Fetal Descent Research Articles

The utilization of transperineal ultrasound following fetal heart deceleration after epidural analgesia: a case report

BackgroundWe report a case of fetal heart rate decelerations and relaxation of pelvic muscles and fetal descent using transperineal ultrasound after initiation of epidural labor analgesia.Case presentationA 32-year-old woman, G1P0 with gestational age of 40 weeks, required epidural analgesia when her cervical dilatation was 2 cm. Baseline transperineal ultrasound examination was performed before epidural puncture. The fetal heart rate tracing was normal before the initiation of analgesia. Approximately 10 min after the epidural administration of the loading dose, the patient reported onset of analgesia and the FHR tracing showed variable-decelerations. There was no hypotension or evidence of uterine tachysystole. Transperineal ultrasound was performed again after epidural analgesia took effect. The anteroposterior diameter of the levator hiatus increased from 5.3 to 6.6 cm and angle of progress increased from 116°to 133°. The relaxation of pelvic muscle and rapid descent of fetal head may have contributed to the FHR deceleration. The midwife elevated the fetal head through the vagina with her hand, and the FHR recovered soon thereafter.ConclusionsChanges in fetal heart rate after initiation of neuraxial analgesia are unpredictable. In addition to FHR and tocodynametric monitoring, performing TPU may helpful in distinguishing the reasons for FHR change and initiating corresponding corrective measures.

A Computational Procedure to Derive the Curve of Carus for Childbirth Computational Modeling.

Computational modeling serves an important role in childbirth-related research. Prescribed fetal descent trajectory is a key characteristic in childbirth simulations. Two major types of fully prescribed fetal descent trajectories can be identified in the literature: straight descent trajectories and curve of Carus. The straight descent trajectory has the advantage of being simpler and can serve as a reasonable approximation for relatively small fetal movements during labor, but it cannot be used to simulate the entire childbirth process. The curve of Carus is the well-recognized fetal descent trajectory with physiological significance. However, no detailed procedure to geometrically define the curve of Carus can be found in existing computational studies. This status of curve of Carus simulation in the literature hinders the direct comparison of results across different studies and the advancement of computational techniques built upon previous research. The goals of this study are: (1) propose a universal approach to derive the curve of Carus for the second stage of labor, from the point when the fetal head engages the pelvis to the point when the fetal head is fully delivered; and (2) demonstrate its utility when considering various fetal head sizes. The current study provides a detailed formulation of the curve of Carus, considering geometries of both the mother and the fetus. The maternal geometries were obtained from MRI data, and the fetal head geometries were based on laser scanning of a replica of a real fetal head.

The Pathophysiology of Labor Dystocia: Theme with Variations.

Abnormally prolonged labor, or labor dystocia, is a common complication of parturition. It is the indication for about half of unplanned cesarean deliveries in low-risk nulliparous women. Reducing the rate of unplanned cesarean birth in the USA has been a public health priority over the last two decades with limited success. Labor dystocia is a complex disorder due to multiple causes with a common clinical outcome of slow cervical dilation and fetal descent. A better understanding of the pathophysiologic mechanisms of labor dystocia could lead to new clinical opportunities to increase the rate of normal vaginal delivery, reduce cesarean birth rates, and improve maternal and neonatal health. We conducted a literature review of the causes and pathophysiologic mechanisms of labor dystocia. We summarize known mechanisms supported by clinical and experimental data and newer hypotheses with less supporting evidence. We review recent data on uterine preparation for labor, uterine contractility, cervical preparation for labor, maternal obesity, cephalopelvic disproportion, fetal malposition, intrauterine infection, and maternal stress. We also describe current clinical approaches to preventing and managing labor dystocia. The variation in pathophysiologic causes of labor dystocia probably limits the utility of current general treatment options. However, treatments targeting specific underlying etiologies could be more effective. We found that the pathophysiologic basis of labor dystocia is under-researched, offering wide opportunities for translational investigation of individualized labor management, particularly regarding uterine metabolism and fetal position. More precise diagnostic tools and individualized therapies for labor dystocia might lead to better outcomes. We conclude that additional knowledge of parturition physiology coupled with rigorous clinical evaluation of novel biologically directed treatments could improve obstetric quality of care.

Use of Nitrous Oxide in Obstetrics

The introduction of nitrous oxide in a labor and delivery unit provides laboring patients with an additional option for coping with labor discomfort and anxiety. The use of nitrous oxide has been found to be helpful to patients who are coping with labor until the birth or until they request an epidural. Nitrous provides the opportunity to continue to remain ambulatory within their room, which may facilitate fetal descent. Patients’ preferences should be respected, and a wide variety of strategies should be available to meet each patient’s unique wants and needs. Nitrous oxide is an easily accessible alternate method to intravenous narcotics or regional anesthesia and may be amenable to patients who are hesitant to use other methods of coping in labor. Our PICO question was, in laboring patients, does the option of nitrous oxide prolong the time to regional anesthesia as measured by dilation progress prior to regional anesthesia administration or discontinuation of nitrous use?

Deep Back Massage Using Lavender Oil on Labor Pain in the Work Area of Polonia Community Health Center

Labor pain is a subjective experience of physical sensations associated with uterine contractions, cervical dilatation and effacement, and fetal descent during labour. One way to reduce the Maternal Mortality Rate (MMR) is through the maternal affection movement which is an aspect of the 5 common threads to help mothers feel safe and during the delivery process. Various efforts have been made to reduce pain both pharmacologically and non-pharmacologically, pharmacological methods are very important because they do not harm the mother and fetus. This study was conducted to identify the reduction of pain in first-stage labor mothers with the deep back massage method with lavender oil. This research is a quantitative study with a quasi-experimental design with a pretest-posttest design in the BPM Working Area of ​​the Polonia Health Center. The sampling technique in this study was a purposive sample with as many as 20 respondents. Pain intensity will be measured using NRS (Numeric Rating Scale). And it was found that being given a deep back massage with lavender oil had an effect on reducing labor pain and it was good to do it when the mother gave birth who had entered the active phase because it could provide physiological and psychological benefits.

Efectividad de los cambios posturales maternos sobre la posición occípito-posterior de la cabeza fetal

Introduction: The main dystocia due to fetal position abnormalities is the occipital posterior (OP) position, which in turn is considered the most common malposition at the time of delivery. Although the incidence of deliveries in OPP is low, the complications that accompany it have led to the consideration of a series of methods that attempt to favor the rotation of the fetal head and thus improve maternal-fetal outcomes. Objective: To evaluate the effectiveness of the hands-knees and lateral decubitus positions towards the side of the fetal dorsum on the rate of rotation of the fetal head from an occipital posterior position to an occipital anterior (OA) position. Methodology: A bibliographic search has been carried out in different databases such as: Pubmed, Cochrane and Scielo. Results: Numerous studies have been carried out to find out which is the most indicated maternal position to rotate posterior fetal positions, demonstrating the effectiveness of the modified Sims position. For the quadruped position, statistically significant results have been obtained for the specific variable of persistent low back pain, notably reducing it during the first stage of labor. Conclusions: Postural changes have been found to be beneficial in favoring the rotation of the fetal head and descent through the birth canal; they are also simple and inexpensive techniques that help to favor the fit of the fetal head.

Early description of amniotomy in medieval Persia.

Artificial rupture of the amniotic membranes during the labor, which is called amniotomy, is a common procedure in modern obstetric and midwifery protocols. There is no definite agreement regarding the timing of amniotomy in a delayed labor. In this study, we have discussed the history of amniotomy in medieval Persia mentioning the Persian medicine recommendations in this regard. We studied main Persian medicine textbooks such as Canon of Medicine by Avicenna to investigate the history of labor management and amniotomy indications. In addition, amniotomy in current literature was studied using PubMed and Google Scholar databases. Persian medicine has recommended artificial rupture of membranes for labor augmentation based on its own theories. Methods for facilitation of the labor have been divided into two groups: one group before and the other during the labor. Avicenna has carefully explained the indication of amniotomy. He has recommended artificial rupture of membranes in cases of intact membranes with cervical dilatation and fetal descent. A needle or a kind of surgical knife called Mabzaa had been introduced for this procedure. It seems that Iranian physicians are the first scholars who have introduced the amniotomy for labor management in the 11th century. Persian medicine recommendations for labor facilitation should be considered in future studies.

4-hourly action line on WHO modified partograph, and maternal and neonatal outcomes

Background: The partograph is a simple, inexpensive tool to provide a continuous pictorial overview of labor. The goal of this study is to use partograph to monitor labor, initiate uterine activity that is sufficient to produce cervical changes, fetal descent while avoiding uterine hyperstimulation, hypostimulation and fetal distress and provide timely surgical intervention where required. Objectives of the study were to evaluate outcome of labour in terms of action line crossed and augmentation of labour and in whom labour has been managed with 4-hour vs no-hour action line on WHO modified partograph. Methods: Every 8th primigravida mother fulfilling the inclusion criteria was enrolled for the study alternatively for 4 hourly and no partogram reading. Results were compared between Group A, with 50 cases, in whom labour has been managed with WHO modified Partograph with 2-hour action line and Group B, with 50 cases, in whom labour has been managed with that of no action line. Results: The present study shows that more women in 2-hour arm crossed the action line, compared with the no partograph arm, and therefore received more interventions to augment labour. Rate of caesarean section was more in group B than in group A which is statistically nonsignificant. Conclusions: Partograph with 4-hour action line did not show any superiority over that of no partograph line but to be associated with higher incidence of intervention. Further research is required in this field of active management.

Exploring concepts and definitions of plateaus during normal labor and birth: a scoping review protocol.

In this scoping review, contemporary concepts and definitions of phenomena during normal labor and birth, wherein the process appears to plateau (slow, stall, or pause) but remains within physiological limits, will be mapped. During labor and birth, it is frequently perceived as pathological if contractions, cervical dilation, or fetal descent plateau. However, there is evidence to suggest that some plateaus during labor may be physiological, and a variety of concepts and terms refer to this phenomenon. Where a physiological plateau is perceived as pathological arrest, this may contribute to undue interventions, such as augmentation of labor. Therefore, it is important to advance understanding of physiological labor patterns, including potentially physiological labor plateaus. Publications mentioning any plateaus of the processes of normal human labor and birth will be considered. This may also include phenomena where labor is perceived to "reverse," for example, a closing cervix or a rise of the presenting fetal part. Publications where plateaus are defined as pathological will be excluded. All types of evidence, published and unpublished, will be considered. The search strategy will be applied to the databases MEDLINE, Embase, MIDIRS, Emcare, CINAHL, and Scopus, and will be limited to the past 30 years. Gray literature will be searched via Open Grey, reference list screening, and contacting authors. Data extraction will comprise information on concept boundaries, terminology, precedents, consequences, concept origin, and types of evidence that report this phenomenon. Results will be presented in tabular, diagrammatical, and narrative manner.

Fetal descent in nulliparous women assessed by ultrasound: a longitudinal study

Ultrasound measurements offer objective and reproducible methods to measure the fetal head station. Before these methods can be applied to assess labor progression, the fetal head descent needs to be evaluated longitudinally in well-defined populations and compared with the existing data derived from clinical examinations. This study aimed to use ultrasound measurements to describe the fetal head descent longitudinally as labor progressed through the active phase in nulliparous women with spontaneous onset of labor. This was a single center, prospective cohort study at the Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland, from January 2016 to April 2018. Nulliparous women with a single fetus in cephalic presentation and spontaneous labor onset at a gestational age of ≥37 weeks, were eligible. Participant inclusion occurred during admission for women with an established active phase of labor or at the start of the active phase for women admitted during the latent phase. The active phase was defined as an effaced cervix dilated to at least 4 cm in women with regular contractions. According to the clinical protocol, vaginal examinations were done at entry and subsequently throughout labor, paired each time with a transperineal ultrasound examination by a separate examiner, with both examiners being blinded to the other's results. The measurements used to assess the fetal head station were the head-perineum distance and angle of progression. Cervical dilatation was examined clinically. The study population comprised 99 women. The labor patterns for the head-perineum distance, angle of progression, and cervical dilatation differentiated the participants into 75 with spontaneous deliveries, 16 with instrumental vaginal deliveries, and 8 cesarean deliveries. At the inclusion stage, the cervix was dilated 4 cm in 26 of the women, 5 cm in 30 of the women, and ≥6 cm in 43 women. One cesarean and 1 ventouse delivery were performed for fetal distress, whereas the remaining cesarean deliveries were conducted because of a failure to progress. The total number of examinations conducted throughout the study was 345, with an average of 3.6 per woman. The ultrasound-measured fetal head station both at the first and last examination were associated with the delivery mode and remaining time of labor. In spontaneous deliveries, rapid head descent started around 4 hours before birth, the descent being more gradual in instrumental deliveries and absent in cesarean deliveries. A head-perineum distance of 30 mm and angle of progression of 125° separately predicted delivery within 3.0 hours (95% confidence interval, 2.5-3.8 hours and 2.4-3.7 hours, respectively) in women delivering vaginally. Although the head-perineum distance and angle of progression are independent methods, both methods gave similar mirror image patterns. The fetal head station at the first examination was highest for the fetuses in occiput posterior position, but the pattern of rapid descent was similar for all initial positions in spontaneously delivering women. Oxytocin augmentation was used in 41% of women; in these labors a slower descent was noted. Descent was only slightly slower in the 62% of women who received epidural analgesia. A nonlinear relationship was observed between the fetal head station and dilatation. We have established the ultrasound-measured descent patterns for nulliparous women in spontaneous labor. The patterns resemble previously published patterns based on clinical vaginal examinations. The ultrasound-measured fetal head station was associated with the delivery mode and remaining time of labor.

Different methods of termination of second trimester pregnancy with scarred uterus at Mansoura University Hospitals

Objective: To describe different methods used in termination of sec- ond trimester pregnancy in those with previous uterine scare(s) and compare their efficacy and safety at a tertiary care center. Patients and Methods: a prospective, randomizedcontrolled com- parative trial conducted at Mansoura University Hospitals, Egypt during February 2018 through March 2019 and involved 105 healthy pregnant women at 14-28 weeks of gestation diagnosed to have missed abortion or intrauterine fetal death with a previous one or more caesarean delivery (CD). They divided into 3 equal groups, GI; received misoprostolalone for termination of pregnancy via ei- ther vaginal or sublingual routes as 400 µg / 6 hours for pregnancy at 14- 20 weeks; 200 µg / 6 hours for pregnancy at 20 -25 weeks or 100 µg / 6hours at 26 -27 weeks; G (II) for whom a Foley’s catheter was inserted under complete aseptic precautions, passed beyond the internal os then its balloon inflated by 20-30 ml normal saline for pregnancy at 14 - 20 weeks; 40-50 ml for pregnancy at 20 - 27 weeks and its position was confirmed by TAS then oxytocin infusion was commenced after the catheter expulsion, GIII; involved women who received a combination of Foley’s catheter inserted intracervical and a misoprostol dose 200 µg for pregnancy from 14-20 weeks or 100 µg for those between 20-27 weeks that was dissolved in 30 ml saline and injected intrauterine through the catheter lumen. Any of the pre- vious method continued for 24 hours otherwise the fetus comes out earlier. All patients in the three groups received oxytocin infusion 20 units in 500 ml normal saline after fetal expulsion to avoid placental retention and post-abortive bleeding.The primary outcome was in- duction-to-abortion interval (IAI) plus the mean time (SD) needed for complete uterine evacuation. Results: The patients’ characteristics and baseline data for the three groups including the age, weight, gravidity, parity, duration of preg- nancy, number of previous scar(s) showed no significant difference (p > 0.05).Studying the mean (SD) of IAI/hourtogether with data ob- served after starting treatment and postoperative complications record- ed a significant difference among the three groups as regard IAI (being shortest in GIII;11.6 ±2.6, longest in GII; 17.3 ±3.4 and in between for GI;15.9 ±3.4 respectively; P< 0.001), the success rate (100% for GIII, 91.4 % for GI and 85.7% for GII, p 0.02) and the occurrence of diar- rhea being lowest in GII (no cases), highest in GI (5 cases) in compare to 1 case only recorded in GIII (P0.024). On the other hand, insignif- icant difference among the study groups was observed as regard the mean (SD) of time/minutes needed for placenta expulsion after the fetal descent being 31.09 ± 5.01, 27.8 ± 7.61 and 26.57 ± 12.17 for the three groupsrespectively, the occurrence of post induction nausea and vomiting, fever or post-evacuation bleeding (p> 0.05). Somecases needed MVA after placental expulsion (6 cases in GI, 7 cases in GII and 4 in GIII) but again with no significant difference. Conclusion:Combined use of misoprostol and Fo- ley’s catheter for termination of mid-trimester preg- nancy with previous uterine scar(s) is found more superior than the use of either method alone regard- ing the success rate and shorter duration with mini- mal non serious complications and side effects.

Impact d’une politique d’utilisation raisonnée de l’oxytocine de synthèse lors du travail spontané à terme

ObjectiveTo assess the effect of a modified definition of dystocia and of a different timing of interventions during spontaneous labor on the rate of oxytocin use and on its consequences on labor outcome. MethodsWe compared oxytocin use and labor outcome before and after the introduction of a new protocol for the management of spontaneous labor. By protocol, oxytocin use and/or artificial rupture of the membranes was restricted to cases without progress in cervical dilatation for≥1h and/or no progress of fetal descent for≥1h at full dilatation. The main outcome measure was the rate of oxytocin use. Secondary outcome criteria were the consequences on labor (duration of labor, tachysystole and uterine hyperstimulation, abnormal fetal heart rate, cesarean delivery rate) and neonatal outcome. ResultsOxytocin use was strongly reduced from 2015 (69.2%) to 2016 (39.8%; P<0.01) and 2017 (31.9%; P<0.01). Abnormal FHR rates decreased simultaneously (respectively 52%, 37% et 29%, P<0.05), as well as uterine hyperstimulation (respectively 33.6%, 21.3% et 23.0%; P<0.05). The cesarean delivery rate did not vary significantly from 2015 (11.5%) to 2016 (8.4%; NS) but it decreased from 2015 to 2017 (11.5% to 2.6%, respectively; P<0.05). No difference was found in postpartum hemorrhage rates or in neonatal outcome. The duration of labor was significantly longer for women who delivered in 2017, compared with 2015 (372 minutes versus 306 minutes, respectively; P<0.05). After multivariate analysis, FHR abnormalities were reduced (aOR 0.65 IC 95% [0.49–0.86]) as well as cesarean deliveries during labor (aOR 0.5 IC 95% [0.26–0.97]) in 2017 only, compared with the reference year 2015. ConclusionA simple and easy-to-use definition of dystocia and of interventions required during labor allowed a strong reduction of oxytocin use during labor with subsequent benefits such as reduced rates of FHR abnormalities, uterine hyperstimulations and cesarean deliveries, at the cost of a limited prolongation of labor, mainly in nulliparous women.

Guidelines for labor assessment: failure to progress?

The ongoing debate about what models of cervical dilatation and fetal descent should guide clinical decision-making has sown uncertainty among obstetric practitioners. We previously argued that the adoption of recently published labor assessment guidelines promoted by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine may have been premature. Before accepting any new clinical approaches as the standard of care, their underlying hypotheses should be thoroughly tested to ensure they are at least equivalent (or, preferably, superior) to existing management paradigms. Some of the apparent urgency to subscribe to new clinical tactics has been fueled by legitimate concerns about the rise in the cesarean delivery rate over the past several decades. A major contributor to this change in practice patterns is that more cesarean deliveries are being done for diagnoses that fall under the rubric of dystocia than ever before. As a consequence, traditional labor curves-fundamental for assessing labor progress-and the practice paradigms associated with them have received intense scrutiny as a possible contributor to this delivery trend. Moreover, the recent proposal of new labor curves and accompanying management guidelines has, understandably, fed the appetite to correct a perceived problem. However, the cesarean delivery rate rose most rapidly during decades when there was no major change in traditional labor curves or in the guidelines for their interpretation. Also, during the years since the new guidelines were first published, there has been no major fall in cesarean delivery frequency. This raises the question of whether there was truly a fundamental flaw in the traditional labor management paradigms or whether their proper interpretation and use had been somehow forgotten, ignored, or corrupted. More important, existing studies have shown that application of the new guidelines often (but not always) results in a modest fall in the cesarean delivery rate, but that this change may be accompanied by significant increases in maternal and neonatal morbidity. These results strongly suggest more caution in the adoption of the American College of Obstetricians and Gynecologists / Society for Maternal-Fetal Medicine labor assessment recommendations. They are based on a hypothesis that has yet to undergo thorough evaluation of its risks and benefits.

Rupture of an unscarred uterus - a case report

Introduction. Rupture of an unscarred uterus is extremely rare and associated with severe maternal and fetal morbidity. Risk factors are second-stage dystocia, grand multiparity, high parity, labor induction or augmentation with oxytocin or prostaglandins, delivery after the 42nd week of gestation, neglected labor, fetal malpresentation, breech extraction, and instrumental delivery. Case Report. A 44-year-old multipara (gravid3 para3) underwent induction of labour at 40 + 3 weeks of gestation. The patient?s medical history showed no uterine surgeries, but her first delivery was instrumental, with vacuum extractor. The induction of labour was initiated by oxytocin infusion of 6 mIU/min. Continuous fetal heart rate monitoring was performed and there were no signs of fetal distress. Fetal descent in the second stage of labor lasted an hour, which is slightly over than average duration for multiparas. A live female infant weighing 3380 g was born and the pediatrician started resuscitation of the baby. Apgar score was 1/3/3. Ten days following the delivery, the patient was admitted to Emergency Gynaecology Department of the Clinic of Gynecology and Obstetrics due to abdominal pain, left sided retrouterine hematoma, and foulsmelling vaginal discharge. Laparotomy was indicated due to suspected uterine rupture. The intraoperative findings showed subinvolution of the uterus with signs of panmetritis and on the left side below the round ligament there was a 2 cm long rupture, passing through and invading the lateral and posterior walls of the uterus. A total abdominal hysterectomy with bilateral salpingo-oophorectomy on the left side was performed. Conclusion. Although a reliable prediction and prevention do not exist, the obstetricians? awareness of this rare event in unscarred uterus may decrease maternal and neonatal morbidity. This case report is an example of a serious and difficult outcome after a seemingly low-risk situation.

Preventing cesareans with peanut ball use

The Association of Women's Health Obstetrical and Neonatal Nurses (AWHONN) has launched a Peanut Ball campaign to help curb the high rate of cesarean births in the United States. Cesarean births are especially likely in women who receive epidural anesthesia due to immobility and pelvic laxity. The peanut ball (PB) is a birthing ball that when placed between the mother's legs can increase pelvic dimensions and facilitate fetal descent and birth. For PB to increase vaginal deliveries (VDs), nurses on obstetrical wards need to “buy in” to using this innovation. Having “innovator” nurses on the shift helped disseminate the PB intervention and increased the rate of VDs. Using a retrospective study design that uses data collected for non-research purposes saves time and cost. Our retrospective study examined the difference in VDs with patient controlled epidural anesthesia (PCEA) in the first five months of 2016 prior to PB use compared with the same months in 2017 post intervention. Using a paired t-test we found a significant difference of successful PCEA vaginal births in 2016 compared to 2017 (p = .008). This relatively inexpensive and easy survey can be done by most obstetrical services and help AWHONN in their campaign to decrease the rate of cesarean sections.

EP23.11: Intrapartum ultrasound is useful in the management of prolonged second stage of labour

Angle of progression (AoP) is an accurate and reproducible parameter for assessment of fetal descent. The aim of this study was to evaluate the usefulness of the AoP in the management of prolonged second stage of labour by analysing the change of AoP during second stage in the vaginal delivery group compared to the failed vaginal delivery group. This study included nulliparous women who had term delivery in cephalic presentation in Korea University Guro Hospital and took intrapartum ultrasonogram to measure AoP since cervix was fully dilated. We compared change of AoP during 2nd stage of the labour between the vaginal delivery group and the failed vaginal delivery group. No significant differences were found between two groups in maternal age, gestational age, birth weight, use of epidural anesthesia and oxytocin. Duration between 6cm cervical dilatation and full dilatation was longer in the failed vaginal delivery group compared to vaginal delivery group. AoP were measured in 176 women (147 vaginal deliveries, 29 emergency Caesarean section) since cervix was fully dilated. We analysed AoP data measured for the last time before delivery. Median AoP was significantly higher in the vaginal delivery group compared to the failed vaginal delivery group (136.16±19.12° vs 118.97±16.11° ; P < 0.01). For the prediction of successful vaginal delivery, the optimal AoP cut-off was 125°. AoP was significantly higher in vaginal delivery group compared to the failed vaginal delivery group when second stage of labour lasted more than 120 minutes (139.79±16.09° vs 119.78±16.82°; P < 0.01). Labour dystocia is the most common indication for primary Caesarean section. To reduce the rate of primary Caesarean section, accurate measurement of fetal station is very crucial during the second stage of labour. AoP seems to be very useful in the management of prolonged second stage of labour. AoP may serve as a guidance to clinicians whether vaginal delivery can be expected or not.

Warm perineal compresses during the second stage of labor for reducing perineal trauma: A meta-analysis

ObjectivePerineal trauma may have a negative impact on women’s lives as it has been associated with perineal pain, urinary incontinence and sexual dysfunction. The aim of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effectiveness of warm compresses during the second stage of labor in reducing perineal trauma. MethodsElectronic databases were searched from inception of each database to May 2019. Inclusion criteria were randomized trials comparing warm compresses (i.e. intervention group) with no warm compresses (i.e. control group) during the second stage of labor. Types of participants included pregnant women planning to have a spontaneous vaginal birth at term with a singleton in a cephalic presentation. The primary outcome was the incidence of intact perineum. Meta-analysis was performed using the Cochrane Collaboration methodology with results being reported as relative risk (RR) with 95% confidence interval (CI). ResultsSeven trials, including 2103 participants, were included in this meta-analysis. Women assigned to the intervention group received warm compresses made from clean washcloths or perineal pads immersed in warm tap water. These were held against the woman’s perineum during and in between pushes in second stage. Warm compresses usually started when the baby’s head began to distend the perineum or when there was active fetal descent in the second stage of labor. We found a higher rate of intact perineum in the intervention group compared to the control group (22.4% vs 15.4%; RR 1.46, 95% CI 1.22 to 1.74); a lower rate of third degree tears (1.9% vs 5.0%; RR 0.38, 95% CI 0.22 to 0.64), fourth degree tears (0.0% vs 0.9%; RR 0.11, 95% CI 0.01 to 0.86) third and fourth degree tears combined (1.9% vs 5.8%; RR 0.34, 95% CI 0.20 to 0.56) and episiotomy (10.4% vs 17.1%; RR 0.61, 95% CI 0.51 to 0.74). ConclusionWarm compresses applied during the second stage of labor increase the incidence of intact perineum and lower the risk of episiotomy and severe perineal trauma.

Effect of training on the knowledge and use of the partograph for low risk pregnancies among health workers in a tertiary hospital in Lagos State, Nigeria

Background: Partogram use is important for early recognition of deviations in labour. This study assessed the effect of training on the knowledge and use of the partogram in low-risk pregnancy (LRP). Methods: This is an analytical before and after study at the Lagos University Teaching Hospital. Fifty-two health personnel who conduct deliveries in the labour ward were assessed before and after a training on the proper utilization of the partogram which used WHO recommendations on the integrated management of pregnancy and child birth. Comparison of knowledge and utilization of the partogram before and after the training was estimated using the chi square test. The level of significance was p<0.05. Results: Thirty-two (61.5%) of the respondents were resident doctors while 38.5% were midwives. Only 27% of them had had any formal training on partogram use in the three years preceding the intervention. Training significantly improved knowledge of the partogram by improving standard records for cervical dilatation, uterine contraction and fetal descent; reducing substandard records for uterine contraction and fetal descent and no records, (p=0.0001). Training only significantly affected the utilization of the partogram in reference to blood pressure readings. There was a significant increase in substandard records and a reduction in standard records, (p=0.001) Conclusion: Training improved knowledge, but not the use of the partogram by health workers. Greater emphasis should be placed on the use of the partogram in monitoring labour progress in women with low risk pregnancies. Keywords: Partogram; Training; Labour management; Intrapartum care

Comparison of effacement curve with dilatation curve for prediction of labor progression.

This study was conducted to evaluate the ability of the effacement curve to predict fetal descent by comparing it to dilatation in order to improve the accuracy of the current partogram. We conducted an observational study of women who were admitted for vaginal delivery at Mobini Hospital, Sabzevar, Iran in 2015. During labor, dilatation and effacement were plotted in different graphs and then their association with fetal descent was separately evaluated and compared. This assessment was performed in two groups: primipara and multipara. From 1750 individuals, 503 primiparous and 512 multiparous women were eligible for the study. An adjusted generalized estimating equations multivariable model showed both dilatation and effacement had a significant relationship with fetal descent either in primipara or multipara. In primipara, the prediction value of effacement equalled dilatation (β,eff 0.29, P < 0.001; β,dil 0.30, P < 0.001). In multipara, the prediction value of effacement was obviously higher than dilatation (β,eff 0.45, P < 0.001; β,dil 0.27, P < 0.001). The strength of effacement to predict labor in multipara was clearly greater than in primipara (β,eff 0.45 and β,eff 0.29, respectively). The strength of dilatation to predict labor in multipara was comparable to primipara (β,dil 0.27 and β,dil: 0.30, respectively). Regarding the acceptable predictive value of effacement, we believe considering effacement, dilatation and station curves altogether can improve the power of the existing partogram for the assessment of labor progression and detection of failure to progress.

Strategies to support women who have had an epidural in labour

Optimal maternal positioning for fetal descent is achieved by creating positions where the mother is upright, has her upper leg as far as possible away from her lower leg (increasing the transverse diameter of the pelvis) and free space to allow the sacrum and coccyx to move back (increasing the anterior-posterior diameter of the pelvis) (Zwelling, 2010). Zwelling also states that maternal movement and position changes during labour assist with the progression of labour. However, upright positions and maternal mobility can be a problem for many women experiencing obstetric interventions such as an epidural.