Clinical significance of precipitous labor

Outcome of Inducing Labor in Pregnancies with Suspected Fetal Growth Restriction: Oxytocin Discontinuation during the Active Phase of Labor versus Conventional Management

OBJECTIVE

Although fetal growth restriction (FGR) is associated with an increased risk of cesarean delivery during induced labor, there is limited evidence to guide labor management. This study aimed to investigate the prognosis of induced labor in pregnancies with suspected FGR and whether oxytocin discontinuation during the active phase of labor affects maternal and neonatal outcomes.

STUDY DESIGN

This retrospective cohort study investigated singleton pregnancies with vertex presentation and indications for labor induction owing to FGR after 34.0 weeks of gestation at Osaka University Hospital. From January 2010 to December 2013, women were conventionally managed, and oxytocin was continued until delivery unless there was an indication for discontinuation (conventional management group). From January 2013 to December 2020, oxytocin was routinely discontinued, or the dose was reduced at the beginning of the active phase of labor (oxytocin discontinuation group).

RESULTS

A total of 161 women (conventional management group, n = 74; oxytocin discontinuation group, n = 87) were included. After the active phase of induced labor, the total incidence of cesarean delivery was very low (3.1%), and the duration was short (173 ± 145 minutes). Oxytocin discontinuation was associated with lower cesarean delivery (1.1 vs. 5.4%; p = 0.12) and uterine tachysystole (9.8 vs. 23.0%; p = 0.08) rates and longer duration of the second stage of labor (mean: 56.5 ± 90 vs. 34.2 ± 45 minutes; p = 0.08) than conventional management; however, the difference was not significant. The other maternal and neonatal outcomes, including postpartum hemorrhage, did not also significantly differ between them.

CONCLUSION

After the active phase of induced labor for suspected FGR, the risk of cesarean delivery is low, and the high incidence of uterine tachysystole and rapid labor progression should be considered cautiously. Oxytocin can be safely discontinued during the active phase of labor in women undergoing labor induction for FGR without an increased risk of cesarean delivery or other unfavorable outcomes.

KEY POINTS

· The cesarean delivery rate was low after the active phase.. · The labor progress after the active phase was rapid.. · Oxytocin can be safely discontinued during the active phase..

Childbearing with Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders: A Large International Survey of Outcomes and Complications

One in 20 births could be affected by hypermobile Ehlers-Danlos syndrome or Hypermobility Spectrum Disorders (hEDS/HSD); however, these are under-diagnosed and lacking research. This study aimed to examine outcomes and complications in people childbearing with hEDS/HSD. A large online international survey was completed by women with experience in childbearing and a diagnosis of hEDS/HSD (N = 947, total pregnancies = 1338). Data were collected on demographics, pregnancy and birth outcomes and complications. Participants reported pregnancies in the UK (N = 771), USA (N = 364), Australia (N = 106), Canada (N = 60), New Zealand (N = 23) and Ireland (N = 14). Incidences were higher in people with hEDS/HSD than typically found in the general population for pre-eclampsia, eclampsia, pre-term rupture of membranes, pre-term birth, antepartum haemorrhage, postpartum haemorrhage, hyperemesis gravidarum, shoulder dystocia, caesarean wound infection, postpartum psychosis, post-traumatic stress disorder, precipitate labour and being born before arrival at place of birth. This potential for increased risk related to maternal and neonatal outcomes and complications highlights the importance of diagnosis and appropriate care considerations for childbearing people with hEDS/HSD. Recommendations include updating healthcare guidance to include awareness of these possible complications and outcomes and including hEDS/HSD in initial screening questionnaires of perinatal care to ensure appropriate consultation and monitoring can take place from the start.

Pregnancy-Related Sacral Stress Fractures: A Single Center Experience of 23 Cases

Purpose

This study aims to find out the incidence, etiology, and risk factors, define clinical features, show the magnetic resonance imaging (MRI) and laboratory findings, and share the experience of treatment and clinical outcome of pregnancy-related sacral stress fractures (SSFs).

Methods

In total, 29,291 (15,008 of them vaginal and 14,283 of them cesarean section delivery) women gave birth in our hospital between January 2016 and December 2021. Twenty-three of them (0.078%) who had low back and pelvic pain were diagnosed with SSFs using pelvic MRI. Dual-energy X-ray absorptiometry (DEXA) was used to rule out underlying osteopenia and osteoporosis and determine the type of SSFs.

Results

The incidence of pregnancy-related SSFs was 0.078% (23/29,291patients). Six patients (26%) experienced pain during the last trimester of pregnancy, remaining seventeen (74%) patients had pain during the postpartum period. 73.91% of the patients were primigravida. Thirteen patients (56.52%) were classified as fatigue SSFs, eight (34.78%) were insufficiency SSFs, and only two (8.7%) were defined as a mixed type of SSFs. MRI imaging showed that nine patients (39.13%) had a left-sided fracture, seven patients (30.43%) had a right-sided fracture, and seven patients (30.43%) had bilateral fractures. Vitamin D deficiency (less than 20 ng/mL) was detected in seven patients (30.44%). One case had hypothyroidism in which thyroid stimulating hormone (TSH) was 5.41 μIU/mL.

Conclusion

Pregnancy-related SSFs are uncommon but should be considered by clinicians in the differential diagnosis of low back and pelvic pain during pregnancy and the postpartum period. We determined that first pregnancy is a risk factor for SSFs. The current study also revealed that laboratory investigation of vitamin D deficiency and DEXA investigation, which may lead to osteoporosis or osteopenia, were crucial in the diagnosis. Furthermore, some SSFs should be reclassified as mixed fractures, fatigue, and insufficiency fractures.

Perinatal outcome and risk factors of precipitate labor in term primipara: an analysis of 381 cases

OBJECTIVE

To investigate the perinatal outcome and risk factors of precipitate labor in term primipara.

METHODS

A total of 6951 full-term singleton primiparas with cephalic vaginal delivery in Women's Hospital, Zhejiang University School of Medicine from January 2020 to December 2020 were enrolled, among whom 381 cases of precipitate labor were classified as the precipitate labor group and 762 cases of normal labor were randomly selected as the control group. The perinatal outcomes of the two groups were compared, and the risk factors of precipitate labor were analyzed by multivariate logistic regression.

RESULTS

The incidence of precipitate labor in full-term, singleton pregnancy and cephalic primiparas was 5.48% (381/6951). The durations of the first and second stages of labor in the precipitate labor group were significantly shorter than that in the control group ( P<0.01); while there was no significant difference in the duration of the third stage of labor between the two groups ( P>0.05). Compared with the control group, the incidence of soft birth canal laceration in the precipitate labor group was increased ( P<0.01). However, there was no significant difference in postpartum hemorrhage and neonatal related perinatal outcomes between the two groups (all P>0.05). Multivariate logistic regression analysis showed that maternal height ( OR=1.038, 95% CI: 1.010-1.067, P<0.01), gestational age at delivery ( OR=0.716, 95% CI: 0.618-0.829, P<0.01), late miscarriage ( OR=1.986, 95% CI: 1.065-3.702, P<0.05), membrane rupture before labor ( OR=1.802, 95% CI: 1.350-2.406, P<0.01), labor induction by transcervical balloon ( OR=3.230, 95% CI: 2.027-5.147, P<0.01), labor induction by propess ( OR=2.332, 95% CI: 1.632-3.334, P<0.01) and labor induction by oxytocin ( OR=0.291, 95% CI: 0.219-0.386, P<0.01) were independently associated with precipitate labor.

CONCLUSIONS

The incidence of precipitate labor in full-term, singleton pregnancy was not low. Precipitate labor could lead to a significant increase in perineal laceration. Maternal height, history of late miscarriage, membrane rupture before labor and labor induction by transcervical balloon, labor induction by propess are risk factors, while labor induction by oxytocin and late gestational time of delivery are protective factors for precipitate labor in term primipara.

Presentation and outcomes of Listeria-affected pregnancies in Johannesburg tertiary hospitals: A 2-year review

OBJECTIVE

To describe maternal risk factors, presentations, peripartum findings, and pregnancy outcomes in Listeria monocytogenes-infected women.

METHODS

A retrospective descriptive case review. The records of 51 pregnant women infected with listeriosis who delivered infants between February 1, 2016 and February 28, 2018 at three academic hospitals in Johannesburg, South Africa, were included. The diagnosis of listeriosis was made on maternal/neonatal-sampled blood or tissue cultures.

RESULTS

Forty-eight (82.3%) Listeria infections of maternal and neonatal listeriosis were diagnosed on blood culture. The median gestational age at diagnosis was at a preterm gestation of 33 (20-43) weeks. Twenty-eight women (54.9%) had normal vaginal deliveries. Precipitous labor was described in 18 (39%) of these women. Fetal distress was the indication for cesarean section in 22 (41.2%) women. Meconium-stained amniotic fluid was found in 21 (61.7%) women at the time of delivery. The category of very low birth weight had 14 (27.4%) neonates with an Apgar score of less than 7 at 5 min. Maternal morbidities included chorioamnionitis (3 [5.8%]) and puerperal infections (7 [13.7%]). The HIV-positive anemic women had a tendency towards listerial infections.

CONCLUSIONS

Symptoms of listeriosis were non-specific and diagnosis was detected on blood culture sampling. Risk factors included HIV seropositivity and were associated with puerperal infections and anemia.

Precipitous delivery complicated by uterine artery laceration and uterine rupture in an unscarred uterus: A case report

Precipitous delivery is associated with rapid cervical dilation and fetal descent. Complications of precipitous delivery can include vascular trauma, uterine rupture, and uterine artery laceration. Uterine artery laceration is a rare complication that can lead to significant postpartum hemorrhage and injury. Careful evaluation for trauma and aggressive resuscitation are critical to prevent maternal morbidity and mortality. This is a case report of a 39-year-old woman, gravida 2 para 1, at 39 weeks of gestation who delivered after induction of labor due to chronic hypertension. Her labor course was precipitous and complicated by uterine rupture and uterine artery laceration with postpartum hemorrhage that required massive transfusion, exploratory laparotomy with a supracervical hysterectomy, and interventional radiology for uterine and cervical artery embolization. This seems to be the first published case report of precipitous delivery associated with uterine artery laceration and uterine rupture. Thorough evaluation after precipitous delivery is critical to decrease maternal morbidity and mortality secondary to uterine artery injury.

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Uterine artery laceration is a rare and serious complication of precipitous labor.

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Uterine rupture and artery laceration increases the risk of postpartum hemorrhage.

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Postpartum hemorrhage requires prompt and thorough evaluation and treatment.

Risk of infection in neonates born in accidental out-of-hospital deliveries

Accidental out-of-hospital deliveries (OHDs) are known to have a higher incidence of maternal and neonatal complications. However, neonatal infection related to OHDs has not been studied. The aim of this study was to determine the infection risk of OHDs. This retrospective cohort study enrolled neonates admitted at a children’s hospital in an urban setting from January 2004 to December 2017. Accidental OHDs were compared with in-hospital births, and neonatal infection was assessed. This study also investigated both maternal and neonatal risk factors associated with OHDs. A cohort of 158 OHD neonates was enrolled, of whom 29 (23.2%) were preterm. Prematurity and low birth weight were significantly associated with OHD. Eight neonates in the OHD cohort had a documented infection within the first 72 hours of life, which was 11-fold higher than infections documented for the in-hospital births. Multivariate analysis identified low birth weight as the only factor independently associated with increased risk of infection in OHD neonates. Several specific characteristics of mothers with OHDs were identified. Forty-nine (31%) OHD mothers lacked antenatal care, and 10 (6.3%) were unaware of their pregnancies. The OHD group comprised of more teenage mothers compared to the in-hospital deliveries category. Neonatal infection was more prevalent among OHDs than for in-hospital deliveries, and the infection rate was associated with low birth weight. Hospitalization for further care and observation is suggested for the OHD neonates. Social support should be provided for populations with an increased risk of OHD, such as teenage mothers.

Impact of precipitous labor on the onset of transient tachypnea in vaginal deliveries at term

OBJECTIVE

The objective of the present research was to study the association between precipitous labor (less than 3 h) and the onset of transient tachypnea in singleton fetuses in cephalic presentation with term vaginal deliveries.

METHODS

This cohort study included women delivered from 2013 through 2017 in our French tertiary university hospital maternity unit. Inclusion criteria were vaginal delivery of liveborn singleton fetus in cephalic presentation and at term. We compared women with precipitous labor and those with longer labor. The principal endpoint was the rate of transient tachypnea of the newborn (TTN). We investigated risk factors for TTN besides duration of labor.

RESULTS

Comparison of 2644 women with precipitous labor and 7571 with longer labor showed a lower TTN rate in the precipitous labor group (1.6 vs 2.7%; P = 0.003). The association was no longer significant after adjustment for the risk factors identified in the univariate analysis (adjusted OR 0.99, 95% CI 0.64-1.54). Risk factors identified for TTN were non-clear amniotic fluid, shoulder dystocia, umbilical cord encirclement, birth weight less than 2500 g, use of cervical ripening and operative vaginal delivery.

CONCLUSION

Precipitous labor, lasting less than 3 h, is not associated with a higher risk of transient tachypnea in term newborns after vaginal delivery.

Understanding hypermobile Ehlers-Danlos syndrome and Hypermobility Spectrum Disorders in the context of childbearing: An international qualitative study

OBJECTIVE

The Ehlers-Danlos syndromes (EDS) and Hypermobility Spectrum Disorders (HSD) have profound and life-threatening consequences in childbearing as they affect connective tissues throughout the body. Hypermobile EDS (hEDS) and HSD are estimated here for the first time to affect 6 million (4.6%) pregnancies globally per year. The aim of this study was to arrive at a deeper biopsychosocial understanding of childbearing in the context of hEDS/HSD.

METHODS

English speaking women aged over 18 years who had previously given birth and had a confirmed medical diagnosis of hEDS/HSD or equivalent diagnosis under a preceding nosology were included in this study (n=40). Narrative interviews were used to collect qualitative data from this international sample of participants. Thematic narrative analysis was used to understand how participants made sense of their experiences.

FINDINGS

Participants were aged between 25 and 55. Births (n= 52) between 1981 and 2018 were captured across United Kingdom=29 (73%), United States of America=10 (25%) and Canada=1 (2%). The majority of participants interviewed recounted a worsening of symptoms during pregnancy and postnatal complications. Anaesthesia was often reportedly ineffective, and for many, long latent phases of labour quickly developed into rapidly progressing active labours and births. Maternity staff were observed to be panicked by these unexpected outcomes and were deemed to lack the knowledge and understanding of how to care for women in this context. Poor maternity care resulted in women disengaging from services, trauma, stress, anxiety and an avoidance of future childbearing.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Cases of hEDS/HSD should no longer be considered rare in maternity services. Maternity staff must be adequately prepared for this new reality. As a first step, www.hEDSTogether.com has been developed to provide a repository of evidence in relation to this topic, along with a freely downloadable toolkit for use in practice. It is important to listen, acknowledge and respond to women with hEDS/HSD appropriately throughout their childbearing journey. Dismissal can lead to trauma and needless morbidity.

Pregnancy outcomes in women with anorexia nervosa

OBJECTIVE

Birth outcomes of women with anorexia nervosa are poorly understood. We hypothesized that hospitalization for anorexia nervosa before or during pregnancy is associated with an elevated risk of adverse maternal and infant birth outcomes.

METHOD

We performed a retrospective cohort study of 2,134,945 pregnancies in Quebec, Canada, from 1989 to 2016. The main exposure measure was anorexia nervosa requiring hospital treatment before or during pregnancy. Outcome measures included stillbirth, preterm birth, low birth weight, small-for-gestational age birth, preeclampsia, gestational diabetes, cesarean delivery, and other pregnancy disorders. We computed risk ratios and 95% confidence intervals (CI) for the association between anorexia nervosa and birth outcomes adjusted for maternal characteristics.

RESULTS

Compared with no hospitalization, anorexia nervosa hospitalization was associated with 1.99 times the risk of stillbirth (95% CI 1.20-3.30), 1.32 times the risk of preterm birth (95% CI 1.13-1.55), 1.69 times the risk of low birth weight (95% CI 1.44-1.99), and 1.52 times the risk of small-for-gestational age birth (95% CI 1.35-1.72). The associations with low birth weight and small-for-gestational age birth were more prominent in women hospitalized for anorexia nervosa during pregnancy or within 2 years of delivery. Hospitalization for anorexia nervosa was associated with certain maternal outcomes, including precipitate labor, acute liver failure, and admission to an intensive care unit.

DISCUSSION

Hospitalization for anorexia nervosa before or during pregnancy is associated with adverse infant and maternal outcomes. Infants are primarily at risk of stillbirth, preterm birth, low birth weight, and small-for-gestational age birth.

Precipitous Labor and Emergency Department Delivery

A precipitous delivery can be among the most stressful events an emergency physician encounters. The physician must assess 2 patients (mother and fetus) and be prepared to manage a variety of complications that may arise during delivery. A majority of precipitous deliveries result in good outcomes for both mother and baby, but emergency physicians must be prepared to manage feared complications, such as tight nuchal cords, shoulder dystocia, and breech presentation. An understanding of the labor process as well as advanced planning can help decrease the stress and chaos inherent to any precipitous delivery.

Cervical Dilatation Curves of Spontaneous Deliveries in Pregnant Japanese Females

Background: Although cervical dilatation curves are crucial for appropriate management of labor progression, abnormal labor progression and obstetric interventions were included in previous and widely-used cervical dilatation curves. We aimed to describe the cervical dilatation curves of normal labor progression in pregnant Japanese females without abnormal labor progression and obstetric interventions. Methods: We completed retrospective obstetric record reviews on 3172 pregnant Japanese females (parity = 0, n = 1047; parity = 1, n = 1083; parity ≥ 2, n = 1042), aged 20 to 39 years old at delivery, with pregravid body mass indices of less than 30. All patients underwent spontaneous deliveries with term, singleton, cephalic and live newborns of appropriate-for-gestational age birthweight, without adverse neonatal outcomes. We characterized labor progression patterns by examining the relationship between elapsed times from the full dilatation and cervical dilatation stages, and labor durations by examining the distribution of time intervals from one cervical dilatation stage, to the next, and ultimately to the full dilatation. Results: Fastest cervical changes occurred at 6 cm (primiparas) and 5 cm (multiparas) of dilatation. The 95%tile of labor progression took over 3 hours to progress from 6 cm to 7 cm (primiparas), and over 2 hours to progress from 5 cm to 6 cm (multiparas). The 5%tile of traverse time to the full dilatation, during the active phase, was less than 1 hour (primiparas) and 0.5 hours (multiparas). At the end of the active phase, no deceleration phase was observed. Conclusions: Active labor may not start until 5 cm of dilatation. At the beginning of the active phase, cervical dilatation was slower than previously described. These results may reduce opportunities for obstetric interventions during labor progression.

Viscous effects in pelvic floor muscles during childbirth: A numerical study

During vaginal delivery, women sustain stretching of their pelvic floor, risking tissue injury and adverse outcomes. Realistic numerical simulations of childbirth can help in the understanding of the pelvic floor mechanics and on the prevention of related disorders. In previous studies, biomechanical finite element simulations of a vaginal delivery have been performed disregarding the viscous effects present on all biological soft tissues. The inclusion of the viscoelastic behaviour is fundamental, since it allows to investigate rate-dependent responses. The present work uses a viscohyperelastic constitutive model to evaluate how the childbirth duration affects the efforts sustained by the pelvic floor during delivery. It was concluded that viscoelasticity adds a stiffness component that leads to higher forces comparing with the elastic response. Viscous solutions are rate dependent, and precipitous labours could be associated to higher efforts, while lower reaction forces were denoted for normal and prolonged labours, respectively. The existence of resting stages during labour demonstrated the capability of the tissue to relax and recover some of the initial properties, which helped to lower the forces and stresses involved. The present work represents a step further in achieving a robust non-invasive procedure, allowing to estimate how obstetrical factors influence labour and its outcomes.