Duration Of Second Stage Research Articles

A Meta-Analysis of Comparing Intermittent Epidural Boluses and Continuous Epidural Infusion for Labor Analgesia.

With the development of medical equipment and techniques in labor anesthesia, it is a major issue to investigate the risks and treatment effects among techniques such as continuous epidural infusion (CEI) and intermittent epidural bolus (IEB). However, there is a controversial result regarding two techniques. This study was conducted through meta-analysis of randomized controlled trials (RCTs) for labor analgesia between the CEI and IEB techniques. The pooled results were presented as weighted mean differences (WMDs) together with 95% confidence intervals (CIs) and odds ratios (ORs) together with 95% CIs, respectively. Eleven RCTs were included in this meta-analysis. Four hundred sixty-five parturients accepted CEI, whereas 473 parturients accepted IEB labor analgesia. Elven identified low- risk bias studies were recruited for meta-analysis. The results presented no statistical difference in cesarean delivery rate between IEB and CEI (OR, 0.96; 95% CI, 0.67–1.37) and duration of second stage of labor (WMD, −3.82 min; 95% CI, −8.28 to 0.64). IEB had statistically significant lessened risk of instrumental delivery (OR, 0.59; 95% CI, 0.39–0.90) and for the use in local anesthetic (WMD, −1.71 mg bupivacaine equivalents per hour; 95% CI, −1.88 and −1.55). Accepted IEB had a higher score of maternal satisfaction (WMD, −6.95 mm; 95% CI, −7.77 to −6.13). Based on evidence, IEB showed a greater benefit for slightly reducing the use in local anesthetic, reduced risk of instrumental delivery, and improved maternal satisfaction for the requirement of labor epidural analgesia for healthy women. In the future, more studies need to be conducted to practice the IEB regimen and explore its influence on labor analgesia.

Determinants of adverse neonatal outcome in vaginal deliveries complicated by suspected intraamniotic infection.

Intraamniotic infection, categorized into isolated maternal fever, suspected intraamniotic infection (SII), and confirmed intraamniotic infection, is associated with neonatal morbidity. However, there is paucity of data regarding the association between intraamniotic infection duration and neonatal outcomes among term singleton vaginal deliveries. We aimed to study the risk factors for adverse neonatal outcome among vaginal deliveries complicated by SII. A retrospective observational study conducted at a tertiary medical center. All consecutive singleton term deliveries with SII were included between 2011 and 2019. Maternal and obstetrical characteristics were evaluated to identify risk factors for adverse neonatal outcome. Correlation between SII duration and neonatal adverse outcome was analyzed. Overall, 882 were analyzed. Most women (85.4%) were primiparous. Median gestation age at delivery was 40 2/7 weeks. Median time from SII to delivery was 170min. Adverse neonatal outcomes occurred in 113 (12.8%) of deliveries. Duration of SII was not associated with adverse neonatal outcome. Analysis for determinants of adverse neonatal outcome revealed that oligohydramnios was more common in pregnancies with adverse neonatal outcome (7/113 (6.2%) vs. 41 (5.4%) OR [95% CI] 2.47 (1.02-5.98), p = 0.03). Duration of second stage of labor was longer in the adverse outcome group (median 179min vs. 126min, p = 0.008). Prolonged second stage was more common in the adverse outcome group (60 (53.1%) vs. 273 (35.5%) OR [95% CI] 2.05 (1.38-3.06), p < 0.001). On logistic regression analysis, prolonged second stage was the only modifiable factor independently associated with adverse neonatal outcome [adjusted OR 2.09 (1.37-3.2), p = 0.001]. Other variables tested did not differ between groups. Only phototherapy and base excess ≥ 12mmol/L were significantly associated with the duration of second stage of labor; for each additional hour of the second stage, the OR for the former increased by 0.34 (p = 0.008), and for the latter by 0.69 (p = 0.007). Duration of suspected intraamniotic infection was not associated with increased neonatal morbidity among women delivering vaginally at term. Prolonged second stage was a strong independent predictor of an adverse neonatal outcome among fetuses exposed to intraamniotic infection.

Effect of induction on maternal and neonatal outcomes of vaginal birth after cesarean

Objective: To investigate the effect of induction on maternal and neonatal outcomes of vaginal birth after cesarean section (VBAC). Methods: Retrospective cohort study. A total of 452 pregnant women who underwent trail of labor after cesarean section (TOLAC) from January 2015 to March 2019 of Beijing Obstetrics and Gynecology Hospital, Capital Medical University were enrolled. According to the mode of the onset of labor, those 331 women who underwent VBAC were divided into spontaneous labor group (n=280) and induction group(n=51). According to induction methods, the pregnant women in the induction group was divided into the low-dose oxytocin subgroup (n=35) and other method subgroup (n=16, 9 cases with cervical ripening by balloon and 7 cases combined with oxytocin). The effect of induction on labor duration and maternal and neonatal outcome in VBAC were analyzed. Results: No maternal and neonatal death occurred. There were 23.0% (76/331) with forceps, 15.1% (50/331) of postpartum hemorrhage, and 24.5% (81/331) of fetal distress. The gravidity, birth weight and the gestational weeks of delivery in the induction group were significantly higher than those in the spontaneous onset group [2.0 (2.0-3.0) vs 2.0(1.0-2.0) times, 39.0(38.0-40.0) vs 38.0(37.0-39.0) weeks, (3 467±372) vs (3 168±538) g, Z=-3.548,-3.892,-3.813, all P<0.01]. The duration of the second stage of labor was significantly longer than that of the spontaneous onset group [43(26-60) vs 30(17-49) min, Z=-2.145,P<0.05], but the duration of the first stage, the total duration of labor, the rate of forceps, the incidence of postpartum hemorrhage, the rate of perineal incision and the incidence of fetal distress were not obvious different (all P>0.05). The duration of the first stage and total duration in oxytocin group were significantly shorter than those other method group [260(210-435) vs 325(250-490) min, 450(355-620) vs 523(370-668) min, Z=-2.001,-1.913, all P<0.05]. There were not significantly different in the duration of second stage, mode of delivery, perineal injury, the rate of postpartum hemorrhage, and fetal distress in the two groups (all P>0.05). Conclusion: Pregnant women who have undergone TOLAC after caesarean section can be induced after fully evaluation. Although induction prolongs the labor duration, it does not affect the maternal and neonatal complication rate.

Postpartum urinary retention and its associated obstetric risk factors among women undergoing vaginal delivery in tertiary care hospital

IntroductionPostpartum urinary retention (PUR) is not an uncommon consequence of bladder dysfunction after vaginal delivery. Despite its ubiquity, morbidity and discomfort brought to the postpartum women, it’s a poorly discussed condition. Patients with Overt PUR are unable to void spontaneously within 6h of vaginal delivery and those with Covert PUR are able to void spontaneously but have a post void residual bladder volume (PVRV) of >150mL. Reported incidences of PUR vary widely ranging from 1.7 %–17.9 %. Aim and ObjectivesTo identify the prevalence and obstetric risk factors for PUR after vaginal delivery in order to identify women with increased risk of PUR. Materials and methodsThe PVRV of women who delivered vaginally was measured after the first spontaneous micturition by ultrasonography. PVRV of more than 150mL was considered as covert PUR. Patient data including age, obstetric history, mode of delivery, duration of labor, PVRV were compared between women with and those without PUR. ResultsOf 878 included women, the overall prevalence of PUR after vaginal delivery was 12.9 %, the prevalence of overt and covert PUR were 1.8 % and 11.04 % respectively. Parturient who were primigravidae, had perineal injury, instrumental delivery, birth weight >3.5kg and a longer duration of second stage of labor were risk factors for developing PUR. ConclusionAny misdiagnosis or delay in diagnosis of PUR can cause bladder over distension leading to irreversible detrusor damage. Hence vigilant monitoring and early detection of PUR helps in facilitating timely interventions and prevention of immediate and long term sequelae.

Severe Perineal Trauma in a Brazilian Southeastern Tertiary Hospital: A Retrospective Cohort Study.

This study aimed to investigate the prevalence of severe perineal trauma (obstetric and anal sphincter injury [OASIS]) in a tertiary high-risk pregnancy facility and the associated factors. A retrospective electronic chart review on perineal lacerations was performed from the period of April 2017 to February 2019. Obstetric and anal sphincter injury was diagnosed by a rectal examination. Primary outcome was the prevalence of OASIS (third- and fourth-degree perineal tear). Independent variables were maternal, intrapartum, and neonatal characteristics. Univariate and multivariate analyses with logistic regression models were performed. A P value lower than 0.05 was considered significant. The prevalence of OASIS (third/fourth-degree laceration) was 1.51% (43/2846) in our population. Our population was mostly white (66.3%) and mostly primiparous (52.1%). By comparison, the prevalence of first/second-degree laceration was 43% (1223/2846). Selective episiotomy occurred in 18.73% (517/2761) of patients, and it was not associated with OASIS (P = 0.211). Advanced maternal age (P = 0.196), higher number of vaginal examinations (P = 0.169), fetal presentation (P = 0.533), and duration of second stage (P = 0.757) were not associated with OASIS. Univariate analysis has found that forceps delivery (odds ratio [OR], 3.68 [1.74-7.79]; P = 0.001), neonatal macrossomy (OR, 3.42 [1.02-11.43]; P = 0.045), and larger head circumference (OR, 1.15 [1.02-1.32]; P = 0.026) were risk factors for OASIS, whereas higher gravidity reduced the risk (OR, 0.61 [0.42-0.91] for OASIS. However, after multivariate analysis, only head circumference (OR, 1.86 [1.10-3.14]; P = 0.020) remained as a risk factor. Larger neonatal head circumference increased in 86% the risk for severe perineal trauma in this cohort of women.

Patient's characteristics and incidence of fecal incontinence after primary repair of Obstetric Anal Sphincter Injuries (OASIS) at three Indonesian tertiary hospitals in 2014-2016.

IntroductionObstetric Anal Sphincter Injuries (OASIS) is a common complication of vaginal delivery. The incidence was 4.53 % of total vaginal deliveries. OASIS is associated with an increased risk of fecal incontinence (FI), which affects one’s quality of life. The incidence of OASIS and FI varied from study to study. In this study, we described the characteristics of patients with OASIS at three Indonesian tertiary hospitals in 2014−2016 and FI outcome among those patients.MethodologyThis is a descriptive study on the characteristics of OASIS patients after primary repair in three tertiary hospitals: dr. Cipto Mangunkusumo National General Hospital, Persahabatan General Hospital and Fatmawati General Hospital from 2014 to 2016. From a total of 234 patients, only 58 patients could be contacted and interviewed using Revised Fecal Incontinence Score (RFIS) questionnaires. Out of the 58 patients, only 16 patients came for transperineal ultrasound. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 20.ResultsFrom a total of 234 patients, the mean age was 26.6 years old with a mean Body Mass Index (BMI) of 24.8 kg/m2. Most of the patients were nulliparous (67.5 %) and the median duration of second stage of labor was 45 min. Episiotomy was not performed on most patients (59.4 %) and most of them underwent spontaneous vaginal delivery (65.4 %) with mean baby’s birthweight of 3217 g. From 58 interviewed patients, three patients complained of FI (5.2 %). Sixteen patients came for transperineal ultrasound examination, and only one of them had FI. Anal sphincter defects were identified in five patients, comprising three external anal sphincter (EAS) and two internal anal sphincter (IAS) defects. All five patients did not experience FI. One patient who had FI had no anal sphincter defect.DiscussionThis is a pilot study for the incidence of FI among the OASIS population in Jakarta, Indonesia. The incidence of FI observed in this study was relatively low (3 out of 58 patients) compared to other studies. This could be due to differences in study population. The fact that the patient with FI had intact anal sphincter suggests that other factors may contribute to the development of FI in addition to the integrity of the anal sphincter. These factors may include pelvic floor muscle and innervation of the surrounding tissues.ConclusionThe outcomes of primary repair of OASIS varied between studies. Patients’ characteristics might play an important role in the development of OASIS as well as the outcome after repair. Further studies with larger sample size are needed.

The effect of antenatal pelvic floor muscle exercises on labour and birth outcomes: a systematic review and meta-analysis.

The current data on the effectiveness of antenatal pelvic floor muscle exercises (PFME) on childbirth outcomes are limited. Therefore, in this study the effect of antenatal PFMEs on labour and birth outcomes was assessed by undertaking a meta-analysis. Databases were systematically searched from 1988 until June 2019. Randomised controlled trials (RCTs) and quasi-experimental studies were included. The methodological quality of studies was assessed using Cochrane Collaboration tools. The outcomes of interest were: duration of first and second stage of labour, episiotomy and perineal outcomes, mode of birth (spontaneous vaginal birth, instrumental birth and caesarean section) and fetal presentation. The mean difference (MD) and risk ratio RR) with the corresponding 95% confidence intervals (CIs) were calculated to assess the association between PFME and the childbirth outcomes. A total of 16 articles were included (n = 2,829 women). PFME shortened the duration of the second stage of labour (MD: -20.90, 95%, CI: -31.82 to -9.97, I2: 0%, p = 0.0002) and for primigravid women (MD: -21.02, 95% CI: -32.10 to -9.94, I2: 0%, p = 0.0002). PFME also reduced severe perineal lacerations (RR 0.57, 95% CI: 0.38 to 0.84, I2: 30%, p = 0.005). No significant difference was seen in normal vaginal birth, caesarean section, instrumental birth and episiotomy rate. Most of the studies carried a moderate to high risk of bias. Antenatal PFME may be effective at shortening the second stage of labour and reducing severe perineal trauma. These findings need to be interpreted considering the included studies' risk of bias. More high-quality RCTs are needed.

Prevalence of levator ani avulsion in a multicenter study (PAMELA study).

The objective is to determine the prevalence of levator ani muscle (LAM) avulsion using four-dimensional ultrasound in primiparous women after vaginal delivery and according to delivery mode. This prospective, multicenter study included 322 women evaluated at 6-12months postpartum by four-dimensional transperineal ultrasound to identify levator ani muscle avulsion. The researcher who performed the ultrasound was blinded to all clinical data. Meaningful data about the birth were also recorded: mode of delivery, mother's age and body mass index, duration of second stage, episiotomy, perineal tearing, anesthesia, assistant, head circumference and fetal weight. 303 volumes were valid for evaluation. The overall prevalence of levator ani muscle avulsion was 18.8% (95% CI 14.4-23.2%). In our multivariate analysis, only mode of delivery reached statistical significance as a risk factor for levator ani muscle avulsion (p < 0.001). The prevalence according to the different modes of delivery was 7.8% in spontaneous delivery, 28.8% in vacuum-assisted and 51.1% in forceps-assisted delivery. Compared with spontaneous delivery, the OR for LAM avulsion was 12.31 with forceps (CI 95% 5.65-26.80) and 4.78 with vacuum-assisted delivery (CI 95% 2.15-10.63). Levator ani avulsion during vaginal delivery in primiparous women occurs in nearly one in every five deliveries. Delivery mode is a significant and modifiable intrapartum risk factor for this lesion. The incidence is lower in spontaneous delivery and significantly increases when an instrument is used to assist delivery, especially forceps.

Risk factors for the recurrence of obstetrical anal sphincter injury and the role of a mediolateral episiotomy: an analysis of a national registry.

The assessment of risk factors, including mediolateral episiotomy (MLE), for the recurrence of obstetric anal sphincter injury (rOASI). Population-based cohort study. Data from the nationwide database of the Dutch Perinatal Registry (Perined). A cohort of 391026 women at term, of whom 9943 had an OASI in their first delivery and had a second vaginal delivery of a liveborn infant in cephalic position. Possible risk factors were tested for statistical significance using univariate and multivariate logistic regression analysis. Rate of rOASI. The rate of rOASI was 5.8%. Multivariate analysis identified a birthweight of ≥4000g (adjusted OR, aOR, 2.1, 95%CI 1.6-2.6) and a duration of second stage of ≥30minutes (aOR 1.8, 95%CI 1.4-2.3) as statistically significant risk factors for rOASI. Mediolateral episiotomy was associated with a statistically significant lower rate of rOASI in spontaneous vaginal delivery (SVD) (aOR0.4, 95%CI 0.3-0.5) and in operative vaginal delivery (OVD) (aOR0.2, 95%CI 0.1-0.5). Women with a history of OASI have a higher rate of OASI in their next delivery. Duration of the second stage of ≥30minutes and a birthweight of ≥4000g are significantly associated with an increased rate of rOASI. Mediolateral episiotomy is associated with a significantly lower rate of rOASI in both SVD and OVD. Mediolateral episiotomy is associated with a significant lower recurrence rate of OASI in women with an OASI in their first delivery.

Intrapartum Ultrasound Measurement of Fetal Head Circumference for Prediction of Prolonged Second Stage of Labor

Background: Fetal head circumference was suggested to play a role in determination of the mode of delivery in nulliparous women. Aim of the work: To determine the capability of intrapartum ultrasound measurement of head circumference to monitor second stage of labor progress in an accurate and objective manner as well as its role as a predictor of successful normal vaginal birth. Patients and Methods:130 females who attended to the labor room and fulfil the inclusion criteria underwent ultrasonographic examination prior to the start of labor, and then followed up until delivery. Every woman was followed up by cervical dilatation, and head station every 4 hours. Woman was transferred to operating room when the cervix is fully dilated and head is engaged to determinate the duration of second stage. Fetal heart sounds were auscultated every 30 minutes and plotted on partogram. Shifting to cesarean section was considered when delivery failed to progress, delayed second stage or fetal bradycardia. Results: By using value of 37.0 for Intrapartum head circumference as a cut-off point, we observed a significant difference between both groups [smaller or larger than 37.0] regarding duration of the 2nd stage of labor [P=0.00] & Mode of delivery [P=0.00]. No statistical difference was observed regarding Maternal morbidity [P=0.374] or Neonatal outcome [P=0.412]. Conclusion: There was significant relation between intrapartum head circumference and length of second stage. Intrapartum fetal head circumference is a useful tool to expect the progress of delivery.

Sonographic fetal head circumference and the risk of obstetric anal sphincter injury following vaginal delivery.

High birth weight is strongly associated with OASIS; nevertheless, it has not been determined which biometric characteristics most affect OASIS occurrence. We aimed to evaluate the association of estimated fetal head circumference with OASIS occurrence among primiparous women delivering by unassisted vaginal delivery. A retrospective study included all primiparous women who delivered at term by spontaneous vaginal delivery from 2011-2019. Women were allocated to two groups: (1) those who experienced OASIS and (2) those who did not experience OASIS. Risk factors for OASIS were analyzed. Overall, 7646 women were included in the study cohort. Of those, 119/7646 (1.6%; 95% CI, 1.3-1.9%) experienced OASIS. Sonographic head circumference and birth weight did not vary between groups. Prolonged second stage was more common in the OASIS group [23 (19%) vs. 986 (13.3%), 1.58 OR (95% CI 1.003-2.51, p = 0.04)]. Absence of epidural analgesia was more common in the OASIS group [30 (25%) vs. 1197 (15.9%), 1.8 OR (95% CI 1.1-2.7, p = 0.006)]. On multivariate logistic regression analysis, the lack of epidural analgesia and duration of second stage of labor were both independently positively associated with OASIS [adjusted OR 2.67 (95% CI 1.55-4.62), p < 0.001, adjusted OR 1.23 (95% CI 1.11-1.43), p < 0.001, respectively)]. Sonographic head circumference and birth weight are not associated with OASIS occurrence among primiparous women delivering by an unassisted vaginal delivery. Prolonged second stage and the use of epidural analgesia are modifiable risk factors among these women.

A double-blind placebo-controlled randomized trial on the effect of hyosine n-butyl bromide for improving duration of labor in term pregnancies.

To compare the effectiveness of intramuscular hyocine n-butyl bromide (HBB) with placebo for shortening the duration of the first stage of labor in term pregnancies. A double blind placebo-controlled randomized trial of parturients who presented at term in the active phase of labor was conducted. They were randomly (1:1 ratio) given intramuscular injection of either 40 mg (2 mL) of HBB or 2 mL of water for injection as a placebo. The primary outcome measures were the duration of first and second stages of labor. Subgroup analysis of primigravid and multigravid women were also performed for various outcomes. We did intention-to-treat analysis. Sixty-two women were randomized to each group and none were lost to follow-up. Baseline characteristics were similar between the HBB and placebo groups. The mean duration of first stage of labor was noted to be significantly shorter in the HBB group for both the primigravidas (246.6 ± 21.9 vs 391.8 ± 56.6 min for control; P < 0.001) and for multigravidas (205.9 ± 17.8 vs 323.8 ± 16.0 min for control;P < 0.001).There was also significantly shorter duration of second stage of labor in the HBB group (primigravida: P = 0.013; multigravida: P = 0.016). The duration of third stage of labor, mode of delivery and maternal and/or neonatal outcomes for both classes of parturients were not significantly different. HBB is effective in reducing the first and second stages of labor without adverse maternal or neonatal outcome. HBB does not significantly influence the duration of third stage of labor including mode of delivery. More evidence is needed to further explore the potential useful role of HBB in the active phase of labor.

A Randomized Clinical Trial to Evaluate the Effect of Programmed Labour and Epidural Analgesia on Onset and Duration of Stages of Labour

Background: The present study was conducted to evaluate the effect of programmed labour and epidural analgesia on onset and duration of stages of labour. Material and Methods: This randomized interventional clinical trial was conducted in department of Anaesthesia at Kamla Nehru State Hospital for Mother and Child, Indira Gandhi medical College Shimla in collaboration with Department of Anaesthesia on eighty uncomplicated pregnant women that were divided into two groups of 40 patients each by block randomization. One group received programmed labour protocol (Injection Pentazocine 6 mg + Injection Diazepam 2 mg IV + Injection Tramadol 1-1.5 mg/kg I.M therafter a single dose of injection Drotaverine 40 mg intravenously) while the other group received epidural analgesia. They were monitored for VAS score before and after intervention. Results: The two groups were comparable in terms of patients characteristics (age, parity, period of gestation). Both groups were comparable in terms of onset of labour Spontaneous labour seen in 65-70% of subjects. Regarding the duration of active phase of labour, In our study, In group 1 duration of active phase of 1 stage of labour was 215 min, and in group 2 it was 204 minutes with standard deviation of 32 minutes in group 1 and 40.4 minutes in group 2 respectively. Using student ‘t’ test this difference was found to be significant statistically. (P value less than 0.005). The mean duration of second stage of labour was 24.3 in group 1 and 35.8 min in group 2 with significant p valueless than 0.005. The mean duration of third stage of labour in our study was 5.89 minutes in group 1 and 5.7 min group 2. This difference is statistically insignificant (using student ‘t’ test (&gt;0.005). Conclusion: Our study concluded that there was significant difference in first and second stage of labour in both groups while there was no significant difference in third stage and onset of labour in both groups.

Malmström vacuum or Kielland forceps: which causes more damage to pelvic floor?

To determine whether differences exist in the rate of levator ani muscle (LAM) avulsion between women who had undergone either Malmström vacuum delivery (MVD) or Kielland forceps delivery (KFD), allowing for potential confounding factors. This was a prospective observational study of nulliparous women undergoing instrumental delivery using Malmström vacuum extractor or Kielland forceps, at two hospital centers in Spain. Fetal head position (anterior, posterior or transverse) and fetal head station (low or mid) were assessed by ultrasound and digital examination, respectively. Avulsion was defined on tomographic ultrasound imaging as an abnormal insertion of the LAM in the three central slices from the plane of minimal hiatal dimensions. In total, 414 patients were included in the study (212 MVD and 202 KFD). We observed a higher rate of LAM avulsion in the KFD group (KFD 49.5% vs MVD 32.5%; P = 0.001). When the results were evaluated according to fetal head position and station, we observed no differences in LAM avulsion. The crude odds ratio (OR) for the difference in avulsion between women in the KFD and MVD groups was 2.03 (95% CI, 1.36-3.03). However, when adjusted for duration of second stage of labor, fetal head circumference and fetal head station, the OR was no longer statistically significant (OR, 2.14 (95% CI, 0.95-4.85); P = 0.068). When potential confounding factors are taken into account, the rate of LAM avulsion does not differ between women according to whether they have undergone KFD or MVD. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Prevalence of levator hiatal overdistension after vacuum and forceps deliveries.

Levator ani avulsion rates after assisted vaginal delivery have been reported in the literature. However, there are no definitive data regarding the association between overdistention and assisted vaginal delivery. Therefore, our aim is to report overdistention rates after assisted vaginal delivery with a postpartum ultrasound examination. This multicenter study involved a retrospective analysis of data from primiparous women (n = 602) who had previously been recruited at three tertiary hospitals between January 2015 and January 2017. Overdistention was assessed at 6 months postpartum using three-/four-dimensional transperineal ultrasound. Patients with levator ani muscle avulsion were excluded. Overdistention was defined as a levator hiatal area ≥ 25 cm2 on Valsalva. Of the 602 primiparous patients, 250 patients who satisfied the inclusion criteria (139 patients who underwent forceps delivery and 111 patients who underwent vacuum delivery) were evaluated. Overdistention occurred in 20% (50 of 250) of these patients. Overdistention was observed for 1% (1/111) of vacuum deliveries and 35.3% (49 of 139) of forceps deliveries. We found an increased risk of overdistention following forceps delivery compared to vacuum delivery, with a crude odds ratio (OR) of 59.9 (95% confidence interval [CI]: 8.1, 442.2) and an adjusted OR (adjusted for maternal age, second-stage duration, and head circumference) of 17.6 (95% CI: 2.3, 136.7). Postpartum overdistention occurred for 20% of assisted vaginal deliveries, with an increased risk of overdistention following forceps delivery compared to vacuum delivery.

Effectiveness Bearing Down Techniques During Second Stage of Labour on Maternal and Neonatal Outcome among Primigravida Mothers

Background: Maternal bearing down efforts plays a vital role in expulsive phase of labor. Various types of bearing down efforts has got its own advantages and disadvantages on mother and fetus. Various studies are done to evaluate the best bearing down techniques and have different results .The investigator personally felt there is a need to investigate the best bearing down technique with less complications to the mother and newborn. Objective: 1. To assess the effect of vulsalva bearing down technique during second stage of labour on maternal and neonatal outcome among primigravida mothers admitted in selected hospitals of pune city. 2.To assess the effect of spontaneous bearing down technique during second stage of labour on maternal and neonatal outcome among primigravida mothers admitted in selected hospitals of pune city. 3. To compare the effectiveness of vulsalva bearing down techniques and spontaneous techniques and duration of second stage of labour on maternal and neonatal outcome among primigravida mothers admitted in selected hospitals of pune city. Methodology: In the present study, Quantitative research approach is applied and approach is applied and pre experimental, Post test only control group design is used. The setting of the study was selected hospital of Pune. The sample size for study was 60, selected by using Non Probability Purposive Sampling Technique. The structured questionnaire and observation checklist was administered. In order to establish the reliability of the tool inter rater method was used. The scores were calculated and the reliability was established by Kappa method, which was 0.90. Results: On Comparison of the Spontaneous and vulsulva bearing down techniques on various maternal and neonatal outcome. Since the P values corresponding to the Maternal outcome, oxytocin given, Perineal laceration ,Type of episiotomy, size of episiotomy ,mode of delivery and fatigue and Neonatal outcome Crown heel length of newborn, Head circumference of newborn, Neonate Resuscitation, Admission to NICU,APGAR score are small (less than 0.005) suggests that vulsulva bearing down technique is significantly different that spontaneous bearing down technique in the above maternal and neonatal outcomes and good result for the health of mother and newborn. Conclusion: The Spontaneous pushing method has a negative effect on various factors related to maternal and neonatal outcome factors according to the results in this study. Vulsalva pushing has various benefits towards the better health of Mother and Newborn so it should be accepted as best clinical practice.

485: Risks during cesarean delivery after prolonging the second stage of labor

Perinatal risks regardless of mode of delivery are known to increase with time spent in the second stage (SS). However, it is unknown if risks specific to cesarean delivery also escalate with time. The aim of this study was to quantify perinatal morbidities associated with cesarean delivery by length of second stage. Retrospective cohort study of nulliparous women with singleton gestations, cephalic presentation and term cesarean deliveries during the SS of labor using the Consortium on Safe Labor database. Exclusion: stillbirth, contraindications to vaginal delivery. Length of SS was grouped by hours: 3, 3-4, 4-5, 5-6, and 6. Demographic and clinical variables were compared by group. Univariable and multivariable analyses of maternal and neonatal outcomes of interest were performed to elucidate the independent effect of length of SS on these outcomes. The primary outcome was a composite of maternal morbidities. Secondary outcomes were individual perinatal morbidities. 6,273 women were evaluated by length of SS: 3,652 (58.2%) 3 hours, 854 (13.6%) 3-4 hours, 618 (9.9%) 4-5 hours, 397 (6.3%) 5-6 hours, and 752 (12.0%) 6 hours. Maternal composite outcome were not statistically different between groups (Table, Figure). Extended maternal length of stay (>5 days), increased birthweight and lower rates of general anesthesia were significantly associated with increased length of SS. Significantly higher odds of hemorrhage (aOR 1.50; 95% CI: 1.05 - 2.13) and 1-minute APGAR score ≤ 5 (aOR 1.67; 95% CI: 1.17 – 2.40) were found when comparing women with SS 3-4 hours vs 3 hours, but this finding was not detected after 4 hours. Chorioamnionitis, wound complications and thrombosis did not increase over time. Composite neonatal morbidity was not statistically different between groups (Figure). After 3 hours of SS, cesarean delivery may accrue more risk for patients. Counseling women about duration of SS should include a discussion of increased risks of cesarean delivery over time; specifically, increased risk of hemorrhage, maternal length of stay and lower 1 minute APGAR score.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Factors associated with the severity of neonatal subgaleal haemorrhage following vacuum assisted delivery

ObjectiveTo evaluate factors associated with subgaleal hemorrhage (SGH) severity following attempted vacuum-assisted delivery (VAD). Study designThis retrospective cohort study was conducted in a tertiary medical center. The population comprised parturients who delivered at our medical center during 2009–2018, and who underwent attempted VAD with singleton pregnancies that resulted in neonatal SGH formation. SGH severity was classified as mild and non-mild (moderate or severe). The main outcome measures were determinants associated with SGH severity. ResultsAmong 350 neonates with SGH, the degree of severity was non-mild for 48 (13.7%). Compared to the mild group, in the non-mild group, small for gestational age was more common (8.2% vs. 2.6%, p = 0.04). Compared to the mothers in the mild group, in the non-mild group, the proportion with two or more deliveries was lower (0% vs. 7.3%, p = 0.05), gestational diabetes was more common (12.5% vs. 4.6%, p = 0.02), the rate of cervical ripening was higher (27.1% vs. 12.9%, p = 0.02), the duration of the second stage of delivery was longer (mean 177 vs. 152 min, p = 0.04), and the rate of two dislodgments was higher (31.2% vs. 15.2%, p = 0.006). On multivariate analysis, only cervical ripening (adjusted odds ratio [OR]: 2.50; 95% confidence interval [CI]: 1.20–5.26; P = 0.01 and second stage duration (adjusted OR: 1.13; 95% [CI]: 1.00-1.29; P = 0.05) were independently associated with more severe SGH. ConclusionsThe duration of second stage and ripening of the cervix during induction of labor are independently associated with SGH severity following attempted VAD.

Effect of maternal birth positions on duration of second stage of labor: systematic review and meta-analysis

BackgroundIt is believed that giving birth in an upright position is beneficial for both mother and the infant for several physiologic reasons. An upright positioning helps the uterus to contract more strongly and efficiently, the baby gets in a better position and thus can pass through the pelvis faster. Upright and lateral positions enables flexibility in the pelvis and facilitates the extension of the outlet. Before implementing a change in birthing positions in our clinics we need to review evidences available and context valid related to duration of second stage of labor and birthing positions. Therefore this review aimed to examine the effect of maternal flexible sacrum birth position on duration of second stage of labor.MethodThe research searched articles using bibliographical Databases: Medline/PUBMED, SCOPUS, Google scholar and Google. All study designs were considered while investigating the impact of maternal flexible sacrum birthing positioning in relation duration of second stage of labor. Studies including laboring mothers with normal labor and delivery. A total of 1985 women were included in the reviewed studies. We included both qualitative and quantitative analysis.ResultsWe identified 1680 potential citations, of which 8 articles assessed the effect of maternal upright birth positioning on the reduction during the duration of second stage of labor. Two studies were excluded because of incomplete reports for meta analysis. The result suggested a reduction in duration of second stage of labor among women in a flexible sacrum birthing position, with a mean duration from 3.2–34.8. The pooled weighted mean difference with random effect model was 21.118(CI: 11.839–30.396) minutes, with the same significant heterogeneity between the studies (I2 = 96.8%, p < 000).ConclusionThe second stage duration was reduced in cases of a flexible sacrum birthing position. Even though the reduction in duration varies across studies with considerable heterogeneity, laboring women should be encouraged to choose her comfortable birth position. Researchers who aim to compare different birthing positions should consider study designs which enable women to choose birthing position.Prospero registration number[CRD42019120618]

Station of the fetal head at complete cervical dilation impacts duration of second stage of labor.

ObjectiveTo examine the association between station of the fetal head at complete cervical dilation and duration of second stage of labor, as well as prolonged second stage of labor, without and with the use of analgesia (EA).Study designWe conducted a population-based retrospective cohort study of 3311 women with a singleton pregnancy, gestational age ≥ 370 weeks, and cephalic presentation. Station of the fetal head at complete cervical dilation was categorized as at the pelvic floor, beneath the ischial spines, but above the pelvic floor, and at or above the ischial spines. In logistic regression analysis, we defined prolonged second stage of labor as > 2 h without and > 3 h with EA in nulliparous women, and > 1 h and > 2 h, respectively, in parous women.ResultsSurvival curves demonstrated longer durations of second stage of labor in nulliparous women and women with EA in each category of station of fetal head. The adjusted odds ratio of prolonged second stage of labor was 13.1 (95% confidence interval (CI): 8.5-20.1) times higher when the fetal head was beneath the ischial spines, but above the pelvic floor, and 32.9 (95% CI: 21.5-50.2) times higher when the fetal head was at or above the ischial spines compared to at the pelvic floor.ConclusionStation of the fetal head at complete cervical dilation was significantly associated with duration of second stage of labor.