Delivery In Nulliparous Women Research Articles

Mode of Delivery in Nulliparous Women and Neonatal Intracranial Injury

When a normal spontaneous vaginal delivery cannot be achieved, one of the following 3 modes of assisted delivery is used: forceps-assisted vaginal delivery, vacuum-assisted vaginal delivery, or cesarean delivery. There is evidence that use of assisted delivery may be associated with adverse neonatal complications that affect long-term cognitive outcome. Few studies have compared the frequency of adverse neonatal outcomes according to mode of delivery; moreover, the results of such studies are unclear. Adverse morbidities in neonates most predictive of future neurodevelopmental deficits are intraventricular hemorrhage, subdural hemorrhage, and seizures; when examined collectively, these best predict neurologic outcome. The aim of this study was to compare adverse neonatal neurologic outcomes among infants delivered by cesarean delivery, forceps-assisted vaginal delivery, or vacuum-assisted vaginal delivery. The association between mode of delivery and adverse neonatal outcomes was examined for 1,025,903 singleton live births born at ≥34 weeks' gestation to nulliparous women using New York City birth certificate data and hospital discharge data from 1995 to 2003. Neonatal morbidities assessed included intraventricular hemorrhage, subdural hemorrhage, seizures, scalp injury or cephalohematoma, skeletal fracture, facial nerve palsy, brachial plexus injury, and a 5-minute Apgar score of <7. Multivariable logistic regression was used to assess associations between delivery mode and neonatal morbidities, adjusting for confounding variables. Fewer seizures and 5-minute Apgar scores <7 were associated with forceps-assisted vaginal delivery compared with vacuum-assisted vaginal delivery and cesarean delivery (P < 0.01 for both). The incidence of subdural hemorrhages was lower among neonates delivered by cesarean delivery compared with forceps-assisted vaginal delivery (P < 0.01) or vacuum-assisted vaginal delivery (P < 0.04). However, forceps-assisted vaginal delivery was associated with fewer composite neurologic complications (intraventricular hemorrhage, subdural hemorrhage, and seizure) than either vacuum-assisted vaginal delivery (adjusted odds ratio, 0.60; 95% confidence interval, 0.40–0.90) or cesarean delivery (adjusted odds ratio, 0.68; 95% confidence interval, 0.48–0.97). Number-needed-to-treat analysis showed that to prevent 1 case of severe neurologic morbidity required 509 forceps-assisted vaginal deliveries compared with vacuum-assisted vaginal deliveries and 559 forceps-assisted vaginal deliveries compared with cesarean deliveries. These findings suggest that a forceps-assisted vaginal delivery is associated with a reduced risk of adverse neonatal neurologic outcomes compared with either vacuum-assisted vaginal delivery or cesarean delivery.

Changes in vaginal breech delivery rates in a single large metropolitan area

Vaginal breech delivery rates have been accepted widely to be in decline and the Term Breech Trial (TBT) has recommended delivery of a breech-presenting infant by elective cesarean section delivery. Our aim was to examine the rate of vaginal delivery of term breech pregnancies in the 8 years before and after the publication of the TBT. We retrospectively examined vaginal delivery rates of breech presentations over a 16-year period in 3 large tertiary maternity hospitals that serve a single large metropolitan population. All 3 hospitals are of similar size and serve a population with similar risk profile. We also examined rates of perinatal mortality in the 3 hospitals over the study period. During the 16-year study period, there were 344,259 deliveries among the 3 hospitals; 11,913 of which were breech deliveries. There were 5655 breech deliveries in the 8 years before the publication of the TBT, with a cesarean delivery rate of 76.9%. There were 6258 breech deliveries in the 8 years since publication of the TBT, and the cesarean delivery rate increased to 89.7% (P < .0001). During the 8 years since publication, the rate of vaginal delivery in nulliparous women decreased from 15.3-7.2% (P < .0001). The vaginal breech delivery rate in multiparous women decreased from 32.6-14.8% (P < .0001). The rates of corrected perinatal mortality showed a significant decrease in the last 4 years of the study. Our study demonstrates that the results and recommendations of the TBT have contributed to decreasing vaginal breech delivery rates, which were already in decline before its publication.

Relationship between Fetal Station and Successful Vaginal Delivery in Nulliparous Women

Relationship between Fetal Station and Successful Vaginal Delivery in Nulliparous Women

Mode of Delivery in Nulliparous Women and Neonatal Intracranial Injury

Mode of Delivery in Nulliparous Women and Neonatal Intracranial Injury

Mode of Delivery in Nulliparous Women and Neonatal Intracranial Injury

To compare neonatal neurologic complication rates of cesarean deliveries, forceps-assisted vaginal deliveries, and vacuum-assisted vaginal deliveries. Data on singleton live births at 34 weeks or greater gestation born to nulliparous women from 1995 to 2003 in New York City were linked to hospital discharge data. Any diagnosis of neonatal subdural hemorrhage, intraventricular hemorrhage, seizures, scalp laceration or cephalohematoma, fracture, facial nerve palsy, brachial plexus injury, or 5-minute Apgar score of less than 7 was considered significant. Multivariable logistic regression was used to estimate associations between delivery mode and these neonatal morbidities. Forceps-assisted vaginal deliveries were associated with significantly fewer seizures and 5-minute Apgar scores less than 7 compared with vacuum-assisted vaginal deliveries and cesarean deliveries. Cesarean deliveries were linked to less subdural hemorrhages compared with forceps-assisted vaginal deliveries or vacuum-assisted vaginal deliveries. When seizure, intraventricular hemorrhage, and subdural hemorrhage were examined collectively to best predict neurologic outcome, forceps-assisted vaginal deliveries had an overall reduced risk compared with both vacuum-assisted vaginal deliveries (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.40-0.90) and cesarean deliveries (OR 0.68, 95% CI 0.48-0.97). The number needed to treat to prevent one case of severe neurologic morbidity is 509 for forceps-assisted vaginal deliveries compared with vacuum-assisted vaginal deliveries and 559 for forceps-assisted vaginal deliveries compared with cesarean deliveries. Compared with vacuum-assisted vaginal delivery or cesarean delivery, a forceps-assisted vaginal delivery is associated with a reduced risk of adverse neonatal neurologic outcomes. II.

Assessing the methods of a recently published study: four placebo groups?

JG. Early versus late epidural analgesia and the risk of instrumental delivery in nulliparous women: a systematic review. BJOG 2011;118:655–61. 3 Luxman D, Wolman I, Groutz A, Cohen JR, Lottan M, Pauzner D, et al. The effect of early epidural block administration on the progression and outcome of labor. Int J Obstet Anesth 1998;7:161–4. 4 Wong CA, Scavone BM, Peaceman AM, McCarthy RJ, Sullivan JT, Diaz NT, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med 2005;352:655–65. 5 Ohel G, Gonen R, Vaida S, Barak S, Gaitini L, Ohel G, et al. Early versus late initiation of epidural analgesia in labor: does it increase the risk of cesarean section? A randomized trial. Am J Obstet Gynecol 2006;194:600–5. 6 Wang F, Shen X, Guo X, Peng Y, Gu X, Labor Analgesia Examining G, et al. Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial. Anesthesiology 2009;111:871–80. 7 Wong CA, McCarthy RJ, Sullivan JT, Scavone BM, Gerber SE, Yaghmour EA, et al. Early compared with late neuraxial analgesia in nulliparous labor induction: a randomized controlled trial. Obstet Gynecol 2009;113:1066–74.

Early versus late epidural analgesia and the risk of instrumental delivery in nulliparous women

Early versus late epidural analgesia and the risk of instrumental delivery in nulliparous women

Early versus late epidural analgesia and the risk of instrumental delivery in nulliparous women

Early versus late epidural analgesia and the risk of instrumental delivery in nulliparous women

Early Versus Late Epidural Analgesia and Risk of Instrumental Delivery in Nulliparous Women: A Systematic Review

The relationship between the timing of epidural anesthesia during labor with delivery and outcome of labor is controversial. A systematic review published in 2007 found a similar rate for cesarean delivery and instrumental vaginal delivery for early epidural analgesia and control group. These results have been questioned, however, because of the use of a broad definition of the early group (before 4–5 cm dilatation) and an incomparable control group. The primary aim of this report was to review recent literature on the effect of the timing of epidural analgesia on the rate of cesarean or instrumental vaginal deliveries in nulliparous women at a gestational age of at least 36 weeks. A search in electronic databases (Pubmed, EMBASE, and the Cochrane Library) was performed until 2010 for randomized controlled trials and prospective and retrospective cohort studies evaluating the effects of early epidural analgesia defined as cervical dilatation ≤3 cm (including combined-spinal epidural) and late-phase epidural analgesia (at least 4 cm) on the mode of delivery in nulliparous term women. The main outcome measure was the rate of cesarean deliveries or instrumental vaginal deliveries. Data extraction was completed using a data extraction form. All study data were pooled. Of the 203 individual studies identified in the initial search, 183 were excluded after review of the abstracts, leaving 20 relevant articles, 6 of which fulfilled inclusion criteria. These 6 studies included 5 randomized controlled trials and 1 retrospective cohort study, and they involved a total of 15,399 nulliparous women. There was no significant difference in the pooled risk of cesarean (risk ratio, 1.02; 95% confidence interval, 0.96–1.08) or instrumental vaginal (risk ratio, 0.96; 95% confidence interval, 0.89–1.05) deliveries among women receiving early epidural analgesia compared with those receiving late epidural analgesia. These findings show no increased risk for cesarean delivery or instrumental vaginal delivery among women receiving early epidural analgesia.

Labor Induction and the Risk of a Cesarean Delivery Among Nulliparous Women at Term

OBJECTIVE:To estimate the association of labor induction with the risk of a cesarean delivery for nulliparous women presenting at term at a regional hospital.METHODS:This was a retrospective cohort study of cesarean delivery among nulliparous women delivering a live, singleton, vertex pregnancy at t

Early versus late epidural analgesia and risk on instrumental delivery in nulliparous women: a systematic review

Review of the literature regarding the relation between the timing of epidural analgesia and the rate of caesarean or instrumental vaginal deliveries. Pubmed, Embase and the Cochrane Library were searched for articles published until 31 July 2010. Studies were selected in which the effects of early latent phase (defined as a cervical dilatation of 3 cm or less) epidural analgesia (including combined-spinal epidural) and late active phase epidural analgesia on the mode of delivery in nulliparous women at 36 weeks of gestation or more were evaluated. Data extraction was completed by using a data-extraction form. Risk ratio and its 95% confidence intervals were calculated for caesarean delivery and instrumental vaginal delivery. Pooled data were calculated. The search retrieved 20 relevant articles, of which six fulfilled the selection criteria of inclusion. These six studies reported on 15,399 nulliparous women in spontaneous or induced labour with a request for analgesia. Risk of caesarean delivery (pooled risk ratio 1.02, 95% CI 0.96-1.08) or instrumental vaginal delivery (pooled risk ratio 0.96, 95% CI 0.89-1.05) was not significantly different between groups. This systematic review showed no increased risk of caesarean delivery or instrumental vaginal delivery for women receiving early epidural analgesia at cervical dilatation of 3 m or less in comparison with late epidural analgesia.

Analyzing the impact of private service on the cesarean section rate in public hospital Thailand

To assess the cesarean section rate and compare the risk profiles of cesarean delivery in nulliparous women between private and non-private service. The computerized delivery records, collected from June 2006 to May 2009 at Rajavithi Hospital were retrospectively reviewed. Of these, 11,049 term singleton nulliparous pregnant women without maternal chronic medical disease were divided into two groups; private and non-private group. Demographic data, cesarean section rate, indication for cesarean section, time of delivery, maternal and neonatal outcomes were assessed and analyzed. The cesarean section rate was markedly different between both groups. The cesarean rates of all pregnant women, women in private group and non-private group were 25.7% (2,841 out of 11,049), 67.3% (1,187 out of 1,765), and 17.8% (1,654 out of 9,284), respectively. The private group's odds of having a cesarean delivery was 9.44 times [95% confidence interval (95% CI) 8.372-10.655] higher than the non-private group's after adjusting for background differences (maternal age, race, gestational age and birth weight). The most common indications for cesarean delivery in private group were elderly gravida, unfavorable cervix and cephalopelvic disproportion. The private group had significantly higher operation rate in the office hours than that of non-private group (70.1 vs. 41.8%; p < 0.0001). After adjusted for background differences, postpartum hemorrhage was significant higher in private group. Conversely, there was fewer admission to neonatal intensive care unit in private group. Low Apgar score at 5 min and perinatal death were not statistically significant in both groups. No cesarean hysterectomy and maternal death in both groups were noted. Private patients had a significantly higher rate of cesarean section than non-private patients. NICU admission was significantly lower in the private group, but postpartum hemorrhage was significantly higher. There were no significant differences in maternal mortality, low Apgar score at 5 min, perinatal death in both group. This study suggests that a significant number of cesarean sections among private services may be unnecessary. To safely reduce a cesarean section rate, an appropriate policy and guideline for auditing cesarean section among private service should be developed.

Elective Induction Compared With Expectant Management in Nulliparous Women With a Favorable Cervix

A number of observational studies have demonstrated increased rates of cesarean delivery in nulliparous women, regardless of favorable or unfavorable cervical status. However, most used a design in which labor induction was compared with spontaneous labor at a given gestational age, not with expectant management, which is a more appropriate clinical comparison. A recent retrospective study demonstrated that nulliparous women who were electively induced had decreased rates of cesarean delivery in comparison to those who were expectantly managed. However, this study did not control for cervical status. In the present study, the investigators hypothesized that after controlling for cervical status, women who were electively induced would have a higher likelihood of cesarean delivery than those who were expectantly managed. A perinatal database was used to identify a population of singleton nulliparous women with a favorable cervix who underwent elective induction of labor (n = 294) or expectant management (n = 294) at 39 to 40 5/7 weeks of gestation, between 2006 and 2008. The elective induction and expectantly managed groups had similar demographic features except that the elective induction group had a slightly higher body mass index (29.4 ± 5.0 vs. 28.2 ± 3.6) and slightly higher Bishop's score (6.8 ± 1.6 vs. 5.8 ± 1.0). No significant differences were observed between the two groups in rates of cesarean delivery, the primary outcome (induction: 20.8% vs. expectant management: 20.1%; P = 0.84). The results remained stable following adjustment for potential confounding variables. Moreover, no significant differences were found for other maternal outcomes (operative vaginal delivery, chorioamnionitis, third- and fourth-degree lacerations, or postpartum hemorrhage), or neonatal outcomes (arterial cord pH less than 7.0, Apgar score less than 4 at 5 minutes, or admission to intensive care unit). The duration of labor and delivery was longer among women undergoing an elective labor induction (median: 12.7 hours) compared with those given expectant management (median: 9 hours; P < 0.001). These findings demonstrate that the likelihood of cesarean delivery among nulliparous women with a favorable cervix is similar for elective induction and expectant management.

The impact of advanced maternal age and parity on obstetric and perinatal outcomes in singleton gestations

ObjectiveTo investigate the effect of advanced maternal age (AMA) separately in nulliparous and multiparous women on obstetric and perinatal outcomes in singleton gestations.Study designA historical cohort study on data from 6,619 singleton pregnancies between 2004 and May 2007 was performed. AMA was defined as 35 years and older. Obstetric and perinatal outcomes in AMA versus women younger than 35 years (non-AMA) were compared for both nulli- and multiparae with Student’s t-test and Chi-square test in univariate analysis. Multiple logistic regression analysis was performed to examine the independent effect of AMA.ResultsOut of 6,619 singleton pregnancies, the frequency of nulliparity was 42.7 and 33.4% of the parturients were of AMA. Among nulliparous women, AMA was significantly associated with a higher frequency of caesarean section both before labour (OR 2.26 with 95% CI 1.74–2.94), in labour (OR 1.44 with 95% CI 1.07–1.93), and more instrumental vaginal deliveries (ORs 1.49 with 95% CI 1.13–1.96). Among multiparous women, AMA was only significantly associated with a higher caesarean section rate before labour (ORs 1.42, 95% CI 1.19–1.69). There were no significant differences between the two age groups in the prevalence of other adverse obstetric outcomes and adverse perinatal outcomes.ConclusionsOperative delivery is increased in AMA, including caesarean sections, as well as instrumental vaginal deliveries in nulliparous women. In multiparous women, however, only the rate of caesarean section before labour was increased. AMA had no significant effect on other adverse obstetric and perinatal outcomes irrespective of parity.

Clinical and sonographic parameters at 37 weeks' gestation for predicting the risk of primary Cesarean delivery in nulliparous women

To identify the clinical and sonographic parameters at 37 weeks' gestation that predict the risk of Cesarean delivery in labor for nulliparas. This prospective observational study recruited nulliparas with singleton pregnancies at 37 weeks' gestation. Determination of the Bishop score, ultrasound measurement of the cervical length, and fetal biometry were performed. The clinical parameters studied were maternal age, height and weight and Bishop score. The sonographic parameters included fetal biparietal diameter, femur length, abdominal circumference (AC), estimated fetal weight (EFW), amniotic fluid index and cervical length. Four hundred and fifty-three women were examined; 57 women (12.6%) underwent an emergency Cesarean delivery in labor. Logistic regression analysis identified maternal age and height and fetal AC and EFW, but not cervical length or Bishop score, as the best predictors of Cesarean delivery. Of these predictors, maternal age and height and fetal AC at 37 weeks were included in a final model for risk scoring. The model was shown to have an adequate goodness of fit (P = 0.473), and the area under the receiver-operating characteristics curve was 0.758, indicating reasonably good discrimination. Maternal age and height and fetal AC and EFW at 37 weeks' gestation are the most important parameters in predicting the risk of Cesarean delivery in nulliparas; sonographic measurement of the cervical length and the Bishop score were not predictive of Cesarean delivery. A predictive model using these parameters at 37 weeks provides useful information in the decision-making process regarding the mode of delivery.

Factors Associated With Cesarean Delivery in Nulliparous Women With Type 1 Diabetes

To identify factors associated with cesarean delivery in nulliparous women with type 1 diabetes mellitus. We performed a nested case-control study within a cohort of nulliparous women with type 1 diabetes mellitus. Independent factors and odds ratios were identified by logistic regression. Among 209 women, a cesarean delivery was performed without labor in 94 women (45%). Gestational weight gain higher than 15 kg (39% compared with 23%; odds ratio [OR], 2.2; 95% confidence interval [CI], 1.1-4.5) and suspected macrosomia (79% compared with 21%; OR, 13.1; 95% CI, 5.3-32.2) were independently associated with cesarean delivery without labor. Among 115 women who underwent a trial of labor, 54 (47%) had a cesarean delivery. Prepregnancy body mass index more than 25 kg/m2 (84% compared with 39%; OR, 7.5; 95% CI, 1.9-29.4) and Bishop score 3 or lower (66% compared with 25%; OR, 5.9; 95% CI, 2.2-16.1) were independently associated with cesarean delivery in labor. Preconception care, presence of a nephropathy, hemoglobin A1C levels during pregnancy, preeclampsia, and preterm delivery were not associated with cesarean delivery. The rates of wound infection and endometritis were 0.7% and 3%, respectively. The rate of cesarean delivery in nulliparous women with type 1 diabetes mellitus is very high. Prepregnancy body weight, gestational weight gain, and accuracy of the prediction of fetal macrosomia are potentially modifiable risk factors for cesarean delivery.

The Active Management of Impending Cephalopelvic Disproportion in Nulliparous Women at Term: A Case Series

Background. The Active Management of Risk in Pregnancy at Term (AMOR-IPAT) protocol has been associated in several studies with significant reductions of group cesarean delivery rate. Present within each of these studies were nulliparous women with risk factors for cephalopelvic disproportion. Risk factors for cephalopelvic disproportion in nulliparous women are especially important because they represent the precursors for the most common indication for primary cesarean delivery. Cases. Three examples of exposure of urban nulliparous women to the AMOR-IPAT protocol are presented. Each woman's risk factor profile for Cephalopelvic Disproportion (CPD) was used to estimate her Upper Limit of Optimal Time of Vaginal Delivery for CPD (UL-OTDcpd). Labor management and clinical outcomes for each case are presented. A simple table summarizing induction rates and birth outcome rates of exposed versus nonexposed nulliparous women is also presented. Conclusion. Because the mode of delivery of the first birth substantially impacts birth options in later pregnancies, the impact of AMOR-IPAT on nulliparous patients is particularly important. Determining the UL-OTDcpd in nulliparous patients, and carefully inducing each patient who has not entered labor by her UL-OTDcpd, may be an effective way of lowering rates of cesarean delivery in nulliparous women.

172: The impact of epidural timing on mode of delivery in nulliparous women at term

To determine if epidural placement in early labor (≤3 cm dilation) compared to late labor (>5 cm dilation) alters the rates of cesarean or operative vaginal delivery in nulliparous women in spontaneous labor at term.

Does Epidural Versus Combined Spinal-epidural Analgesia Prolong Labor and Increase the Risk of Instrumental and Cesarean Delivery in Nulliparous Women?

Abstract Study Objective To compare duration of labor, mode of delivery, and local anesthetic consumed in women who received labor analgesia with epidural or combined spinal-epidural technique. Design Retrospective, observational study. Setting Delivery room of a university hospital. Patients 788 nulliparous women in labor at term with cervical dilation between three and 5 cm. Interventions In Group E (epidural alone), parturients received an epidural solution of 8 mL (levobupivacaine 0.125% with fentanyl 5 μg/mL). In Group CSE (combined spinal-epidural), parturients received a spinal injection of levobupivacaine two mg with fentanyl 15 μg (total volume two mL). Then an epidural catheter was placed in all patients and connected to a patient-controlled analgesia pump (basal infusion rate of 8 mL/hr of 0.1% levobupivacaine and fentanyl two μg/mL, patient-controlled bolus dose of three mL, and lockout time of 30 min). Measurements Labor duration, mode of delivery (spontaneous vaginal vs. instrumental delivery vs. cesarean section), and local anesthetic consumed, were recorded. Main Results Labor analgesia was performed with an epidural technique in 322 patients (40.9%), and a combined spinal-epidural technique in 466 patients (59.1%), of whom 39 Group E women (12.1%) and 46 Group CSE women (9.9%) required cesarean section ( P =ns). No differences in the mode of delivery were observed between the groups. Time from analgesia to delivery (Group E: 217 ± 111 min vs. Group CSE: 213 ± 115 min; P =ns), and epidural local anesthetic consumed (Group E: 35 ± 20 mL vs. Group CSE: 33 ± 20 mL; P =ns), were similar in both groups. Conclusions No significant differences were observed between epidural and combined spinal-epidural given for labor analgesia in nulliparous women in duration of labor, mode of delivery, or local anesthetic consumed.

Labor Pain at the Time of Epidural Analgesia and Mode of Delivery in Nulliparous Women Presenting for an Induction of Labor

To assess whether the degree of labor pain at the initiation of neuraxial analgesia is associated with mode of delivery. Nulliparous women who presented to the labor department for an induction of labor, who were between 37 and 41 weeks of gestation, and who requested labor epidural analgesia with a pain score of 0-3 (low pain) and a cervical dilatation less than 4 cm were assessed retrospectively. Maternal and neonatal outcome including mode of delivery and duration of labor were compared with a similar group of women with pain scores of 4-6 (moderate pain), and 7-10 (severe pain). Assessing whether there was an association between pain level at the time of epidural and operative delivery rates was analyzed using a chi test for trend and by logistic regression to include potentially relevant covariates. We found 185 nulliparous women with low pain and compared them with a randomly selected equal number of women in each of the other pain groups. There was no significant association between pain groups in terms of duration of the first or second stage of labor or mode of delivery. Women with low pain had an operative delivery rate (instrumental assisted vaginal delivery plus cesarean delivery) of 49%, compared with 45% and 45% in those with moderate and severe pain, respectively (P=.40). We did not find an association between the degree of labor pain at initiation of epidural analgesia and mode of delivery or duration of labor. II.