Complete Dilatation Research Articles

Emergent cesarean section during active labor-does cervical dilatation matter?

To compare the immediate and late complications associated with emergent cesarean sections (CS) performed during the first and second stages of active labor. We conducted a retrospective analysis of electronic medical records from a single academic center, including data from 577 patients who underwent emergent cesarean sections at 4cm or more of cervical dilatation. Patients were divided into two groups: those who had CS during the first stage of labor (4-9cm dilatation) and those who had CS at complete dilatation (10cm). Maternal and neonatal outcomes were compared, including rates of complications such as uterine atony, post-partum hemorrhage, infection, and neonatal intensive care unit (NICU) admission. Of the 577 patients, 352 underwent CS during active labor and 255 at complete dilatation. The complete dilatation group exhibited significantly higher rates of uterine atony (19.6% vs. 11.6%, p = 0.009) and uterine incision extension (34.2% vs. 16.5%, p = 0.0001). In addition, they had longer hospital stays (4.8 vs. 4.25days, p = 0.003) and higher outpatient clinic visit rates (21.3% vs. 9.9%, p = 0.0001). Infection-related complications on readmission were more common in the complete dilatation group (20% vs. 9.7%, p = 0.001). Neonatal outcomes, including APGAR scores and NICU admissions, did not differ significantly between the groups. Emergent cesarean sections performed at complete cervical dilatation are associated with increased intra-operative and post-operative complications compared to those performed during active labor. These findings highlight the importance of considering the stage of labor when planning cesarean delivery to minimize risks and optimize outcomes for both mother and neonate.

Exploration of the optimal programmed intermittent epidural bolus volume with the dural puncture epidural technique for labour analgesia: a biased-coin up-and-down sequential allocation study.

To determine the optimal programmed intermittent epidural bolus (PIEB) volume for providing effective analgesia in 90% of patients (EV90) during the first stage of labour using the dural puncture epidural (DPE) technique to initiate labour analgesia. We conducted a biased-coin up-and-down sequential allocation study. We included 40 nulliparous women requiring epidural labour analgesia. We used a 25G Whitacre spinal needle to puncture the dural mater and then administered a loading dose of 12mL of ropivacaine 0.1% and sufentanil 0.3μg·mL-1. Subsequently, the PIEB pump delivered boluses with an identical solution at a fixed 40-min interval, starting 1hr after epidural initiation. The bolus volume for the first patient was 7mL and was adjusted for subsequent patients according to the study protocol (bolus volume, 7-12mL). The primary endpoint was effective analgesia, indicated by no need for patient-controlled or manual boluses within 6hr after analgesia initiation or until complete cervical dilation, whichever came first. Outcome evaluators assessed the patients' pain ratings, Bromage scores, sensory blockade level, and maternal blood pressure hourly. Using the truncated Dixon and Mood method, the estimated EV90 was 9.2mL (95% confidence interval [CI], 8.5 to 9.9) whereas the isotonic regression method yielded a value of 8.8mL (95% CI, 8.6 to 9.8). None of the patients experienced a motor block. Two patients experienced hypotension without the need for vasopressors. The estimated PIEB EV90 for ropivacaine 0.1% and sufentanil 0.3μg·mL-1 approached 9mL when DPE was combined with a fixed 40-min interval. ChiCTR.org.cn ( ChiCTR2300067281 ); first submitted 3 January 2023.

Assessment of Intrarenal Pressure through Dilatation State of the Renal Collecting System

Introduction: The aim of the study was to explore the relationship between the dilation states of the renal collecting system in flexible ureteroscopy (f-URS) view and intrarenal pressure (IRP). Methods: Fifteen porcine kidneys were randomly selected and numbered 1 through 15. Pressure transducers were inserted into the renal calyx via puncture and adjusted to a zero position. The distal end of the f-URS probe was placed within the renal pelvis. Perfusion rates of 50 mL/min, 80 mL/min, and 100 mL/min were utilized. We observed the relationship between the dilation state of the renal collecting system and changes in IRP. The state of complete dilation was defined as an unchanging spatial morphology of the renal collecting system as visualized during f-URS. Results: With irrigation rates of 50 mL/min, 80 mL/min, and 100 mL/min, IRP values at the moment of complete dilation of the renal collecting system ranged from 16 to 18 cm H2O, 16–19 cm H2O, and 16–19 cm H2O, respectively. Maximum IRPs ranged from 47 to 49 cm H2O, 82–85 cm H2O, and 97–100 cm H2O, respectively. Prior to complete dilation of the renal collecting system, IRP consistently remained below 20 cm H2O. However, following full dilation of the renal collecting system, IRP rose rapidly and rapidly surpassed 20 cm H2O. Despite sustained elevations in IRP following full dilation, no significant alterations in the renal collecting system dilated morphological were observed with f-URS. Conclusions: In vitro experiments indicate that when the renal collecting system is not fully dilated, the IRP is consistently less than 20 cm H2O. Evaluation of IRP being within a safe range can be determined by assessing the dilation status of the renal collecting system.

Ambulation During Neuraxial Analgesia in Obese Patients: A Pilot Study

Objective: Obese patients are known to have prolonged labors and an increased risk of cesarean delivery in comparison to their normal weight counterparts. Movement has previously been shown to have beneficial effects on the labor process; however, neuraxial analgesia is often recommended in obese women and in common practice limits mobility. The benefits of continuing to ambulate during neuraxial analgesia are not known. As prior studies have postulated a soft tissue dystocia as a potential etiology for prolonged labor among obese patients, ambulation and encouraged movement throughout the labor process may be of particular benefit for these patients. The purpose of this study was to evaluate the feasibility of ambulation with neuraxial analgesia in nulliparous obese patients admitted for labor. Study Design: This is a pilot study conducted at a single tertiary care center. Patients with a BMI of >=35 were approached if they were nulliparous, term, and planned vaginal trial of labor. Patients were excluded if there were contraindications to ambulation, including magnesium administration. Participants were identified at >=34 weeks estimated gestational age through clinic templates and induction of labor schedules, and were approached either in person or with a standard phone consent. Combined spinal-epidural analgesia was initiated per our institution’s policy, with the exception that during the latter portion of the study the test dose was eliminated in order to decrease the immediate motor block from this dose. Following epidural catheter placement, serial blood pressure measurements and motor assessments were completed to ensure safety including a straight leg test and a step stool test. Patients who passed these assessments were enrolled in the trial. Patients were encouraged to ambulate for 20 minutes of every hour while maintained on fetal and uterine telemetry. Ambulation was discouraged after complete dilation. Demographics and delivery outcomes were collected. Results: 105 patients were identified for consent for the trial, of whom 20 were ineligible for the study, 20 were not approached, and 40 declined study participation, leaving 25 patients who were consented. Of those 25, 14 completed the study. Reasons for not completing the study included ineligible by motor assessment, BMI less than 35 at time of delivery admission, preterm delivery, withdrawal, complete dilation at time of epidural without time to ambulate, magnesium administration during labor. A total of 14 participants were enrolled in the pilot trial, of which 11 were able to ambulate. The average BMI of participants was 43 kg/m2. Patients received epidural analgesia at a median cervical dilation of 4 cm and the average time from initiation of epidural analgesia to delivery was 15.4 hours. 65% of patients enrolled had a cesarean delivery. Of the 5 patients with a vaginal delivery, there was 1 shoulder dystocia. The median time spent ambulating was 58.5 minutes, with a range of 20-230 minutes. No patients fell during the trial. While one patient developed a spinal headache, it was not thought to be related to ambulation. Conclusions: A pilot trial of ambulation during neuraxial analgesia demonstrated no safety concerns among an obese nulliparous population. This pilot study was underpowered and is not designed to determine if there is an effect of ambulation with neuraxial analgesia on mode of delivery. Strengths of this study were interdisciplinary collaboration and biologic plausibility of decreased cesarean delivery through ambulation. Limitations included a low enrollment rate and the COVID pandemic, which halted the study as well as limited patients from being able to ambulate in the hallways. A larger study is needed to assess the efficacy of this intervention.

A Prospective Study of Lactate Levels in Uncomplicated Spontaneous and Induced Labor.

Maternal pushing can yield lactate levels that are above the normal range for nonpregnant individuals. Many hospitals require lactate levels as part of sepsis bundles, and this can confuse the clinicians when measured during labor. The objective of this study was to observe lactate levels in uncomplicated labor. This was a prospective study of patients presenting to Labor and Delivery in early labor. Patients met inclusion criteria if they presented at 37 weeks' gestation or greater and were either 3 to 4 cm dilated, in early labor with rupture of membranes less than 12 hours, or were being induced for oligohydramnios or postdates gestation. A baseline maternal lactate level was collected at enrollment. Further levels were collected at complete cervical dilation and every 30 minutes during the second stage of labor up to 3 hours or until delivery. From January 7, 2021, through December 30, 2021, a total of 148 screened patients met the inclusion criteria and 38 were enrolled. Eight (21%) patients withdrew after baseline lactate level was drawn. Twenty-three (61%) patients had a level drawn at complete dilation. Of the 12 (32%) patients with a lactate level drawn at complete and after 30 minutes of pushing, the mean change in lactate level was 2.0 ± 1.8 mmol/L or 0.07 ± 0.06 mmol/L/min (p < 0.01). This change is more pronounced in the second stage of labor for patients with chorioamnionitis (2.6 mmol/L), although this difference is not statistically significant (p = 0.41). Lactate levels increase significantly once a patient reaches complete cervical dilation within 30 minutes of pushing. This increase is more pronounced, although significantly, in patients with chorioamnionitis. As sepsis is one of the leading causes of maternal morbidity and mortality, this pilot study is relevant for providers to see the natural course of lactate levels in labor. · The change in lactate level during normal labor is unknown.. · We measured lactate levels in uncomplicated labor.. · Lactate levels can be elevated in uncomplicated labor..

Clinical management of dystocia due to dicephalic foetal monster in a Jaffarabadi buffalo - A case report

Jaffarabadi buffalo of 13 years of age at full term gestation were presented with a history of parturient signs and continuously straining for over 6 h, ruptured water bag and both the forelimb were in birth canal. Per vaginal examinations revealed complete cervical dilatation and presence of dead foetus in anterior presentation having double head and one head having enlarged forehead stuck in birth canal. Following diagnosis fetotomy was the performed under epidural anaesthesia relieve the condition.

Changes in rate-pressure product associated with pregnancy

In nonpregnant individuals, the rate-pressure product, the product of heart rate and systolic blood pressure, is used as a noninvasive surrogate of myocardial O2 consumption during cardiac stress testing. Pregnancy is considered a physiological cardiovascular stress test. Evidence describing the impact of pregnancy on myocardial O2 demand, as assessed by the rate-pressure product, is limited. This study aimed to describe changes in the rate-pressure product for each pregnancy trimester, during labor and delivery, and the postpartum period among low-risk pregnancies. This was a retrospective cohort study that assessed uncomplicated pregnancies delivered vaginally at term. We collected rate-pressure product (heart rate × systolic blood pressure) values preconception, during pregnancy for each trimester (at ≤13 weeks + 6/7 days, at 14 weeks + 0/7 days through 27 weeks + 6/7 days, and at ≥28 weeks + 0/7 days), during the labor and delivery encounter (hospital admission until complete cervical dilation, complete cervical dilation until placental delivery, and after placental delivery until hospital discharge), and during the outpatient postpartum visit at 2 to 6 weeks after delivery. We calculated the percentage change at each time point from the preconception rate-pressure product (delta rate-pressure product). We used a mixed-linear model to analyze differences in the mean delta rate-pressure product over time and the influence of prepregnancy age, prepregnancy body mass index, and neuraxial anesthesia status during labor and delivery on these estimates. Our cohort comprised 316 patients. The mean rate-pressure product increased significantly from preconception starting at the third trimester of pregnancy and during labor and delivery (P≤.05). The mean delta rate-pressure product peaked at 12% and 38% in the third trimester and during labor and delivery, respectively. Prepregnancy body mass index was inversely correlated with the mean delta rate-pressure product changes (estimate, -0.308; 95% confidence interval, -0.536 to -0.80; P=.008). In contrast, neither the prepregnancy age, nor neuraxial anesthesia status during labor had a significant influence on this parameter. This study validates the transient but significant increase in the rate-pressure product, a clinical estimate of myocardial O2 demand, during uncomplicated pregnancies delivered vaginally at term. Pregnant individuals with lower prepregnancy body mass index experienced a sharper increase in this parameter. Patients who receive neuraxial anesthesia during labor and delivery experience similar changes in the rate-pressure product as those who did not.

Rebozo Technique on Pain Intensity in the First Stage of the Active Phase and Length of Labor in Multigravida Mothers, Wanayasa District, Purwakarta Regency, Indonesia

Background: Pain during the first stage of the active phase is one of the main obstacles in the labor process. The rebozo technique, a traditional technique from Mexico, has been proven to be effective in reducing labor pain. This study aims to determine the effectiveness of the rebozo technique on the intensity of pain in the first stage of the active phase and the duration of labor in multigravida mothers in Wanayasa District, Purwakarta Regency.&#x0D; Methods: This research used a quasi-experimental design with a pre-test and post-test with a control group design. The research sample was 60 multigravida mothers who were divided into two groups: the intervention group (n=30), who received the rebozo technique, and the control group (n=30), who received standard care. Pain intensity was measured using the visual analogue scale (VAS) and duration of labor was calculated from 4 cm of cervical dilatation to complete dilation.&#x0D; Results: The results showed that there was a significant difference in the intensity of pain during the first active phase between the intervention group and the control group (p=0.001). The mean pain intensity in the intervention group was lower than the control group (VAS: 4.2 ± 1.5 vs. 6.1 ± 1.8). There was no significant difference in length of labor between the two groups (p=0.123).&#x0D; Conclusion: The rebozo technique is effective in reducing the intensity of pain during the first active phase in multigravida mothers but has no effect on the length of labor.

Effect of vaginal douching with normal saline before insertion of dinoprostone vaginal insert for labor induction.

Vaginal pH has been suggested to be one of the causative factors, responsible for variation in prostaglandin efficacy for induction of labour. The purpose of this study was to analyse the effect of vaginal douching with normal saline before insertion of dinoprostone vaginal insert for induction of labour. This randomised controlled study was done in the Department of Obstetrics and Gynaecology for a period of 1 year. Using a computer-generated random number table, subjects were allocated in two groups. In group A (study group), vaginal douching was done with 20 cc of sterile 0.9% NaCl and vaginal pH was again measured with pH paper strips just before inserting dinoprostone pessary. Dinoprostone pessary was inserted without douching in group B (control group). There was a significant increase in the vaginal pH after douching with normal saline (4.91 vs 5.52, P < 0.001). Mean intrinsic vaginal pH (pH before inserting dinoprostone insert) in women who delivered vaginally was significantly higher than that of the women who had a caesarean section (5.10 vs 4.63, P < 0.001). Time interval between dinoprostone insertion to active phase of labour, duration of active phase of labour, time interval between dinoprostone insertion, and complete cervical dilatation and mode of delivery were not significantly different between the two groups. Although douching with normal saline increases vaginal pH, douching does not help in increasing the chances of vaginal delivery because it gives a transient effect. Rather, it is intrinsic vaginal pH, which is a better decisive factor for successful vaginal delivery.

Pengaruh Upright Position terhadap Lama Persalinan Kala 1 Fase Aktif

Background: Prolonged labor in the active phase of first stage increase discomfort on birthing mother, including experience more pain, anxiety, and fatigue. The discomfort during labor can be decreased by doing a birthing position. This study aims to determine the effect of upright position on the length of labor in the active phase of first stage. &#x0D; Methods: The study used a quasi-experimental posttest only design with control group. A total of thirty birthing mothers in the active phase of first stage became the subject of the study. Subjects were grouped into two: the upright position group (n=15) and the control group (n=15). The upright position group regularly performed an upright position, including squatting and standing during the active phase of first stage labor. The control group was not directed to perform the upright position. The length of labor in the active phase of first stage between two groups was compared when the cervical dilatation reached 10 cm (complete cervical dilatation).&#x0D; Results: Upright position significantly affected the length of labor in the active phase of first stage, p-value=0,009 (&lt;0,05). There were twelve subjects (80%) of upright position group experienced the length of labor in the active phase of first stage less than six hours (fast category). Meanwhile, in the control group, there were only three subjects experienced the length of labor in the active phase of first stage in fast category. &#x0D; Conclusion: The upright position performed by birthing mother has a posiive effect, namely accelerate the duration of labor in the active phase of first stage.&#x0D; Keywords : Upright Position, Length of Labor, The Active Phase of First Stage Labor.

Enhancing the Study of Quantal Exocytotic Events: Combining Diamond Multi-Electrode Arrays with Amperometric PEak Analysis (APE) an Automated Analysis Code.

MicroGraphited-Diamond-Multi Electrode Arrays (μG-D-MEAs) can be successfully used to reveal, in real time, quantal exocytotic events occurring from many individual neurosecretory cells and/or from many neurons within a network. As μG-D-MEAs arrays are patterned with up to 16 sensing microelectrodes, each of them recording large amounts of data revealing the exocytotic activity, the aim of this work was to support an adequate analysis code to speed up the signal detection. The cutting-edge technology of microGraphited-Diamond-Multi Electrode Arrays (μG-D-MEAs) has been implemented with an automated analysis code (APE, Amperometric Peak Analysis) developed using Matlab R2022a software to provide easy and accurate detection of amperometric spike parameters, including the analysis of the pre-spike foot that sometimes precedes the complete fusion pore dilatation. Data have been acquired from cultured PC12 cells, either collecting events during spontaneous exocytosis or after L-DOPA incubation. Validation of the APE code was performed by comparing the acquired spike parameters with those obtained using Quanta Analysis (Igor macro) by Mosharov et al.

Unlocking physiological transformations in riverine buffaloes following uterine torsion correction

This study aimed to examine the physiological alterations in riverine buffaloes with incompletely dilated cervix after the uterine torsion correction and the main objective was to understand the hormonal changes that lead to complete cervical dilatation following detorsion, facilitating per-vaginal birth. Torsion characteristics in buffaloes (n=24) were examined, and detorsion was performed using Sharma’s Modified Schaffer’s approach. Blood samples were collected pre-detorsion, post-detorsion, and at parturition. The average cervical dilation rate was 1.22±0.16 cm/h, and detorsion-to-parturition duration averaged 17.38±1.44 h. There were no significant differences between haematological and biochemical parameters at three-time intervals except serum calcium. Progesterone levelsdecreased progressively (1.43±0.01 ng/mL, 1.37±0.01 ng/mL, 1.34±0.01 ng/mL), while estradiol levels increased significantly (65.86±2.05 pg/mL, 77.08±2.05 pg/mL, 91.8±2.55 pg/mL) from pre-detorsion to post-detorsion and parturition. The levels of cortisol were significantly higher pre-detorsion (24.3±2.07 ng/mL) and post-detorsion (27.1±2.5 ng/mL) than at parturition (18.31±1.76 ng/mL). In conclusion, elevated estradiol levels, coupled with reduced progesterone, post-detorsion, trigger complete cervical dilatation, facilitating per-vaginal birth. This study sheds light on the hormonal dynamics driving the birthing process in buffaloes after uterine torsion correction.

Use of hyaluronidase enzyme for hastening the cervical dilatation in successfully detorted uterine torsion affected buffaloes

The successfully detorted uterine torsion buffaloes were either subjected to routine post-detorsion treatment (n=10) or in addition to routine treatment, intracervical hyaluronidase enzyme was administered (10,000 IU; 2.5 ml at each of 3, 6, 9, 12 o’clock position of cervix) immediately post-detorsion (n=10), followed by repeated administration at 6h interval (0, 6, 12, 18 h) till complete cervical dilatation or till 24 h post-detorsion. The time elapsed between successful uterine detorsion to complete cervical dilatation was reduced (P&lt;0.05) in buffaloes subjected to enzyme treatment in comparison to their control counterparts (754.6±114.0 vs. 213.5±33.1 minutes). In buffaloes delivering dead fetus, following intracervical treatment, the interval between detorsion to complete cervical dilatation was reduced (P&lt;0.05) to 240.8±44.0 minutes in comparison to their control counterparts (838.1±126.2 minutes). Moreover, following hyaluronidase treatment, the time interval from detorsion of a buffalo to complete cervical dilatation with respect to degree of uterine torsion was much lower (P&lt;0.05) in treated compared to their control group counterparts having either &lt;180o or ≥180o uterine torsion. The fertility parameters (number of days to first estrus and duration of service period) were improved (P&gt;0.05) in hyaluronidase-treated buffaloes of both the groups (&lt;18 h or ≥18 h duration of torsion) as compared to their control counterparts. Conclusion: Intracervical hyaluronidase treatment hastens the cervical dilatation in successfully detorted uterine torsion affected buffaloes with a subsequent potentially beneficial impact on fertility.

The impact of intracervical hyaluronidase enzyme on cervical histomorphology in successfully detorted uterine torsion affected buffaloes

The present study evaluated the impact of intracervical hyaluronidase enzyme on cervical histomorphology in successfully detorted uterine torsion affected buffaloes. These animals were either subjected to routine post-detorsion treatment (n=10) or in addition to routine treatment, hyaluronidase enzyme (10,000 IU; 2.5 ml at each of 3, 6, 9, 12 o’clock position of cervix) was administered intracervically immediately post-detorsion (n=10), followed by repeated administration at 6 h interval (0, 6, 12, 18 h) till complete cervical dilatation or till 24 h after detorsion. The pre-treatment cervical biopsy samples were collected immediately after detorsion and post-treatment samples were collected at complete cervical dilatation which happened within 24 h after detorsion in all the cases. Following histomorphology, the quantification of collagen fibers as mean percentage area occupied collagen out of total tissue area in pre-treatment cervical biopsy samples of all the buffaloes was revealed as 21.0±5.7. During post-treatment period, at the time of complete cervical dilatation, this value exhibited a decrease in control (9.1±2.2; P&gt;0.05) as well as hyaluronidase group (5.8±2.1; P&lt;0.05). In summary, collagen fiber dispersion in cervical tissue of successfully detorted uterine torsion affected buffaloes suggested their role in cervical dilatation, whereby, intracervical hyaluronidase was able to enhance the cervical tissue collagen dispersion.

The Impact of Cervical Effacement at Time of Amniotomy in Patients Undergoing Induction of Labor.

There is evidence to suggest that early amniotomy during induction of labor is advantageous. However, following cervical ripening balloon removal, the cervix remains less effaced and the utility of amniotomy in this setting is less clear. We investigated whether cervical effacement at the time of amniotomy impacts outcomes among nulliparas undergoing induction of labor. This was a secondary analysis of a prospective cohort of singleton, term, nulliparous patients at a tertiary care center undergoing induction of labor and amniotomy. The primary outcome was completion of the first stage of labor. Secondary outcomes were vaginal delivery and postpartum hemorrhage. Outcomes were compared between patients with cervical effacement ≤50% (low effacement) and >50% (high effacement) at time of amniotomy. Multivariable logistic regression was used calculate risk ratios (RR) to adjust for confounders including cervical dilation. Stratified analysis was performed in patients with cervical ripening balloon use. A post hoc sensitivity analysis was performed to further control for cervical dilation. Of 1,256 patients, 365 (29%) underwent amniotomy at low effacement. Amniotomy at low effacement was associated with reduced likelihood of completing the first stage (aRR: 0.87 [95% confidence interval, CI: 0.78-0.95]) and vaginal delivery (aRR: 0.87 [95% CI: 0.77-0.96]). Although amniotomy at low effacement was associated with lower likelihood of completing the first stage in all-comers, those who had amniotomy performed at low effacement following cervical ripening balloon expulsion were at the highest risk (aRR: 0.84 [95% CI: 0.69-0.98], p for interaction = 0.04) In the post hoc sensitivity analysis, including patients who underwent amniotomy at 3- or 4-cm dilation, low cervical effacement remained associated with a lower likelihood of completing the first stage of labor. Low cervical effacement at time of amniotomy, particularly following cervical ripening balloon expulsion, is associated with a lower likelihood of successful induction. · Low cervical effacement at amniotomy was associated with lower rates of complete dilation.. · Effacement at amniotomy is especially important for patients who had a cervical ripening balloon.. · Providers should consider cervical effacement when timing amniotomy for nulliparous term patients..

Experience on trial of labor and vaginal delivery after two previous cesarean sections: A cohort study from a limited-resource setting.

To determine the success rate of trial of labor after two cesarean sections (TOLA2C) in the low-resource setting of the Democratic Republic of Congo (DRC) and to describe factors associated with success and related complications. A prospective cohort study was conducted from 2015 to 2020 in a teaching hospital. Patients who underwent TOLA2C were followed across prenatal visits, onset of spontaneous labor, and delivery. Demographics and clinical characteristics were documented. Pearson and Fisher χ2 tests were used. Predictors of successful vaginal delivery were determined by logistic regression (P˂0.05). Among 532 patients, the success rate of TOLA2C was 405 (76.1%). Factors associated with success included birth spacing ≥24 months (adjOR: 2.02 ; 95% CI 1.14-3.56; P=0.015), previous vaginal delivery (adjOR: 5.02; 95% CI 2.71-9.31; P˂0.001), intercalated vaginal delivery (adjOR: 5.15; 95% CI 2.28-11.65; P˂0.001), cervical dilation >6 cm (adjOR: 2.37; 95% CI 1.92-6.05; P=0.031) and/or complete dilation on arrival in the delivery room (adjOR: 1.96; 95% CI 1.33-11.45; P=0.047) and oxytocin stimulation (adjOR: 4.24; 95% CI 1.82-9.91; P˂0.001). No association with hemorrhage, uterine rupture, transfer to neonatology, or maternal-neonatal deaths was observed. TOLA2C is possible in a low-resource setting with a high success rate and low rates of complications. Patient selection and obstetrical team competency are required.

Potentially acute misoprostol toxicity during third-trimester pregnancy: a case report

Background: The International Federation of Gynecology and Obstetrics (FIGO) recommends the dosage of misoprostol for pregnancy termination in &gt;28 weeks is 25 mcg to 100 mcg per-vaginal or sublingual or buccal, every 6 hours, and the maximum dose is 6 mg. Acute misoprostol toxicity is rarely reported, including in the case of pregnant women. This study aims to discuss the effect of potentially acute misoprostol toxicity in pregnant women and the fetus. Case Presentation: A 17 years-old woman, G1, 32 weeks, presented with singleton intrauterine fetal death. The patient previously consumed 14 tabs of oral misoprostol and 4 tabs of misoprostol intravaginally. Her vital signs were within a normal level, his 4x/10'/40", and her fetal heart rhythm was negative. From vaginal touché found complete dilation. The patient led to bear down and born baby boy, demise fetal, 1965-gram, 43 cm, no maceration and placenta born completely. After delivery, the mother was in good condition. Misoprostol is a synthetic analog of prostaglandin E1, which can be used for uterotonics and cervical ripening. In pregnant women, misoprostol toxicity can induce hypertonic uterine contractions, leading to fetal distress and death, rhabdomyolysis, hyperthermia, respiratory alkalosis, hypoxemia, and metabolic acidosis. One article reported maternal death due to upper gastrointestinal bleeding and multiorgan failure. We analyze that intrauterine fetal death may happen because of excessive misoprostol that induces hypertonic uterine contraction, causing fetal distress and leading to fetal demise. Conclusion: Excessive consumption of misoprostol or potentially acute misoprostol during the third-semester pregnancy can lead to harmful effects for both mother and fetus.

Mode of delivery and birth outcomes in relation to the duration of the passive second stage of labour: A retrospective cohort study of nulliparous women.

To investigate the mode of delivery and birth outcomes in relation to the duration of the passive second stage of labour in nulliparous women. A retrospective cohort study of all nulliparous women (n = 1131) at two delivery units in Sweden. Maternal and obstetric data were obtained from electronic medical records during 2019. The passive second stage was defined as the complete dilation of the cervix until the start of the active second stage. The duration of the passive second stage was categorized into three groups: 0 to 119 min (0 to <2 h), 120-239 min (2- <4h) and ≥240 min (≥4h). Differences between the groups were examined using t-test and Chi2-tests and regression analyses were used to analyse adjusted odds ratio with 95% confidence intervals. The primary outcome was mode of delivery in relation to the duration of the passive second stage and the secondary outcomes covered a series of adverse maternal and neonatal birth outcomes. The rates of instrumental and caesarean deliveries increased as the duration of the passive second stage increased. A ≥4-hour duration of the passive second stage was associated with a nine-times increased risk of caesarean section, and a four-times risk of instrumental delivery compared to a duration of <2 hours in the adjusted analyses. No differences were found in the maternal birth outcomes. The risk of a 5-minute Apgar score <7 was increased in the 2-<4h group. A longer passive second stage was not associated with an increased risk of negative birth experience. Our study demonstrates an increased risk of operative delivery for a longer duration (>2h) of the passive second stage in nulliparous women, although most of the women gave birth by spontaneous vaginal delivery even after ≥4 hours. There was no evidence of an increased risk of adverse maternal outcomes in a longer duration of the passive second stage but there were indications of increased adverse neonatal outcomes. Assessment of fetal well-being is important when the duration of the passive phase is prolonged.

Immediate or Delayed Pushing After Complete Cervical Dilation.

Marlene M. Corton is from the Department of Obstetrics and Gynecology in the Division of Female Pelvic Medicine and Reconstructive Surgery at the University of Texas Southwestern Medical Center, Dallas, Texas; email: [email protected]. Financial Disclosure The author did not report any potential conflicts of interest.

Lactate levels increase significantly in the second stage of spontaneous and induced labor

Lactate is frequently observed as a component of sepsis bundles, however, there is a paucity of data for normal ranges in labor. Because of this, our aim was to survey maternal lactate levels in uncomplicated labor. This was a prospective convenience sampling of patients at term presenting with spontaneous labor and for induction at a single academic center. Blood was collected at admission, complete cervical dilation, and every 30 minutes during the second stage of labor for up to 3 hours or until delivery. Samples were processed and transported on ice to an on-site laboratory within 30 minutes for analysis of plasma lactate using enzymatic oxidation and colorimetric assay (Roche Lactate Gen.2). The primary outcome was change in lactate level over time during the second stage of labor. Statistical analysis included a mixed effects repeated measures model, with chorioamnionitis as a fixed effect and time as a random effect with p < 0.05 considered significant. From January 7, 2021, through December 30, 2021, 38 patients were enrolled. Eight patients withdrew after the baseline level was drawn. Lactate was obtained for 23 patients at complete dilation, and for 14 patients during maternal pushing. Beginning at the second stage, mean lactate was 2.76 mmol/L (95% CI 2.01, 3.51). Lactate significantly increased with time (p < 0.001) with mean change in lactate level 1.9 mmol/L over 30 minutes of observation (Figure 1a). Lactate level was increased in patients with chorioamnionitis compared to uninfected laboring patients, but this difference was not statistically significant (p = 0.67) (Figure 1b). Lactate increases significantly in the second stage of uncomplicated spontaneous or induced labor from a baseline considered outside the normal range in nonpregnant individuals. Obstetricians should use caution in interpreting abnormal lactate levels in otherwise uncomplicated laboring patients with or without chorioamnionitis.