Pregnancy outcome in patients with repeat visits to the labor observation area near term

Patients whose pregnancies are near term and who repeatedly visit the labor observation area but are found not to be in labor and have no clear diagnosis for their complaints remain a source of concern for the obstetrician. In order to determine whether this is a population with special perinatal risks, such cases were reviewed over a 4-month period at Charity Hospital in New Orleans. Seventy-one patients were identified who had repeatedly visited the labor observation area near term. Compared with those in the general obstetrics population, these patients had a significantly increased risk of cesarean section for "failure to progress." Repeat visitors to the labor observation area should be viewed as having a high risk for later abnormalities of active labor. Careful management of labor abnormalities in such patients could theoretically lower their need for cesarean section.     

The Strategy of Fetal Risk Management

Current concepts of perinatal intensive care seem to place disproportionate emphasis on sophisticated electronic and biochemical techniques. There is a need for a balanced approach to the strategy of fetal risk management: the planning, the timing, and the decision making. Ten basic principles underlying good perinatal care are presented. All pregnancies should be assumed to be at risk until it can be proved otherwise. Ideally, no fetus should be submitted to the acknowledged risks of labor until one has some reasonably precise information of the extent to which that fetus is at risk before labor begins. A plea is made for greater communication between the attending physician and those physicians who may well be involved with the care of the infant during and after labor and delivery.     

妊娠风险预警评估模式在孕产妇管理中的应用效果

目的分析妊娠风险预警评估模式在孕产妇管理中的应用效果。方法选取2017年8月至2018年6月在启东市人民医院产检并分娩的1867例孕产妇为研究对象,根据不同的危险评估方法分为预警评估组和高危评估组。预警评估组对孕产妇采用妊娠风险预警评估方法进行妊娠和分娩危险程度的评定;高危评估组对孕产妇采用高危产妇风险评估方法进行妊娠和分娩危险程度的评定。比较预警评估组和高危评估组孕产妇的分娩方式、分娩结局、新生儿结局以及产妇满意度。结果预警评估组剖宫产率显著低于高危评估组(P<0.05)。预警评估组产后2 h出血量、第一产程时间、第二产程时间和总产程时间均低于高危评估组(P<0.05),第三产程时间两组差异无统计学意义(P>0.05)。在新生儿体重和5 min Apgar评分方面两组差异无统计学意义(P>0.05),但预警评估组新生儿1 min Apgar评分高于高危评估组,胎儿窘迫和新生儿窒息率低于高危评估组,产妇满意度高于高危评估组,差异均有统计学意义(P<0.05)。结论妊娠风险预警评估模式能够有效指导孕产妇分娩、降低剖宫产率、缩短产程、改善产妇和新生儿结局并提高产妇满意度。     

Spontaneous vaginal delivery

Vaginal delivery is a natural process that usually does not require significant medical intervention. Management guided by current knowledge of the relevant screening tests and normal labor process can greatly increase the probability of an uncomplicated delivery and postpartum course. All women should be screened for group B streptococcus; women who test positive should be treated with antibiotics during labor. Routine human immunodeficiency virus screening of all pregnant women, and treatment with antiretroviral medication for those who test positive, can reduce perinatal transmission of the infection. Once a woman is in labor, management should focus on the goal of delivering a healthy newborn while minimizing discomfort and complications for the mother. In a patient who tests negative for group B streptococcus, delaying admission to the labor ward until she is in active labor decreases the number of possible medical interventions during labor and delivery. Once a patient has been admitted to the hospital, providing her with continuous emotional support can improve delivery outcomes and the birthing experience. Epidural analgesia is effective for pain control and should not be discontinued late in labor to reduce the need for operative vaginal delivery. Epidurals prolong labor, but do not increase the risk of cesarean delivery. Research has shown that labor may not progress as rapidly as historically reported; this should be considered before intervening for dystocia. Routine episiotomy increases morbidity and should be abandoned. Once the infant has been delivered, active management of the third stage of labor decreases the risk of postpartum hemorrhage.     

Ultrasound detection of nuchal cord prior to labor induction and the risk of Cesarean section.

OBJECTIVES: To investigate the ability of ultrasound to detect the presence of a nuchal cord immediately prior to induction of labor and the association of its presence with delivery by Cesarean section. METHODS: A transabdominal ultrasound scan using gray-scale and color Doppler imaging was performed immediately prior to induction of labor in 289 women in a prospective study to assess the presence of a nuchal cord. The presence of a nuchal cord was classified as present, absent or uncertain. The outcomes of labor, delivery and the neonates were obtained from the patient notes after delivery. RESULTS: A nuchal cord was present at 18% of deliveries. The incidence was not affected by parity, fetal position or reduced amniotic fluid volume. The sensitivity of ultrasound in diagnosing a nuchal cord was 37.5%, with specificity, positive and negative predictive values of 80%, 29% and 85%, respectively. The presence of a nuchal cord did not significantly increase the risk of delivery by Cesarean section (35% vs. 28%; relative risk = 1.22; 95% CI, 0.80-1.87), instrumental delivery for fetal distress, an abnormal cardiotocograph in labor or at delivery, an Apgar score < 7 at 1 min, arterial cord pH < 7.1 or neonatal unit admission. CONCLUSIONS: The sensitivity of the ultrasound diagnosis of a nuchal cord is low prior to induction of labor at term. A nuchal cord does not appear to increase the risk of Cesarean section or of poor neonatal outcome. The low ultrasound detection rate of a nuchal cord limits its use in decision making prior to induction of labor in high-risk pregnancies.     

Bleeding and the third stage of labor

The third stage of labor often is scarcely considered by parturients and birth attendants although it is thought to be the most dangerous stage of labor because of the risk of significant hemorrhage. Safe clinical management based on respect and understanding of the anatomy and physiology of the third stage of labor may prevent many complications. Management of third stage labor is presented. Uterotonic agents and techniques for control of bleeding are discussed.     

Effect of peridural analgesia on labor progress

Epidural analgesia (EDA) is the most effective method of intrapartum pain relief. Its influence on the course of labor continues to be controversial. Although a cause-and-effect relationship has not been proven, this form of analgesia has been blamed for a host of adverse maternal/fetal events during labor, including prolonged first and second stage of labor, dystocia, malrotation of the fetal head and an increased risk of operative delivery (instrumental delivery, Caesarean section). Our own data from the Department of Obstetrics and Gynaecology at the University of Leipzig demonstrate that women with epidural analgesia had a longer duration of labor (the greater proportion taking more than 13 hours), although labor was often already protracted before the start of epidural analgesia. Early epidural analgesia with a cervical dilatation of less than 4 cm does not have any negative impact on the progress of labor. The duration of second-stage pushing and the rate of instrumental deliveries were not increased in our patients. Although the Caesarean section rate for women with an EDA was elevated, the total proportion of secondary Caesarean section remained unchanged despite increased use of EDA. Our findings suggest that women selected for intrapartal EDA already represent a population with an increased risk of an unfavourable course of labor, priming of the cervix, increased need of oxytocin and nulliparity. Pain relief in itself is sufficient indication for the use of intrapartal epidural analgesia.     

分娩风险分级评分管理对产妇分娩方式的影响

目的探讨分娩风险分级评分和分类分级管理对产妇分娩方式的影响。方法选择2008年4月～2011年9月本院收治的6210例产妇,按照入院的单双月分为对照组3150例和实验组3060例。对照组采用常规的方法对分娩方式进行评估,并实施分娩护理,实验组采用分娩风险分级评分及分类分级管理,同时对产妇进行分娩风险告知,观察两组产妇分娩方式及产程的差异。结果实验组产妇剖宫产率低于对照组,顺产产程短于对照组(均P<0.01)。结论应用分娩风险分级评分、分类分级管理和分娩风险告知,可以降低产妇的剖宫产率,缩短顺产产程,从而提高产房的护理质量。     

Foley导尿管水囊引产效果的预测模型建立

目的：探讨 Foley 导尿管水囊用于妊娠晚期孕妇引产效果的影响因素,并建立风险预测模型。方法：选择 2019 年 1 月 1 日至 2021 年 12 月 31 日在常熟市第一人民医院采用Foley 导尿管水囊进行引产的单胎产妇1149 例,对比分析年龄、身高、体重、产时BMI、孕次、产次、孕周、宫高、腹围、Bishop 评分、胎先露衔接、新生儿体重以及引产指征（包括羊水偏少及过少、妊娠期高血压疾病、妊娠期肝内胆汁淤积症、妊娠期糖尿病）等各项危险因素,通过Logistic 回归分析确定影响因素,应用列线图建立预测模型。结果：本研究通过放置Foley导管后48小时内的阴道分娩率评估引产效果,最终纳入研究的 1149 例妊娠晚期产妇引产成功率为 83.55%（960/1149）。通过单因素回归分析发现,身高、孕次、产次与引产效果呈正相关（p＜0.05）,年龄、体重、产时 BMI、宫高、腹围、妊娠期高血压病与引产效果呈负相关（p＜0.05）,由此将年龄、身高、BMI 和产次纳入Logistic 回归方程,基于最终多因素分析构建出列线图,偏倚校正 c 指数为 0.748（95%可信区间 0.716~0.788）。结论：身高、孕次、产次、年龄、体重、产时 BMI、宫高、腹围、妊娠期高血压可作为 Foley 导尿管水囊引产效果的预测指标,基于年龄、身高、BMI 和产次所绘制的列线图可作为Foley 导尿管水囊引产效果的评估手段。     

Preterm labor

Preterm labor is the leading cause of perinatal morbidity and mortality in the United States. It is characterized by cervical effacement and/or dilatation and increased uterine irritability before 37 weeks of gestation. Women with a history of preterm labor are at greatest risk. Strategies for reducing the incidence of preterm labor and delivery have focused on educating both physicians and patients about the risks for preterm labor and methods of detecting preterm cervical dilatation. Methods used to predict preterm labor include weekly cervical assessment, transvaginal ultrasonography, detection of fetal fibronectin and home uterine activity monitoring. As yet, it is unclear if any of these strategies should be routinely employed. At present, management of preterm labor may include the use of tocolytic agents, corticosteroids and antibiotics.     

改革用工和分配制度 促进护理质量提高

为调动护理人员的积极性、主动性和创造性,提高护理质量,该院深化了护理人事用工和劳动分配制度的改革,规范了医院及职工双方的责权利关系;采取了双向选择、择优上岗、尾数陶汰制;实行了综合考评与自荐相结合的择岗方案.在分配上,按照岗位的责任、风险、劳动强度以及质量考核拉开挡次.形成一种优胜劣汰、按需用人、公平竞争的局面.竞争上岗增加了护士的紧迫感,激发了护士的自我提高、自我完善意识和主动服务的自觉性,使整体护理落到实处,护理质量明显提高,促进了护理事业的发展.     

高危妊娠孕妇剖宫产术前心理状况及相关社会心理因素分析

目的：探讨与分析高危妊娠孕妇剖宫产术前心理状况,并了解相关社会心理因素.方法：选取2012年1月～2013年1月我院妇产科收治的150例高危妊娠孕妇为研究对象,根据其是否存在心理问题将其分为对照组87例与心理组63例.将两组患者的临床资料进行收集、统计,采用单因素及多因素分析影响高危妊娠孕妇剖宫产术前的心理因素.结果：本组150例高危妊娠孕妇中,SDS评分为（61.72±18.26）分,SAS评分为（59.61±16.49）分.高危妊娠孕妇剖宫产术前心理问题的发生与孕前思想准备、分娩恐惧、担心分娩安全、担心原有不良妊娠史、担心某些家族疾病史会影响到胎儿、分娩知识了解及待产准备等因素有关.Logistic多因素逐步回归分析显示,担心分娩安全是高危妊娠孕妇的独立危险因素,待产准备则为保护因素.结论：为了降低不良因素对高危妊娠孕妇的影响,高危妊娠孕妇在剖宫产术前需做好待产准备,并做好相关的健康指导,让孕妇对分娩有个正确的认识,降低孕妇对胎儿安全的担心.     

Induction of labor in the absence of standard medical indications: incidence and correlates

BACKGROUND: Induction of labor is an increasingly common obstetrical procedure, with approximately 20-34% of women undergoing labor induction in the United States annually. OBJECTIVE: To determine the extent of labor induction in the absence of standard medical indications and to assess possible associations with maternal and infant characteristics and hospital factors. METHODS: We ascertained induction of labor and associated details as part of a medical record validation study of 4541 women with live, singleton births in 2000 in Washington State using medical record, birth certificate, and hospital discharge data. In this analysis, we report findings for the 1473 women (33% of original cohort) whose medical records indicated that their labors were induced. RESULTS: Among women with induced labor, 7.9% had no clinical information providing an indication for the induction, and 6.4% had only "nonstandard" indications recorded. Compared with women delivering in moderate volume hospitals, women who delivered at lower volume (odds ratios [OR] 3.9; 95% confidence intervals [CI] 1.8-8.6) or higher volume hospitals (OR 4.2; 95% CI 2.4-7.2) had significantly increased risk for undocumented indication of labor. Women who had undocumented indication for induction were at significantly decreased risk of giving birth at a teaching hospital and a public nonfederally owned hospital, and were at greater risk to give birth at a private religious hospital. Factors that remained independently associated with nonstandard indication for induction of labor were primiparas (OR 2.4; 95% CI 1.3-4.2); multiparas (OR 4.3; 95% CI 2.5-7.4), pregnancy-induced hypertension (OR 0.2; 95% CI 0.1-0.4), hospital volume >or=2000 births annually (OR 19.9; 95% CI 6.7-58.6), primary (OR 11.7; 95% CI 4.1-33.6), and tertiary level hospital (OR 0.4; 95% CI 0.2-0.7). CONCLUSIONS: Our findings suggest that nearly 15% of inductions either were not clinically indicated according to standard protocols or indications were incompletely documented. At minimum, further studies are needed to explore how best to improve documentation of indications of labor because accurately describing, among other things, the process of labor induction, is a basic benchmark of care.     

宫颈超声检查结合临床高危因素预测早产的价值

目的 研究早产的危险因素以及对妊娠结局的影响,评估超声测量宫颈长度对预测早产的价值.方法 超声测量131例有先兆早产症状的孕妇的宫颈,追踪孕妇的妊娠结局,并对照133例足月分娩孕妇,分析早产高危因素及母婴结局.结果 早产组中,胎膜早破占42.75%,阴道炎症占32.06%,产前出血占20.61%,均较对照组高,差异有统计学意义（P〈0.05）.早产儿的窒息率为16.79%,死亡率为6.87%,均较对照组高（P〈0.05）.131例先兆早产孕妇中,68例宫颈大于30 mm,3 d、7 d、14 d内分娩率分别为15.64%、27.6%、56.76%;63例宫颈小于30 mm的孕妇3 d、7 d、14 d内分娩率分别为52.38%、30.15%、17.47%.同样宫颈条件下,因高危因素不同则早产结局不同.结论 先兆早产孕妇宫颈长度超声筛查对早产的发生有一定的预测价值,结合高危因素对预测其短期内发生早产的临床价值更大.     

阴道分娩后急性尿潴留的影响因素及护理

目的：分析阴道分娩后急性尿潴留的影响因素,并提出护理干预对策。方法选取我院2014年9月至2015年1月期间阴道分娩后出现急性尿潴留的100例患者及100例阴道分娩未发生尿潴留的产妇为研究对象,用Logistic回归的统计方法分析各因素对经阴道分娩后急性尿潴留的影响力,找出相关危险因素,并提出护理干预对策。结果两组产妇在第一产程、第二产程、产钳助产、胎头吸引术、手转胎头、无痛分娩、住院时间方面均有统计学意义( P<0.05)。将有统计学意义的高危因素纳入多因素Logistic回归分析发现产钳助产、手转胎头、无痛分娩是产后急性尿潴留的独立危险因素( P<0.05)。结论产钳助产、手转胎头、无痛分娩是产后急性尿潴留的独立危险因素,应加强对以上高危人群尿潴留的预防,采用综合性的护理干预措施。     

Influence of labor induction on obstetric outcomes in patients with prolonged pregnancy

BACKGROUND: Prolonged pregnancy is the most frequent reason for induction of labor. This study aims to determine the effects of labor induction on delivery outcome and to quantify the risks of cesarean delivery associated with labor induction in post-date pregnancies. PATIENTS AND METHODS: This retrospective case-control study included a total of 205 women who reached 42 weeks' gestation (41 weeks and 3 days) between January 2002 and April 2004 and who were scheduled for induction of labor with vaginal prostaglandins. These cases were matched for age and parity with controls in spontaneous labor beyond 41 weeks' gestation. Women with any additional medical or obstetric risk factors were excluded from the study. Maternal, neonatal and delivery outcomes were the main variables of interest. RESULTS: During the study period the data of 410 women were available for analysis. Our data revealed that the use of amniotomy (p=0.02), oxytocin (p=0.006) and epidural analgesia (p=0.001) was increased significantly in the induction group compared with the control group of women with spontaneous onset of labor beyond term. The frequency of cesarean delivery and vacuum extraction was also significantly higher in the induction group (p=0.0001). The Bishop score before induction was an important factor that affected the delivery outcome, resulting in significantly higher rates of cesarean section and vacuum extraction when the score was unfavorable (p=0.0001). A univariate regression model revealed induction per se (p=0.0001), primiparity (p= 0.0001), increased maternal age (p=0.006) and an unfavorable Bishop score (p=0.0001) as statistically significant risk factors for cesarean section. In a multivariate logistic regression model, primiparity (p=0.03), increased maternal age (p=0.02) and an unfavorable Bishop score (p=0.01) remained independent risk factors for cesarean section. High infant birth weight was also an independent risk factor (p=0.03). CONCLUSIONS: Our data suggest that women undergoing labor induction because of prolonged pregnancy should be sufficiently informed regarding the risks of a cesarean section or a vacuum extraction. Furthermore, the option of elective cesarean section should be considered, particularly in primiparous women with an unfavorable cervix, higher age, and high estimated infant birth weight.     

Transvaginal sonography of the uterine cervix prior to labor induction.

OBJECTIVES: To compare the Bishop score and transvaginal sonographic measurement of cervical length for predicting the mode of delivery following medically indicated induction of labor in term patients. METHODS: The study was conducted prospectively in 179 women who required medically indicated induction of labor. Inclusion criteria were singleton pregnancy, gestational age > 37 weeks of amenorrhea, cephalic presentation and intact fetal membranes. Cervical length was measured upon arrival in the labor room but was not considered when choosing the induction procedure. Two receiver-operating characteristic curves were plotted to calculate the best threshold value for the Bishop score and for cervical length for predicting the risk of Cesarean section. RESULTS: Fifty-three women (29.6%) had a Cesarean section. The Bishop score was not predictive of the delivery mode, although Cesarean section for failure to progress was more frequent when the Bishop score was < or = 5. Among the women with a Bishop score > 5, the cervical length was not predictive of the induction outcome. However, among the women with a Bishop score < or = 5, a cervical length < 26 mm was associated with a lower Cesarean section rate (20.6 vs. 42.9%; P = 0.006). Furthermore, the interval between the beginning of cervical ripening and delivery was shorter in the case of a short cervix (11.01 +/- 6.7 vs. 18.55 +/- 7.07 h; P < 10(-5)). CONCLUSION: The length of the uterine cervix, measured by transvaginal sonography, is a better predictor of the risk of Cesarean section than the Bishop score after induction of labor for medical reasons. In women with an unfavorable Bishop score, a cervical length of < 26 mm is associated with a lower risk of Cesarean section and a shorter duration of labor.     

早发型重度子痫前期患者胎死宫内引产的护理

目的:探讨早发型重度子痫前期患者胎死宫内后,在实施腔内引产过程中的危险因素及护理对策.方法:对16例发生胎死宫内的早发型重度子痫前期患者应用羊膜腔穿刺利凡诺注射进行引产,分析引产过程中威胁孕妇生命健康及影响引产成功的因素,制定出相应的护理措施,并在引产过程中进行针对性的护理.结果:16例早发型重度子痫前期患者全部安全、顺利分娩,无重大合并症发生.结论:积极寻找引产过程中的危险因素,制定完善的护理措施,精心护理是危重的早发型重度子痫前期患者引产成功的重要保障.     

A review of the role of proinflammatory cytokines in labor and noninfectious preterm labor

The prevention of preterm labor has the potential to reduce newborn morbidity and mortality by decreasing the incidence of preterm birth. Half of all preterm births occur in women with no known clinical risk factors. Labor onset and progress is multifactorial, and we are just beginning to understand the role of cytokines in uterine activity. The purpose of this article is to review the role of cytokines in labor and preterm labor not associated with infection and to provide implications for research and practice.