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.     

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.     

Transcutaneous electrical nerve stimulation (TENS) for adjuvant pain-relief during labor and delivery

Objective: We examined the efficacy of transcutaneous electrical nerve stimulation (TENS) in general and the new Freemom TENS device (LifeCare, Israel) in particular, for pain relief during labor and delivery. Methods: The study group consisted of 104 women. Forty-six nulliparas (44.2%) and 58 multiparas (55.8%), all of whom used the TENS device for pain relief during labor. All participants completed a questionnaire on the degree of pain relief afforded them by TENS during the delivery and related questions. The objective evaluation was based on the documented labor and delivery parameters including medical interventions during delivery. Results: The majority of subjects (72% of the nulliparas and 69% of the multiparas) considered TENS effective for the relief of pain during labor. Most of them (67% of the nulliparas and 60% of the multiparas) responded positively to the use of TENS in future deliveries. Sixty-five percent of the multiparas considered TENS at least as effective as the other pain relief methods they had used before. TENS significantly reduced the duration of the first stage of labor P<0.001 for nulliparas, P<0.005 for multiparas and it significantly decreased the amount of analgesics administered to individual patients. No significant difference was found in fetal heart rate tracings, Apgar scores and cord blood pH between the study group and an equal number of matched controls who used other forms of pain management. Conclusions: TENS is an effective non-pharmacological, non-invasive adjuvant pain relief modality for use in labor and delivery. TENS application reduced the duration of the first stage of labor and the amount of analgesic drug administered. There were no adverse effects on mothers or newborns.     

Characteristics of normal labor

The length of the first and second stages of labor was evaluated in 6991 women with singleton gestations at 37-42 weeks with vertex presentation. All patients delivered spontaneously without the use of oxytocin. Four study groups were created based on parity and whether conduction anesthesia was used. The mean lengths and limits (95th percentile) for the first stage of labor, respectively, were as follows: nulliparas: no anesthesia--8.1 and 16.6 hours, conduction anesthesia--10.2 and 19.0 hours; multiparas: no anesthesia--5.7 and 12.5 hours, conduction anesthesia--7.4 and 14.9 hours. Similar data for the second stage were as follows: nulliparas: no anesthesia--54 and 132 minutes, conduction anesthesia--79 and 185 minutes; multiparas: no anesthesia--19 and 61 minutes, conduction anesthesia--45 and 131 minutes. These statistical parameters are useful for defining when a labor becomes abnormal and intervention should be considered.     

The Impact of Parity on Course of Labor in a Contemporary Population

Abstract: Background: Few studies have examined in depth the labor progression of multiparas to determine if there is any additional impact of being parous beyond the first birth. The objective of this study was to determine the effect of parity on labor progression in contemporary obstetric practice. Methods: Our sample consisted of all low‐risk women who delivered a term, live‐born infant from January 2002 to March 2004 at a single institution in Delaware, United States (n = 5,589). The median duration of labor by each centimeter of cervical dilation was computed for parity = 0 (n = 2,645); parity = 1 (n = 1,839); parity = 2 (n = 750); and parity = 3 + (n = 355). Results: Multiparas had a significantly faster labor progression from 4 to 10 cm (293, 300, and 313 min, respectively, for parity = 1, parity = 2, and parity = 3 +), compared with nulliparas (383 min for parity = 0), as well as a shorter second stage of labor. However, no significant differences were found in duration of the active phase or the second stage of labor among multiparas. Conclusions: Additional childbearing appears to have no effect of on the progression of labor among multiparous subgroups. The difference in duration of the active phase between nulliparas and multiparas is substantially smaller in a contemporary population. (BIRTH 33:1 March 2006)     

Singleton vaginal breech delivery at term: still a safe option

OBJECTIVE: To examine the obstetric and perinatal outcome of pregnancies with singleton breech presentation at term when selection for vaginal delivery was based on clear prelabor and intrapartum criteria. METHODS: The outcomes of all pregnancies with a breech presentation after 37 weeks of gestation were retrospectively reviewed from January 1997 to June 2000. Criteria for prelabor cesarean or trial of vaginal breech delivery included type of breech, estimated fetal weight (more than 3,800 g), maternal preference, and gestation more than 41 weeks. An intrapartum protocol excluded induction and oxytocin augmentation of labor, combined with a low threshold for cesarean delivery for dystocic labor; an experienced obstetrician was in attendance during labor and delivery. RESULTS: Of 641 women, 343 (54%) underwent prelabor cesarean, and 298 (46%) had a trial of vaginal delivery, of whom 146 (49%) delivered vaginally. Significantly fewer nulliparas (58 of 158, 37%) than multiparas (88 of 140, 63%; P <.001) achieved vaginal delivery after trial of labor. Significantly more infants weighing more than 3,800 g were selected for prelabor (87 of 343, 25%) and intrapartum (31 of 152, 20%) cesarean than delivered vaginally (15 of 146, 10%). Two neonates (0.7%) had Apgar scores of less than 7 at 5 minutes; both were neurologically normal at 6 weeks. There were no nonanomalous perinatal deaths and no cases of significant trauma or neurological dysfunction; 3 infants delivered vaginally died due to lethal anomalies. CONCLUSION: Safe vaginal breech delivery at term can be achieved with strict selection criteria, adherence to a careful intrapartum protocol, and with an experienced obstetrician in attendance. Our protocol effectively selects larger infants for cesarean delivery. LEVEL OF EVIDENCE: II-2     

Effects of sitting position on uterine activity during labor

To determine which components of uterine activity are affected by different positions of labor, 116 intrauterine pressure records in the sitting and supine positions were analyzed in order to measure resting, contraction, and bearing down pressures. The resting pressure in the sitting position showed consistent elevation compared to the supine position, while the contraction pressure did not differ strikingly in the two positions. The bearing down pressure in the sitting position for nulliparas during the second stage and for multiparas at the time of the 8- to 10-cm dilation was significantly higher than that in the supine position. Also, the sitting position led to a significantly shorter duration of the second stage in nulliparas and the 5- to 10-cm dilation period in multiparas. These findings suggest that the maternal position does not affect uterine contractility, that the increased resting pressure in the sitting position is of some importance in supplementing the downward delivery force, and that the increased bearing down pressure in the sitting position could help to significantly shorten the duration of labor.     

Labor length among overweight and obese women undergoing induction of labor

Abstract

Objective: Maternal weight is thought to impact labor. With rising rates of obesity and inductions, we sought to evaluate labor times among induced women by body mass index (BMI) category.

Methods: Retrospective cohort study of term inductions from 2005 to 2010. BMI categories were: normal weight (NW), overweight (OW), and obese (Ob) (18.5–24.9, 25–29.9, ≥30?kg/m²). Kruskal–Wallis tests compared median latent labor (LL) length and active labor (AL) length. Chi-square determined associations. Multivariable logistic regression controlled for confounders. Analyses were stratified by parity.

Results: A total of 448 inductions were analyzed. For nulliparas, there was no difference in LL by BMI category (p?=?0.22). However, OW nulliparas had a longer AL compared to NW and Ob nulliparas (3.2, 1.7, 2.0?h, p?=?0.005). For multiparas, NW had the shortest LL (5.5?h, p?=?0.025) with no difference in AL among BMI categories (p?=?0.42). The overall cesarean rate was 23% with no difference by BMI category (p?=?0.95). However, Ob women had a greater percentage of first stage cesareans (41%) and NW had a greater percentage of second stage cesareans (55%), p?=?0.06.

Conclusion: The association between BMI and labor length among inductions differs by phase of labor and parity. BMI also influences the stage of labor in which a cesarean occurs.     

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).     

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.     

Maternal position during parturition in normal labor

While controversy exists as to the relationship between maternal position in labor and such measures as the labor duration, subjective discomfort, and fetal outcome, little appears to be known about the positions women assume in labor when they are permitted to do so without coercion or instruction. To learn more about maternal position in labor, we observed 80 consecutive patients with uncomplicated normal spontaneous vaginal delivery over the course of labor to ascertain the positions volitionally chosen by each. Data were collected on position preferences and phase of labor. All labors were analyzed; a codified lexicon was established to describe the position pattern in each phase and the principal positions the patient assumed over the course of labor. The frequencies and distributions were determined for nulliparas and multiparas separately and rates of position change were assessed. It was found that gravidas chose a number of different principal positions in the early phases of labor, but that they became more narrowly selective in the deceleration phase and second stage; at the same time, they tended to change position more often in late labor.     

The influence of birth weight on labor in nulliparas

The purpose of this study was to examine the hypothesis that dystocia in nulliparas is directly related to birth weight. The study was confined to the first 1000 nulliparas delivered in 1988 who went into labor after 37 weeks' gestation with a single live fetus and cephalic presentation. The management of labor was standardized. As birth weight increased, there was an increase in the mean duration of labor and of the second stage of labor, in the incidence of oxytocin augmentation, and in the incidence of both cesarean and forceps delivery for dystocia. The direct relationship between birth weight and the mean duration of labor was independent of gestation and oxytocin augmentation. These findings suggest that birth weight is an important factor in the development of dystocia in nulliparas.     

Outcomes of women presenting in active versus latent phase of spontaneous labor

OBJECTIVE: To evaluate outcome differences between women presenting in latent and active labor. METHODS: We evaluated all low-risk women with term, singleton, vertex gestations who presented in active phase or latent phase labor at MetroHealth Medical Center from January 1993 to June 2001. Baseline characteristics were compared. Labor outcomes were assessed by logistic regression, controlling for parity. RESULTS: A total of 6,121 active phase and 2,697 latent phase women met the study criteria. More latent phase women were nulliparous (51 compared with 28%). Latent phase women had more cesarean deliveries (nulliparas 14.2% compared with 6.7%, multiparas 3.1% compared with 1.4%). Controlling for parity, latent phase women had more active phase arrest (odds ratio [OR] 2.2), oxytocin use (OR 2.3), scalp pH performed (OR 2.2), intrauterine pressure catheter placed (OR = 2.2), fetal scalp electrocardiogram monitoring (OR = 1.7), and amnionitis (OR 2.7) (P < .001 for each). CONCLUSION: It is uncertain whether inherent labor abnormalities resulted in latent phase presentation and subsequent physician intervention or early presentation and subsequent physician intervention are the cause of labor abnormalities.     

Risk for one or two very low birth weight twins: a population study

OBJECTIVE: To calculate the frequencies of very low birth weight (VLBW) neonates among twins in a large population database. METHODS: The database comprised 12,567 live-born twin pairs delivered from 1993 to 1998 in Israel. Low birth weight (LBW) and VLBW were defined as less than 2500 and 1500 g, respectively. We counted the number of pairs with VLBW neonates in three combinations: VLBW-VLBW, VLBW-LBW, and VLBW-over 2500 g. We compared the subsets of nulliparas and multiparas and the frequency of like- versus unlike-sex twins. RESULTS: The frequency of at least one VLBW twin was significantly higher among nulliparas than multiparas (odds ratio [OR] 2.3; 95% confidence interval [CI] 2.1, 2.6; P <.001). For pairs with VLBW-VLBW and VLBW-LBW combinations, a significantly higher frequency was found among nulliparas than multiparas (OR 2.0; 95% CI 1.7, 2.8; P <.001 and OR 2.6; 95% CI 2.2, 3.1; P <.001, respectively). The risk seemed to be accentuated in like-sex twins. Overall, the risk of having at least one VLBW infant was 1:5 among nulliparas and 1:12 among multiparas. The risk of having two VLBW twins among nulliparas (1:11) was double that of multiparas (1:22). CONCLUSION: Nulliparas are at significantly increased risk of delivering one or two VLBW twins.     

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.     

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.     

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.     

The Second Time Around: Parity and Birth Experience

Both patients and professionals generally believe that the easier obstetrical experience of the multipara also characterizes her subjective experiences. Among 249 women, we found that the multiparas had more physical discomfort, but fewer worries, during pregnancy, and that they worried about labor more, but prepared for birth less, than did the primiparas. Although the multiparas had obstetrically easier labors, they received less support from their husbands during labor and there was no significant parity difference in the subjective pain or enjoyment. After birth, the multiparas generally sought less contact with their babies during the hospital stay than did the primibaras. The sample was representative of urban, middle class women. Implications regarding prepared versus nonprepared childbirth were also noted. The findings challenge the conventional emphasis on supportive care mainly for primiparas.     

Cortisol levels in human pregnancy in relation to parity and age

Data are presented of a study on the relationship between cortisol, amenorrhea, parity, and age among pregnant women. Total cortisol concentrations were measured by a radioimmunoassay in healthy pregnant women (n = 527), including 105 nulliparas and 422 multiparas. The serum concentration of total cortisol increased linearly with progression of amenorrhea. Significantly higher cortisol levels were found in nulliparas compared to multiparas and independent of amenorrhea. Since parity and age are strongly correlated, age-dependent changes may contribute to the difference in cortisol level between nulliparas and multiparas. Analysis of the age-dependent changes on this difference in cortisol level showed no significant influence.