Cesarean Delivery For Dystocia Research Articles

Neonatal head circumference to maternal mid-transverse pelvic distance ratio as a key anatomical predictor for dystocia: Retrospective case-control study.

This study aimed to examine maternal and neonatal factors in cesarean deliveries due to dystocia, including cephalopelvic disproportion, latent-phase prolongation, and fetal malposition or malpresentation. Additionally, we sought to compare the differences between the dystocia subgroups. This retrospective case-control study included women who delivered between January 2010 and June 2021 after 37 weeks of pregnancy and underwent abdominal-pelvic CT scans within 5 years before and after delivery. Neonatal factors were extracted from medical charts immediately after delivery. Among the 292 women studied, those with cesarean deliveries for dystocia were older (mean ± SD, 34.2 ± 4.27 vs. 32.2 ± 3.8, p-value = 0.002), had higher pre-pregnancy BMI (22.7 ± 3.67 vs. 21.4 ± 3.48, p-value = 0.012) and term-BMI (27.4 ± 3.72 vs. 25.9 ± 3.66, p-value = 0.010), shorter interspinous distance (ISD, the distance between ischial spine) (10.8 ± 0.76 vs. 11.2 ± 0.85 cm, p-value = 0.003), and longer head circumference (HC) (35 ± 1.47 vs. 34.4 ± 1.36 cm, p-value = 0.003) compared to those who had vaginal deliveries. Univariate logistic regression for dystocia revealed associations between HC/maternal height and HC/ISD ratios (OR, 2.02 [95% confidence interval, CI, 1.4 ~ 2.92], 12.13 [3.2 ~ 46.04], respectively). Multivariate logistic analysis indicated that maternal age, ISD, and HC were significant factors for dystocia (OR, 1.11 [95% CI, 1.01 ~ 1.21], 0.49 [0.26 ~ 0.91], 1.53 [1.07 ~ 2.19], respectively). The subgroup with latent-phase prolongation exhibited the lowest birthweight/term-BMI ratio (124 ± 18.8 vs. 113 ± 10.3 vs. 134 ± 19.1, p-value = 0.013). The HC/ISD ratio emerged as a crucial predictor of dystocia, suggesting that reducing term-BMI could potentially mitigate latent-phase prolongation. Further research assessing the maternal mid-pelvis during pregnancy and labor is warranted, along with efforts to reduce BMI during pregnancy.

Maternal obesity and contraction strength in the first stage of labor

The purpose of this study was to determine whether maternal obesity is associated with cesarean delivery and decreased contraction strength in the first stage of labor. We studied a retrospective cohort of women who delivered within a single healthcare system from 2007-2009; we included 5410 women with an intrauterine pressure catheter during the last 2 hours of the first stage of labor and who either had a vaginal delivery or cesarean delivery for dystocia. Logistic regression was used to determine how body mass index was associated with cesarean delivery or mean Montevideo units of ≥200. Although obese women were at significantly greater odds of cesarean delivery than normal-weight women (odds ratio, 2.4; 95% confidence interval, 1.9-3.1), they were equally able to achieve Montevideo units of ≥200. Among women with a vaginal delivery, obese women had a longer first stage of labor compared with normal-weight women (597 vs 566 min; P = .003). Obese women have longer labors but are equally able to achieve adequate Montevideo units as normal-weight women.

Cesarean Delivery for Dystocia in Nulliparous Women

To examine the relationships between prepregnancy body mass index (BMI) categories and Cesarean delivery for dystocia among nulliparous women with a single fetus at term gestation in a head down position.

Is a trial of labor indicated after a prior cesarean delivery for dystocia when the estimated fetal weight is greater than the prior newborn's weight?

DELIVERY FOR DYSTOCIA WHEN THE ESTIMATED FETAL WEIGHT IS GREATER THAN THE PRIOR NEWBORN’S WEIGHT? EMMANUEL BUJOLD, ISRAEL HENDLER, SUSAN BERMAN, SEAN BLACKWELL, ROBERT GAUTHIER, Wayne State University, Obstetrics and Gynecology, Detroit, MI Sainte-Justine Hospital, Obstetrics & Gynecology, Montreal, Quebec, Canada OBJECTIVE: To estimate if the rates of failed TOL and uterine rupture in patients with a prior cesarean delivery for dystocia are increased if the neonatal birth weight is higher than the one at the prior cesarean. STUDY DESIGN: Charts of all patients at term who had a trial of labor after a prior cesarean for dystocia in our institution between 1988 and 2002 were reviewed. The rates of successful VBAC, uterine rupture, and adverse obstetrical outcomes were associated with birth weight at the time of the prior cesarean, birth weight at the time of TOL, and the difference between the two. To adjust for confounding variables, univariate and multivariate regression analysis were performed . RESULTS: Out of 1015 patients with a prior cesarean for dystocia, 191 (19%) had a prior baby over 4000 g, 138 (14%) had a neonate with an actual birth weight over 4000 g, and 470 (46%) had a neonate with an actual birth weight greater than the birth weight of the prior newborn. In a univariate analysis, a neonate > 4000 g at the time of TOL (51% vs 69%, P 4000 g at the time of TOL was associated with a failed TOL (see Table). None of those three factors related to neonatal birth weight were associated with a higher risk of uterine rupture. CONCLUSION: Contrary to popular belief, the prior neonatal birth weight is not related to obstetrical outcomes in patients with a prior history of cesarean for dystocia.

Changes in maternal characteristics and obstetric practice and recent increases in primary cesarean delivery.

To estimate the contribution of changes in maternal characteristics (namely, age, parity, prepregnancy weight, weight gain in pregnancy, smoking status) and obstetric practice (namely, labor induction, epidural anesthesia, delivery by an obstetrician, midpelvic forceps delivery) to recent increases in primary cesarean delivery rates. We studied all deliveries in Nova Scotia, Canada, between 1988 and 2000 after excluding women who had a previous cesarean delivery (n = 127,564). Logistic regression was used to study the effect of changes in maternal characteristics and obstetric practice on primary cesarean delivery rates. The effect of changes in midpelvic forceps delivery was examined through ecologic Poisson regression. Primary cesarean delivery rates increased from 13.4% of deliveries in 1988 to 17.5% in 2000. This was due to increases in cesarean deliveries for dystocia (14% increase), breech (24% increase), suspected fetal distress (21% increase), hypertension (47% increase), and miscellaneous indications (73% increase). Adjustment for maternal characteristics reduced the temporal increase in primary cesarean delivery rates between 1988-1991 and 1998-2000 from 21% (95% confidence interval [CI] 16%, 25%) to 2% (95% CI -2%, 7%). Additional adjustment for obstetric practice factors further reduced period effects. Midpelvic forceps delivery was significantly and negatively associated with primary cesarean delivery (P =.001). Recent increases in primary cesarean delivery rates are a consequence of changes in maternal characteristics. Obstetric practice, which has altered due to changes in maternal characteristics and concerns related to fetal and maternal safety, has also contributed to increases in primary cesarean delivery.

Changes in Maternal Characteristics and Obstetric Practice and Recent Increases in Primary Cesarean Delivery

In Brief OBJECTIVE To estimate the contribution of changes in maternal characteristics (namely, age, parity, prepregnancy weight, weight gain in pregnancy, smoking status) and obstetric practice (namely, labor induction, epidural anesthesia, delivery by an obstetrician, midpelvic forceps delivery) to recent increases in primary cesarean delivery rates. METHODS We studied all deliveries in Nova Scotia, Canada, between 1988 and 2000 after excluding women who had a previous cesarean delivery (n =127,564). Logistic regression was used to study the effect of changes in maternal characteristics and obstetric practice on primary cesarean delivery rates. The effect of changes in midpelvic forceps delivery was examined through ecologic Poisson regression. RESULTS Primary cesarean delivery rates increased from 13.4% of deliveries in 1988 to 17.5% in 2000. This was due to increases in cesarean deliveries for dystocia (14% increase), breech (24% increase), suspected fetal distress (21% increase), hypertension (47% increase), and miscellaneous indications (73% increase). Adjustment for maternal characteristics reduced the temporal increase in primary cesarean delivery rates between 1988–1991 and 1998–2000 from 21% (95% confidence interval [CI] 16%, 25%) to 2% (95% CI −2%, 7%). Additional adjustment for obstetric practice factors further reduced period effects. Midpelvic forceps delivery was significantly and negatively associated with primary cesarean delivery (P = .001). CONCLUSION Recent increases in primary cesarean delivery rates are a consequence of changes in maternal characteristics. Obstetric practice, which has altered due to changes in maternal characteristics and concerns related to fetal and maternal safety, has also contributed to increases in primary cesarean delivery. Recent increases in primary cesarean delivery are due to changesin maternal characteristics and obstetric practice.

A Randomized Study of Combined Spinal-Epidural Analgesia Versus Intravenous Meperidine During Labor

Background: Combined spinal-epidural (CSE) analgesia produces rapid-onset pain relief and allows ambulation in early labor. Epidural local anesthetics may contribute to an increase in operative deliveries by decreasing perineal sensation and causing motor weakness. Operative delivery rates might be reduced with CSE, by avoiding or delaying administration of local anesthetics. This study compares the operative delivery rates associated with a CSE technique and those associated with intravenous meperidine for labor analgesia. Methods: Healthy parturients at full term were assigned randomly to receive CSE or intravenous meperidine analgesia The CSE group received 10 μg intrathecal sufentanil, followed by epidural bupivacaine and fentanyl at their next request for analgesia. Parturients receiving intravenous meperidine had 50 mg on demand (maximum, 200 mg in 4 h). Labor and delivery outcomes in both groups were recorded and compared. Results: An intent-to-treat analysis of 1,223 women indicated that CSE does not increase the rate of cesarean delivery for dystocia in nulliparous and parous women (CSE, 3.5% vs. intravenous meperidine, 4; P = not significant) or in nulliparous women alone (CSE, 7% vs. intravenous meperidine, 8%; P = not significant). Profound fetal bradycardia that necessitated emergency cesarean delivery within 1 h of the time the mother received sufentanil occurred in 8 of 400 parturients (compared with 0 of 352 who received meperidine; P < 0.01). However, the method of fetal monitoring differed between the two groups. Despite this, neonatal outcomes were similar overall. Conclusions: Combined spinal-epidural analgesia during labor does not increase the cesarean delivery rate for dystocia in healthy parturient patients at full term, regardless of parity. However, an unexpected increase in the number of cesarean deliveries for profound fetal bradycardia after intrathecal sufentanil was observed. Further investigation is warranted.

Epidural Analgesia and Cesarean Delivery

In Response: We appreciate Dr. Tarshis' comments and interest in our report [1]. The primary reason we performed our study [1] was to test the inverse of Thorp's hypothesis [2,3], i.e., a large increase in labor epidural use would be associated with an increase in dystocia cesarean delivery. We successfully refuted this theory in a large, stable patient population with stable obstetric attending staff and policies. In fact, obstetric staff changes determined the start and end dates of our study. Among patients delivering before epidural analgesia was available, the dystocia (3.0%) and total (9.1%) cesarean delivery rates were quite low. In fact, these rates were among the lowest in Missouri at the time. It is not likely that changes in obstetric practice could have decreased these rates enough to counterbalance a cesarean-increasing effect of epidural analgesia. In addition, our results agree with those of Johnson and Rosenfeld [4], Lyon et al. [5], and Gribble and Meier [6]. It is highly unlikely that concurrent, unsuspected changes in obstetric practice coincided with large changes in epidural use in all four studies. As in many retrospective studies, there were undesirable deficiencies in our database. We were not able to separate patients in the after-group by both parity and epidural status. Because nulliparous patients have higher rates of both cesarean delivery and epidural use, not being able to separate After-Epidural and After-noEpidural patients by parity could have magnified the reported difference between these groups. Nonetheless, our results are similar to those of both Lyon et al. [5] and Gribble and Meier [6], who did separate patients by parity. We practice in an era in which third-party payor denials of epidural labor analgesia are justified as efforts to "save" women from cesarean delivery. Thus, we believe that it is important to compare our After-Epidural and After-noEpidural groups and to summarize the published and unpublished results of previous authors to emphasize that association does not prove causation. Women predestined to cesarean delivery request epidural analgesia much more frequently than women who deliver vaginally because dysfunctional labor hurts. Providing effective labor pain relief need not change a hospital's cesarean delivery rate. Steven T. Fogel, MD Department of Anesthesiology; Washington University School of Medicine; St. Louis, MO 63110-1093 Barbara L. Leighton, MD Department of Anesthesiology; Allegheny University Hospital for Women; Philadelphia, PA 19131-1696

Epidural Analgesia and Cesarean Delivery

In Response: We appreciate Dr. Tarshis' comments and interest in our report [1]. The primary reason we performed our study [1] was to test the inverse of Thorp's hypothesis [2,3], i.e., a large increase in labor epidural use would be associated with an increase in dystocia cesarean delivery. We successfully refuted this theory in a large, stable patient population with stable obstetric attending staff and policies. In fact, obstetric staff changes determined the start and end dates of our study. Among patients delivering before epidural analgesia was available, the dystocia (3.0%) and total (9.1%) cesarean delivery rates were quite low. In fact, these rates were among the lowest in Missouri at the time. It is not likely that changes in obstetric practice could have decreased these rates enough to counterbalance a cesarean-increasing effect of epidural analgesia. In addition, our results agree with those of Johnson and Rosenfeld [4], Lyon et al. [5], and Gribble and Meier [6]. It is highly unlikely that concurrent, unsuspected changes in obstetric practice coincided with large changes in epidural use in all four studies. As in many retrospective studies, there were undesirable deficiencies in our database. We were not able to separate patients in the after-group by both parity and epidural status. Because nulliparous patients have higher rates of both cesarean delivery and epidural use, not being able to separate After-Epidural and After-noEpidural patients by parity could have magnified the reported difference between these groups. Nonetheless, our results are similar to those of both Lyon et al. [5] and Gribble and Meier [6], who did separate patients by parity. We practice in an era in which third-party payor denials of epidural labor analgesia are justified as efforts to "save" women from cesarean delivery. Thus, we believe that it is important to compare our After-Epidural and After-noEpidural groups and to summarize the published and unpublished results of previous authors to emphasize that association does not prove causation. Women predestined to cesarean delivery request epidural analgesia much more frequently than women who deliver vaginally because dysfunctional labor hurts. Providing effective labor pain relief need not change a hospital's cesarean delivery rate. Steven T. Fogel, MD Department of Anesthesiology; Washington University School of Medicine; St. Louis, MO 63110-1093 Barbara L. Leighton, MD Department of Anesthesiology; Allegheny University Hospital for Women; Philadelphia, PA 19131-1696

Nulliparous Active Labor, Epidural Analgesia, and Cesarean Delivery for Dystocia

Abstract OBJECTIVE: Our purpose was to examine the effect of epidural analgesia on dystocia-related cesarean delivery in actively laboring nulliparous women. STUDY DESIGN: Active labor was confirmed in nulliparous women by uterine contractions, cervical dilatation of 4 cm, effacement of 80%, and fetopelvic engagement. Patients were randomized to one of two groups: epidural analgesia or narcotics. A strict protocol for labor management was in place. Patients recorded the level of pain at randomization and at hourly intervals on a visual analog scale. Elective outlet operative vaginal delivery was permitted. RESULTS: One hundred women were randomized. No difference in the rate of cesarean delivery for dystocia was noted between the groups (epidural 8%, narcotic 6%; p = 0.71). No significant differences were noted in the lengths of the first ( p = 0.54) or second ( p = 0.55) stages of labor or in any other time variable. Women with epidural analgesia underwent operative vaginal delivery more frequently ( p = 0.004). Pain scores were equivalent at randomization, but large differences existed at each hour thereafter. The number of patients randomized did not achieve prestudy estimates. A planned interim analysis of the results demonstrated that we were unlikely to find a statistically significant difference in cesarean delivery rates in a trial of reasonable duration. CONCLUSIONS: With strict criteria for the diagnosis of labor and with use of a rigid protocol for labor management, there was no increase in dystocia-related cesarean delivery with epidural analgesia.(Am J Obstet Gynecol 1997;177:1465-70.)

Epidural Labor Analgesia and the Incidence of Cesarean Delivery for Dystocia

We performed this retrospective study to examine the changes in cesarean delivery rates associated with the establishment of a labor epidural service.In April 1993, St. Louis Regional Medical Center established an on-demand labor epidural service. We obtained demographic data for all patients and reviewed the operative records of all patients undergoing cesarean section who delivered 12 mo before and 16 mo after the start of the labor epidural service. We compared labor epidural rates and total and nulliparous dystocia cesarean delivery rates before and after the epidural service started and among patients who did and did not receive labor epidural analgesia when it was available. Included were 3195 patients who delivered before and 3733 patients who delivered after epidural analgesia became available. Labor epidural rates were 1.2% vs 29.4% for the Before group versus the After group (P < 0.001). Total (9.1% vs 9.7%) and nulliparous dystocia (5.7% vs 6.4%) cesarean delivery rates did not significantly change with the availability of epidural analgesia. However, the total (11.6% vs 8.8%; P = 0.009) and dystocia (8.0% vs 1.0%; P = 0.001) cesarean delivery rates were higher among patients who received epidural analgesia when it was available. We conclude that epidural labor analgesia is associated with, but does not cause, cesarean delivery for dystocia. Implications: Increased epidural analgesia use did not change the overall dystocia cesarean delivery rate, although dystocia was more common among women who chose an epidural analgesia. Consequently, limiting epidural availability will not affect cesarean delivery rates. The evidence does not support advising patients that epidural labor analgesia increases the risk of cesarean delivery. (Anesth Analg 1998;87:119-23)

Managing Difficult Labor: Avoiding Common Pitfalls

The suggestions offered in this article represent an effort to reduce the incidence of cesarean delivery for dystocia while maintaining a safe course to vaginal birth. Avoiding difficult labor induction in which a compelling indication is lacking, providing prompt and effective oxytocin therapy of arrested first stage labor, and liberalizing the use of oxytocin therapy in selected cases of second-stage arrest are emphasized. With the widening use of conduction analgesia, indicated operative vaginal delivery has an increasingly important role in tempering cesarean birth rates. Operative vaginal delivery can play an effective role only when strict conditions to insure its safety are met.

The value of urine screening for glucose at each prenatal visit

To determine whether chemical (dipstick) urinalysis for glucose at each prenatal visit predicts gestational outcomes such as gestational diabetes, abruptio placentae, preterm delivery, fetal heart rate abnormality, cesarean delivery for dystocia, fetal macrosomia, and shoulder dystocia. We retrospectively evaluated each of the 3217 women who were delivered at St. Joseph's Hospital between July 1, 1990, and September 1, 1993, and who had received all prenatal care at Marshfield Clinic. Study subjects had complete urinalyses at the first prenatal visit, blood glucose diabetes screening at 24-28 weeks, and dipstick urinalysis for glucose at each prenatal visit. Women were excluded because of preexisting diabetes, multiple gestation, glucosuria at the first prenatal visit, or failure to complete the recommended blood screening at 24-28 weeks. The remaining 2965 women were grouped according to whether their dipstick urine tests were positive for glucose. Then the two groups were compared with regard to relevant pregnancy outcomes. Women with glucosuria in the first two trimesters had a significantly higher incidence of gestational diabetes (12.8 versus 2.9%, P = .003). For women without evidence of gestational diabetes, there were no clinically important differences in the measured pregnancy outcomes between the two groups. Routine dipstick urinalysis for glucose can identify gravidas at increased risk for gestational diabetes, possibly allowing certain women with gestational diabetes to be diagnosed earlier than 24-28 weeks. However, most glucosuria testing is performed after a patient has completed routine blood screening for gestational diabetes. This third-trimester testing is not predictive of any clinically important pregnancy outcome.

Epidural analgesia in labor and cesarean delivery for dystocia.

Published studies assessing the effect of epidural analgesia in nulliparous labor on the frequency of cesarean delivery for dystocia are reviewed. There are at least four retrospective studies and two prospective studies that suggest that epidural analgesia may increase the risk of cesarean delivery for dystocia in first labors. The potential for epidural to increase the frequency of cesarean delivery for dystocia is likely influenced by multiple variables including parity, cervical dilatation at epidural placement, technique of epidural placement, management of epidural during labor, and the obstetrical management of labor after placement of epidural analgesia. Two studies suggest that delaying placement of the epidural until 5 cm of cervical dilatation or greater may reduce the risk of cesarean birth. Epidural is safe and may be a superior labor analgesic when compared with narcotics. However, patients should be informed that epidural analgesia may increase the risk of cesarean birth in first labors.