Influence of persistent occiput posterior position on delivery outcome.

OBJECTIVE: To evaluate the influence of intrapartum persistent occiput posterior position of the fetal head on delivery outcome and anal sphincter injury, with reference to the association with epidural analgesia. METHODS: We conducted a prospective observational study of 246 women with persistent occiput posterior position in labor during a 2-year period, compared with 13,543 contemporaneous vaginal deliveries with occiput anterior position. RESULTS: The incidence of persistent occiput posterior position was significantly greater among primiparas (2.4%) than multiparas (1.3%; P <.001; 95% confidence interval 1.4, 2.4) and was associated with significantly higher incidences of prolonged pregnancy, induction of labor, oxytocin augmentation of labor, epidural use, and prolonged labor. Only 29% of primiparas and 55% of multiparas with persistent occiput posterior position achieved spontaneous vaginal delivery, and the malposition was associated with 12% of all cesarean deliveries performed because of dystocia. Persistent occiput posterior position was also associated with a sevenfold higher incidence of anal sphincter disruption. Despite a high overall incidence of use of epidural analgesia (47% versus 3%), the institutional incidence of persistent occiput posterior position was lower than that reported 25 years ago. CONCLUSION: Persistent occiput posterior position contributed disproportionately to cesarean and instrumental delivery, with fewer than half of the occiput posterior labors ending in spontaneous delivery and the position accounting for 12% of all cesarean deliveries for dystocia. Persistent occiput posterior position leads to a sevenfold increase in the incidence of anal sphincter injury. Use of epidural analgesia was not related to the malposition.     

Epidural analgesia and third- or fourth-degree lacerations in nulliparas.

OBJECTIVE: To determine if epidural analgesia is associated with differences in rates of severe perineal trauma during vaginal deliveries. METHODS: We studied 1942 consecutive, low-risk, term, vaginal deliveries in nulliparas, including spontaneous and induced labors, at a single institution from December 1994 to August 1995. The rate of third- and fourth-degree lacerations was compared for women who had and did not have epidural analgesia for labor-pain relief. Statistical significance was determined using chi2. Logistic regression analyses were used to evaluate associations while controlling for possible confounding variables. RESULTS: Overall rates of third- and fourth-degree lacerations were 10.8% (n = 210) and 3.4% (n = 63), respectively. Epidural analgesia was given to 1376 (70.9%) women. Among women who had epidurals, 16.1% (221 of 1376) had severe perineal lacerations compared with 9.7% (n = 55) of the 566 women who did not have epidurals (P < .001; odds ratio [OR] 1.8, 95% confidence interval [CI] 1.3, 2.4). When controlling for birth weight, use of oxytocin, and maternal age in logistic regression analysis, epidural remained a significant predictor of severe perineal injury (OR 1.4, 95% CI 1.0, 2.0). Epidural use is consistently associated with increased operative vaginal deliveries and consequent episiotomies, so we constructed a logistic regression model to evaluate whether the higher rates of those procedures were responsible for the effect of epidurals on severe perineal traumas. With operative vaginal delivery and episiotomy in the model, epidural was no longer an independent predictor of perineal injury (OR 0.9, 95% CI 0.6, 1.3). CONCLUSION: Epidural analgesia is associated with an increase in the rate of severe perineal trauma because of the more frequent use of operative vaginal delivery and episiotomy.     

Epidural analgesia need not increase operative delivery rates

OBJECTIVE: We sought to examine the relationship between epidural analgesia and cesarean and instrumental vaginal delivery rates. STUDY DESIGN: This is a retrospective analysis of the first 1000 nulliparous pregnancies in women with a cephalic presentation in spontaneous labor at term in each of 3 different years, over which the epidural rate increased from 10% to 57%. RESULTS: Cesarean and instrumental vaginal delivery rates were similar in all 3 years. Demographic characteristics remained unchanged or altered in a manner that has previously been associated with an increase in intervention. Electronic fetal monitoring and first-stage oxytocin use remained unchanged, but oxytocin use in the second stage increased considerably. CONCLUSIONS: Increased use of epidural analgesia had no effect on cesarean delivery rates. Although randomized trials have suggested that it increases instrumental vaginal delivery rates, this might be overcome by active management of labor or judicious use of oxytocin in the second stage.     

Active-phase labor arrest: oxytocin augmentation for at least 4 hours

OBJECTIVE: To assess a labor-management protocol that mandated at least 4 hours of oxytocin augmentation before cesarean delivery for active-phase labor arrest. METHODS: We prospectively evaluated term gravidas in spontaneous labor with active-phase labor arrest (cervix at least 4 cm dilated and 1 cm or less of cervical progress in 2 hours). Exclusion criteria included nonvertex presentation, previous cesarean, multiple gestation, and a nonreassuring fetal heart rate tracing or chorioamnionitis at the time of labor arrest. After the diagnosis of active-phase arrest, oxytocin was initiated with an intent to achieve a sustained uterine contraction pattern of greater than 200 Montevideo units. Cesarean delivery was not performed for labor arrest until at least 4 hours of a sustained uterine contraction pattern of greater than 200 Montevideo units, or a minimum of 6 hours of oxytocin augmentation if this contraction pattern could not be achieved. RESULTS: Five hundred forty-two women were managed by the protocol, and 92% delivered vaginally. The subsequent vaginal delivery rate for parous women who had not progressed (1 cm of cervical dilation or less) despite 2 hours of oxytocin augmentation was 91%, and it was 74% for nulliparas. With no labor progress after 4 hours of oxytocin augmentation, the subsequent vaginal delivery rates were 88% for parous women and 56% for nulliparas. There were no severe maternal complications. One neonate had persistent fetal circulation and one had a positive blood culture, but both did well. CONCLUSION: Extending the minimum period of oxytocin augmentation for active-phase labor arrest from 2 to at least 4 hours was effective and safe.     

Labor course and delivery in epidural analgesia: a case-control study.

BACKGROUND: We aimed to establish if epidural analgesia is associated with a higher incidence of operative vaginal delivery, longer duration of labor and more frequent use of oxytocin than labor without analgesia. METHODS: We analyzed a cohort of 207 women with no risk factors who delivered with epidural analgesia in the labor unit of Spedali Civili, Brescia, Italy, during 2001. Length of the first and second stage of labor, mode of delivery, neonatal cord blood pH, neonatal Apgar score and neonatal outcomes were evaluated. RESULTS: Epidural analgesia was performed on request in 6%: in this group (group A) there were 141 (68%) nulliparae and 66 (32%) pluriparae; mean ( +/- standard deviation) gestational age at delivery was 39.4 +/- 1.3 weeks (range: 34.1-41.5 weeks). In this group, 184 (89%) had vaginal delivery and 23 (11%) delivered by Cesarean section. Among controls (group B), 368 (89%) had a vaginal delivery and 46 (11%) delivered by Cesarean section; vacuum extraction was used in 18 deliveries (9%) in group A and in 13 deliveries (3%) in group B. The duration of the second stage of spontaneous labor in the nulliparae of group A was significantly longer than in group B. No statistically significant differences were found between mean umbilical artery pH values of groups A and B. CONCLUSION: Our results confirm that epidural analgesia does not affect the rate of Cesarean delivery, while increasing the use of oxytocin augmentation, the duration of the second stage of labor and the rate of instrumental vaginal delivery.     

Does epidural analgesia prolong labor and increase risk of cesarean delivery? A natural experiment

OBJECTIVE: More than 50% of pregnant women in the United States are using epidural analgesia for labor pain. However, whether epidural analgesia prolongs labor and increases the risk of cesarean delivery remains controversial. STUDY DESIGN: We examined this question in a community-based, tertiary military medical center where the rate of continuous epidural analgesia in labor increased from 1% to 84% in a 1-year period while other conditions remained unchanged-a natural experiment. We systematically selected 507 and 581 singleton, nulliparous, term pregnancies with spontaneous onset of labor and vertex presentation from the respective times before and after the times that epidural analgesia was available on request during labor. We compared duration of labor, rate of cesarean delivery, instrumental delivery, and oxytocin use between these two groups. RESULTS: Despite a rapid and dramatic increase in epidural analgesia during labor (from 1% to 84% in 1 year), rates of cesarean delivery overall and for dystocia remained the same (for overall cesarean delivery: adjusted relative risk, 0.8; 95% confidence interval, 0.6-1.2; for dystocia: adjusted relative risk, 1.0; 95% confidence interval, 0.7-1.6). Overall instrumental delivery did not increase (adjusted relative risk, 1.0; 95% confidence interval, 0.8-1.4), nor did the duration of the first stage and the active phase of labor (multivariate analysis; P >.1). However, the second stage of labor was significantly longer by about 25 minutes (P <.001). CONCLUSION: Epidural analgesia during labor does not increase the risk of cesarean delivery, nor does it necessarily increase oxytocin use or instrumental delivery caused by dystocia. The duration of the active phase of labor appears unchanged, but the second stage of labor is likely prolonged. (Am J Obstet Gynecol 2001;185:128-34).     

The effect of early epidural versus early intravenous analgesia use on labor progression: a natural experiment

OBJECTIVE: The purpose of this study was to compare the effect of early epidural with the use of early intravenous analgesia on labor progression. STUDY DESIGN: We systematically selected singleton, nulliparous term pregnancies with a spontaneous labor and analgesia placement 相似文献   

Is the management of epidural analgesia associated with an increased risk of cesarean delivery?

OBJECTIVE: The aim of this study was to quantify the association of cesarean delivery with epidural analgesia management, specifically with the timing of epidural catheter placement in relation to labor, the type of epidural analgesia, and the use of bolus dosing.Study Design: A retrospective cohort design was used to investigate 1561 consecutive nulliparous parturients whose labor occurred between November 1, 1996, and June 30, 1997, at Northwestern Memorial Hospital and who were delivered of term, singleton neonates in a cephalic presentation. The relationship between the management of epidural analgesia and the risk for cesarean delivery was determined with stepwise logistic regression to control for potential confounding variables. RESULTS: There was a significantly increased risk of cesarean delivery associated with decrements in cervical effacement (P =.001), cervical dilatation (P =.001), and fetal station (P =.001) at the time of epidural catheter placement. An increasing number of epidural boluses during the first stage of labor was also associated with increased risk of cesarean delivery (P =.001). After we controlled for maternal age, maternal body mass index, gestational age, infant birth weight, induction of labor, use of magnesium sulfate, and presence of chorioamnionitis, the adjusted odds of cesarean delivery associated with fetal station (odds ratio, 1.45; 95% confidence interval, 1.2-1.7) and epidural boluses (odds ratio, 1.55; 95% confidence interval, 1.3-1.8) during the first stage of labor remained significant. CONCLUSION: The management of epidural analgesia during labor was associated with the potential for increased risk of cesarean delivery. This risk increased with higher stations of the fetal head at the time of epidural catheter placement and with more frequent epidural boluses of local anesthetic during the first stage of labor.     

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.     

Epidural analgesia during labour: maternal, fetal and neonatal aspects

AIM: The most effective technique for eliminating labour and childbirth pain is continuous lumbar epidural analgesia. The preoccupation regarding the possible negative effects on the time taken for labour and on dystocias in general represents one of the greatest hindrances in the way of its wider use. The purpose of the present study is to monitor the effects of continuous lumbar epidural analgesia on delivery times, on the state of the fetus, on the incidence of dystocic deliveries and on neonatal outcome. METHODS: Comparative prospective study. The data relating to the deliveries of 148 nulliparas and 51 pluriparas at term, submitted to epidural analgesia at the Obstetric Clinic of the University of Parma in 1999-2000 were compared with data from 144 nulliparas in labour and 60 pluriparas without epidural analgesia, selected in random fashion out of 4251 women who delivered children in the same period. The anesthetic procedure employed consisted in an injection of 20 mg/10 ml ropivacaine and 50 mg fentanyl in the epidural space at intervals of 1-2 h. RESULTS: The duration of the dilatation period was not influenced by administration of epidural analgesia while the expulsion period was longer in the course of epidural analgesia. There were no significant differences between delivery modalities in the 2 groups either as regards vaginal operative delivery or the number of cesarean sections for dystocia. The cardiotocographic profile was similar in the 2 groups. The neonatal outcome (Apgar index at 1' and 5' and transfer to the intensive care department) did not show significant differences, confirming the absence of noteworthy side-effects even from the neonatal standpoint. CONCLUSIONS: The use of low concentrations of ropivacaine (0.2%) associated with fentanyl in the epidural space proved to be a safe and effective technique for controlling labour and delivery pain.     

Epidural analgesia and the course of delivery in term primiparas

OBJECTIVES: Epidural analgesia provides the most effective pain control during labor. Of great concern is its influence on the course of delivery and perinatal complications. DESIGN: The aim of the study was to assess the effect of epidural analgesia on the course of delivery and perinatal outcome. MATERIALS AND METHODS: 609 deliveries among 1334 (323 women with epidural analgesia (53%) and 548 without epidural analgesia (47%)) met the following criteria: primipara, singleton, live pregnancy, > =37 weeks' gestation, cephalic presentation of a fetus, lack of contraindication for vaginal delivery. The incidence of instrumental deliveries and fetal distress, duration of the first, second and third stage of labor, perinatal outcome, perinatal complications and perinatal blood loss and were analyzed. RESULTS: The incidence of fetal distress during second stage of labor was significantly higher in the epidural group (12.69 vs. 6.99%, P=0.02). The incidence of fetal distress during first stage of labor did not differ in both groups (10.53% vs. 8.74%, NS). Cesarean sections rate was similar in epidural and non-epidural group (17.7 vs. 18.2%, NS). Among vaginal deliveries duration of the first and second stage of labor was longer in epidural group (6.5+/-2.4 vs. 5.4+/-2.5 godz., P=0,000003 and 47.3+/-34.8 vs. 29.1+/-25.8 min., P=0.000003) and this was independent of period of time between onset of first stage of labor and epidural analgesia. Oxitocin use was significantly more frequent in the epidural group (20.6 vs. 10.3%, P<0.004). There were no statistically significant differences in the rates of instrumental vaginal deliveries, 1 and 5-minute Apgar scores, length of third stage of labor and perinatal blood loss in patients with and without epidural analgesia. Perinatal outcome did not depend on previous use of epidural analgesia or mode of analgesia for the operation in cesarean section subgroup. CONCLUSION: Epidural labor analgesia is associated with slower progress of labor but has no adverse effect on perinatal outcome and perinatal complications.     

Predictors of episiotomy use at first spontaneous vaginal delivery

OBJECTIVE: To identify factors associated with the use of episiotomy at spontaneous vaginal delivery. METHODS: We studied 1576 consecutive term, singleton, spontaneous vaginal deliveries in nulliparas at Brigham & Women's Hospital between December 1, 1994 and July 31, 1995. The association of demographic variables and obstetric factors with the rate of episiotomy use were examined. Adjusted odds ratios (OR) and confidence intervals (CI) were estimated from multiple logistic regression analysis. RESULTS: The overall rate of episiotomy was 40.6% (640 of 1576). Midwives performed episiotomies at a lower rate (21.4%) than faculty (33.3%) and private providers (55.6%) (P =. 001). After controlling for confounding factors with logistic regression, private practice provider was the strongest predictor of episiotomy use (OR, 4.1; 95% CI, 3.1, 5.4) followed by faculty provider (OR, 1.7; 95% CI, 1.1, 2.5), prolonged second stage of labor (OR, 1.8; 95% CI, 1.2, 2.7), fetal macrosomia (OR, 1.6; 95% CI, 1.1, 2.5), and epidural analgesia (OR 1.4, 95% CI, 1.1, 1.8). CONCLUSION: The strongest factor associated with episiotomy at delivery was the category of obstetric provider. Obstetric and demographic factors evaluated did not readily explain this association.     

Nulliparas' Preferences for Epidural Analgesia: Their Effects on Actual Use in Labor

Background: Few studies have directly examined the reasons for choices of pain relief during labor. The purpose of this study was to investigate if women's preferences for epidural analgesia in labor have an impact on the use of intrapartum epidural analgesia. Methods: Nulliparous women attending childbirth classes completed questionnaires about their antenatal preferences for the use of intrapartum epidural analgesia. Data on actual use of analgesia was obtained by chart review. The analysis included 303 women with either spontaneous or induced labor at term. Results: The 185 women who planned to receive epidural analgesia had a markedly higher rate of epidural use (91%) than the 110 women who hoped to avoid it (57%) ( p= 0.001). Of 237 epidurals administered, 169 (71%) were planned during the antenatal period. Among women receiving epidural analgesia, those planning to receive it tended to have more frequent early administration (≤ 3 cm cervical dilation) than women who unsuccessfully tried to avoid epidural use (54% vs. 24%, p= 0.003). Conclusion: In our population of nulliparas, a woman's antenatal plan to receive epidural analgesia is strongly associated with her likelihood of receiving it. Women who plan to receive epidural analgesia have earlier administration.     

Low concentration Ropivacaine in labor epidural analgesia. A prospective study on obstetric and neonatal outcome]

BACKGROUND: Epidural analgesia effectively alleviates labor pain. However controversy exists about the effect of epidural analgesia on labor outcome. The aim of this study is to assess the effect of a low concentration local anesthetic (ropivacaine 0.08%) in labor epidural analgesia (LEA) on labor pain relief, on the incidence of cesarean sections and instrumental vaginal deliveries, and on neonatal outcome. METHODS: In the period April 1998 - July 2000, 323 women in active labor with live, singleton and in vertex presentation fetuses at term of gestation were included in this prospective study. Women with pre-gestational and/or obstetric diseases or previous caesarean deliveries were excluded. One-hundred and five patients requiring - by written informed consent - LEA were allocated to receive standardised protocol of a low concentration local anesthetic (ropivacaine 0.08%) coadministered with opioid (sufentanil): ropivacaine group. The remaining 239 parturients who didn't require LEA were included in the control group. RESULTS: The demographic characteristics of the two groups were similar; 12 (10.4%) patients receiving LEA delivered by cesarean section, 17 (14.8%) by vacuum extractor whereas 86 (74.8%) had a spontaneous delivery. The risk of cesarean section (adjusted for age, BMI, parity, neonatal weight and gynecologist) resulted lower, even if not significantly, in the ropivacaine group (OR 0.9; 95% IC: 0.6-1.3), while a significant increased instrumental vaginal delivery rate has been reported, although little numbers reduce statistical significance. Neonatal outcome was unaffected by the use of LEA. CONCLUSIONS: The conclusion is drawn that a lower concentration of ropivacaine (0.08%) in LEA produces good labor pain relief with no detectable adverse effects on mother and neonate, and without significantly increasing cesarean section rate.     

The effect of a rapid change in availability of epidural analgesia on the cesarean delivery rate: a meta-analysis

OBJECTIVE: This study was undertaken to quantitatively estimate the effect of a rapid introduction or withdrawal of on-demand epidural analgesia on the cesarean delivery rate. STUDY DESIGN: MEDLINE and meeting abstracts were searched for studies reporting the cesarean delivery rate immediately before and after a rapid change in the availability of epidural analgesia. Nine studies reporting data on 37,753 patients were selected. Meta-analysis was performed to estimate the means and 95% confidence intervals for the changes in rates of total cesarean deliveries, cesarean deliveries among nulliparous women, cesarean deliveries for dystocia, and operative vaginal deliveries. RESULTS: There was no significant change in the overall cesarean delivery rate with an increase in the availability of epidural analgesia. Similarly, the rates of cesarean deliveries among nulliparous patients, of cesarean deliveries for dystocia, and of operative vaginal deliveries did not significantly differ between periods of high and low epidural analgesia availability. CONCLUSION: A rapid change in the availability of epidural analgesia is not associated with any increase in the cesarean delivery rate.     

Does the station of the fetal head during epidural analgesia affect labor and delivery?

OBJECTIVE: To assess whether the station of the fetal head when lumbar epidural analgesia is administered influences the duration or the mode of delivery in low-risk laboring women. METHODS: We prospectively evaluated 131 consecutive cases of low-risk parturients at term who requested intrapartum epidural analgesia. Obstetric outcome of 65 parturients who underwent epidural analgesia when the fetal head was low in the birth canal was compared to 66 patients whose fetal head station was above the ischial spine. RESULTS: Both groups were similar in their obstetric characteristics. Cervical dilatation when performing the epidural analgesia was similar in both groups. The duration of labor and mode of delivery, as well as percentage of malpositions, were not significantly different in the two groups. CONCLUSIONS: The station of the fetal head while initiating epidural analgesia does not influence the duration of labor or the mode of delivery. Therefore, there is no justification to delay epidural analgesia in labor until the presenting fetal part is engaged.     

Risk factors for forceps delivery in nulliparous patients

OBJECTIVE: To identify risk factors for forceps delivery during first pregnancy. MATERIALS AND METHODS: A retrospective case-control study was carried out in a tertiary maternity ward between January 2001 and December 2003. A total of 582 nulliparous women, with full-term (>37 weeks gestation), singleton, cephalic pregnancies, who delivered by the vaginal route with or without instrumental assistance were evaluated. RESULTS: The strongest risk factors for forceps delivery were birth weight greater than 4000 g (OR: 6.5; 95% CI: 1.6, 26.9), the occiput posterior position of the fetal head (OR: 5.8; 95% CI: 2.5, 13.8), and epidural analgesia (OR: 7.7; 95% CI: 4.1, 14.7). Other significant risk factors for forceps delivery were age over 35 years (OR: 2.4; 95% CI: 1.1, 5.1), induction of labor (OR: 2.1; 95% CI: 1.4, 3.1), first stage of labor longer than 420 min (OR: 2.3, 95% CI: 1.3,4.2), and a prolonged second stage of labor (OR: 1.6, 95% CI: 1.1, 2.4). CONCLUSION: Age over 35 years and induction of labor are risk factors for forceps delivery at admission. Epidural use, fetal head in occiput posterior position, and birth weight >4000 g are strong intrapartum risk factors for instrumental delivery in nulliparous women.     

Outcomes of induced versus spontaneous labor

Purpose: Induced labor is associated with a higher request for analgesia than spontaneous labor. This study compared duration of labor, mode of delivery, quantity of blood loss, type of perineal outcome and neonatal outcomes between women in induced labor and women in spontaneous labor, both on epidural analgesia (administered at cervical dilation ≤?4?cm).

Methods: In a two-year longitudinal cohort study, data were gathered from nulliparous women with a single cephalic pregnancy of at least 37 weeks attending the labor and delivery ward in Policlinico San Matteo Fundation-Pavia. Data were compared for women with early labor analgesia in (1) spontaneous labor (Robson group 1) and (2) induced labor (dinoprostone – vaginal insert or gel, Robson group 2a).

Results: Of the 1104 women who underwent epidural analgesia in the study period, 531 were included: 326 in spontaneous labor and 205 in induced labor. The only significant difference found was duration of the first stage, which lasted 305 (200–390) min in spontaneous labor compared to 205?min (120–345) in induced labor (p <0.001).

Conclusions: In women on early epidural analgesia, induction is associated with a shorter duration of the first stage of labor and does not affect other outcomes.     

Clinical triggers to initiate intrapartum penicillin therapy for prevention of group B streptococcus infection

Despite national recommendations for prophylactic group B streptococci intrapartum penicillin therapy (GBS-IPT), there is little guidance for clinicians regarding to how to achieve the recommended 4 hours of therapy. We sought to identify clinical triggers for effective temporal prompts to initiate GBS-IPT to achieve the recommended duration of therapy. GBS-colonized women who delivered between 37 and 42 weeks were analyzed retrospectively. The clinical record was reviewed for clinical events including rupture of membranes, oxytocin therapy, 4-cm dilation, active labor, narcotic analgesia, epidural analgesia. In addition, combinations of these triggers were evaluated using the first appearance of 4-cm dilation or active labor, narcotic analgesia or epidural, and a composite indicator of each of these four triggers. Antibiotic duration and proportion receiving 4 hours of GBS-IPT for each trigger were compared with the conventional penicillin management the patient actually received (CM). Data were analyzed with Z-test for proportions with Bonferroni correction and one-way analysis of variance. Two hundred thirteen women met study criteria and were reviewed. Using CM, 90.8% of nulliparas and 68.7% of parous women achieved adequate GBS-IPT. In nulliparas, each clinical trigger resulted in equivalent rates of adequate GBS-IPT compared with CM. The duration of therapy was less for 4-cm dilation, epidural, epidural or narcotic analgesia, and 4-cm dilation or active labor triggers in nulliparas, suggesting better identification of the period 4 hours prior to delivery. In parous women, clinical triggers did not perform better than CM. In nulliparous women, clinical triggers to initiate therapy may achieve high rates of GBS-IPT, with a significant decrease in the duration of antibiotic therapy. In nulliparous women, clinical triggers better identify the 4-hour window prior to delivery than CM.     

The characteristics of the second stage of labour in 25,069 singleton deliveries in the North West Thames Health Region, 1988.

OBJECTIVE: To define the contemporary characteristics of the second stage of labour in one Health Region. DESIGN: Retrospective analysis of a regional obstetric database. SETTING: Seventeen maternity units in the North West Thames Health Region. SUBJECTS: Selected from 36,727 consecutive singleton deliveries in 1988. The analysis was confined to the 25,069 women delivered of an infant of at least 37 weeks gestation with a cephalic presentation following the spontaneous onset of labour. MAIN OUTCOME MEASURES: Second stage duration, obstetric intervention and maternal and fetal morbidity. RESULTS: The duration of the second stage and the use of operative intervention were strongly negatively associated with parity and positively associated with the use of epidural analgesia. Maternal age, fetal birthweight and maternal height were also independently associated with the duration of the second stage. There were small but significant differences in the characteristics of women using epidural analgesia and those using alternative methods of pain relief. Parous women using epidural analgesia behaved in a similar manner to nulliparae without epidurals. Despite the longer second stages observed in women using epidural analgesia there appeared to be no significant increase in fetal morbidity. Within the region the epidural rate in individual units positively correlated with the overall forceps rate, the rate of caesarean section in the second stage of labour and the duration of the second stage. CONCLUSIONS: In our study the duration of the second stage in women not using epidural analgesia was similar to previous findings, but in those using epidural analgesia, the duration of the second stage was longer than has been reported previously, possibly reflecting a more conservative approach to operative intervention. Survival analysis indicates that in multiparae not using epidural analgesia the likelihood of spontaneous vaginal delivery after 1 h in the second stage was low, but in those multiparae using epidural analgesia and in all nulliparae there was no clear cut-off point for expectation of spontaneous delivery in the near future; they continue to give birth at a steady rate over several hours. While maternal and fetal conditions are satisfactory, intervention should be based on the rate of progress rather than the elapsed time since full cervical dilatation.