A study on intrauterine fetal resuscitation with terbutaline

A randomized study on the effect of terbutaline on fetal distress was carried out in 20 patients who showed evidence of ominous fetal heart rate patterns and fetal scalp blood pH values of less than 7.25. Of those, 11 received terbutaline (study group) and nine did not (control group). There was a significant improvement in the acid-base status of the fetus in the study group compared with those in the control group (p less than 0.01). No significant maternal or fetal morbidity occurred in the study group. Apgar scores at 1 minute were 7 or greater in 10 of the 11 study subjects whereas only four of the nine control subjects had a score of 7 or greater. These results suggest that terbutaline may become a useful agent in the treatment of intrauterine fetal distress.     

Hexoprenaline tocolysis for intrapartum fetal distress and acidosis

Hexoprenaline, a selective beta 2-sympathomimetic drug, was administered to 12 patients with severe distress in labor. The fetal distress was documented by fetal heart rate abnormalities in association with a fetal scalp blood pH of less than 7.20. The mean fetal scalp pH was 7.17 +/- 0.17 before treatment. A 7.5- to 10-micrograms intravenous bolus of hexoprenaline was followed by an intravenous infusion titrated to inhibit uterine contractions. According to protocol, all patients delivered by cesarean section approximately 40 minutes after the bolus injection. The mean cord blood pH was 7.31 +/- 0.06. No infant had a five-minute Apgar score of less than 8, and there were no significant maternal or fetal side effects.     

Intrapartum fetal distress and magnesium sulfate.

OBJECTIVE: Intrapartum fetal distress is an obstetric emergency traditionally managed by immediate delivery by either the vaginal route or cesarean section. However, there is usually time to attempt intrauterine resuscitation. The purpose of this study was to report the utilization of magnesium sulfate for intrauterine resuscitation. METHOD: Twenty-one fetuses received magnesium sulfate 4-g intravenous bolus in mothers awaiting cesarean section for fetal distress in the labor room of the Complejo Hospitalario Metropolitano de la Caja de Seguro Social de Panamá, from March through August 1997. Fetal distress in labor was defined as the presence of repetitive late decelerations, persistent loss of baseline variability, severe variable decelerations, or bradycardia. RESULTS: Twenty-one fetuses received magnesium sulfate 4-g intravenous bolus in mothers awaiting cesarean section for fetal distress. Uterine activity ceased in seven patients, diminished in 13 patients and did not change in one. In all cases, but one, there was recovery of the FHR within 4 min; furthermore there was rose reactive of FHR in nine patients. The 1-min Apgar scores were 7 or above in 18 cases and the 5-min Apgar scores were 7 or above in 20 patients. CONCLUSIONS: In summary, magnesium sulfate may be useful in the management of acute intrapartum fetal distress when there is evidence of increased uterine activity.     

Patient-controlled analgesia with nalbuphine during labor

The effectiveness and safety of nalbuphine administered via the patient-controlled analgesia system were investigated in 82 parturients during labor. Comparison of nalbuphine via the patient-controlled system versus 66 control patients receiving the same drug via intermittent intravenous bolus injections revealed it to be safe and effective in both cases. Patients receiving nalbuphine by the pump had less drowsiness and were more satisfied with their analgesia than those in the control group. There were no differences in the frequency of fetal distress or in Apgar scores.     

Terbutaline Tocolysis Prior to Cesarean Section for Fetal Distress

Two hypotheses are examined: l) side effects of terbutaline tocolysis are limited to maternal tachycardia and 2) terbutaline tocolysis at the diagnosis of fetal distress will facilitate intrauterine resuscitation while preparation for cesarean delivery is underway. This is a 10-year chart review of terbutaline tocolysis as part of the management of acute fetal distress prior to cesarean delivery. All charts were reviewed for side effects of terbutaline use. During the final 27 months, efficacy of terbutaline resuscitation was studied by comparing the scalp-pH-to-cord-pH difference of individual fetuses in the terbutaline group with those where terbutaline was not used. The mean maternal pulse after terbutaline was 113 ± 20 (SD) beats per minute (bpm). A pulse of ≥140 bpm occurred in 11.7% of the terbutaline group (n = 368). A pulse of ≥140 bpm was more common (51.0%) when preoperative vagolytic medication (n = 119) was also administered. A pulse of ≥140 bpm occurred in 1.9% of the control group (n = 215). Mean arterial pressure was not changed by terbutaline, even in the presence of preeclampsia. Of those in the terbutaline group with a scalp pH value <7.25, there were significantly fewer low, 5-min Apgar scores; fewer fetuses demonstrating a fall in pH between the paired scalp and cord values; and a greater mean pH increase than in the respective control group. Of strong clinical pertinence is that the fetuses with the lowest scalp pH had the greatest increase in pH value. Our study supports the safety and efficacy of intrauterine resuscitation by terbutaline tocolysis.     

Submucous paracervical blockade compared with intramuscular meperidine as analgesia during labor: a double-blind study

A double-blind study was carried out to compare the effect of submucous paracervical blockade using 12 mL 0.25% bupivacaine (55 women) to the effect of intramuscular injection of 75 mg meperidine (62 women) during the first stage of labor. All 117 were normal primiparous pregnancies. Seventy-eight percent of the women in the paracervical blockade group achieved full or acceptable pain relief against 31% in the meperidine group (P less than .01). Transient fetal bradycardia occurred in two cases in the paracervical blockade group and one in the meperidine group; all infants were born in good condition. Fetal distress, defined as an umbilical artery pH of 7.15 or less and/or a one-minute Apgar score of 7 or less was more frequent in the meperidine group (16 infants) than in the paracervical blockade group (six infants) (P less than .05). Submucous paracervical blockade is superior to intramuscular meperidine as pain relief during labor. Furthermore, meperidine results in more infants with asphyxia as compared with paracervical blockade.     

Effect of third-trimester premature rupture of membranes on fetal breathing movements: a prospective case-control study

Fetal breathing movements were examined in 44 women with premature rupture of membranes. All had previously uncomplicated singleton pregnancies (28 to 41 weeks). Of these 44 women, 13 had complications based on later amnionitis/neonatal infection or antepartum fetal distress. Thirty-one normal antepartum patients, matched for gestational age, served as a normal control group. These women had intact membranes and were without any known or suspected maternal, fetal, or neonatal complications. Fetal breathing movements were found in 90% of cases in the control group, compared with 65% in the 31 women with premature rupture of membranes (p less than 0.05). In the group of 13 women with premature rupture of membranes and complications, the incidence of fetal breathing movements was 38%. Therefore, it is possible that the absence of fetal breathing movements can be due to premature rupture of membranes alone. There was a statistically higher incidence of low-birth-weight infants and low Apgar scores in the group of 13 women with premature rupture of membranes and complications compared with the group of 31 women with premature rupture of membranes.     

Inducción del parto en gestantes con prueba de oxitocina de resultado dudoso

ObjetiveTo compare obstetric and perinatal outcomes in induction of labor between women with pre-pathologic or negative result of oxytocin challenge test (OCT)Material and metodsWe compared 143 women with a pre-pathologic OCT result and 306 women with a negative result. The main outcome variables were the rate of cesarean sections due to fetal distress, admision to the neonatal unit and Apgar score less than 7 at five minutes of lifeResultsThe rate of cesarean section due to fetal distress was significantly increased in the group of women with a pre-pathologic result (13.3% vs 1.9%) (p<0.001). No significant differences were found in the percentage of admissions to the neonatal unit or in Apgar scoreConclusionsInduction of labor appears to be safe in women with a pre-pathologic OCT result, even though, the rate of cesarean section due to fetal distress is obviously increased     

Single injection of terbutaline in term labor. II. Effect on uterine activity

The effect of terbutaline, 250 micrograms given as an intravenous bolus injection in term labor, was investigated with use of a transducer-tipped catheter placed in the uterine cavity. Maternal side effects were common but well tolerated. No fetal side effects were recorded. The results suggest that 250 micrograms of terbutaline as a bolus injection gives a safe and effective inhibition of uterine activity in term labor. Possible indications and benefits of transient inhibition of uterine activity in term labor, particularly when fetal distress is associated with abnormal uterine activity, are discussed.     

Clinical characteristics of pregnancies complicated by intrapartum fetal asphyxia.

The clinical characteristics of 124 pregnancies complicated by intrapartum fetal asphyxia have been reviewed. The evidence of fetal asphyxia tends to appear earlier in patients with maternal medical and obstetric complications than in those with labor complications. Evidence of clinical fetal distress was present in 36 per cent and was not related to the severity of the asphyxia. Low Apgar scores occurred in 40 per cent of infants with moderate asphyxia and in 80 per cent of infants with severe asphyxia at delivery. In the newborn infants, clinical evidence of cerebral abnormality was observed in 3 per cent, and evidence of the respiratory distress syndrome was seen in 3 per cent of the study group.     

Oxytocin use in grand-multiparous patients: safety and complications.

OBJECTIVE: To determine whether the use of oxytocin for the augmentation of labor in grandmultiparous women increases the risk of peripartum complications. STUDY DESIGN: During the years 1989-97, 11 075 grand-multiparous women delivered at our institution. In 424 grand-multiparous women, intravenous oxytocin was used for augmentation of labor. The control group consisted of the other 10 651 grand-multiparous women. All women were monitored for fetal heart rate and uterine contractions. We compared the rates of maternal and perinatal complications in these two groups by using chi(2) analysis and Fisher's exact test when appropriate. RESULTS: No significant differences were found between the oxytocin and the control groups in the rates of placental abruption, intrapartum fetal death, postpartum hemorrhage, uterine rupture, fetal distress, meconium-stained amniotic fluid, an Apgar score of less than 7 at 5 min, Cesarean section, retained placenta and vaginal and cervical lacerations. In contrast, a significant increase in the rate of vacuum deliveries was observed in patients given oxytocin as compared to controls (3.5% vs. 1.4%, respectively; p = 0.001). CONCLUSIONS: The use of oxytocin in the grand-multiparous parturient was a safe procedure with no significant increase in peripartum complications. However, a higher rate of vacuum deliveries was found.     

Oxytocin use in grand-multiparous patients: safety and complications

Objective: To determine whether the use of oxytocin for the augmentation of labor in grandmultiparous women increases the risk of peripartum complications. Study design: During the years 1989-97, 11 075 grand-multiparous women delivered at our institution. In 424 grand-multiparous women, intravenous oxytocin was used for augmentation of labor. The control group consisted of the other 10 651 grand-multiparous women. All women were monitored for fetal heart rate and uterine contractions. We compared the rates of maternal and perinatal complications in these two groups by using &#104 2 analysis and Fisher's exact test when appropriate. Results: No significant differences were found between the oxytocin and the control groups in the rates of placental abruption, intrapartum fetal death, postpartum hemorrhage, uterine rupture, fetal distress, meconium-stained amniotic fluid, an Apgar score of less than 7 at 5 min, Cesarean section, retained placenta and vaginal and cervical lacerations. In contrast, a significant increase in the rate of vacuum deliveries was observed in patients given oxytocin as compared to controls (3.5% vs. 1.4%, respectively; p = 0.001). Conclusions: The use of oxytocin in the grand-multiparous parturient was a safe procedure with no significant increase in peripartum complications. However, a higher rate of vacuum deliveries was found.     

Neonatal acidosis and method of delivery

Seven hundred and four women who had a forceps termination (177 elective, 293 indicated low, and 234 indicated midforceps) of labor over 24 months were compared with 303 spontaneous and 111 cesarean deliveries over the same time period. There was no significant difference between indicated low or midforceps either for fetal distress or arrest of descent with regard to fetal acidosis (pH less than 7.20), one- or five-minute Apgar scores less than 7, fetal trauma, or neurologic deficit at discharge. Fourteen percent of indicated forceps for arrest of descent had neonatal acidosis, versus 8% of cesarean sections for cephalopelvic disproportion (P = NS), and 23% of indicated forceps for fetal distress had acidosis, versus 33% of cesarean sections (P = not significant). There was no significant difference either in the incidence of acidosis or in low Apgar scores in neonates delivered by elective low forceps compared with those born by spontaneous vaginal delivery. The only significant differences in midforceps versus low forceps were between maternal pre- and postdelivery hematocrits (P less than .0001) and vaginal lacerations (P less than .0001). The authors' data support the continued usage of indicated low and selected midforceps operations.     

Neonatal Outcome and Its Relationship with Maternal Age

The relationship between maternal age and neonatal outcome was examined in 22,689 pregnancies using various determinants of neonatal well-being which included evidence of fetal distress, birth-weight, Apgar scores, the necessity for admission to the neonatal unit and other indicators of neonatal morbidity. Differences in the incidence of congenital malformations and perinatal mortality were also studied. There was a trend towards more frequent fetal heart monitoring, lower birth-weight and a higher rate of neonatal unit admission for infants delivered by younger women. There was also a significant increase in the Caesarean section rate with advancing maternal age. Maternal age had no effect, however, on the incidence of fetal distress, Apgar score, the development of respiratory disease, the need for intubation and ventilation nor on subsequent neonatal central nervous system complications. There was also no association between maternal age and either perinatal mortality or the incidence of congenital malformations. The favourable outcome in teenagers in this study may have been influenced by the extremely low pregnancy rate amongst young adolescents in Hong Kong, but a similar outcome in the mature age women was likely to have reflected the recognition of risk and its appropriate management.     

Elective repeat cesarean delivery versus trial of labor: a meta-analysis of the literature from 1989 to 1999

OBJECTIVE: The aim of this study was to compare a trial of labor with elective repeat cesarean delivery among women with previous cesarean delivery. STUDY DESIGN: We searched MEDLINE and EMBASE databases from 1989 through 1999 with the following terms: vaginal birth after cesarean delivery, trial of labor, trial of scar, and uterine rupture. We included all controlled trials from developed countries in which the control group had been eligible for a trial of labor. Outcomes of interest were uterine rupture, hysterectomy, maternal febrile morbidity, maternal mortality, 5-minute Apgar score <7, and fetal or neonatal mortality. We computed pooled odds ratios for each outcome. RESULTS: The search strategy identified 52 controlled studies, 37 of which were excluded because many of the control subjects were not eligible for a trial of labor. Fifteen studies with a total of 47,682 women were included. Uterine rupture occurred more frequently among women undergoing a trial of labor than among those undergoing elective repeat cesarean delivery (odds ratio, 2.10; 95% confidence interval, 1.45-3.05). There was no difference in maternal mortality risk between the 2 groups (odds ratio, 1.52; 95% confidence interval, 0.36-6.38). Fetal or neonatal death (odds ratio, 1.71; 95% confidence interval, 1.28-2.28) and 5-minute Apgar scores <7 (odds ratio, 2.24; 95% confidence interval, 1.29-3.88) were more frequent in the trial of labor group than in the control group. Mothers undergoing a trial of labor were less likely to have febrile morbidity (odds ratio, 0.70; 95% confidence interval, 0.64-0.77) or to require transfusion (odds ratio, 0.57; 95% confidence interval, 0.42-0.76) or hysterectomy (odds ratio, 0.39; 95% confidence interval, 0.27-0.57). CONCLUSION: A trial of labor may result in small increases in the uterine rupture rate and in fetal and neonatal mortality rates with respect to elective repeat cesarean delivery. Maternal morbidity, including febrile morbidity, and the need for transfusion or hysterectomy may be reduced with a trial of labor.     

The use of fetal biophysical profile improves pregnancy outcome in premature rupture of the membranes

A protocol using daily fetal biophysical assessment was applied in 73 consecutive patients with premature rupture of the membranes and no clinical signs of infection or labor. A persistently low biophysical score (7 or less on two examinations 2 hours apart) in the presence of a nonreactive nonstress test and absence of fetal breathing was used as an indication for delivery. Measures of pregnancy outcome included the presence of amnionitis or neonatal infection. The outcome of pregnancy in this group of patients was compared with the outcomes of two historic groups: one managed conservatively (control group) and the other managed with amniocentesis on admission to the hospital (amniocentesis group). Infection outcome, maternal as well as neonatal, and low 5-minute Apgar scores were significantly less in the study than in the control group. The frequency of neonatal sepsis was significantly less in the study than in the amniocentesis group. These data suggest that management of premature rupture of the membranes with daily fetal biophysical profiles improves pregnancy outcome by reducing the incidence of maternal and neonatal infection.     

A prospective controlled trial of metoprolol-hydralazine treatment in hypertension during pregnancy

In an open, controlled trial, treatment with a combination of metoprolol and hydralazine was compared with non-pharmacological management of mild and moderate hypertension in pregnancy. One hundred and sixty-one women participated in the study. The drug-treated group showed significantly better blood pressure control than the group not given antihypertensives. Induction of labor before term, because of maternal or fetal complications, was somewhat more frequent in the control group. Nine women in the treatment group and 5 in the control group developed albuminuria. Three infants in the drug-treated group died perinatally, and one in the control group. The outcome for the newborns was similar in both groups concerning birth weight, head circumference and Apgar score and in the frequencies of respiratory distress, bradycardia and hypoglycemia. The better blood pressure control achieved with these drugs makes it possible to treat the patient at home and reduce the risk of emergency delivery, but treatment does not seem to be mandatory for a good outcome of the pregnancy in cases of mild and moderate hypertension during pregnancy.     

Intrauterine resuscitation with terbutaline: a method for the management of acute intrapartum fetal distress

Terbutaline, a selective beta-2 adrenergic receptor stimulator, has been used to decrease myometrial activity and improve uteroplacental blood flow in 15 patients with acute intrapartum fetal distress. In all cases electronic monitoring gave evidence of partial or total fetal recovery after therapy. Thirteen of these patients were delivered by cesarean section and two were allowed to resume labor and deliver vaginally. In 10 cases the initial Apgar score was 7 or more and in all cases the score was 7 or more after 5 minutes of life. No significant maternal morbidity occurred as a consequence of the treatment. These results suggest that inhibition of uterine activity with terbutaline may be a valuable maneuver in the management of patients with severe intrapartum fetal distress.     

Induction of labor with vaginal prostaglandin E2 pessaries

Prostaglandin E2 vaginal pessaries (3 mg) were compared with conventional amniotomy and oxytocin infusion as a method of induction of labor in 160 patients in the study group compared with 160 in the control group. Each group consisted of 100 primigravidae and 60 multigravidae. When the features of labor, delivery and fetal status were analyzed for the study and the control groups, the patients who received PGE2 pessaries had a better outcome. The difference was more significant for those patients with a low Bishop score. Compared with controls, the PGE2-treated patients had fewer cesarean sections either for failed induction or fetal distress (P less than 0.01); the incidence of infants with low Apgar score was significantly less (P less than 0.05) and there were fewer postpartum haemorrhages (P less than 0.01).     

Acute Tocolysis for Fetal Distress: Terbutaline Versus Magnesium Sulphate

Summary: Forty-six women in active labour who developed fetal distress requiring abdominal delivery were randomized to receive 0.25 mg of terbutaline (subcutaneously) or magnesium sulphate as a 4-g bolus (intravenously) to decrease uterine activity. The terbutaline-treated group in contrast to the magnesium sulphate-treated group had reduced uterine activity as measured by Montevideo units (p <0.002). This decrease in uterine activity was noted more rapidly in all 23 patients who received terbutaline, 1.8 ±0.74 minutes compared to 7.5 ±2.1 minutes in the 16 of 23 patients (magnesium sulphate-treated women) in whom a decrease in uterine activity occurred (p <0.001). Umbilical cord arterial blood pH at delivery was less than 7.20 in only 2 of the 23 patients treated with terbutaline versus 7 of the 23 in the magnesium sulphate-treated group. We conclude that terbutaline is an effective and more rapid-acting tocolytic agent to arrest uterine activity prior to delivery for fetal distress.