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.     

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.     

Shock management in acute fetomaternal hemorrhage

Abstract

The determination of fetal head position can be useful in labor to predict the success of labor management, especially in case of malpositions. Malpositions are abnormal positions of the vertex of the fetal head and account for the large part of indication for cesarean sections for dystocic labor. The occiput posterior position occurs in 15–25% of patients before labor at term and, however, most occiput posterior presentations rotate during labor, so that the incidence of occiput posterior at vaginal birth is approximately 5–7%. Persistence of the occiput posterior position is associated with higher rate of interventions and with maternal and neonatal complications and the knowledge of the exact position of the fetal head is of paramount importance prior to any operative vaginal delivery, for both the safe positioning of the instrument that may be used (i.e. forceps versus vacuum) and for its successful outcome. Ultrasound (US) diagnosed occiput posterior position during labor can predict occiput posterior position at birth. By these evidences, the time requested for fetal head descent and the position in the birth canal, had an impact on the diagnosis of labor progression or arrested labor. To try to reduce this pitfalls, authors developed a new algorithm, applied to intrapartum US and based on suitable US pictures, that sets out, in detail, the quantitative evaluation, in degrees, of the occiput posterior position of the fetal head in the pelvis and the birth canal, respectively, in the first and second stage of labor. Authors tested this computer system in a settle of patients in labor.     

A prospective randomised trial on the effect of position in the passive second stage of labour on birth outcome in nulliparous women using epidural analgesia

OBJECTIVE: To determine whether the rate of instrumental birth in nulliparous women using epidural analgesia is affected by maternal position in the passive second stage of labour. DESIGN: A pragmatic prospective randomised trial. SETTING: Consultant maternity unit in the Midlands. PARTICIPANTS: One hundred and seven nulliparous women using epidural analgesia and reaching the second stage of labour with no contraindications to spontaneous birth. INTERVENTIONS: The lateral versus the supported sitting position during the passive second stage of labour. MEASUREMENTS: Mode of birth, incidence of episiotomy, and perineal suturing. FINDINGS: Recruitment was lower than anticipated (107 vs. 220 planned). Lateral position was associated with lower rates of instrumental birth rate (lateral group 33%; sitting group 52%; p=0.05, RR 0.64, CI for RR: 0.40-1.01; Number-needed-to-treat (NNT)=5), of episiotomy (45% vs. 64%; p=0.05, RR 0.66, CI for RR: 0.44-1.00, NNT=5), and of perineal suturing (78% vs. 86%; p=0.243, RR 0.75, CI for RR 0.47-1.17). The odds ratio for instrumental birth in the sitting group was 2.2 (CI 1.00-4.6). Logistic regression of potential confounder variables was undertaken, due to a large variation in maternal weight between the randomised groups. Of the nine possible confounders tested, only position of the baby's head at full dilation affected the risk of instrumental birth significantly (p=0.4, OR 2.7 where the fetal head was in the lateral or posterior position). Maternal weight did not appear to have any effect. The odds ratio for instrumental delivery for women randomised to the sitting position was slightly higher within the logistic regression model (adjusted OR 2.3). KEY CONCLUSIONS: Women randomised to the lateral position had a better chance of a spontaneous vaginal birth than those randomised to the supported sitting position. Position of the babies head at full dilation had an additional effect on mode of birth. These effects are not conclusively generalizable. RECOMMENDATIONS FOR PRACTICE: The lateral position is likely to be at best beneficial, and at the worst no less harmful than the sitting position for most women and their babies who meet the criteria set for this study. Conclusive evidence for or against the technique should be established using larger trials.     

The Fetal Occiput Posterior Position: State of the Science and a New Perspective

Abstract: Background: The fetal occiput posterior position poses challenges in every aspect of intrapartum care—prevention, diagnosis, correction, supportive care, labor management, and delivery. Maternal and newborn outcomes are often worse and both physical and psychological traumas are more common than with fetal occiput anterior positions. The purpose of this paper is to describe nine prevailing concepts that guide labor and birth management with an occiput posterior fetus, and summarize evidence to clarify the state of the science. Methods: A search was conducted of the databases of PubMed and the Cochrane Library. Additional valuable information was obtained from obstetric and midwifery textbooks, books and websites for the public, conversations with maternity care professionals, and years of experience as a doula. Results: Nine prevailing concepts are as follows: (1) prenatal maneuvers rotate the occiput posterior fetus to occiput anterior; (2) it is possible to detect the occiput posterior fetus prenatally; (3) a fetus who is occiput anterior at the onset of labor will remain in that position throughout labor; (4) back pain in labor is a reliable sign of an occiput posterior fetus; (5) the occiput posterior fetus can be identified during labor by digital vaginal examination; (6) an ultrasound scan is a reliable way to detect fetal position; (7) maternal positions facilitate rotation of the occiput posterior fetus; (8) epidural analgesia facilitates rotation; (9) manual rotation of the fetal head to occiput anterior improves the rate of occiput anterior deliveries. Concepts 1, 2, 3, 4, 5, and 8 have little scientific support whereas concepts 6, 7, and 9 are supported by promising evidence. Conclusions: Many current obstetric practices with respect to the occiput posterior position are unsatisfactory, resulting in failure to identify and correct the problem and thus contributing to high surgical delivery rates and traumatic births. The use of ultrasound examination to identify fetal position is a method that is far superior to other methods, and has the potential to improve outcomes. Research studies are needed to examine the efficacy of midwifery methods of identification, and the effect of promising methods to rotate the fetus (simple positional methods and digital or manual rotation). Based on the findings of this review, a practical approach to care is suggested. (BIRTH 37:1 March 2010)     

The effect of epidural analgesia on rates of episiotomy use and episiotomy extension in an inner-city hospital

Objective : To determine the relationship between epidural analgesia and episiotomy usage and episiotomy extension in parturients delivering vaginally. Methods : A database of 20 888 women experiencing spontaneous vaginal delivery at Grady Memorial Hospital from 1990 to 1995 was examined to identify those receiving epidural analgesia. Patients who underwent epidural catheter placement and had adequate perineal anesthesia at delivery comprised the epidural group, and all others comprised the control group. Demographic characteristics and obstetric outcomes were compared. Univariate and multivariate analyses were used to test the association between epidural analgesia, rates of episiotomy and episiotomy extension. Results : Of the 20 888 women experiencing spontaneous vaginal deliveries 6785 (32.5%) received epidural analgesia. Women receiving epidural analgesia were more likely than those not receiving epidural analgesia to be African-American and nulliparous, and to have an occiput posterior presentation. Women receiving epidural analgesia were also more likely to receive an episiotomy (27.8% vs. 13.1%, odds ratio (OR) 2.56, 95% confidence interval (CI) 2.38-2.75) and were less likely to experience a second-degree perineal laceration (11.6% vs. 14.4%, OR 0.75, 95% CI 0.69-0.82) or a third- or fourth-degree extension (8.9% vs. 12.4%, OR 0.81, 95% CI 0.68-0.97). When the results were adjusted for nulliparity, posterior presentation, macrosomia, shoulder dystocia and prolonged second stage, epidural analgesia remained independently associated with receipt of episiotomy (OR 1.97, 95% CI 1.88-2.06) and reduced episiotomy extension (OR 0.74, 95% CI 0.54-0.94). Conclusion : Epidural analgesia increases the rates of episiotomy use, and decreases the rate of episiotomy extension, independently of clinical factors associated with episiotomy.     

Associated factors and outcomes of persistent occiput posterior position: A retrospective cohort study from 1976 to 2001

Objective. To identify maternal and fetal risk factors associated with persistent occiput posterior position at delivery, and to examine the association of occiput posterior position with subsequent obstetric outcomes.

Methods. This is a retrospective cohort study of 30 839 term, cephalic, singleton births. Women with persistent occiput posterior (OP) position at delivery were compared to those with occiput anterior (OA) position. Demographics, obstetric history, and labor management were evaluated and subsequent obstetric outcomes examined. Potential confounding variables were controlled for using multivariate logistic regression analysis.

Results. The overall frequency of OP position was 8.3% in the study population. When compared to Caucasians, a higher rate of OP was observed among African-Americans (OR = 1.4, 95% CI 1.25–1.64) while no other racial/ethnic differences were noted. Other associated factors included nulliparity, maternal age ≥35, gestational age ≥41 weeks, and birth weight >4000 g, as well as artificial rupture of the membranes (AROM) and epidural anesthesia (p < 0.001 for all). Persistent OP was associated with increased rates of operative vaginal (OR = 4.14, 95% CI 3.57–4.81) and cesarean deliveries (OR = 13.45, 95% CI 11.94–15.15) and other peripartum complications including third or fourth degree perineal lacerations (OR = 2.38, 95% CI 2.03–2.79), and chorioamnionitis (OR = 2.10, 95% CI 1.81–2.44).

Conclusion. Epidural use, AROM, African-American ethnicity, nulliparity, and birth weight >4000 g are associated with persistent OP position at delivery, with higher rates of operative deliveries and obstetric complications. This information can be useful in counseling patients regarding risks and associated outcomes of persistent OP position.     

The effect of epidural analgesia on rates of episiotomy use and episiotomy extension in an inner-city hospital

OBJECTIVE: To determine the relationship between epidural analgesia and episiotomy usage and episiotomy extension in parturients delivering vaginally. METHODS: A database of 20 888 women experiencing spontaneous vaginal delivery at Grady Memorial Hospital from 1990 to 1995 was examined to identify those receiving epidural analgesia. Patients who underwent epidural catheter placement and had adequate perineal anesthesia at delivery comprised the epidural group, and all others comprised the control group. Demographic characteristics and obstetric outcomes were compared. Univariate and multivariate analyses were used to test the association between epidural analgesia, rates of episiotomy and episiotomy extension. RESULTS: Of the 20888 women experiencing spontaneous vaginal deliveries 6785 (32.5%) received epidural analgesia. Women receiving epidural analgesia were more likely than those not receiving epidural analgesia to be African-American and nulliparous, and to have an occiput posterior presentation. Women receiving epidural analgesia were also more likely to receive an episiotomy (27.8% vs. 13.1%, odds ratio (OR) 2.56, 95% confidence interval (CI) 2.38-2.75) and were less likely to experience a second-degree perineal laceration (11.6% vs. 14.4%, OR 0.75, 95% CI 0.69-0.82) or a third- or fourth-degree extension (8.9% vs. 12.4%, OR 0.81, 95% CI 0.68-0.97). When the results were adjusted for nulliparity, posterior presentation, macrosomia, shoulder dystocia and prolonged second stage, epidural analgesia remained independently associated with receipt of episiotomy (OR 1.97, 95% CI 1.88-2.06) and reduced episiotomy extension (OR 0.74, 95% CI 0.54-0.94). CONCLUSION: Epidural analgesia increases the rates of episiotomy use, and decreases the rate of episiotomy extension, independently of clinical factors associated with episiotomy.     

The association between persistent occiput posterior position and neonatal outcomes

OBJECTIVE: To examine the effect of persistent occiput posterior position on neonatal outcome. METHODS: This is a retrospective cohort study of 31,392 term, cephalic, singleton births. Women with neonates born in persistent occiput posterior position at delivery were compared to those with occiput anterior position. Women with occiput transverse position were excluded. The association between occiput posterior position and neonatal outcomes, including 5-minute Apgar scores, umbilical cord gases, meconium-stained amniotic fluid, meconium aspiration syndrome, birth trauma, admission to the intensive care nursery, and length of stay were examined using chi(2) and Student t tests. Potential confounders (maternal age, ethnicity, parity, gestational age, epidural anesthesia, labor induction, length of labor, meconium, chorioamnionitis, birth weight, and year of delivery) were controlled for by using multivariable logistic regression and linear regression analyses. RESULTS: There were 2,591 (8.2%) neonates delivered in occiput posterior position of the total cohort of 31,392 deliveries. Compared with occiput anterior, neonates delivered in occiput posterior position had higher risks for adverse outcomes, including 5-minute Apgar score less than 7 (odds ratio [OR] 1.50, 95% confidence interval [CI] 1.17-1.91), acidemic umbilical cord gases (OR 2.05, 95% CI 1.52-2.77), meconium-stained amniotic fluid (OR 1.29, 95% CI 1.17-1.42), birth trauma (OR 1.77, 95% CI 1.22-2.57), admission to the intensive care nursery (OR 1.57, 95% CI 1.28-1.92), and longer neonatal stay in the hospital (OR 2.69, 95% CI 2.22-3.25). CONCLUSION: Persistent occiput posterior position at delivery is associated with higher risks of adverse neonatal outcomes compared with neonates delivered in the occiput anterior position. This information may be important in counseling women who experience persistent occiput posterior position in labor. Level of Evidence: II-2.     

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.     

Associated factors and outcomes of persistent occiput posterior position: A retrospective cohort study from 1976 to 2001.

OBJECTIVE: To identify maternal and fetal risk factors associated with persistent occiput posterior position at delivery, and to examine the association of occiput posterior position with subsequent obstetric outcomes. METHODS: This is a retrospective cohort study of 30 839 term, cephalic, singleton births. Women with persistent occiput posterior (OP) position at delivery were compared to those with occiput anterior (OA) position. Demographics, obstetric history, and labor management were evaluated and subsequent obstetric outcomes examined. Potential confounding variables were controlled for using multivariate logistic regression analysis. RESULTS: The overall frequency of OP position was 8.3% in the study population. When compared to Caucasians, a higher rate of OP was observed among African-Americans (OR = 1.4, 95% CI 1.25-1.64) while no other racial/ethnic differences were noted. Other associated factors included nulliparity, maternal age > or =35, gestational age > or =41 weeks, and birth weight >4000 g, as well as artificial rupture of the membranes (AROM) and epidural anesthesia (p < 0.001 for all). Persistent OP was associated with increased rates of operative vaginal (OR = 4.14, 95% CI 3.57-4.81) and cesarean deliveries (OR = 13.45, 95% CI 11.94-15.15) and other peripartum complications including third or fourth degree perineal lacerations (OR = 2.38, 95% CI 2.03-2.79), and chorioamnionitis (OR = 2.10, 95% CI 1.81-2.44). CONCLUSION: Epidural use, AROM, African-American ethnicity, nulliparity, and birth weight >4000 g are associated with persistent OP position at delivery, with higher rates of operative deliveries and obstetric complications. This information can be useful in counseling patients regarding risks and associated outcomes of persistent OP position.     

A Review of Evidence‐Based Practices for Management of the Second Stage of Labor

Management of the second stage of labor often follows tradition‐based routines rather than evidence‐based practices. This review of second‐stage labor care practices discusses risk factors for perineal trauma and prolonged second stage and scrutinizes a variety of care practices including positions, styles of pushing, use of epidural analgesia, and perineal support techniques. Current evidence for management of the second stage of labor supports the practices of delayed pushing, spontaneous (nondirected) pushing, and maternal choice of positions. Perineal compresses, perineal massage with a lubricant, and controlling the rate of fetal extension during crowning may prevent severe perineal trauma at birth. Supine positioning is not recommended. Upright positions and directed pushing can shorten the time from onset of second stage to birth and may be indicated in certain situations, although directed pushing has some associated risks. If the fetus is in the occiput posterior position, immediate pushing is not recommended, and manual rotation can be effective in correcting the malposition. Women should be informed of the potential effects of epidural analgesia on labor progress. Consultation and intervention to expedite birth may be indicated when birth is not imminent after 2 hours of active pushing, or 4 hours complete dilatation, for nulliparous women; or one hour of pushing, or 2 hours complete dilatation, for multiparous women. Each woman should be individually assessed and apprised of the potential risks to her and her fetus of a prolonged second stage of labor, and some women may choose to continue pushing beyond these time limits.     

Risk factors for failed vacuum extraction and associated complications in term newborn infants: a population-based cohort study

Objective: The aims of the present study were to investigate risk factors for failed vacuum extraction (VE), and to compare neonatal complications among infants delivered by failed VE with those delivered by successful VE.

Methods: Population-based study including all women (and their newborn infants) with singleton pregnancy who gave birth at term by failed VE (n?=?4747) or successful VE (n?=?83?671) in Sweden between 1999 and 2010. Failed VE was defined as VE followed by an emergency cesarean section (ECS), forceps, or both forceps and ECS. We used logistic regression to examine the association between failed VE in relation to intracranial hemorrhage, subgaleal hemorrhage, Apgar scores <7 at 5?min, and neonatal convulsions.

Results: Risk factors for failed VE included occipito posterior position, mid-pelvic fetal station, high birth weight, short maternal stature, epidural analgesia, and induction of labor. Compared with infants born after a successful VE, those delivered by failed VE had a higher risk of subgaleal hemorrhage OR 7.3 CI (5.5–9.7), convulsions OR 1.9 CI (1.4–2.7), and low Apgar OR 2.6 CI (2.3–3.0), but not of ICH.

Conclusion: Failed VE is associated with neonatal complications. Fetal head position and station should be carefully assessed prior to the extraction.     

Occiput posterior fetal head position increases the risk of anal sphincter injury in vacuum-assisted deliveries

OBJECTIVE: The purpose of this study was to determine whether an occiput posterior (OP) fetal head position increases the risk for anal sphincter injury when compared with an occiput anterior (OA) position in vacuum-assisted deliveries. STUDY DESIGN: We conducted a retrospective cohort study of 393 vacuum-assisted singleton vaginal deliveries. Maternal demographics and obstetric and neonatal data were collected from an obstetric database and chart review. RESULTS: Within the OP group, 41.7% developed a third- or fourth-degree laceration compared with 22.0% in the OA group (OR 2.5, 95% CI 1.4-4.7). In a logistic regression model that controlled for BMI, race, nulliparity, length of second stage, episiotomy, birth weight, head circumference, and fetal head position, OP position was 4.0 times (95% CI 1.7-9.6) more likely to be associated with an anal sphincter injury than OA position. CONCLUSION: Among vacuum deliveries, an OP head position confers an incrementally increased risk for anal sphincter injury over an OA position.     

Association between epidural analgesia and intrapartum fever

The objective of this paper is to determine whether or not epidural analgesia is an independent risk factor for intrapartum fever. Maternal temperature was measured every 4 h during labor to 1004 consecutive women in term labor. Women with fever or on antibiotics were excluded. Epidural analgesia was administered upon patients' request. Of the 406 (40%) women who received epidural analgesia, 11.8% (n = 48) developed a fever > or = 37.8 degrees C during labor compared with only 0.2% (n = 1) of women not receiving epidural analgesia. Women who received epidural analgesia were more likely to have one or more risk factors for intrapartum infection. Their labor and ruptured membranes were longer, they were more likely to have internal monitoring and have more vaginal examinations. Compared with women who received epidural analgesia and did not develop intrapartum fever, women that did develop fever had longer epidurals and more risk factors for infection. However, in a logistic regression analysis with fever as dependent variable, only the duration of epidural was significantly associated with the occurrence of fever. The rate of fever increased with longer labors, from 5% with labor < 3 h to 28% with labor > 6 h. In 90% of women the fever resolved within a few hours after delivery. Sepsis evaluation was negative in all of the newborns to mother who had intrapartum fever. Our data support a noninfectious etiology for intrapartum fever in the vast majority of our patients. However, infection must be ruled out before a decision is made to withhold antibiotic therapy.     

Ultrasonographic occiput position in early labour in the prediction of caesarean section

OBJECTIVE: To investigate the value of ultrasonographically determined occiput position in the early stages of the active phase of labour, in addition to traditional maternal, fetal and labour-related characteristics, in the prediction of the likelihood of caesarean section. DESIGN: Prospective observational study. SETTING: District general hospital in the UK. POPULATION: Six hundred and one singleton pregnancies with cephalic presentation in active labour at term with cervical dilatation of 3-5 cm. METHODS: Transabdominal sonography to determine fetal occiput position was carried out by an appropriately trained sonographer immediately before or after the routine clinical examination by the attending midwife or obstetrician. MAIN OUTCOME MEASURE: Caesarean section. RESULTS: Delivery was vaginal in 514 (86%) cases and by caesarean section in 87 (14%). The fetal occiput position was posterior in 209 (35%) cases and in this group the incidence of caesarean section was 19% (40 cases), compared with 11% (47 of 392) in the non-occiput posterior group. Multiple regression analysis revealed that significant independent contribution in the prediction of caesarean section was provided by maternal age (OR 1.1, 95% CI 1.0-1.2), Afro-Caribbean origin (OR 2.4, 95% CI 1.2-4.6), height (OR 0.93, 95% CI 0.89-0.97), parity (OR 0.2, 95% CI 0.1-0.4), type of labour (OR 2.2, 95% CI 1.3-3.8), gestation (OR 1.4, 95% CI 1.1-1.7), fetal head descent (OR 0.6, 95% CI 0.4-0.9), occiput posterior position (OR 2.2, 95% CI 1.3-3.7) and male gender (OR 2.0, 95% CI 1.2-3.5). CONCLUSIONS: The risk of caesarean section can be estimated during the early stage of active labour by the sonographically determined occiput position, in addition to traditional maternal, fetal and labour-related characteristics.     

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.     

Epidural analgesia and fetal head malposition at vaginal delivery

OBJECTIVE: To determine if nulliparas who delivered with on-demand epidural analgesia are more likely to have malpositioning of the fetal vertex at delivery than women delivered during a period of restricted epidural use. METHODS: A retrospective cohort of nulliparous women with spontaneous labor delivered during a 12-month period immediately before the availability of on-demand labor epidural analgesia was compared with a similar group of nulliparas delivered after labor epidural analgesia was available on request. The primary outcome variable was a non-occiput anterior position or malpositioned fetal head at vaginal delivery. RESULTS: The frequency of epidural use increased from 0.9% before epidural analgesia became available on demand to 82.9% afterward. Fetal head malpositioning at vaginal delivery occurred in 26 of 434 (6.0%) women delivered in the before period compared with 29 of 511 (5.7%) in the after period (relative risk 0.95, 95% confidence interval 0.6, 1.6). No statistically significant difference in the incidence of fetal head malpositioning was present after patients were stratified by mode of delivery (Mantel-Haenszel weighted relative risk 0.94, 95% confidence interval 0.6, 1.4). The study sample size provided 85% power to detect a two-fold increase in the incidence of fetal malpositioning from a baseline rate of 6% associated with on-demand epidural use. CONCLUSION: Providing on-request labor epidural analgesia to nulliparas in spontaneous labor did not result in a clinically significant increase in the frequency of fetal head malpositioning at vaginal delivery.     

Maternal satisfaction with childbirth and intrapartum analgesia in nulliparous labour

OBJECTIVE: To assess maternal satisfaction with childbirth and intrapartum pain relief in nulliparous women labouring at term. METHODS: Prospective randomised clinical trial comparing epidural and non-epidural analgesic techniques on term labour outcomes in nulliparous women. Within 24 h of delivery the women were surveyed regarding their opinions about the birthing experience and the allocated analgesic regimen. A postal survey was conducted 6 months postpartum to assess opinions about intrapartum analgesia in a subsequent pregnancy. RESULTS: A total of 992 women were randomised to receive continuous midwifery support (CMS) or epidural (EPI) analgesia on presentation for delivery. There was a high crossover rate from CMS to EPI (61.2%) and a lesser non-compliance rate in the EPI group (27.8%). The early post-partum recollections revealed a high satisfaction with epidural analgesia and lower satisfaction with alternative pain relief measures. Ten percent of women in the CMS group reported negative feelings about their allocated pain relief compared with 1% in the EPI group (P < 0.001), and 10% of all women reported negative feelings about their overall childbirth experience. At the 6-month postpartum survey factors associated with the planned use of epidural analgesia in a subsequent pregnancy were induction of labour (odds ratio (OR) 2.4, 95% confidence interval (CI) 1.2, 4.7) and prior utilisation of epidural analgesia (OR 28.1, 95% CI 14.5, 54.7). CONCLUSIONS: Maternal satisfaction with intrapartum analgesia was significantly higher with epidural analgesia than non-epidural analgesic techniques. Overall satisfaction scores for labour and delivery were high regardless of analgesic approach, reflecting the multiple issues other than pain relief that are involved in the childbirth experience.     

Risk factors for anal sphincter tear during vaginal delivery

OBJECTIVE: To identify risk factors associated with anal sphincter tear during vaginal delivery and to identify opportunities for preventing this cause of fecal incontinence in young women. METHODS: We used baseline data from two groups of women who participated in the Childbirth and Pelvic Symptoms (CAPS) study: those women who delivered vaginally, either those with or those without a recognized anal sphincter tear. Univariable analyses of demographic and obstetric information identified factors associated with anal sphincter tear. We calculated odds ratios (ORs) for these factors alone and in combination, adjusted for maternal age, race, and gestational age. RESULTS: We included data from 797 primaparous women: 407 with a recognized anal sphincter tear and 390 without. Based on univariable analysis, a woman with a sphincter tear was more likely to be older, to be white, to have longer gestation or prolonged second stage of labor, to have a larger infant (birth weight/head circumference), or an infant who was in occiput posterior position, or to have an episiotomy or operative delivery. Logistic regression found forceps delivery (OR 13.6, 95% confidence interval [CI] 7.9-23.2) and episiotomy (OR 5.3, 95% CI 3.8-7.6) were strongly associated with a sphincter tear. The combination of forceps and episiotomy was markedly associated with sphincter tear (OR 25.3, 95% CI 10.2-62.6). The addition of epidural anesthesia to forceps and episiotomy increased the OR to 41.0 (95% CI 13.5-124.4). CONCLUSION: Our results highlight the existence of modifiable obstetric interventions that increase the risk of anal sphincter tear during vaginal delivery. Our results may be used by clinicians and women to help inform their decisions regarding obstetric interventions. LEVEL OF EVIDENCE: II.