evaluate the discrepancy between historical and more recent descriptions of the first stage of labour by testing whether the statistical techniques used recently (repeated-measures polynomial and interval-censored regression) were appropriate for detection of periods of rapid acceleration of cervical dilatation as might occur at the time of transition from a latent to an active phase of labour.

DESIGN AND SETTING

A simulation study using regression techniques.

SAMPLE

We created a simulated data set for 500 000 labours with clearly defined latent and active phases using the parameters described by Friedman. Additionally, we created a data set comprising 500 000 labours with a progressively increasing rate of cervical dilatation.

METHODS

Repeated-measures polynomial regression was used to create summary labour curves based on simulated cervical examinations. Interval-censored regression was used to create centimetre-by-centimetre estimates of rates of cervical dilatation and their 95th centiles.

MAIN OUTCOME MEASURES

Labour summary curves and rates of cervical dilatation.

RESULTS

Repeated-measures polynomial regression did not detect the rapid acceleration in cervical dilatation (i.e. acceleration phase) and overestimated lengths of labour, especially at smaller cervical dilatations. There was a two-fold overestimation in the mean rate of cervical dilatation from 4 to 6 cm. Interval-censored regression overestimated median transit times, at 4- to 5-cm cervical dilatation or when cervical examinations occurred less frequently than 0.5- to 1.5-hourly.

CONCLUSION

Repeated-measures polynomial regression and interval-censored regression should not be routinely used to define labour progress because they do not accurately reflect the underlying data.

TWEETABLE ABSTRACT

Repeated-measures polynomial and interval-censored regression techniques are not appropriate to model first stage of labour.

Contemporary duration of spontaneous labor and association with maternal characteristics: A French national population-based study

BACKGROUND

The objective of this study was to describe labor duration of women managed with current obstetric practices in a French national population-based cohort and to assess the association of age and BMI on this duration.

METHODS

All women in the French perinatal survey of 2016 with a singleton cephalic fetus, delivering at term after a spontaneous labor were included. Duration of labor was defined as time between admission to the labor ward and birth. Duration of total labor and first and second stage of labor were described. Then, duration of labor was estimated according to maternal age and BMI, using Kaplan-Meier's method and compared with the log-rank test after stratification on parity. Intrapartum cesarean birth was considered as a censoring event. Multivariable modeling was performed using Cox's proportional hazard's method.

RESULTS

Data of 3120 nulliparous and 4385 multiparous women were analyzed. Median labor duration was 6.1 hours ([5th; 95th percentile]) [1.4; 12.6] and 3.1 hours [0.3; 8.5] in nulliparous and multiparous women. Multivariable Cox analysis showed no independent association of maternal age and duration of labor. Nulliparous obese women had significantly lower odds of having a shorter labor than women with a BMI < 25 kg/m² , HR: 0.75; 95% CI [0.64-0.88], but BMI was not associated with labor duration in multiparous women.

CONCLUSIONS

Our study provides important information for both women and care practitioners on what to expect when entering the labor ward. There appears to be little association between maternal characteristics and labor duration, with the exception of BMI in nulliparous women.

Analgesia for vaginal birth: Secondary analysis from the WHO Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To evaluate the use of analgesia during labor in women who had a vaginal birth and to determine the factors associated with its use.

METHODS

A secondary analysis was performed of the WHO Multicountry Survey on Maternal and Newborn Health, a cross-sectional, facility-based survey including 359 healthcare facilities in 29 countries. The prevalence of analgesia use for vaginal birth in different countries was reported according to the Human Development Index (HDI). Sociodemographic and obstetric characteristics of the participants with and without analgesia were compared. The prevalence ratios were compared across countries, HDI groups, and regions using a design-based χ² test.

RESULTS

Among the 221 345 women who had a vaginal birth, only 4% received labor analgesia, mainly epidural. The prevalence of women receiving analgesia was significantly higher in countries with a higher HDI than in countries with a lower HDI. Education was significantly associated with increased use of analgesia; nulliparous women and women undergoing previous cesarean delivery had a significantly increased likelihood of receiving analgesia.

CONCLUSION

Use of analgesia for women undergoing labor and vaginal delivery was low, specifically in low-HDI countries. Whether low use of analgesia reflects women's desire or an unmet need for pain relief requires further studies.

First stage progression in women with spontaneous onset of labor: A large population-based cohort study

Objective

To describe the duration, progression and patterns of first stage of labor among Swedish women.

Design

Population-based cohort study.

Population

Data from Stockholm-Gotland Obstetric Cohort 2008–2014 including ¼ of all births in Sweden, the final sample involved a total of 85,408 women with term, singleton, vertex, live fetuses experiencing spontaneous labor onset and vaginal delivery with normal neonatal outcomes.

Main outcome measures

Time to progress during first stage of labor using three approaches: 1) Traverse time in hours to progress centimeter to centimeter, 5^th, 50^th (and 95^th percentile); 2) Dilation curves for different percentiles, and; 3) Cumulative duration for the 95^th percentile by parity and dilation at admission.

Results

Variation in both the total duration and the trajectory of cervical change over time is large. Similar to the general held view, the rate of cervical dilation accelerates at 5–6 centimeters. Among nulliparous women, the median time found in our population was faster than their counterparts in studies conducted on American and African cohorts. Among nulliparous and multiparous women our data suggest that the median cervical change over time is faster than 1 cm per hour during the first stage of labor. However, traverse time of cervical change at and beyond the 95^th percentile is longer than 1 cm per hour.

Conclusions

Labor progression varies widely and labors experiencing a prolonged first stage can still result in normal outcomes. The assumption of 1 cm per hour cervical dilation rate for the first stage of labor may not be universally meaningful. There are differences in progression for women during first stage of labor in different populations. For prolonged labor progression to be more clinically meaningful, the association with adverse birth outcomes needs to be further investigated in specific populations.

Augmentation of labor with oxytocin and its association with delivery outcomes: A large-scale cohort study in 12 public hospitals in Nepal

INTRODUCTION

The use of oxytocin to augment labor is increasing in many low-resource settings; however, little is known about the effects of such use in contexts where resources for intrapartum monitoring are scarce. In this study, we sought to assess the association between augmentation of labor with oxytocin and delivery outcomes.

MATERIAL AND METHODS

We conducted a cohort study in 12 public hospitals in Nepal, including all deliveries with and without augmentation of labor with oxytocin, but excluding elective cesarean sections, women with missing information on augmentation of labor, and women without fetal heart rate on admission. Bivariate and multivariate logistic regression calculating the crude and adjusted risk ratio (aRR) with corresponding 95% CI were performed, comparing (a) intrapartum stillbirth and first-day mortality (primary outcome); and (b) intrapartum monitoring, mode of delivery, postpartum hemorrhage, bag-and-mask ventilation of the newborn, Apgar score, and neonatal death before discharge (secondary outcomes) among women with and without oxytocin-augmented labor.

RESULTS

The total cohort consisted of 78 931 women, of whom 28 915 (37%) had labor augmented with oxytocin and 50 016 (63%) did not have labor augmented with oxytocin. Women with augmentation of labor had no increased risk of intrapartum stillbirth and first-day mortality (aRR 1.24, 95% CI 0.65-2.4), but decreased risks of suboptimal partograph use (aRR 0.71, 95% CI 0.68-0.74), suboptimal fetal heart rate monitoring (aRR 0.50, 95% CI 0.48-0.53), and emergency cesarean section (aRR 0.62, 95% CI 0.59-0.66), and increased risks of bag-and-mask ventilation (aRR 2.1, 95% CI 1.8-2.5), Apgar score <7 at 5 minutes (aRR 1.65, 95% CI 1.49-1.86), and neonatal death (aRR 1.93, 95% CI 1.46-2.56).

CONCLUSIONS

Although augmentation of labor with oxytocin might be associated with beneficial effects, such as improved monitoring and a decreased risk of cesarean section, its use may lead to an increased risk of adverse perinatal outcomes. We urge for a cautious use of oxytocin to augment labor in low-resource contexts, and call for evidence-based guidelines on augmentation of labor in low-resource settings.

Effectiveness of an Electronic Partogram: A Mixed-Method, Quasi-Experimental Study Among Skilled Birth Attendants in Kenya

Use of the electronic partogram, a digital labor-support application, is associated with improved fetal outcomes and greater use of interventions to maintain normal labor compared to the paper partograph.

Background:

Timely identification and management of intrapartum complications could significantly reduce maternal deaths, intrapartum stillbirths, and newborn deaths due to hypoxia. The World Health Organization (WHO) identifies monitoring of labor using the paper partograph as a high-priority intervention for identifying abnormities in labor and fetal well-being. This article describes a mixed-method, quasi-experimental study to assess the effectiveness of an Android tablet-based electronic, labor clinical decision-support application (ePartogram) in limited-resource settings.

Methods:

The study, conducted in Kenya from October 2016 to May 2017, allocated 12 hospitals and health centers to an intervention (ePartogram) or comparison (paper partograph) group. Skilled birth attendants (SBAs) in both groups received a 2-day refresher training in labor management and partograph use. The intervention group received an additional 1-day orientation on use and care of the Android-based ePartogram app. All outcomes except one compare post-ePartogram intervention versus paper partograph controls. The exception is outcome of early perinatal mortality pre- and post-ePartogram introduction in intervention sites compared to control sites. We used log binomial regression to analyze the primary outcome of the study, suboptimal fetal outcomes. We also analyzed for secondary outcomes (SBAs performing recommended actions), and conducted in-depth interviews with facility in-charges and SBAs to ascertain acceptability and adoptability of the ePartogram.

Results:

We compared data from 842 clients in active labor using ePartograms with data from 1,042 clients monitored using a paper partograph. SBAs using ePartograms were more likely than those using paper partographs to take action to maintain normal labor, such as ambulation, feeding, and fluid intake, and to address abnormal measurements of fetal well-being (14.7% versus 5.3%, adjusted relative risk=4.00, 95% confidence interval [CI]=1.95–8.19). Use of the ePartogram was associated with a 56% (95% CI=27%–73%) lower likelihood of suboptimal fetal outcomes than the paper partograph. Users of the ePartogram were more likely to be compliant with routine labor observations. SBAs stated that the technology was easy to use but raised concerns about its use at high-volume sites. Further research is needed to evaluate costs and benefit and to incorporate recent WHO guidance on labor management.

Conclusion:

ePartogram use was associated with improvements in adherence to recommendations for routine labor care and a reduction in adverse fetal outcomes, with providers reporting adoptability without undue effort. Continued development of the ePartogram, including incorporating new clinical rules from the 2018 WHO recommendations on intrapartum care, will improve labor monitoring and quality care at all health system levels.

Labor patterns in Asian American women with vaginal birth and normal perinatal outcomes

BACKGROUND

The pattern of normal labor progression can help to define prolonged labor and dystocia. Several studies had tried to establish the process of normal labor in different races. Previous findings in Asian women were limited and often incomparable. Our aim was to examine labor patterns in Asian American women.

STUDY DESIGN

A total of 3079 women with singleton term gestation, vertex presentation, vaginal delivery, and a normal perinatal outcome were extracted from the Consortium on Safe Labor study. A repeated measure analysis and an interval-censored regression were applied to depict the average labor curves and estimate the time interval of cervical dilation by 1 cm, respectively. A sensitivity analysis was conducted to assess the impact of oxytocin augmentation. The cumulative duration of the 1st stage of labor was calculated to draw a partograph.

RESULTS

It took an average of 5.2 hours for nulliparous Asian women with spontaneous labor onset to complete the 1st stage of labor, and the 95th centile was 14.4 hours. Labor progressed at a similar rate between nulliparous and multiparous women before 6 cm. Afterward, multiparous women progressed noticeably faster than nulliparous women. The differences in labor duration between women with and without oxytocin augmentation were <0.5 hour for both nulliparous and multiparous women.

CONCLUSIONS

A new partograph that restricted the diagnosis of dystocia to the slowest 5% of nulliparous women with normal perinatal outcomes was proposed. The labor pattern in Asian American women was similar to that of the overall United States population.

The Labour Progression Study (LaPS): Duration of labour following Zhang's guideline and the WHO partograph - A cluster randomised trial

OBJECTIVE

To investigate labour duration in different phases of labour when adhering to Zhang's guideline for labour progression compared with the WHO partograph.

DESIGN

A secondary analysis of a cluster randomised controlled trial.

SETTING

Fourteen Norwegian birth care units, each with more than 500 deliveries per year constituted the clusters.

PARTICIPANTS

A total of 7277 nulliparous women with singleton foetus in a cephalic presentation and spontaneous onset of labour at term were included.

INTERVENTION

Seven clusters were randomised to the intervention group that adhered to Zhang's guideline (n = 3972) and seven to the control group that adhered to the WHO partograph (n = 3305) for labour progression.

MEASUREMENTS

The duration of labour from the first registration of cervical dilatation (≥ 4 cm) to the delivery of the baby and the duration of the first and second stages of labour; the time-to-event analysis was used to compare the duration of labour between the two groups after adjusting for baseline covariates.

FINDINGS

The adjusted median duration of labour was 7.0 h in the Zhang group, compared with 6.2 h in the WHO group; the median difference was 0.84 h with 95% confidence interval [CI] (0.2-1.5). The adjusted median duration of the first stage was 5.6 h in the Zhang group compared with 4.9 h in the WHO group; the median difference was 0.66 h with 95% CI (0.1-1.2). The corresponding adjusted median duration of the second stage was 88 and 77 min; the median difference was 0.18 h with 95% CI (0.1-0.3).

KEY CONCLUSIONS

The women who adhered to Zhang's guideline had longer overall duration and duration of the first and second stages of labour than women who adhered to the WHO partograph.

IMPLICATIONS FOR PRACTICE

Understanding the variations in the duration of labour is of great importance, and the results offer useful insights into the different labour progression guidelines, which can inform clinical practice.

Expert perspectives on essential parameters to monitor during childbirth in low resource settings: a Delphi study in sub-Saharan Africa

OBJECTIVE

There is no consensus on the essential parameters to monitor during childbirth, when to start, and the rate of monitoring them. User disagreement contributes to inconsistent use of the twelve-item modified World Health Organization partograph that is started when the cervix is at least 4 cm dilated. The inconsistent use is associated with poor outcomes at birth. Our objective was to identify the perspectives of childbirth experts on what and when to routinely monitor during childbirth in low resource settings as we develop a more acceptable childbirth clinical decision support tool.

METHOD

We carried out a Delphi study with two survey rounds in early 2018. The online questionnaire covered the partograph items like foetal heart, cervical dilation, and blood pressure, and their monitoring rates. We invited panellists with experience of childbirth care in sub-Saharan Africa. Consensus was pre-set at 70% panellists rating a parameter and we gathered some qualitative reasons for choices.

RESULTS

We analysed responses of 76 experts from 13 countries. There was consensus on six important parameters including foetal heart rate, amniotic fluid clearness, cervical dilation, strength of uterine contractions, maternal pulse, and blood pressure. Two in three experts expressed support for changing the monitoring intervals for some parameters in the partograph. 63% experts would raise the partograph starting point while 58% would remove some items from it. Consensus was reached on monitoring the cervical dilation at 4-hourly intervals and there was agreement on monitoring the foetal heart rate one-hourly. However, other parameters only showed majority intervals and without reaching agreement scores. The suggested intervals were two-hourly for strength of uterine contractions, and four-hourly for amniotic fluid thickness, maternal pulse and blood pressure. The commonest reason for their opinions was the more demanding working conditions.

CONCLUSION

There was agreement on six partograph items being essential for routine monitoring at birth, but the frequency of monitoring could be changed. To increase acceptability, revisions to birth monitoring guidelines have to be made in consideration of opinions and working conditions of several childbirth experts in low resource settings.

A mathematical model to predict mean time to delivery following cervical ripening with dinoprostone vaginal insert

The main objective of our study was to analyze the mean time to delivery following cervical ripening with a 10 mg dinoprostone vaginal insert. We performed a retrospective observational study at the level III maternity ward of Angers university hospital. We included all women who had cervical ripening with dinoprostone between January 1st, 2015 and September 30th, 2016. Overall, 405 patients were included, and 59.3% (240/405) were nulliparous. The mean time to delivery was 20h39 min ± 10h49 min. 21% of deliveries (86/405) occurred between midnight and 6 h a.m., and the cesarean section rate was 33% (132/405). Multiple regression analysis showed that nulliparity, overweight (BMI ≥ 25), a closed cervix on initial examination and the absence of premature rupture of membranes (PRM) all significantly increased the mean time to delivery. We developed a mathematical model integrating the aforementioned factors and their impact to help predict the mean time to delivery following cervical ripening with dinoprostone vaginal insert: Y = 961.188-80.346 × parity + 21.437 × BMI-165.263 × cervical dilation-241.759 × PRM. This equation allows obstetricians to calculate a personalized time to delivery for each patient, allowing a precise scheduling of dinoprostone insert placement, and thus improving the organization in busy maternity wards.

Indications for increase in caesarean delivery

BACKGROUND

The increasing caesarean delivery rate worldwide is followed by increased maternal morbidity due to pathological placentation, peripartum hysterectomy and obstetric bleeding. The aim of this study was to investigate the indications for caesarean delivery.

STUDY DESIGN

A retrospective observational study. Data were retrieved from the Swedish Pregnancy Register and obstetric records at a tertiary hospital in Sweden between the early 1990s and 2015.

RESULTS

Caesarean delivery in Sweden increased from 10% in the early 1990s to 17% in 2015 concomitantly with decreased instrumental delivery and increased labour induction. Most planned caesareans at the tertiary hospital were performed on maternal request with a rate increasing from 0.6 to 4.6% of all deliveries (p < 0.001), and 60% of these women reported secondary fear of vaginal delivery. The second most common indication previous uterine scar increased from 1.2 to 2.3% (p < 0.001). Most urgent caesareans in 2015 were carried out because of prolonged labour with the rate increasing from 2.1% to 5.4% of all deliveries (p < 0.001). The second most common indication was imminent fetal asphyxia which increased from 2.4 to 2.6% (p < 0.01).

CONCLUSIONS

The Swedish caesarean delivery rate increased concomitantly with a decrease in instrumental delivery and an increase in labour induction. Most of the planned caesareans were performed on maternal request and most of the urgent caesareans were carried out because of prolonged labour. These findings emphasise the importance of standardised definitions of maternal request and follow-up after a negative birth experience, as well as adequate definitions of prolonged labour and foetal asphyxia to decrease unnecessary caesareans.

Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Universal and timely access to a caesarean section is a key requirement for safe childbirth. We identified the burden of maternal and perinatal mortality and morbidity, and the risk factors following caesarean sections in low-income and middle-income countries (LMICs).

METHODS

For this systematic review and meta-analysis, we searched electronic databases including MEDLINE and Embase (from Jan 1, 1990, to Nov 20, 2017), without language restrictions, for studies on maternal or perinatal outcomes following caesarean sections in LMICs. We excluded studies in high-income countries, those involving non-pregnant women, case reports, and studies published before 1990. Two reviewers undertook the study selection, quality assessment, and data extraction independently. The main outcome being assessed was prevalence of maternal mortality in women undergoing caesarean sections in LMICs. We used a random effects model to synthesise the rate data, and reported the association between risk factors and outcomes using odds ratios with 95% CIs. The study protocol has been registered with PROSPERO, number CRD42015029191.

FINDINGS

We included 196 studies from 67 LMICs. The risk of maternal death in women who had a caesarean section (116 studies, 2 933 457 caesarean sections) was 7·6 per 1000 procedures (95% CI 6·6-8·6, τ²=0·81); the highest burden was in sub-Saharan Africa (10·9 per 1000; 9·5-12·5, τ²=0·81). A quarter of all women who died in LMICs (72 studies, 27 651 deaths) had undergone a caesarean section (23·8%, 95% CI 21·0-26·7; τ²=0·62).

INTERPRETATION

Maternal deaths and perinatal deaths following caesarean sections are disproportionately high in LMICs. The timing and urgency of caesarean section pose major risks.

FUNDING

Ammalife Charity and ELLY Appeal, Barts Charity, and the UK National Institute for Health Research.

The frequency of intrapartum caesarean section use with the WHO partograph versus Zhang's guideline in the Labour Progression Study (LaPS): a multicentre, cluster-randomised controlled trial

BACKGROUND

There is an ongoing debate concerning which guidelines and monitoring tools are most beneficial for assessing labour progression, to help prevent use of intrapartum caesarean section (ICS). The WHO partograph has been used for decades with the assumption of a linear labour progression; however, in 2010, Zhang introduced a new guideline suggesting a more dynamic labour progression. We aimed to investigate whether the frequency of ICS use differed when adhering to the WHO partograph versus Zhang's guideline for labour progression.

METHODS

We did a multicentre, cluster-randomised controlled trial at obstetric units in Norway, and each site was required to deliver more than 500 fetuses per year to be eligible for inclusion. The participants were nulliparous women who had a singleton, full-term fetus with cephalic presentation, and who entered spontaneous active labour. The obstetric units were treated as clusters, and women treated within these clusters were all given the same treatment. We stratified these clusters by size and number of previous caesarean sections. The clusters containing the obstetric units were then randomly assigned (1:1) to the control group, which adhered to the WHO partograph, or to the intervention group, which adhered to Zhang's guideline. The randomisation was computer-generated and was done in the Unit of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway, and investigators in this unit had no further involvement in the trial. Our study design did not enable masking of participants or health-care providers, but the investigators who were analysing the data were masked to group allocation. The primary outcome was use of ICS during active labour (cervical dilatation of 4-10 cm) in all participating women. The Labour Progression Study (LaPS) is registered with ClinicalTrials.gov, number NCT02221427.

FINDINGS

Between Aug 1, 2014, and Sept 1, 2014, 14 clusters were enrolled in the LaPS trial, and on Sept 11, 2014, seven obstetric units were randomly assigned to the control group (adhering to the WHO partograph) and seven obstetric units were randomly assigned to the intervention group (adhering to Zhang's guideline). Between Dec 1, 2014, and Jan 31, 2017, 11 615 women were judged to be eligible for recruitment in the trial, which comprised 5421 (46·7%) women in the control group units and 6194 (53·3%) women in the intervention group units. In the control group, 2100 (38·7%) of 5421 women did not give signed consent to participate and 16 (0·3%) women abstained from participation. In the intervention group, 2181 (35·2%) of 6194 women did not give signed consent to participate and 41 (0·7%) women abstained from participation. 7277 (62·7%) of 11 615 eligible women were therefore included in the analysis of the primary endpoint. Of these women, 3305 (45·4%) participants were in an obstetric unit that was randomly assigned to the control group (adhering to the WHO partograph) and 3972 (54·6%) participants were in an obstetric unit that was randomly assigned to the intervention group (adhering to Zhang's guideline). No women dropped out during the trial. Before the start of the trial, ICS was used in 9·5% of deliveries in the control group obstetric units and in 9·3% of intervention group obstetric units. During our trial, there were 196 (5·9%) ICS deliveries in women in the control group (WHO partograph) and 271 (6·8%) ICS deliveries in women in the intervention group (Zhang's guideline), and the frequency of ICS use did not differ between the groups (adjusted relative risk 1·17, 95% CI 0·98-1·40; p=0·08; adjusted risk difference 1·00%, 95% CI -0·1 to 2·1). We identified no maternal or neonatal deaths during our study.

INTERPRETATION

We did not find any significant difference in the frequency of ICS use between the obstetric units assigned to adhere to the WHO partograph and those assigned to adhere to Zhang's guideline. The overall decrease in ICS use that we observed relative to the previous frequency of ICS use noted in these obstetric units might be explained by the close focus on assessing labour progression more than use of the guidelines. Our results represent an important contribution to the discussion on implementation of the new guideline.

FUNDING

Østfold Hospital Trust.

Strategies for intrapartum foetal surveillance in low- and middle-income countries: A systematic review

BACKGROUND

The majority of the five million perinatal deaths worldwide take place in low-resource settings. In contrast to high-resource settings, almost 50% of stillbirths occur intrapartum. The aim of this study was to synthesise available evidence of strategies for foetal surveillance in low-resource settings and associated neonatal and maternal outcomes, including barriers to their implementation.

METHODS AND FINDINGS

The review was registered with Prospero (CRD42016038679). Five databases were searched up to May 1st, 2016 for studies related to intrapartum foetal monitoring strategies and neonatal outcomes in low-resource settings. Two authors extracted data and assessed the risk of bias for each study. The outcomes were narratively synthesised. Strengths, weaknesses, opportunities and threats analysis (SWOT) was conducted for each monitoring technique to analyse their implementation. There were 37 studies included: five intervention and 32 observational studies. Use of the partograph improved perinatal outcomes. Intermittent auscultation with Pinard was associated with lowest rates of caesarean sections (10-15%) but with comparable perinatal outcomes to hand-held Doppler and Cardiotocography (CTG). CTG was associated with the highest rates of caesarean sections (28-34%) without proven benefits for perinatal outcome. Several tests on admission (admission tests) and adjunctive tests including foetal stimulation tests improved the accuracy of foetal heart rate monitoring in predicting adverse perinatal outcomes.

CONCLUSIONS

From the available evidence, the partograph is associated with improved perinatal outcomes and is recommended for use with intermittent auscultation for intrapartum monitoring in low resource settings. CTG is associated with higher caesarean section rates without proven benefits for perinatal outcomes, and should not be recommended in low-resource settings. High-quality evidence considering implementation barriers and enablers is needed to determine the optimal foetal monitoring strategy in low-resource settings.

Duration of spontaneous labour in 'low-risk' women with 'normal' perinatal outcomes: A systematic review

BACKGROUND

Despite decades of research, the concept of normality in labour in terms of its progression and duration is not universal or standardized. However, in clinical practice, it is important to define the boundaries that distinguish what is normal from what is abnormal to enable women and care providers have a shared understanding of what to expect and when labour interventions are justified.

OBJECTIVES

To synthesise available evidence on the duration of latent and active first stage and the second stage of spontaneous labour in women at low risk of complications with 'normal' perinatal outcomes.

SEARCH STRATEGY

PubMed, EMBASE, CINAHL, POPLINE, Global Health Library, and reference lists of eligible studies.

SELECTION CRITERIA

Observational studies and other study designs.

DATA COLLECTION AND ANALYSIS

Four authors extracted data on: maternal characteristics; labour interventions; duration of latent first stage, active first stage, and second stage of labour; and the definitions of onset of latent and active first stage, and second stage where reported. Heterogeneity in the included studies precluded meta-analysis and data were presented descriptively.

MAIN RESULTS

Thirty-seven studies reporting the duration of first and/or second stages of labour for 208,000 women met our inclusion criteria. Among nulliparous women, the median duration of active first stage (when the starting reference point was 4 cm) ranged from 3.7-5.9 h (95th percentiles: 14.5-16.7 h). With active phase starting from 5 cm, the median duration was from 3.8-4.3 h (95th percentiles: 11.3-12.7 h). The median duration of second stage ranged from 14 to 66 min (95th percentiles: 65-138 min) and from 6 to 12 min (95th percentiles: 58-76 min) in nulliparous and parous women, respectively. Sensitivity analyses excluding first and second stage interventions did not significantly impact on these findings CONCLUSIONS: The duration of spontaneous labour in women with good perinatal outcomes varies from one woman to another. Some women may experience labour for longer than previously thought, and still achieve a vaginal birth without adverse perinatal outcomes. Our findings question the rigid limits currently applied in clinical practice for the assessment of prolonged first or second stage that warrant obstetric intervention.