A comparison of two methods of labor induction with vaginal misoprostol

Objectives: To evaluate if labor induction with 50 μg of vaginal misoprostol twice per day is as effective as and safer than 100 μg used once per day. Methods: Misoprostol was used to induce labor in 204 consecutive pregnant women assessed as needing labor induction, 104 at the University Hospital of the West Indies in Kingston, Jamaica, and 100 at the Victoria Jubilee Hospital, also in Kingston. At the former institution the women were administered 100 μg of misoprostol once per 24 h and at the latter 50 μg every 12 h. The doses were repeated if there was no cervical change or if the woman was not in labor. Bishop scores were determined before initiation of induction and again 12 h later. Women's records were reviewed after 24 h to determine delivery outcome. Results: The indications for labor induction were similar in each group. There was no significant difference in the group demographics. In the group given 50 μg of misoprostol twice per day the mean time±S.D. from insertion of misoprostol to delivery was significantly shorter than in the other group (560.14±269.20 min vs. 729.90±471.65 min; P<0.01), and the percentage of women who were delivered within 12 h was higher (75% vs. 56.8%; P<0.002). There was no significant difference between the two groups in the rate of cesarean births, the need for oxytocin, or blood loss. Only two patients experienced uterine hyperstimulation, both in the group that had received 100 μg of misoprostol per day. There was no significant difference between the two groups in the birthweight of the neonates and in the number of neonates with Apgar scores less than 7 at 1 min and 5 min. There were, however, significantly fewer neonates who needed resuscitation (6% vs. 14.7%; P=0.04) and admission to the special care nursery (7% vs. 17%; P=0.03) in the group that had received 50 μg of misoprostol twice per day. Conclusions: A dose of 50 μg of misoprostol twice per day appears to be more efficient and safer than a dose of 100 μg once per day, but this may partially be due to weaknesses in the study design.     

Outcome in obstetric care related to oxytocin use. A population-based study

BACKGROUND: The purpose of this study was to investigate the delivery outcome in relation to oxytocin use in labor. METHODS: We studied 106,755 deliveries from 1995 to 2002 in the Perinatal Revision South, a population-based register comprising information from 10 hospitals in southern Sweden. RESULTS: Oxytocin use in labor increased from 27.6% in 1995/96 to 33.2% in 2001/02 (p<0.000006). Oxytocin was administered to 47.7% of the nulliparas and 18.5% of the multiparas. There were large differences between hospitals (range among nulliparas: 32.6-60.4%; among multiparas: 13.9-27.0%). After exclusion of deliveries with induction of labor and deliveries lasting >12 h, there was a significant association between oxytocin use and Apgar score < 7 at 5 min (OR 2.3; 95% CI 1.8-2.9), need for neonatal intensive care (OR 1.6; 95% CI 1.5-1.7), and operative delivery (OR 4.0; 95% CI 3.7-4.2). CONCLUSIONS: In deliveries with relatively short duration (< or =12 h), a significant association was seen between oxytocin use and adverse outcome. Even though the results are difficult to interpret, the significant difference between the use of oxytocin in different hospitals, as well as the increase of oxytocin use over time, calls for a randomized controlled study to elucidate the advantages and disadvantages of oxytocin use during labor and delivery.     

Meconium stained amniotic fluid in very low risk pregnancies at term gestation

Objective: To determine the prevalence and clinical significance of meconium stained amniotic fluid (MSAF) in a low risk population at term gestation and to investigate whether MSAF is a predictor for intrapartum and neonatal morbidity. Methods: A very low risk population including 37 085 consecutive deliveries at term composed the study population. A cross-sectional study was conducted and two groups of patients were identified according to the presence (n=6164) or absence (n=30 921) of meconium in the amniotic fluid at delivery and the outcomes of the two groups compared. Results: The prevalence of MSAF was 16.6%. The incidence of cesarean section (5.6% vs 2.3% P<0.01), instrumental deliveries (3.2% vs 1.8% P<0.01), fetal distress (6.5% vs. 2.1% P<0.01), clinical chorioamnionitis (0.2% vs. 0.1% P<0.01), post-partum infection (0.5% vs. 0.2% P<0.01), 1-minute Apgar score <3 (1.9% vs. 1.1% P<0.01), small for gestational age (7.4% vs. 6.4% P<0.01). was significantly higher in the MSAF compared with the clear amniotic fluid group. Intrapartum and neonatal mortality in this low risk population was significantly higher in the MSAF group ( ) compared with women with clear AF ( ). Conclusions: MSAF in a low risk population at term gestation is a predictor for adverse perinatal outcome and peripartum complications.     

Impact of labor induction,gestational age,and maternal age on cesarean delivery rates

OBJECTIVE: To quantify the impact of labor induction and maternal age on cesarean delivery rates in nulliparous and multiparous women between 36 and 42 weeks' gestation. METHODS: We performed a retrospective cohort study on 14,409 women delivering at two teaching hospitals in metropolitan Boston during 1998 and 1999. Women who had contraindications to labor, including a prior cesarean delivery, were excluded. The risks for cesarean delivery by induction status, gestational age by completed week between 36 and 42 weeks, maternal age <35, 35-39, and >/=40 years, and stratified by parity, were calculated by logistic regression. RESULTS: In nulliparas, labor induction was associated with an increase in cesarean delivery from 13.7% to 24.7% (adjusted odds ratio [OR] 1.70; 95% confidence interval [CI] 1.48, 1.95]). In multiparas, induction was associated with an increase from 2.4% to 4.5% (OR 1.49; 95% CI 1.10, 2.00). Other variables that placed a nulliparous woman at increased risk for cesarean delivery included maternal age of at least 35 years and gestational ages over 40 weeks. For multiparas, only maternal age 40 years or older and gestational age of 41 weeks were associated with an increase in cesarean deliveries. CONCLUSION: Induction of labor, older maternal age, and gestational age over 40 weeks each independently increase the risk for cesarean delivery in both nulliparous and multiparous women. Although the relative risk from induction is similar in nulliparas and multiparas, the absolute magnitude of the increase is much greater in nulliparas (11% versus 2.1%).     

Evaluating progress of labor in nulliparas and multiparas using the modified WHO partograph

OBJECTIVE: To evaluate the progress of labor in nulliparas and multiparas using the modified World Health Organization (WHO) partograph. METHOD: In a prospective study 259 nulliparas and 204 multiparas were compared for rates of normal labor progression in the active phase; of cervical dilatation plots crossing the alert line of the partograph; and of plots reaching or crossing the action line. Outcome measures were total duration of labor, mode of delivery, incidence of labor augmentation, and number of vaginal examinations. RESULTS: Labor duration was similar in the 2 groups and cervical dilatation remained normal for most women. In both groups, the incidence of spontaneous vaginal delivery was highest among women with normal labor progress and the incidence of both labor augmentation and operative intervention increased when labor progress was delayed. CONCLUSION: Labor progress and duration were found similar for nulliparas and multiparas when monitored with the modified WHO partograph. Delay in labor progress increased the need for operative intervention and adversely affected fetal outcome.     

Cervical assessment in women with threatened preterm labor.

OBJECTIVE: The aim of the study was to examine the clinical value of cervical assessment by transvaginal ultrasonography in women with symptoms of preterm labor. METHODS: We prospectively evaluated 172 women with singleton pregnancies and symptoms of preterm labor. Seventy of them were nulliparas, while 102 were multiparas. Gestational age ranged between 24 and 34 wks. All women underwent cervical assessment with transvaginal ultrasonography and were given intravenous tocolytics. The only parameter evaluated was cervical length. Women with multiple pregnancies, gestational age <24 wks or >34 wks, cervical dilatation >2 cm, placenta praevia, premature rupture of membranes, or cervical cerclage were excluded from the study. The outcome measure was delivery before 34 wks gestation. RESULTS: The preterm delivery rate before 34 wks was 37%. The sensitivity and the specificity of a cervical length of less than 20 mm was 60 and 53.8% and 97.7 and 95.2% for nulliparas and multiparas, respectively. A cervical length <20 mm was also 93.7% predictive of preterm delivery in nulliparas and 87.5% in multiparas, while the corresponding numbers for its negative predictive value (NPV) were 81.4 and 76.9%, respectively. CONCLUSIONS: Cervical assessment in women with symptoms of preterm labor can distinguish those at high risk for preterm delivery. Cervical sonography can be a valuable adjunct to the clinical evaluation of these patients.     

Cervical score and onset of spontaneous labor in prolonged pregnancy dated by second-trimester ultrasonic scan

The interval from expected day of delivery to spontaneous onset of labor was correlated with parity and cervical score in 103 women with uncomplicated prolonged pregnancy (greater than 294 days). All women had a routine ultrasonic scan in weeks 16-18 for the purpose of dating. The mean (+/- SD) modified Bishop score on entry to the study was 4.15 +/- 2.0 for nulliparas and 4.90 +/- 2.1 for multiparas. The duration beyond 294 days to spontaneous onset of labor varied little (mean 3.5-4.5 days) for nulliparas with scores greater than 2 and for multiparas regardless of score. Nulliparous women with a poor score (less than 3) had spontaneous onset of labor and delivery within a mean of 9.8 days. Half of the multiparas (50.0%) and 43.9% of the nulliparas gave birth within 3 days. About 90% of all women gave birth within 7 days. All but three had a vaginal delivery; the instrumental vaginal delivery rate was 16.3%. The results suggest that in postterm women dated with a second-trimester ultrasonic scan, the cervical scores are in general more favorable than previously reported in series not dated with early scans. The postterm group is also much smaller, and the time interval from entry into the postterm period to spontaneous onset of labor is shorter.     

Membrane sweeping in conjunction with labor induction

OBJECTIVE: To determine whether cervical membrane sweeping (stripping) during induction of labor is beneficial.METHODS: We compared outcomes of labor after induction in pregnant women at term in a randomized trial. Women were assigned to having their membranes swept or not during induction. Outcome measures included duration of labor, maximum dose of oxytocin used, induction-labor interval, and mode of delivery.RESULTS: We recruited 130 nulliparas (64 sweep, 66 nonsweep) and 118 multiparas (60 sweep, 58 nonsweep). Among nulliparas who received intravaginal prostaglandin (PG) E(2) and oxytocin, those who had simultaneous sweeping had significantly shorter mean (+/- standard error of mean) induction-labor interval (13.6 +/- 1.4 versus 17.3 +/- 1.2 hours, P =.048), lower mean maximum dose of oxytocin (6.8 +/- 0.8 versus 10.35 +/- 1.1 mU/minute, P =.01), and increased normal delivery rates (vaginal delivery 83. 3% versus 58.2%, P =.01). Sweeping also had a favorable effect on nulliparas who received oxytocin alone (mean induction-labor interval 5.8 +/- 3.1 versus 11.2 +/- 3.6 hours, P =.04; mean maximum dose 8.8 +/- 1.3 versus 16.3 +/- 1.9 mU/min, P =.01). Those differences were limited to women with unfavorable cervices. There were no differences in any outcome measures in multiparous women. CONCLUSION: Sweeping of the membranes during induction of labor had a beneficial effect on labor and delivery, which appeared to be limited to nulliparas with unfavorable cervices who needed cervical priming with PGE(2).     

Recrudescent herpes labialis during and prior to early pregnancy

Objectives: To assess the experience of recrudescent herpes labialis (RHL) before and during early pregnancy. Methods: History of RHL prior to and during the first trimester of pregnancy was obtained from 3738 women attending at 10–15 weeks’ gestation. The influence of age, ethnicity, socioeconomic group, smoking behavior, and alcohol intake on RHL was assessed. Results: 1066 women (28.5%) reported a history of RHL lesions, with reduced incidence of RHL during pregnancy (0.111 lesions/subject per month) compared with outside pregnancy (0.19 lesions/subject per month) (P<0.0001). Those who did report lesions during pregnancy (n=296) experienced them at a higher monthly rate (0.41 lesions/subject per month) than before pregnancy (0.25 lesions/subject per month) (P<0.0001). RHL rate in early pregnancy was related solely to the previous rate of lesion recrudescence (P<0.001). Conclusion: Pregnant women with a history of RHL report reduced incidence of RHL during pregnancy.     

Effect of availability of a parturient-elective regional labor pain relief service on the mode of delivery.

BACKGROUND/PURPOSE: Regional analgesia for labor pain relief is effective and widely used. This study evaluated the controversial association between mode of operative delivery and patient-elective labor regional analgesia. METHODS: We retrospectively compared the rates of instrumental vaginal and cesarean deliveries in parturients before the introduction, in the first 15 months after, and in the subsequent 36 months after the implementation of an elective labor regional analgesia service. A total of 9779 low-risk singleton cephalic pregnancies above 36 weeks of gestation were included. The maternal and fetal outcomes for parturients before the service was implemented and in those with or without pain relief service in the two postimplementation periods were analyzed. Multivariate logistic regression analyses were used to investigate the effects of maternal age, gestational weeks and newborn weight, in addition to regional analgesia, on the mode of delivery in nulliparous women. RESULTS: After adjusting for maternal age, gestational weeks, and newborn weight, no significant association was found between regional analgesia and cesarean delivery in nulliparas. Further, this lack of association was not affected by the receipt of regional analgesia in the early period of program implementation or in the period after staff had become familiar with the service. A higher rate of instrumental vaginal delivery was noted in nulliparas given regional analgesia. CONCLUSION: Regional analgesia for pain relief increased the likelihood of instrumental vaginal delivery, but did not increase the likelihood of cesarean delivery.     

Acupuncture as Pain Relief During Delivery: A Randomized Controlled Trial

ABSTRACT: Background: Many women need some kind of analgesic treatment to relieve pain during childbirth. The objective of our study was to compare the effect of acupuncture with transcutaneous electric nerve stimulation (TENS) and traditional analgesics for pain relief and relaxation during delivery with respect to pain intensity, birth experience, and obstetric outcome. Methods: A randomized controlled trial was conducted with 607 healthy women in labor at term who received acupuncture, TENS, or traditional analgesics. Primary outcomes were the need for pharmacological and invasive methods, level of pain assessed by a visual analogue scale, birth experience and satisfaction with delivery, and pain relief evaluated at 2 months postpartum. Secondary obstetric outcomes were duration of labor, use of oxytocin, mode of delivery, postpartum hemorrhage, Apgar score, and umbilical cord pH value. Analysis complied with the intention‐to‐treat principle. Results: Use of pharmacological and invasive methods was significantly lower in the acupuncture group (acupuncture vs traditional, p < 0.001; acupuncture vs TENS, p = 0.031). Pain scores were comparable. Acupuncture did not influence the duration of labor or the use of oxytocin. Mean Apgar score at 5 minutes and umbilical cord pH value were significantly higher among infants in the acupuncture group compared with infants in the other groups. Conclusions: Acupuncture reduced the need for pharmacological and invasive methods during delivery. Acupuncture is a good supplement to existing pain relief methods. (BIRTH 36:1 March 2009)     

Foley catheter with simultaneous oxytocin on labor induction: a meta-analysis of randomized controlled trials

Objective: It is unclear that whether Foley catheter with simultaneous oxytocin could improve the efficacy of induction outcome.

Method: To conduct a meta-analysis of randomized controlled trial (RCT) studies to evaluate the effect of Foley catheter with simultaneous oxytocin on labor induction. PubMed, Embase, and other databases were searched from their inception to July 2017. We included all RCTs comparing Foley catheter with simultaneous oxytocin (i.e. intervention group) with Foley catheter followed by oxytocin (i.e. control group) in the three kinds of women (nulliparas and multiparas/only nulliparas/only multiparas). We estimate summarized relative risk (RR) and 95% confidence intervals (CIs) for dichotomous outcomes, standard mean difference for continuous outcomes. Fixed- and random-effects models were used, depending on heterogeneity.

Results: After application of our inclusion and exclusion criteria, six RCTs with a total of 1133 participants were identified. We found that only nulliparas had significant RR of delivery within 24?h (RR?=?1.32, 95% CI: 1.12, 1.55, I²?=?46.5%). Meanwhile, there was no statistically significant difference between intervention and control groups in vaginal delivery in 24?h, cesarean delivery, time to delivery, and Apgar score at 5?min less than 7. Foley catheter with simultaneous oxytocin did not increase the risk of side effects, included chorioamnionitis, postpartum hemorrhage, uterine hyperstimulation, and neonatal intensive care unit admission.

Conclusion: The results seem to support the use of oxytocin to a Foley catheter at the initiation of labor induction, as it might lead to increases the rate of delivery within 24?h in nulliparas.     

Duration of labor. An analysis of influencing factors

9703 labors at Akershus Central Hospital during the period January 1979 to January 1984 were analysed to see which factors influenced the duration of labor. Median duration was 8.2 h for nulliparas, 5.3 h for multiparas. Parity greater than one had no influence on duration. Induced labors were 1.9 h (nulliparas) and 1.4 h (multiparas) shorter than those with spontaneous onset. Stepwise linear regression showed that duration of labor was positively correlated with the weight of the infant, duration of pregnancy, weight gain and prepregnant weight. It was negatively correlated with mother's height. Mother's age did not influence duration of labor. Occiput posterior presentation and extensions of the head prolonged labor in nulliparas, but not in multiparas, while breech presentation had no influence.     

Cervical assessment in women with threatened preterm labor

Objective.?The aim of the study was to examine the clinical value of cervical assessment by transvaginal ultrasonography in women with symptoms of preterm labor.

Methods.?We prospectively evaluated 172 women with singleton pregnancies and symptoms of preterm labor. Seventy of them were nulliparas, while 102 were multiparas. Gestational age ranged between 24 and 34 wks. All women underwent cervical assessment with transvaginal ultrasonography and were given intravenous tocolytics. The only parameter evaluated was cervical length. Women with multiple pregnancies, gestational age <?24 wks or >?34 wks, cervical dilatation >?2?cm, placenta praevia, premature rupture of membranes, or cervical cerclage were excluded from the study. The outcome measure was delivery before 34 wks gestation.

Results.?The preterm delivery rate before 34 wks was 37%. The sensitivity and the specificity of a cervical length of less than 20?mm was 60 and 53.8% and 97.7 and 95.2% for nulliparas and multiparas, respectively. A cervical length <?20?mm was also 93.7% predictive of preterm delivery in nulliparas and 87.5% in multiparas, while the corresponding numbers for its negative predictive value (NPV) were 81.4 and 76.9%, respectively.

Conclusions.?Cervical assessment in women with symptoms of preterm labor can distinguish those at high risk for preterm delivery. Cervical sonography can be a valuable adjunct to the clinical evaluation of these patients.     

Effect of long-term hormone replacement therapy on the bone in ovariectomized women with cancer

Objective: To evaluate longitudinally the effectiveness of long-term hormone replacement therapy (HRT) in preserving the bone mineral density (BMD) over a 5-year period in ovariectomized patients treated for gynecologic malignancies. Methods: A total of 70 pre-menopausal women ovariectomized for gynecologic malignancies at our hospital were divided non-randomly into two groups: HRT (+) group (n=59) and HRT (−) group (n=11). HRT was administered in a sequential regimen of 0.625–1.25 mg conjugated estrogen for 24 days and 5–10 mg medroxyprogesterone acetate for 10 days. Results: The BMD of the lumbar vertebrae decreased significantly in the HRT (−) group (pre-operative BMD was 91.8%, 91.0% and 91.3% at 1, 2 and 3 years post-ovariectomy), but no decrease in the BMD was observed in the HRT (+) group (pre-operative BMD was 98.4%, 99.0%, 99.4%, 98.8% and 98.7% at 1, 2, 3, 4 and 5 years post-ovariectomy); the difference in BMD between the two groups was statistically significant (P<0.01). Serum alkaline phosphatase levels were significantly lower in the HRT (+) group than in the HRT (−) group (P<0.01). There were four recurrences of cancer in the HRT (+) group. Conclusion: HRT appeared to have beneficial effects on bone metabolism by maintaining BMD for 5 years in ovariectomized patients for gynecologic malignancies.     

Tamoxifen and proliferation of vaginal and cervical epithelium in postmenopausal women with breast cancer

Objective: The estrogenic effect of tamoxifen on vaginal and cervical epithelium in postmenopausal women with breast cancer is evaluated. Study Design: The tamoxifen group consisted of 92 postmenopausal breast cancer patients, the control group I of 30 postmenopausal women with breast cancer receiving no endocrine therapy and the control group II of 40 postmenopausal women without primary breast cancer taking no hormones. We determined the maturation index and the incidence of endocervical cell hyperplasia and metaplasia in cervical and vaginal smears. Results: The maturation index increased under tamoxifen within the first 24 months from 0.4011 before taking tamoxifen (n = 56) to 0.6039 (n = 138, P<0.0001). The maturation index in the group treated with tamoxifen was statistically significantly higher (P<0.0001) than in the control groups (control group I: 0.3975, P<0.0001; control group II: 0.4102, P<0.0001). Under therapy with tamoxifen endocervical cell hyperplasia (P=0.00156) and metaplasia (P=0.00123) appeared significantly more often. Conclusion: An apparent increase not only of the incidence of endocervical cell hyperplasia and metaplasia but also of the maturation of the vaginal epithelium caused by the estrogenic effect of tamoxifen could be demonstrated.     

An Evaluation of Pain and “Fitness” During Labor and Its Acceptability to Women

Abstract: Background : Labor experiences involve many dimensions that change during labor but are rarely measured contemporaneously and longitudinally. We examined pain and “fitness” aspects of women's labor experience and assessed the acceptability to participants. Methods : Thirty nulliparas and 20 multiparas in term labor indicated pain and fitness every 45 minutes in contraction‐free intervals on visual analog scales from 0 to 10. Fitness implied both physical and psychological strength. Data were analyzed cross‐sectionally and longitudinally, with adjustment for analgesia and time dependency. Women received feedback and evaluated their participation on the first day postpartum. Results : Measurements of pain and fitness ranged from 2 to 22 per woman (mean ± SD: 7.4 ± 4.4). Pain scores showed various patterns, mostly increasing from 1.4 (± 1.9) at the first to 6.6 (± 3.8) at the last measurement in nulliparas and from 1.3 (± 2.1) to 6.2 (± 4.0) in multiparas. One half of the women declined steadily in fitness throughout labor, occasionally after a slight increase early on. Multiparas entered labor more fit (5.9 ± 3.0) than nulliparas (3.9 ± 2.7), but showed a sharper decline so that the difference leveled out just before birth. Although fitness at any one time did not reflect pain levels, fitness and pain were inversely related, especially in nulliparas (p = 0.003). Analgesia affected pain scores but affected fitness only a little. Women's responses were mainly positive, especially in appreciating the feedback. Nevertheless, 32 percent of women skipped one or more measurements, often toward the end or when too close to a contraction. Conclusions : Pain and “fitness” are two distinctly different dimensions of labor experience. Repeated longitudinal measurements of elements of well‐being are clearly feasible and acceptable to laboring women. They may be useful to assess how labor events and interventions affect women's well‐being.     

Calcium to creatinine ratio in a spot sample of urine for early prediction of pre-eclampsia

Objectives: Based on the fact that urinary calcium excretion decreases in pre-eclampsia, this study was designed to determine the predictive value of calcium to creatinine ratio in a spot urine sample. Methods: The calcium to creatinine ratio was measured in a spot urine sample of 102 normotensive women at 20–24 weeks’ gestation who attended the prenatal care clinic of the Shiraz University of Medical Sciences. The women were followed-up until delivery and grouped according to pre-eclampsia occurrence. The prevalence of pre-eclampsia was measured and compared with the calcium to creatinine ratio. Results: Ninety-four women remained normotensive during pregnancy and eight developed pre-eclampsia. Mean age, gestational age at the beginning of the study, and gestational age at delivery did not differ significantly between the two groups. Mean urinary calcium concentration (15.9±8.5 mg/dl in normotensive vs. 10.2±7.5 mg/dl in pre-eclamptic women), and mean birth weight (3192±336.3 g vs. 2712±468.9 g) were significantly lower in pre-eclamptic patients (P=0.03 and 0.005, respectively). Mean calcium to creatinine ratio was also significantly lower in the pre-eclamptic group (P<0.03). Conclusions: Single urine calcium to creatinine ratio may be an effective method for screening women at greatest risk for pre-eclampsia.     

A comparative study of transcutaneous electrical nerve stimulation (TENS), entonox, pethidine + promazine and lumbar epidural for pain relief in labor

Analgesic effect, labor outcome, safety and consumer satisfaction were compared in 170 primigravid women; 50 using TENS initially for pain relief, 20 using entonox, 50 pethidine + promazine and 50 lumbar epidural. 88% choosing epidural related it fully effective. 90% using entonox, 96% using TENS and 54% given pethidine + promazine found partial relief. 82% of patients given TENS and 80% given pethidine + promazine required additional analgesia. This was also needed by one of the 20 patients choosing entonox. Women using entonox alone had the shortest labors and women using lumbar epidural, the longest. Operative delivery was significantly more common in women receiving lumbar epidural. No significant inter-group differences were noted in cord pH or Apgar scores. Parturients and midwives both gave high consumer satisfaction ratings to all methods--except for pethidine + promazine, whose use must therefore be questioned. The analgesic efficacy of lumbar epidural outweighs any possible side effects. Entonox appears suited to those able to cope with the earlier part of labor, drug-free. Realization of the potential of TENS requires the design of machines specifically to cope with the quality of the pain of labor.     

Three-dimensional ultrasound power Doppler assessment of the cervix: comparison between nulliparas and multiparas

AIM: To assess the sonographic cervical characteristics between nulliparous and multiparous women. SUBJECT AND METHODS: Transvaginal three-dimensional ultrasound and power Doppler using the virtual organ computer-aided analysis (VOCAL) program were performed on 71 nulliparas and 59 multiparas at a mean gestational age of 25.3+/-7.9 weeks. We compared the cervical volume and power Doppler vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) between nulliparas and multiparas. RESULTS: The mean cervical volume and mean VI, VFI, FI measurements were not significantly different between multiparas and nulliparas. CONCLUSION: Our observations suggest that the morphological changes in the cervix of parous women are merely configurational without a change in cervical mass and vascularization. These configurational changes might result from the inevitable cervical stretching during labor and represent a healing process that does not involve a subsequent change in mass or vascularity.