Does a policy of earlier induction affect labour outcomes in women induced for postmaturity? A retrospective analysis in a tertiary hospital in the North of England

Objectivesto investigate whether a change in the management of postmature pregnancy to earlier induction affects the length of labour and the induction process. Secondly, to assess the feasibility of the research process to inform a future larger study.Designa change in management of postmature pregnancy in an NHS hospital in October 2013, from induction at 42 weeks gestation to induction between 41–42 weeks, provided an opportunity to conduct a retrospective analysis. Pre-existing data from the maternity database and casenotes were collected and primary outcomes analysed using the Mann-Whitney test and the Hodges-Lehman confidence interval for differences in medians.Settinga large city based tertiary referral hospital in the North of England.Participants125 women induced before the change in policy were compared with 309 women induced after the change.Measurementsprimary outcomes were length of 1st and 2nd stage of labour, overall length of labour, length of induction to established labour and length of induction to birth.Findingsthe median overall length of labour for women induced at 42 weeks was 6.5 hours, while for women induced at 41–42 weeks this was 5.2 hours. The difference was not statistically significant (p=0.15, 95% CI for median difference −0.27 to 1.93 hours) with a small effect size (Pearson's r=−0.08). The median length of induction to birth was 13.6 hours for women induced at 42 weeks and 16.5 hours for women induced at 41–42 weeks. This difference was also not statistically significant (p=0.14, 95% CI for median difference −7.25 to 1.20 hours) with a small effect size (Pearson's r=−0.13).Key conclusions and implications for practiceThis study demonstrated no statistically significant differences in length of labour and induction following a change in the management of postmature pregnancy to earlier induction. A large study is needed to establish definitively the effects of earlier induction on labour outcomes.     

Is there a place for inhibition of cervical ripening in the management of preterm labour?

Although premature cervical ripening is one of the two major pathophysiological processes occurring in preterm labour, research has mostly focused on the development of tocolytic agents. Our goal in this study was to review the recent progress made in the understanding of cervical ripening physiology and to explore the molecules that could be targeted for the development of new pharmacological compounds capable of inhibiting this process and to further improve the management of preterm labour.     

Does fetal fibronectin testing change patient management in women at risk of preterm labour?

Objective

To determine clinicians’ indications for, and actions following, fetal fibronectin testing in both symptomatic and asymptomatic women between 23⁺⁰ and 34⁺⁶ weeks’ gestation.

Study design

Following clinician education of the predictive ability of fetal fibronectin testing, results of all fetal fibronectin tests done at St Thomas’ Hospital over a 6-week period were analysed. Clinicians were asked if the result changed management and if a reciprocal result would have altered management.

Results

Ninety-seven fetal fibronectin tests were conducted of which 21 (22%) were positive. Follow-up was done for 91 tests of which 25 (28%) test results directly changed management; 81 (89%) test results had the potential to change management independent of the test result.

Conclusion

The results of fetal fibronectin testing directly influenced management in a significant number of patients. A large number of women were asymptomatic at testing. Fetal fibronectin testing could be offered more widely and has the potential to benefit patient management.     

What do midwives need to know about approaches of women towards labour pain management? A qualitative interview study into expectations of management of labour pain for pregnant women receiving midwife-led care in the Netherlands

Objective

to investigate factors important to women receiving midwife-led care with regard to their expectations for management of labour pain.

Design

semi-structured ante partum interviews and analyses using constant comparison method.

Participants

fifteen pregnant women between 36 and 40 weeks gestation receiving midwife-led care.

Setting

five midwifery practices across the Netherlands between June 2009 and July 2010.

Main outcome

women's expectations regarding management of labour pain.

Results

we found three major themes to be important in women's expectations for management of labour pain: preparation, support and control and decision-making. In regards to all these themes, three distinct approaches towards women's planning for pain management in labour were identified: the ‘pragmatic natural’, the ‘deliberately uninformed’ and the ‘planned pain relief’ approach.

Conclusion

midwives need to recognise that women take different approaches to pain management in labour in order to adapt care to the individual woman.     

How does a concomitant surgery effect the outcomes of Burch colposuspension?

AIM: To evaluate the outcomes of 90 Burch colposuspension procedures with or without concomitant surgery after a 6-year follow-up period. METHODS: The study was carried out in the urogynecology department of Ankara Etlik Women's and Maternity Teaching Hospital, Turkey. Ninety women who were diagnosed as having genuine stress urinary incontinence (GSI) were enrolled in this study. The Burch colposuspension procedure was performed for the treatment of genuine stress urinary incontinence with or without a concomitant surgery RESULTS: After a 6-year follow-up, it has been noted that concomitant surgeries have no effect on the outcome of continence (P>0.05). Pelvic prolapse incidence was 7%. No voiding difficulty was observed. CONCLUSION: The study shows that concomitant surgeries have no effect on the outcome of continence. However, concomitant surgery can increase operational morbidity. Modified McCall culdoplasty does not seem to be a preventive measure for pelvic organ prolapse.     

What is the role of assisted reproduction technology in the management of age-related infertility?

Although in the UK the upper age limit for National Health Service (NHS) provision of in?vitro fertilisation (IVF) is 39 years of age there has been an increase in number of women having fertility treatment in their 40s. However, the success rates of IVF and intra-uterine insemination (IUI) in this group remain low. Human Fertilisation and Embryology Authority (HFEA) data from 2006 showed that the live-birth rate from IVF in the UK was 11% in the age group 40-42, 4.6% in the age group 43-44 and less than 4% in women over 44. We performed a literature search for studies using terms and combinations of terms in online databases and published meta-analyses reporting the outcome of interventions in older women. This review showed that assisted reproduction technologies (ARTs) continue to have low live-birth rates in women over 40. Trials showed that assisted hatching may increase the chance of pregnancy in women with poor history. Blastocyst transfer is associated with better outcome, whereas application of pre-implantation genetic screening (PGS) in older women has not increased the success rates. It appears that, with the exception of egg-donation, ART has no answer yet to age-related decline of female fertility.     

Does a change in obstetric management influence the incidence of traumatic birth lesions in mature, otherwise healthy newborn infants?

AIM: The incidence of lesions due to birth trauma can be generally regarded as a characteristic of obstetric management; since obstetric management has changed through the years, one might expect a decrease or increase of lesions due to birth trauma in mature newborn infants. METHODS: In a retrospective study, the incidence of lesions due to birth trauma was recorded in the year 2000. In 1989, an identical study had already been carried out in the same department, employing the same criteria. The new findings were compared with the historical data. RESULTS: In the year 1989 24.6% and in 2000 13.2% showed lesions due to obstetric trauma. The episiotomy rate and lesions due to birth trauma had significantly decreased. A decline regarding the traumas per se was noticed in caput succedaneum traumas, in hematomas due to birth trauma and in clavicle fracture. The cesarean section rate among the study group increased. The cesarean section rate among the traumatized newborns decreased. CONCLUSION: Episiotomy does not prevent newborns from traumatic lesions. Gestational age and birthweight have not significantly changed throughout the years; therefore an increase in the cesarean section rate must have contributed to the decrease of birth traumas. Even during abdominal operative delivery, obstetric traumas in newborns do occur. However, an increase in cesarean sections alone can not thoroughly explain the reduction of birth lesion among newborns. Improvement in prenatal diagnostic tools and procedures, respectively, and a goal-oriented use of labor induction might also play a major role.     

Is the prophylactic administration of magnesium sulphate in women with pre-eclampsia indicated prior to labour?

Objective To determine whether prophylactic magnesium sulphate is necessary to prevent eclampsia and associated complications among women with pre-eclampsia prior to labour.
Design Case series.
Setting Tertiary referral centre.
Population Three hundred and eighteen women with pre-eclampsia (blood pressure > 140/90 mmHg and > 2+ proteinuria) who were not in labour or for planned induction thereof and had not received magnesium sulphate during transfer.
Methods Clinical evaluation of the pregnant women with careful blood pressure control. Magnesium sulphate was withheld even in the presence of imminent eclampsia. During labour, the option of magnesium sulphate prophylaxis was left to the clinician, but magnesium sulphate was administered in cases of eclampsia.
Main outcome measures Eclampsia and related complications.
Results Five women (1.5%) developed eclampsia, although none developed related complications. Women presented at an early gestational age (mean 30 weeks), with high blood pressure, often suffering from headaches. Twenty pregnancies were terminated prior to viability, of which half were terminated for maternal reasons. Ten intrauterine deaths occurred. Most often fetal distress (38.6%) initiated the delivery process, which was mainly by caesarean section (68.5%). With the exception of epigastric discomfort, symptoms and signs of imminent eclampsia decreased after admission. Blood pressure values were significantly lower at delivery although biochemistry results deteriorated from admission to delivery.
Conclusion In women with pre-eclampsia prior to labour, where blood pressure control was carefully applied but magnesium sulphate not given, the eclampsia rate was low and eclampsia did not appear to worsen the existing prognosis for mother or fetus.     

What is the role of lymphadenectomy in surgical management of patients with endometrial carcinoma?

The role of lymphadenectomy in the management of endometrial carcinoma remains controversial in gynecologic oncology. Comprehensive pelvic and paraaortic lymphadenectomy should be performed in patients with intermediate- and high-risk endometrial cancer.     

Cervical cancer screening of HIV-positive women: is a prolongation of the screening interval meaningful?

OBJECTIVE: Cervical cancer screening guidelines stated recently that the screening interval of healthy women can be extended up to 3 years. Can those recommendations be applied for high risk populations? MATERIAL AND METHODS: In a prospective setting 305 HIV-positive women have been enrolled in this analysis between September 2000 and December 2003. Patients have been characterized according to HPV (human papilloma virus) prevalence, CIN (cervical intraepithelial neoplasia) incidence and CD4 cell count. RESULTS: 41 % of all HIV-positive women were HPV positive (oncogene subtypes). In patients with diminished CD4 cells the HPV prevalence increased to 60 % (54/90). CIN was found in 27 % (83/305) women. CIN was more frequent by HPV-positive women with a CD4 cell count < 200 mm (3) (52 %, 38/72). The CIN incidence was also high in HIV-positive women with negative HPV infection and diminished CD4 cell count (39 %, 7/18 vs.7 %, 11/161). CONCLUSIONS: The current cervical cancer screening guidelines are not helpful in HIV-positive women. The CIN incidence is significantly higher as in the HIV-positive population. For this reason this high risk population as e. g. HIV-infected women need an intensive care of diagnostic tools and short screening intervals to detect CIN.     

How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes?

OBJECTIVE: The purpose of this study was to examine maternal and neonatal outcomes in relation to lengthening intervals of the second stage of labor. STUDY DESIGN: This is a retrospective cohort study of 15,759 nulliparous, term, cephalic, singleton births at the University of California, San Francisco, between 1976 and 2001. The second stage of labor was divided into 1-hour intervals. Maternal and neonatal outcomes were compared with the use of chi-squared and Student t tests, and a probability value of < or =.05 was used to indicate statistical significance. Potential confounders were controlled for with multivariate logistic regression. RESULTS: Increasing rates of cesarean delivery, operative vaginal delivery, and perineal trauma were associated with the second stage beyond the first hour. In multivariate analysis, the >4-hour interval group had higher rates of cesarean delivery (odds ratio, 5.65; P < .001), operative vaginal deliveries (odds ratio, 2.83; P < .001), 3rd- or 4th-degree perineal lacerations (odds ratio, 1.33; P = .009), and chorioamnionitis (odds ratio, 1.79; P < .001). There were no differences in neonatal acid-base status associated with length of second stage. However, there were fewer neonates with a 5-minute Apgar score of <7 (odds ratio, 0.45; P = .01). CONCLUSION: Although the length of the second stage of labor is not associated with poor neonatal outcome, a prolonged second stage is associated with increased maternal morbidity and operative delivery rates.