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.     

Does the way that women experience the onset of labour influence the duration of labour?

OBJECTIVE: To assess whether the way in which women experience the onset of their labour influences the duration of their labour. DESIGN: Longitudinal study on a convenient sample of women in spontaneous labour with a singleton pregnancy in cephalic presentation at term. SETTING: University hospital in Germany. POPULATION/SAMPLE: Six hundred and fifty-one women (347 primiparae and 304 parae). METHODS: Women recorded how and when labour had started. Responses were subjected to structured content analysis. Two investigators independently subdivided women's reported signs and symptoms into eight predefined categories. These data were related to maternal characteristics and to the course and outcome of labour as documented in the perinatal record. MAIN OUTCOME MEASURES: Women's perception of how labour had started, interval between onset of labour and rupture of the membranes and duration of first stage labour and overall duration of labour. RESULTS: Only 60% of women reported contractions as a sign of the onset of their labour. These women had a longer interval between the onset of labour and rupture of the membranes but a similar duration of labour when compared with women who did not report contractions as a sign of the onset of labour. Self-reported loss of amniotic fluid was the only sign that showed a consistent relationship with the duration of labour. Other patterns of labour onset had no effect on the duration of labour. CONCLUSION: Irrespective of whether they have given birth before, women experience their onset of labour in a variety of ways. A large proportion of these experiences bear no resemblance to the classical diagnosis of labour and most are unrelated to the duration of labour.     

Active management of third stage of labour: a survey of providers’ knowledge in southwest Nigeria

Background  

The disparity between current evidence and practice on active management of third stage of labour (AMTSL) demands assessment of providers’ knowledge on the subject.     

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.     

Do ventilated neonates require pain management?

Mechanical ventilation is a stressful experience in neonates resulting in changes in neuroendocrine parameters, pain scores, and physiologic responses. Assisted ventilation in neonates is presumed to be associated with chronic repetitive pain, which in turn is associated with adverse long-term sequelae. Reasons to routinely sedate ventilated neonates include improved ventilator synchrony, improved pulmonary function, and decreased neuroendocrine responses, including cortisol, beta-endorphine, and catecholamines. Reasons not to treat include the well-known adverse side effects of pain medication, especially the opiates, including hypotension from morphine, chest wall rigidity from fentanyl, and tolerance, dependence, and withdrawal from both opiates and benzodiazepines. Additionally, adverse effects such as death and IVH are not improved with preemptive treatment. Chronic pain assessment is poorly validated and difficult to assess in this population, and most studies have evaluated only acute pain scores. If patients are treated, opiates are the most common class of drugs, with morphine the most well studied. Fentanyl may be advantageous in hypotensive, younger neonates because it has fewer cardiovascular effects. The benzodiazepines, midazolam and lorazepam, have been used in ventilated neonates, but midazolam has been associated with adverse effects in one small study so concern remains regarding its use. Significant gaps in our knowledge exist, especially in regard to long-term effects of treatment, or lack thereof, and in the assessment of the chronic pain associated with assisted ventilation.     

Effect of perceptions of menstrual blood loss and menstrual pain on women’s quality of life

Objectives: The aim of the study was to explore Australian women’s experiences of menstruation and effect on quality of life (QoL).

Methods: A representative sample of women recruited through a commercial social research sampling organisation completed a detailed online questionnaire about menstruation. Specific detailed questions were asked about perceptions of heavy menstrual bleeding (HMB) and menstrual pain.

Results: The questionnaire was completed by 1575 women aged 20–39 years. Most perceived their bleeding to be light (11.6%) or moderate (60.5%); 363 (22.5%) perceived it to be heavy and 86 (5.3%) very heavy. Women who experienced severe or very severe menstrual pain were significantly more likely to report periods as heavy or very heavy (p?12 times more likely to be confined to bed for 0.5–1?day during menstruation than if they reported HMB without pain.

Conclusion: Severe menstrual pain with HMB has a much more profound effect on all aspects of women’s QoL than HMB alone; it accounts for more days in bed and for loss of productivity.     

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.     

Anesthetic management of labor pain: what does an obstetrician need to know?

Background Obstetrical anesthesia is considered by many to be a high-risk subspecialty of anesthesia practice that is laden with clinical challenges and medico-legal liability. Anesthesia-related complications are the sixth leading cause of pregnancy-related maternal mortality in the United States.Complications Difficult or failed intubation following induction of general anesthesia for cesarean delivery remains the major contributory factor to anesthesia-related maternal complications.Requirements Communication skills and exchange of information (between anesthesiologists, obstetricians, and nurses) in an ever changing environment of labor and delivery are essential for a perfect outcome, which is always expected when providing safe passage for both the mother and her fetus from antepartum to postpartum period. The safe provision of labor anesthesia and/or analgesia requires appropriate staff, facilities, and equipment for proper patient safety.Discussion This article is intended for obstetricians and reviews the current guidelines for the administration of obstetrical anesthesia and analgesia.     

Surgical management of pelvic organ prolapse in women: laparoscopic or vaginal sacrocolpopexy?

OBJECTIVE: To compare the safety and the efficacy of the laparoscopic and vaginal technique for the surgical management of pelvic organ prolapse, with systematic support of the three compartments and prosthetic reinforcements. PATIENTS AND METHODS: Retrospective study of 154 patients presenting a stage 3 or 4 prolapse on one of the three compartments. Laparoscopic procedures were performed with subtotal hysterectomy, double synthetic prosthesis attached to promontory, and douglassectomy. Vaginal procedures were performed with vaginal hysterectomy, anterior colporrhaphy with a hammock using porcine skin collagen implant fixed by transobturator passages, unilateral sacral colpopexy and posterior colporrhaphy. Monitoring was performed at six months and then annually. RESULTS: The laparoscopic technique requires a more important operating time, but a shorter hospitalization. The discovery of three carcinoma reinforces the idea of the interest of uterine radical surgery in these patients. The tolerance of prostheses by laparoscopy is safe. The biological prostheses, introduced vaginally, offer the same advantages. The anatomical results in the medium term (30 months) seem more favorable to laparoscopy than transvaginal approach, as well as functional results but they still need to better evaluated. DISCUSSION AND CONCLUSION: The two techniques must coexist, ideally without competing with each other but rather complementarily, as the overall rate of recurrence, requiring additional procedure does not exceed 2%. It is therefore important that surgeons, who support prolapse, have a good comprehensive training of the laparoscopic and vaginal techniques.     

Maternal height and length of gestation: Does this impact on preterm labour in Asian women?

Background: Both maternal height and ethnicity may influence the gestation length, but their independent effect is unclear.
Aim: This study was performed to examine the relationship between maternal height and gestational length in women with singleton pregnancies in a Chinese and southeast Asian population.
Methods: A retrospective cohort study was performed on women carrying singleton pregnancies with spontaneous labour in a 48-month period managed under our department to determine the relationship between maternal height, expressed in quartiles, with the mean gestational age and incidence of preterm labour.
Results: Of the 16 384 women who delivered within this period, the 25th, 50th and 75th percentile values of maternal height were 153 cm, 156 cm and 160 cm respectively. Excluded from analysis were 6597 women because of multifetal pregnancy, teenage pregnancy (maternal age ≤ 19 years old), induction of labour or elective caesarean section, or incomplete data due to no antenatal booking in our hospital. Significant differences were found in the maternal weight and body mass index, incidences of multiparity and smokers, gestational age and birthweight among the four quartiles. There was significantly increased incidence of preterm birth between 32 and 37 weeks gestation in women with shorter stature.
Conclusions: In our population, maternal height has an influence on gestational length, and the lower three quartiles was associated with increased odds of labour at > 32 to < 37 weeks. This effect should be taken into consideration in the adoption of international recommendations in obstetric management and intervention.     

Presentation and management of vesicovaginal fistulae after delivery at a German women’s hospital

Vesicovaginal fistulae are rarely seen after childbirth in developed countries. This article deals with the causes, presentation, and management of obstetric vesicovaginal fistulae in patients treated at a German women’s hospital.     

Onset of labour: women’s experiences and midwives’ assessments in relation to first stage duration

Aim  

The study aimed to assess the time of labour onset and its symptoms as perceived by women in labour and midwives, and the relationship between these and first stage duration.     

Birth place preferences and women’s expectations and experiences regarding duration and pain of labor

Introduction: We know a great deal about how childbirth is affected by setting; we know less about how the experience of birth is shaped by the attitudes women bring with them to the birthing room. In order to better understand how women frame childbirth, we examined the relationship between birth place preference and expectations and experiences regarding duration of labor and labor pain in healthy nulliparous women.

Methods: A prospective cohort study (2007–2011) of 454 women who preferred a home birth (n?=?179), a midwife-led hospital birth (n?=?133) or an obstetrician-led hospital birth (n?=?142) in the Netherlands. Data were collected using three questionnaires (before 20 weeks gestation, 32 weeks gestation and 6 weeks postpartum) and medical records. Analyses were performed according to the initial preferred place of birth.

Results: Women who preferred a home birth were significantly less likely to be worried about the duration of labor (OR 0.5, 95%CI 0.2–0.9) and were less likely to expect difficulties with coping with pain (OR 0.4, 95%CI 0.2–0.8) compared with women who preferred an obstetrician-led birth. We found no significant differences in postpartum accounts of duration of labor. When compared to women who preferred an obstetrician-led birth, women who preferred a home birth were significantly less likely to experience labor pain as unpleasant (OR 0.3, 95%CI 0.1–0.7). Women who preferred a midwife-led birth – either home or hospital – were more likely to report that it was not possible to make their own choices regarding pain relief compared to women who preferred obstetrician-led care (OR 4.3, 95%CI 1.9–9.8 resp. 3.4, 95%CI 1.5–7.7). Compared to women who preferred a midwife-led hospital birth, women who preferred a home birth had an increased likelihood of being dissatisfied about the management of pain relief (OR 2.5, 95%CI 1.1–6.0).

Discussion: Our findings suggest a more natural orientation toward birth with the acceptance of labor pain as part of giving birth in women with a preference for a home birth. Knowledge about women’s expectations and experiences will help caregivers to prepare women for childbirth and will equip them to advise women on birth settings that fit their cognitive frame.     

Is it worth inducing labour in women with a previous caesarean delivery?

The aim of this study was to determine the outcome of labour induction following a previous caesarean section. A total of 43 cases were identified; 23 out of those (53.5%) achieved vaginal delivery. The remaining 20 cases (46.5%) had a repeat caesarean. A total of 25 women had ≥ 1 previous vaginal deliveries and in the remaining 18, the previous caesarean was the only pregnancy carried before the current pregnancy. Out of the 23 women who successfully delivered vaginally, 16 cases (69.6%) had a history of ≥ 1 previous vaginal delivery, while no such history was reported in the remaining seven cases (30.4%). The indications for a repeat caesarean were failed induction of labour in five cases (25%); fetal distress in seven cases (35%); failure-to-progress in eight cases (40%). Only one case (2.3%) of uterine rupture was reported. In conclusion, labour induction following a previous caesarean section is an effective and safe intervention. Vaginal delivery can be anticipated in the majority of these women. This study emphasises the need for thorough counselling of these women regarding benefits and risks of induction of labour, and also highlights the necessity of shared patient-doctor decision-making.     

Intrapartum intervention rates and perinatal outcomes following induction of labour after 41 + 0 weeks compared to expectant management

Objective: There is limited evidence regarding the incidence of intrapartum fetal compromise in women who are induced compared to those managed expectantly. The aim of this study was to investigate intrapartum and perinatal outcomes in women who were induced at >41?+?0 weeks compared to an expectantly managed cohort.

Methods: This was a retrospective cohort study of singleton, non-anomalous pregnancies delivering between 41?+?0 to 43?+?0 weeks at the Mater Mothers’ Hospital, Brisbane. We compared outcomes between women who were induced and those that laboured spontaneously.

Results: Six thousand five hundred and one women met the inclusion criteria. Three thousand five hundred and eighty-eight women (55.2%) underwent IOL and 2913 women (44.8%) were managed expectantly. Higher rates of emergency caesarean section (29.4% versus 18.5%, p?p?=?0.012) were found in the IOL cohort. The odds of requiring an emergency CS for non-reassuring fetal status was increased (OR 1.51, 95% CI 1.21–1.90). Other than a high proportion of neonatal acidosis in the IOL cohort, there were no differences in perinatal outcomes between the two groups.

Conclusion: IOL >?41 weeks compared to expectant management results in higher rates of emergency caesarean section mainly due to intrapartum fetal compromise.