Duration Of Second Stage Research Articles

Detection of Occult Anal Sphincter Injuries in Primipara by 2D Transperineal Ultrasound and its Clinical Association: A Cohort Study

Introduction: Endoanal Ultrasound (EAUS), the gold standard for the detection of occult Obstetric Anal Sphincter Injuries (OASI) has limited clinical application due to its intrusiveness and need for specialised equipment and personnel. A 2D Transperineal Ultrasound (TPU) is simple, non invasive and shows a high degree of agreement with EAUS. Few studies have evaluated the use of 2D TPU in determining the incidence and clinical outcomes of occult OASI in primigravida. Aim: To study the incidence, risk factors, and clinical outcome of occult obstetric anal sphincter injury using 2D TPU in primigravida. Materials and Methods: The present cohort study was conducted in the Department of Obstetrics and Gynaecology in collaboration with the Department of Radiology at Guru Teg Bahadur Hospital, Delhi, India, from November 2018 to April 2020. A total of 200 low risk primigravida ≥36 weeks period of gestation underwent baseline TPU of the anal sphincter complex antenatally and on day 2 postpartum. On the basis of difference between pre and postdelivery measurements, they were divided into group I (n=91): women with occult OASI (diagnosed as thinning of the internal and External Anal Sphincter (EAS), interruption in the anal sphincter, alteration in mucosa and half-moon sign) and group II (n=109): no OASI. Group I was followed at two and six weeks postpartum with TPU and clinical tests were applied at 6 weeks to assess clinical outcomes of sphincter injury. Data was analysed using Chi-square test/Fisher’s-exact test for qualitative parameters, Analysis of Variance (ANOVA) for comparison of predelivery and postpartum measurements; and multiple logistic regression for determining sphincter injury determinants. Results: Incidence of occult OASI was 91/200 (45.5%). Significant risk factors for OASI were lower baseline thickness of anal sphincter, position of baby (p=0.028), longer duration of second stage of labour (p<0.001), greater length and angle of episiotomy (p<0.001) and greater baby weight (p=0.042). Group I had significantly lower pelvic floor muscle strength testing score (p<0.001), Digital Rectal Examination Scoring System (DRESS) resting (p=0.013) and squeeze scores (p=0.008), weaker muscle contraction (p<0.001), reduced anal sphincter tone, and was more clinically symptomatic at six weeks postpartum. Conclusion: The technique of 2D TPU is simple and feasible to detect OASI. Women, who sustain OASI, can be followed up in perineal clinic more meticulously, using TPU for pelvic floor rehabilitation.

Late preterm delivery has a distinctive second-stage duration and characteristics

Late preterm neonates born between 34.0 and 36.6 weeks' gestation are at increased risk for short- and long-term morbidity and mortality when compared with their term counterparts. Currently, no separate labor curve is available for late preterm births, and this group's optimal duration of the second stage of labor has never been defined separately. This study aimed to compare the second stage duration between late preterm and term births. This was a retrospective study from May 2014 until May 2021. Eligible were women with a singleton pregnancy, vertex presentation, spontaneous or induced onset of labor, and those who delivered vaginally beyond 34.0 weeks of gestation. The primary outcome of our study was to compare and characterize the second stage of labor duration between late preterm and term births. We analyzed 962 late preterm and 9476 term vaginal deliveries. Women who delivered during the late preterm period were more likely to be multiparous (52.4% vs 45.2%; P<.001) and fewer required oxytocin during labor (41.2% vs 54.4%; P<.001) or used epidural analgesia (75.2% vs 83.6%; P<.001). The overall mean duration of the second stage of labor was significantly shorter in the late preterm period than at term (1.08±1.09 hours vs 1.49±1.22 hours; P<.001). This was even more pronounced for nulliparous women (1.05±1.00 hours vs 2.10±1.17 hours; P<.001). Among multiparous women, epidural use significantly affected the duration of the second stage of labor, and the second stage was relatively longer during the late preterm period than at term in this subgroup (1.16 vs 0.5 hours; P<.001). Using a multivariate Cox regression, variables such as maternal age (hazard ratio, 1.02; 95% confidence interval, 1.01-1.04), parity (hazard ratio, 4.11; 95% confidence interval, 3.65-4.63), preterm birth (hazard ratio, 2.08; 95% confidence interval, 1.4-3.10), and birthweight at delivery (hazard ratio, 1.15; 95% confidence interval, 1.01-1.30) shortened the second stage, whereas induction of labor (hazard ratio, 0.75; 95% confidence interval, 0.66-0.86) and epidural use (hazard ratio, 0.68; 95% confidence interval, 0.64-0.86) extended its total duration. Regardless of parity, lower rates of operative vaginal deliveries were observed in the late preterm period than at term (3.7% vs 15.5%; P<.001). This period was also associated with lower rates of third- and fourth-degree perineal lacerations (0.2% vs 2.2%; P<.001) but higher rates of chorioamnionitis (1.7% vs 0.1%; P<.001), Apgar score at 5 minutes <7 (1.0% vs 0.2%; P<.001), and admission to the neonatal intensive care unit (19.3% vs 1.0%; P<.001). Women who delivered vaginally during the late preterm period had a distinctive second-stage duration. Primarily, it was shown to be significantly shorter for nulliparous and multiparous women. Future studies should further clarify the optimal duration of this stage in relation to neonatal outcomes at such a vulnerable period.

Restrictive v/s Routine episiotomy in Primigravida

Introduction: Episiotomy is the surgical enlargement of the vaginal orifice by an incision on the perineum during the last part of the second stage of labour or delivery. Episiotomy is the most common surgical procedure experienced by women. In near past there were many studies pointed out its disadvantages like more post-delivery pain, wound complications and dyspareunia. So, this study was done to compare use of restrictive episiotomy and routine episiotomy in primigravidae undergoing vaginal birth. Aims and objectives: To assess the effects of restrictive use of episiotomy in comparison with routine episiotomy in primigravida during vaginal birth in terms of - (1) No. of episiotomies can be avoided (2) Perineal tear (3) Blood loss (4) Hematoma &amp; Healing complications (5) Faecal &amp; urinary incontinence (6) Dyspareunia. Material and methods: This study was descriptive analytic study conducted in the Department of Obstetrics and Gynecology, Surat municipal institute of medical education and research (SMIMER), Surat from January 2017 to June 2019 with sample size of 148 patients. Results: This study included total 148 patients, where 74 were selected randomly in each group. In Restrictive Episiotomy group, out of 74 patients, Episiotomy was required in 18 (24.32%) patients. Thus, Episiotomy was avoided in 56 (75.68%) patients. Mean duration of second stage of labour in Routine Episiotomy group was 31.88 ± 5.37min and in Restrictive Episiotomy group it was 32.35 ± 3.73min, which was suggestive of no statistically significant difference. (p value = 0.5375). Total 4.05% patients in Routine group and 13.51% patients in Restrictive group suffered from anterior vaginal tear which was statistically significant (p value = 0.021). There were 2 cases (18%) of 2nd degree perineal tear in routine episiotomy group which were 8(40%) in restrictive episiotomy group. The difference was statistically assessed by Chi-square and found to be significant (p value=0.2399). Not a single case of 3rd &amp; 4th degree perineal tear in either group. In Routine Episiotomy group, suturing was done in 100% patients. While restricted episiotomy group only 44.59% needed suturing which was statistically significant (p value:&lt;0.0001). Average blood loss in Routine group was 341.89 ± 49.33ml and in Restrictive group was 301.01 ± 52.41ml. So, there was significantly higher blood loss in Routine Episiotomy group. (p value= 0.000002). Complications rate in the form of episiotomy wound gap and hematoma was higher in routine group in 5.41% patients as compared to 1.35% patients in Restrictive group. Postpartum perineal pain at 1 week (14 v/s 5) and 2 weeks (5 v/s 1) was significantly higher in routine group as compared to the restrictive group. Postpartum perineal pain at 1 week and 2 weeks was significantly higher in routine group as compared to the restrictive group. Conclusion: In conclusion on the basis of our study, the immediate outcomes of routine episiotomy are no better than the restrictive use of episiotomy. Indeed, routine use is harmful to the degree that some proportion of women who would have had lesser injury instead had a surgical incision. The routine use of episiotomy has higher incidence of peripartum blood loss, requirement of suturing, postpartum perineal pain and healing complications. The policy of restrictive use of episiotomy is not associated with any third and fourth degree perineal tear or adverse neonatal outcomes.

Perineal stress as a predictor of performing episiotomy in primiparous women: a prospective observational study

BackgroundEpisiotomy is a surgical solution to relieve perineal stress, resulting in an easily repairable incision, in comparison to the risks of serious vaginal trauma during delivery. The midwife typically adopts such a clinical decision, on experience and subjective judgment. However, the association between perineal stress and episiotomy is poorly characterized. Our aim was to identify a threshold value for perineal stress leading to episiotomy, which eventually may be employed as a clinical tool for assessing whether an episiotomy is required or not.MethodsIn total, 245 nulliparous women were investigated for perineal stress during non-instrumental vaginal delivery in Ningbo Women & Children’s Hospital. During the second stage of labor, a flexible membrane stress sensor was placed between the fetal head and perineal wall above the anal fissure. Once the entire fetal head pressed against the sensor, real-time perineal stress was measured, and the peak value was recorded. Cases were divided into non-episiotomy group (n = 173) and episiotomy group (n = 72). The correlations between perineal stress and episiotomy was assessed through logistic regression with adjustment for maternal age, estimated birthweight, duration of second stage of labor, maternal body mass index, and presence of analgesia. Midwives were blinded to all stress measurement values. The predictive value of perineal stress on performing episiotomy was evaluated, together with the ideal cut-off perineal stress value for performing episiotomy. A ROC analysis was also performed.ResultsThe episiotomy group had significantly higher levels of perineal stress in comparison to the non-episiotomy group (140.50 ± 16.03 N versus 118.37 ± 19.21 N, p < 0.01). The episiotomy group was linked to significantly higher perineal stress in comparison to the non-episiotomy group (140.50 ± 16.03 VS 118.37 ± 19.21 N, p < 0.01). ROC analysis between perineal stress and episiotomy revealed a high area under the curve (AUC 0.81, 95% CI 0.75–0.86) and a cut-off value for perineal stress of 124.49 N was identified for episiotomy decision.ConclusionThe level of perineal stress was an independent predictor of performing episiotomy in nulliparous women during non-instrumental vaginal delivery. Perineal stress exceeding 124.49 N was identified as the cut-off prompting midwives to perform episiotomy.

Assessment of Impact of Regional Analgesia on Labor and Neonates in Hilla City

Background: Epidural is the most effective form of pain relief in labor with around 30% of laboring women in the UK and 60% in the USA receiving epidural analgesia. Objectives: To assess effect of regional analgesia on labor pain, duration, outcome of delivery and neonates. Materials and Methods: Case control study included 400 pregnant woman 200 of them delivered by painless labour and other 200 whose delivered without analgesia who attended to the babylon maternity and pediatric hospital, Al sadiq hospital and private hospitals in al hilla city which included private Teiba, Al Fayhaa hospitals from first of february 2022 to June 2022. Results: The duration of first stage of labor was significantly prolonged at control mothers 26%(52) in compare to 10%(20) of mothers with epidural anesthesia had prolonged labor. While second stage shown no significant association with epidural anesthesia (P = 0.47). Fetal heart rate abnormalities shown no significant association with epidural analgesia (P = 0.96). While back pain and headache was significantly higher in mothers with epidural analgesia (P &lt; 0.001). Conclusions: EA was not associated with a higher instrumental delivery rate and higher rate of c/s, EA not cause significant maternal or neonatal complications in primi- and multiparas. Importantly, EA associated with short first stage of labor and not higher rate effect on duration of second stage of labour.

Peripartum outcomes after combined myo-inositol, probiotics, and micronutrient supplementation from preconception: the NiPPeR randomized controlled trial

Evidence that nutritional supplementation before and during pregnancy improves peripartum outcomes is sparse. In the Nutritional Intervention Preconception and During Pregnancy to Maintain Healthy Glucose Metabolism and Offspring Health (NiPPeR) trial, we previously reported that a combined myo-inositol, probiotics, and micronutrient supplement started at preconception showed no difference in the primary outcome of gestational glycemia, but did reduce the risk of preterm delivery, preterm prelabor rupture of membranes, and major postpartum hemorrhage. This study aimed to examine the hypothesis that a reduction in major postpartum hemorrhage following a combined nutritional (myo-inositol, probiotics, and micronutrients) intervention is linked with promotion of labor progress and reduced operative delivery. This double-blind randomized controlled trial recruited 1729 women from the United Kingdom, Singapore, and New Zealand, aged 18 to 38 years, and planning conception between 2015 and 2017. The effects of the nutritional intervention compared with those of a standard micronutrient supplement (control), taken at preconception and throughout pregnancy, were examined for the secondary outcomes of peripartum events using multinomial, Poisson, and linear regression adjusting for site, ethnicity, and important covariates. Of the women who conceived and progressed beyond 24 weeks' gestation with a singleton pregnancy (n=589), 583 (99%) provided peripartum data. Between women in the intervention (n=293) and control (n=290) groups, there were no differences in rates of labor induction, oxytocin augmentation during labor, instrumental delivery, perineal trauma, and intrapartum cesarean delivery. Although duration of the first stage of labor was similar, the second-stage duration was 20% shorter in the intervention than in the control group (adjusted mean difference, -12.0 [95% confidence interval, -22.2 to -1.2] minutes; P=.029), accompanied by a reduction in operative delivery for delayed second-stage progress (adjusted risk ratio, 0.61 [0.48-0.95]; P=.022). Estimated blood loss was 10% lower in the intervention than in the control group (adjusted mean difference, -35.0 [-70.0 to -3.5] mL; P=.047), consistent with previous findings of reduced postpartum hemorrhage. Supplementation with a specific combination of myo-inositol, probiotics, and micronutrients started at preconception and continued in pregnancy reduced the duration of the second stage of labor, the risk of operative delivery for delay in the second stage, and blood loss at delivery.

Maternal and Foetal Outcome in Routine versus Selective Use of Episiotomy

Introduction: An episiotomy is a surgical incision of the perineum made to increase the diameter ofthe vulval outlet during child birth. Aim of the study: To evaluate the maternal and foetal outcome in routine versus selective use ofepisiotomy. Material &amp; Methods: This prospective interventional study was conducted at the Department ofObstetrics and Gynaecology, Sir Salimullah Medical College and Mitford Hospital during January 08to June 08. A total of 160 patients were included for the study. The patient of group I were givenepisiotomy with all aseptic precaution after infiltration of 10 ml of 1% solution of lignocaine. For groupII patients episiotomy was restricted and w. only given for specific indications. Statistical analysis wereperformed using computer- based software, statistical package for social science (SPSS). Results: In the study, 65(40.6%) cases received episiotomy, 86(53.8%) not received episiotomy and only9(5.6%) needed episiotomy. Maximum number was found in the age group of 20-25 years in both groups.Most of the study patients were primi. Regarding the duration of second stage of labour of maximumnumber belongs to 30 - 90 minutes in all groups. In group I there was 2° tear in 61(93.8%), 3rd degreetear 4(6.2%) and none had 1° perineal tear, whereas in group II it was observed that 45(52.3%) had notear. In group I, 24(36.9%) patients complained difficulty in defecation and 30(46.2%) felt difficulty insitting. But in patients needing episiotomy in group II 4(44.4%). There was no still birth found in anygroup. The mean± (SD) head circumference of the baby was 36.4±6.05 cm and 34.7±1.26 cm in group Iand group II respectively. Conclusion: In a poor country like ours, where pregnancy rate is very high, reducing episiotomy ratecan eliminate morbidity associated with episiotomy and can ensure early resumption of women to theirnormal life. JBSA 2022; 35 (2) : 51-57

Association between the second-stage duration of labor and perinatal outcomes in women with a prior cesarean delivery

BackgroundThe cesarean delivery (CD) rate has been increasing globally. Trial of labor after cesarean delivery (TOLAC) has been used as a key method for the reduction of the CD rate. Little is known, however, about the association between the second-stage duration of TOLAC and adverse maternal and neonatal outcomes. This study evaluated the association between perinatal outcomes and the duration of second-stage labor in women undergoing TOLAC.MethodsA 10-year retrospective cohort study was performed at the Department of Obstetrics and Gynecology, Third Affiliated Hospital of Guangzhou Medical University, between January 2010 and January 2020. Women undergoing TOLAC who reached the second stage of labor were included in this study. Duration of the second stage of labor was examined as a categorical variable (group I: <0.5 h, group II: 0.5–2 h and group III: ≥2 h) and as a continuous variable to evaluate the association with adverse perinatal outcomes by using multivariable regression models and a Cox proportional hazards regression model adjusting for potential confounders.ResultsOf the 1,174 women who met the inclusion criteria, the median (interquartile range) length of the second stage was 0.5 h (0.3–0.9 h). Among them, 1,143 (97.4%) delivered vaginally and 31 underwent an unplanned CD. As the second-stage duration increased, operative vaginal delivery (OVD), CD, and postpartum hemorrhage (PPH) rates increased. Women in group III had higher risks of OVD (aOR = 11.34; 95% CI [5.06–25.41]), CD (aOR = 4.22; 95% CI [1.32–13.43]), and PPH (aOR = 2.43; 95% CI [1.31–4.50]) compared with group I. Correspondingly, blood loss and the oxytocin used to treat PPH increased significantly, while the postpartum hemoglobin reduced significantly in group III compared with group I. The incidence of uterine rupture, uterine atony, cervical laceration, red blood cell transfusion, and intensive care unit admission were similar in all three groups. Neonatal outcomes were not affected by the second-stage duration.ConclusionsWomen undergoing TOLAC with second-stage duration of ≥2 h have higher odds of OVD, unplanned intrapartum CD, and PPH.

The incidence of breakthrough pain associated with programmed intermittent bolus volumes for labor epidural analgesia: a randomized controlled trial

BackgroundIn this randomized, blinded study, we evaluated the effects of different programmed intermittent epidural bolus (PIEB) volumes for labor analgesia on the incidence of breakthrough pain and other analgesic outcomes. MethodsNulliparous women with term cephalic singleton pregnancies who requested labor analgesia had epidural analgesia initiated with 10 mL 0.1% ropivacaine with sufentanil 0.3 μg/mL. The pump was programmed to deliver a 4, 6 or 8 mL bolus every 45 min (groups 4, 6 or 8, respectively). The primary outcome was the incidence of breakthrough pain, defined as inadequate analgesia after two patient-controlled epidural analgesia administrations in a 20-min period. Secondary outcomes included ropivacaine consumption, time of the first patient-controlled epidural analgesia request, duration of the second stage of labor, and incidence of motor block. ResultsAmong 210 women randomly allocated the incidence of breakthrough pain was 34.9%, 19.7%, and 13.1%, for groups 4, 6 and 8, respectively (P=0.011). The incidence of breakthrough pain in group 8 was lower than in group 4 (P=0.006). The median (interquartile range) hourly ropivacaine consumption was 8.2 mg/h (7.1–11.3), 10.4 mg/h (9.2–13.0), and 12.0 mg/h (11.2–13.8) in groups 4, 6 and 8, respectively (P <0.001). Group 8 had a longer duration of effective analgesia and longer second stage of labor than group 4. There was no significant difference between groups in the incidence of motor block. ConclusionThe larger PIEB volumes were preferred for epidural labor analgesia compared with a smaller volume because of improved analgesia without clinically significant increases in adverse effects.

Effect of Epidural Bolus Levobupivacaine and Lignocaine in Late Second Stage of Parturition in Combined Spinal Epidural Labor Analgesia

Background: Use of minimum local analgesic concentration in the epidural component of combined spinal epidural (CSE) effectively maintains analgesia in the first stage of labor. However, local anesthetic concentration needs to increase to achieve effective analgesia in the second stage as there are more recruitment of A-δ fiber occurs. This study compared the effect of epidural bolus of Levobupivacaine and Lignocaine in the late second stage of parturition in combined spinal epidural labor analgesia.Methods: This multicenterd, open-label, randomized controlled trial was conducted under supervision of Department of Anesthesia, Analgesia, and Intensive Care Medicine of Bangabandhu Sheikh Mujib Medical University from July 2019 to June 2020 including 80 parturients of 18-35 years old, ASA status I and II, full-term, primiparous, who were randomized into two groups to receive either 10ml bolus of 0.0625% levobupivacaine with fentanyl 2μg/ml or 10ml bolus of 0.5% lignocaine with fentanyl 2μg/ml after CSE analgesia at first stage of labor. Level of analgesia, duration of second stage of labor, quality of pain relief, maternal satisfaction, mode of delivery and APGAR score of neonate were evaluated.Results: During delivery, levobupivacaine group had a lower intensity of pain compared to lignocaine group (VAS score 1.89±0.67 vs 2.64±0.92, p = 0.001). Duration of second stage of labor in levobupivacaine group was significantly shorter compared to lignocaine group (48.4±16 minutes vs 63.5±28.4, p-value 0.007). Besides, quality of pain relief and maternal satisfaction were better in levobupivacaine group compared to lignocaine group. Moreover, instrumental delivery rate was high in lignocaine group. Fetal outcome measured as APGAR score was similar in both groups.Conclusion: Epidural bolus of levobupivacaine-fentanyl produces more adequate analgesia than lignocaine-fentanyl in late second stage of labor and does not increase instrumental delivery rate with similar fetal outcome.

COMPARISON OF INTERMITTENT BOLUS AND CONTINUOUS INFUSION OF 0.1% LEVOBUPIVACAINE WITH FENTANYL FOR EPIDURAL LABOR ANALGESIA

Objectives: This study was carried out to compare intermittent bolus and continuous infusion for epidural labor analgesia in terms of total dose requirement of local anesthetic and quality of analgesia as primary objective. Secondary objective was level of sensory block, motor block, hemodynamic variables, mode of delivery, duration of second stage, neonatal outcome, side effects, and postpartum complications. Methods: Eighty women of ASA physical status I or II, with single pregnancy, cephalic presentation and cervical dilatation 3–5 cm, that is, during active labor were included in the study. Patients were randomly divided into two groups. In Group A, a bolus of 8 ml of 0.1% levobupivacaine (plain) with fentanyl 2 mcg/ml was given every hour and in Group B, an infusion of 0.1% levobupivacaine (plain) with fentanyl 2 mcg/ml at 8 ml/h was given. Pain scores using visual analog scale and verbal rating score, additional bolus requirement and total dose of local anesthetic, motor blockade, fetal and neonatal outcome, mode of delivery, and duration of second stage were recorded and compared. Side effects and postpartum complications if any were documented. Results: Additional bolus requirement and total dose of local anesthetic were significantly high in Group B (45.60±6.67 mg) as compared to Group A (34.20±5.58 mg). There was no difference in the quality of analgesia, neonatal outcome, mode of delivery, duration of second stage, side effects, and complications. Conclusion: Intermittent epidural bolus is better in terms of less drug consumption and less number of additional bolus requirement.

Duration of second stage of labor and factors associated with prolonged second stage: A national population-based study in France

ObjectivesProlonged second stage of labor could be associated with an increase in maternal and neonatal morbidity. However, in France, no consensual definition of prolonged 2nd stage of labor exists and therefore factors associated with prolonged second stage have not yet been studied. From national population-based data, we aimed at defining the prolonged 2nd stage of labor in France and identifying its associated factors for women with epidural. Study designFrom the French national perinatal survey of 2016, we included all women who reached 2nd stage of labor and delivered at term of a singleton infant in cephalic presentation. We studied the distribution of the duration of the 2nd stage according to parity and defined prolonged 2nd stage as the 90th percentile. Among women with epidural, factors associated with a prolonged 2nd stage of labor were then explored by univariate and multilevel multivariable analysis, to take the cluster effect into account. The proportional change of variance was estimated for each multivariate model. ResultsAmong the 8154 women included, 3574 were nulliparous and 4580 multiparous. Prolonged second stage was defined as a duration of more than 89.6 min and 30.6 min for nulliparous and multiparous women without epidural; and respectively 185.7 min and 120.1 min for women with epidural analgesia. The factors associated with prolonged 2nd stage of labor were respectively for nulliparous and multiparous women, macrosomia (aOR 1.74 [1.03–2.94] and ORa 2.52 [1.69–3.76]), prenatal preparation classes (aOR 1.47 [1.04–2.08] and aOR 1.56 [1.21–2.01]), a prolonged 1st stage (aOR 1.47 [1.14–1.87] and aOR 1.52 [1.19–1.95]) and delivery in a public maternity unit (aOR 2.68 [1.50–4.78] and aOR 3.12 [1.88–5.17]). Women’s characteristics accounted for 3.4% of the variance and maternity organizational characteristics for 26.1%. ConclusionIn France, prolonged 2nd stage of labor can be defined as a 2nd stage exceeding 3 h in nulliparous and 2 h in multiparous women with epidural analgesia. The identification of its associated factors allows determining a target population of women at risk of prolonged 2nd stage and improve their 2nd stage’s management.

Intravenous butorphanol as an adjunct to patient-controlled epidural analgesia with ropivacaine and sufentanil in labor: a randomized controlled study

Background: Butorphanol was safely used for obstetric analgesia for many years. We attempted to determine if it increases the analgesic effect during patient-controlled epidural labor analgesia (PCEA) and if it affects the labor-process. Methods: Term pregnant women (N = 60) were randomly assigned to two groups, to receive either 1 mg intravenously butorphanol or 10 mL normal saline as placebo at 10 min before intrathecal anesthesia. Pain score, duration of first and second stage of labor, mode of delivery, umbilical artery blood gas, Apgar scores and adverse effects were recorded. Result: Butorphanol shortened the duration of the second stage of labor (t = –2.41, p = 0.019). Women in butorphanol group showed significantly increased incidence of pruritus (x2 = 20.32, p = 0.000), but they also showed significantly increased incidence of the adverse events such as maternal somnolence and dizziness (x2 = 8.366, p = 0.004; x2 = 26.447, p = 0.000 respectively). The pain scores of the two groups showed a linear reduction within 1 h (F = 8.878, p = 0.004), and from intravenous injection of butorphanol to the 5th minute after intrathecal analgesia, the analgesic scores of butorphanol group were significantly lower than those of placebo group (p &lt; 0.05). At the third hour after intrathecal injection, the Visual analogue scale (VAS) score was significantly lower in butorphanol group than placebo group (95% Confidence Interval (CI) –3.02 to –0.28; t = –2.51, p = 0.021). Conclusions: i.v. butorphanol 1 mg alleviates the labor pain during intrathecal puncture, and It will be easier to get the cooperation of pregnant women and shortens the second stage of labor. It effectively relieved the pruritus, but increased the incidence of dizziness and somnolence.

The association of hourly second-stage documentation with cesarean delivery and maternal blood loss

Purpose of the article Cesarean rates and maternal morbidity increase with the duration of the second stage of labor. We studied the effect of hourly evaluation and documentation during the second stage of labor on maternal and fetal outcomes. Materials and methods We performed a retrospective cohort study of all women who delivered at our urban, tertiary care hospital and underwent a second stage of greater than 60 min between 1 June 2016 and 31 May 2019. There were 1498 patients with complete data. Four hundred forty patients had hourly evaluation and documentation throughout the second stage and 1058 did not. We performed t-tests, Chi-squared, and regression analyses to compare cesarean delivery rate, second-stage duration, quantitative blood loss, hemorrhage and blood transfusion rates, and fetal outcomes. We performed regression analyses to evaluate for independent effect of this intervention on each outcome. Results Patients with hourly evaluation and documentation had a decreased likelihood of cesarean delivery (8.2% vs. 20.3%, p < .001), shorter second-stage of labor (98.1 min vs. 177.5 min, p < .001), decreased quantitative blood loss (514.4 mL vs. 667.7 mL, p < .001), and hemorrhage rate (12.5% vs. 19.9%, p < .001). Hourly evaluation was associated with decreased transfusion rates (3.2% vs. 5.6%, p = .05) but was not related to the number of units transfused. Regression analyses confirmed the impact of hourly documentation when potential confounders were included. These differences in outcomes were also noted when evaluation was performed and documented within every 75 min. Hourly second-stage evaluation and documentation did not affect other maternal or infant morbidities. Conclusion Hourly evaluation and documentation in the second stage was associated with decreased cesarean delivery rate, second-stage duration, quantitative blood loss, hemorrhage, and transfusion.

Are levator hiatal dimensions in mid-pregnancy associated with mode of delivery?

Introduction and hypothesisSlow progress of labour is a risk for operative delivery. Smaller levator hiatal dimensions are possible risk factors for slow progress and operative delivery. Our aim was to explore associations between hiatal dimensions antenatally, duration of second stage of labour and mode of delivery.MethodsProspective cohort study of 65 nullipara examined at 20 weeks gestation and 6 months postpartum. Levator hiatal anteroposterior diameter and area were measured using 2D/3D transperineal ultrasound and compared between women with normal vaginal delivery and operative delivery (vacuum or caesarean) using t-test and with Spearman’s rank to explore correlations with duration of second stage. ROC analysis established a cut-off for high risk of operative delivery.ResultsTwo-dimensional anteroposterior diameter and 3D hiatal area at rest were smaller in women with operative delivery than with normal delivery, 5.0 cm vs. 5.7 cm, p = 0.007 and 18.5 cm2 vs. 14.9 cm2, p < 0.001. From the ROC curve for 2D anteroposterior diameter, a cut-off of 5.6 cm, (sensitivity = 0.94, specificity = 0.63) and for 3D hiatal area a cut-off of 17.6 cm2 (sensitivity = 0.94, specificity = 0.65) predicted operative delivery. We found inverse correlations between second stage of labour and anteroposterior diameter at rest, r = −0.330, contraction, r = −0.365, area at rest, r = −0.324, and contraction, r = −0.521, all p < 0.05.ConclusionsSmaller hiatal dimensions at 20 weeks gestation were associated with longer second stage of labour and increased risk of operative delivery in nullipara. A 2D anteroposterior hiatal diameter < 5.6 cm and 3D hiatal area < 17.6 cm2 at rest imply increased risk of operative delivery.

Quality of Labor Analgesia with Dural Puncture Epidural versus Standard Epidural Technique in Obese Parturients: A Double-blind Randomized Controlled Study.

The dural puncture epidural technique may improve analgesia quality by confirming midline placement and increasing intrathecal translocation of epidural medications. This would be advantageous in obese parturients with increased risk of block failure. This study hypothesizes that quality of labor analgesia will be improved with dural puncture epidural compared to standard epidural technique in obese parturients. Term parturients with body mass index greater than or equal to 35 kg · m-2, cervical dilation of 2 to 7 cm, and pain score of greater than 4 (where 0 indicates no pain and 10 indicates the worst pain imaginable) were randomized to dural puncture epidural (using 25-gauge Whitacre needle) or standard epidural techniques. Analgesia was initiated with 15 ml of 0.1% ropivacaine with 2 µg · ml-1 fentanyl, followed by programed intermittent boluses (6 ml every 45 min), with patient-controlled epidural analgesia. Parturients were blinded to group allocation. The data were collected by blinded investigators every 3 min for 30 min and then every 2 h until delivery. The primary outcome was a composite of (1) asymmetrical block, (2) epidural top-ups, (3) catheter adjustments, (4) catheter replacement, and (5) failed conversion to regional anesthesia for cesarean delivery. Secondary outcomes included time to a pain score of 1 or less, sensory levels at 30 min, motor block, maximum pain score, patient-controlled epidural analgesia use, epidural medication consumption, duration of second stage of labor, delivery mode, fetal heart tones changes, Apgar scores, maternal adverse events, and satisfaction with analgesia. Of 141 parturients randomized, 66 per group were included in the analysis. There were no statistically or clinically significant differences between the dural puncture epidural and standard epidural groups in the primary composite outcome (34 of 66, 52% vs. 32 of 66, 49%; odds ratio, 1.1 [0.5 to 2.4]; P = 0.766), its individual components, or any of the secondary outcomes. A lack of differences in quality of labor analgesia between the two techniques in this study does not support routine use of the dural puncture epidural technique in obese parturients.

A Search for Novel Risk Factors for Obstetric Anal Sphincter Injury

The objective of this study is to evaluate factors associated with obstetric anal sphincter injury and identify modifiable risks. A retrospective case-control study was performed in women who gave birth at our institution between May 2008 and December 2012. Patients who had a third- or fourth-degree lacerations were compared with those who did not. Parity, stretch marks, age, body mass index, tobacco use, fetal weight, operative delivery, labor, and second stage duration were compared between groups. Multivariate direct logistic regression was conducted on all patients who had complete data to calculate the adjusted odds ratio. We identified 299 patients with third- or fourth-degree lacerations and 8,459 patients without third- or fourth-degree lacerations during the time frame. Duration of second stage between 1 hour and 2 hours (P < 0.0001), duration of second stage greater than 2 hours (P < 0.0001), midline or unknown type episiotomy (P < 0.0001), mediolateral episiotomy (P < 0.0001), vacuum delivery (P < 0.0001), forceps delivery (P < 0.0001), fetal weight greater than 4,000 g (P < 0.0001), and antepartum stress urinary incontinence (P < 0.006) were associated with a significant increase in high-risk lacerations. This study did not find a statistically significant association between parity and these lacerations. We, as others, found that episiotomy and operative delivery were modifiable risks of obstetrical care. Furthermore, even a short second stage of labor (1-2 hours) was associated with significant risk of injury.

Duration of the second stage of labour and risk of subsequent spontaneous preterm birth.

To determine the risk of spontaneous preterm birth (sPTB) associated with the length of second stage of labour in the first term delivery. Retrospective cohort study. University hospital. Women with first two consecutive singleton births and the first birth at term. Those who did not reach the second stage of labour in the first delivery were excluded. Charts from 2007 to 2019 were reviewed. Rate of sPTB (<37weeks of gestation) in the second delivery. Of 13958 women who met study inclusion criteria, 1464 (10.5%) parturients had a prolonged second stage (≥180min) in their first term delivery. The rate of sPTB in the second delivery was similar in those with and without a prolonged second stage in first delivery (2.8% versus 2.8%; adjusted odds ratio [aOR] 1.35, 95% CI 0.96-1.90). After adjustment for mode of delivery, prolonged second stage was also not associated with subsequent sPTB in those who delivered by spontaneous and operative vaginal delivery. Those delivered by second-stage caesarean section in the first delivery had a higher risk of sPTB in the second delivery (25/526, 4.8%; aOR 2.66, 95% CI 1.71-4.12; p<0.001), with a more pronounced risk in those with second-stage caesarean following a prolonged second stage of labour (15/259, 5.8%; aOR 3.40, 95% CI 1.94-5.94; p<0.001). Second-stage duration in a first term vaginal delivery is not associated with subsequent sPTB. The risk of sPTB is increased following second-stage caesarean section, particularly if performed after a prolonged second stage. Second-stage caesarean delivery, particularly after prolonged second stage, increases the risk of preterm birth.

Factors Associated With Normal Physiologic Birth for Women Who Labor In Water: A Secondary Analysis of A Prospective Observational Study.

IntroductionResearch to understand factors associated with normal physiologic birth (unassisted vaginal birth, spontaneous labor onset without epidural analgesia, spinal, or general anesthetic, without episiotomy) is required. Laboring and/or giving birth in water has been shown to be associated with a high proportion of physiologic birth but with little understanding of factors that may influence this outcome. This study explored factors associated with normal physiologic birth for women who labored in water.MethodsWe conducted a secondary analysis of a UK‐based prospective observational study of 8064 women at low risk of childbirth complications who labored in water. Consecutive women were recruited from birth settings in England, Scotland, and Northern Ireland. Planned place of birth, maternal characteristics, intrapartum events, and maternal and neonatal outcomes were measured. Univariable and multivariable logistic regression modelling explored factors associated with normal physiologic birth.ResultsIn total, 5758 (71.4%) of women who labored in water had a normal physiologic birth. Planned birth in the community (adjusted odds ratio [aOR], 2.58; 95% CI, 2.22‐2.99) or at an alongside midwifery unit (aOR, 1.21; 95% CI, 1.04‐1.41) was positively associated with normal physiologic birth compared with planned birth in an obstetric unit. Duration of second stage (aOR, 0.66; 95% CI, 0.62‐0.70), duration in the pool [aOR, 0.93; 95% CI, 0.90‐0.96), and birth weight of the neonate (aOR, 0.74; 95% CI, 0.65‐0.85) were negatively associated with normal physiologic birth. Parity was not associated with normal physiologic birth in multivariate analyses.DiscussionOur findings largely reflected wider research, both in and out of water. We found midwifery‐led birth settings may increase the likelihood of normal physiologic birth among healthy women who labor in water, irrespective of parity. This association supports growing evidence demonstrating the importance of planned place of birth on reducing intervention rates and adds to research on labor and birth in water.

THE PREVALENCE AND RISK FACTORS FOR HYPERBILIRUBINEMIA IN NEONATES

Background: Jaundice is very common in the neonatal period of life especially hyperbilirubinemia&gt;12 mg/dl. Although it is not a major cause of mortality, it is an important cause of morbidity. So, assessment of the prevalence and risk factors of neonatal jaundice is very important. Objectives: The objectives of the study were to estimate the prevalence,to identify the risk factors and to findout the association between hyperbilirubinemia with selected neonatal,maternal,environmental and socio demographic variablesand to identify the risk factors. Methodology: This descriptive cross sectional survey study was conducted among 200 neonates of 37 completed weeks of gestation. Subjects were selected by using total enumerative sampling.Transcutaneous bilirubin was measured by bilirubinometer,clinical and demographic variables collected by using semi structured questionnaire and the risk factors were assessed by interview schedule. Results:Research showed that most of neonates (81.5%) had Transcutaneous bilirubin level more than 12mg/dl, out of that (15% )subjects had elevated level of bilirubin 15- 20mg/dl. It is concluded that there is high prevalence of hyperbilirubinemia among neonates . It is evident that neonates developed hyperbilirubinemia by 48 to 72 hours. It is inferred that prevalence of hyperbilirubinemia was high at 72 hours (56.5%) after birth compared to 48 hours of birth (38%). There was a significant association between level of hyperbilirubinemia and family history of genetic diseases (P=0.003),parity (p=0.03, χ2=4.37),mode of conception(p=0.012, χ2=6.37), and gestational age(P=0.04),gender of the neonate (p=0.004, χ2=8.1)and duration of second stage of labour (p=0.026, χ2=7.27). The study revealed that the family history of genetic diseases (p=0.004),(OR=0.09) at level of significance 0.05,is a risk factor leads to hyperbilirubinemia. Conclusion: Neonatal jaundice is a leading cause of hospitalisation in the first few weeks of life throughout the world.Though major complications may arise like kernicterus,encephalopathy and neural sequlae.Hence there is an exigent need for assessing the bilirubin value in the routine neonatal assessment.