First Stage Of Spontaneous Labor Research Articles

Progression of the first stage of spontaneous labour.

This chapter reviews and compiles the most recent published evidence assessing the overall labour duration and patterns of progression for both nulliparous and parous women, as well as the accuracy of the alert and action lines in the World Health Organization (WHO) partograph for the identification of women at risk of birth complications. Systematic reviews of observational studies reporting on the duration of the first and the second stages of labour, and on cervical dilatation patterns for women with low risk of complications with 'normal' perinatal outcomes were identified and updated. The accuracy of the alert (1cm/h) and action lines of the cervicograph in the partogram to predict adverse birth outcomes among women in first stage of labour was also reviewed, questioning the appropriateness of considering cervical dilatation over time as an isolated indicator to define labour progression or arrest.

The Correlation of the Level of Anxiety of Nulliparous Women to the Length of First Stage of Spontaneous Labor at Private Maternity Clinics in the Working Area of Delitua Puskesmas, Deli Serdang District in 2013

Abnormal length of first stage of labor in nulliparous women (first pregnancy) can be related by severe anxiety during labor. Based on the preliminary survey in several private maternity clinics at the working area of Delitua Puskesmas, Deli Serdang District, it was found that there was a prolonged first stage of labor (27.65%) in nulliparous women. The purpose of this study was to analyze the influence of anxiety level to the lenght of first stage of labor. The type of this study was an analytic survey with explanatory research type. The samples comprised 40 childbearing women in private maternity clinics of Kasih Ibu,Kurnia,Tanjung,Wanda,and Mayana which were located in the working area of Delitua Puskesmas , Deli Serdang District,using accidental sampling technique. The data were gathered by using questionnaires and analyzed in univariet analysis by using frequency distribution form, and bivariate analysis using Chi Square test. The result of this study showed that the level of anxiety (p = 0.001) significantly related the lenght of first stage of labor in which mothers who had severe anxiety. It is recomended that health providers should provide standardized services to childbearing women, especially to nulliparous women, so that their level of anxiety can be decreased facing the first stage of labor process. It is also recommended that the husbands should support their wives by positive behaviors so they will not think about bad things on their babies and on themselves.

Progression of the first stage of spontaneous labour: A prospective cohort study in two sub-Saharan African countries.

BackgroundEscalation in the global rates of labour interventions, particularly cesarean section and oxytocin augmentation, has renewed interest in a better understanding of natural labour progression. Methodological advancements in statistical and computational techniques addressing the limitations of pioneer studies have led to novel findings and triggered a re-evaluation of current labour practices. As part of the World Health Organization's Better Outcomes in Labour Difficulty (BOLD) project, which aimed to develop a new labour monitoring-to-action tool, we examined the patterns of labour progression as depicted by cervical dilatation over time in a cohort of women in Nigeria and Uganda who gave birth vaginally following a spontaneous labour onset.Methods and findingsThis was a prospective, multicentre, cohort study of 5,606 women with singleton, vertex, term gestation who presented at ≤ 6 cm of cervical dilatation following a spontaneous labour onset that resulted in a vaginal birth with no adverse birth outcomes in 13 hospitals across Nigeria and Uganda. We independently applied survival analysis and multistate Markov models to estimate the duration of labour centimetre by centimetre until 10 cm and the cumulative duration of labour from the cervical dilatation at admission through 10 cm. Multistate Markov and nonlinear mixed models were separately used to construct average labour curves. All analyses were conducted according to three parity groups: parity = 0 (n = 2,166), parity = 1 (n = 1,488), and parity = 2+ (n = 1,952). We performed sensitivity analyses to assess the impact of oxytocin augmentation on labour progression by re-examining the progression patterns after excluding women with augmented labours. Labour was augmented with oxytocin in 40% of nulliparous and 28% of multiparous women. The median time to advance by 1 cm exceeded 1 hour until 5 cm was reached in both nulliparous and multiparous women. Based on a 95th percentile threshold, nulliparous women may take up to 7 hours to progress from 4 to 5 cm and over 3 hours to progress from 5 to 6 cm. Median cumulative duration of labour indicates that nulliparous women admitted at 4 cm, 5 cm, and 6 cm reached 10 cm within an expected time frame if the dilatation rate was ≥ 1 cm/hour, but their corresponding 95th percentiles show that labour could last up to 14, 11, and 9 hours, respectively. Substantial differences exist between actual plots of labour progression of individual women and the ‘average labour curves’ derived from study population-level data. Exclusion of women with augmented labours from the study population resulted in slightly faster labour progression patterns.ConclusionsCervical dilatation during labour in the slowest-yet-normal women can progress more slowly than the widely accepted benchmark of 1 cm/hour, irrespective of parity. Interventions to expedite labour to conform to a cervical dilatation threshold of 1 cm/hour may be inappropriate, especially when applied before 5 cm in nulliparous and multiparous women. Averaged labour curves may not truly reflect the variability associated with labour progression, and their use for decision-making in labour management should be de-emphasized.

On predicting time to completion for the first stage of spontaneous labor at term in multiparous women

BackgroundLabor that progresses faster than anticipated may lead to unplanned out-of-hospital births. With the aim to improve planning of transportation to birthing institutions, this study investigated predictors of time to completion for the first stage of labor conditional on cervical opening (conditional time) in multiparous women at term.MethodsWe performed a retrospective analysis of partograms for women in Robson’s group 3 who delivered at one hospital from 2003 to 2013. A generalized additive mixed model was fitted, accounting for possible non-linear relationships between the predictor variables and outcome, e.g. the time from each cervical measurement to full dilation, using multiple measurements for each woman. The following predictors were included: cervical dilation (cm), parity (1, 2, or ≥3 previous vaginal births), oxytocin infusion (no/yes), epidural (no/yes), maternal age (years), maternal height (cm), body mass index (BMI, kg/m2), birthweight (kg), spontaneous rupture of membranes (no/yes). A modified regression model with gestational age (days) instead of birthweight was used to predict conditional time to full cervical dilation for combinations of the most relevant predictors.ResultsA total of 1753 partograms were included in the analysis. The strongest predictors were birthweight, epidural and oxytocin use, and spontaneous rupture of membranes, along with cervical measurements. For birthweight, there was an almost 40% increase in time to full cervical dilation for each 1-kg increment. Conditional time was on average 23% longer in cases with epidural use and 53% longer in cases requiring oxytocin augmentation. Spontaneous rupture of the membranes shortened conditional time by 31%. Maternal age was not associated with the outcome, while increasing BMI and parity modestly reduced conditional time.ConclusionsHigher parity, lower fetal weight (gestational age), and spontaneous rupture of the membranes are associated with more rapid labor.

The Correlation of the Level of Anxiety of Nulliparous Women to the Length of the First Stage of Spontaneous Labor at Private Maternity Clinics in the Working Area of Delitua Puskesmas, Deli Serdang District in 2013

Abnormal length of the first stage of labor in nulliparous women (first pregnancy) can be related to severe anxiety during labor. Based on the preliminary survey in several private maternity clinics at the working area of Delta Puskesmas, Deli Serdang District, it was found that there was a prolonged first stage of labor (27.65%) in nulliparous women. The purpose of this study was to analyze the influence of anxiety level to the length of the first stage of labor. The type of this study was an analytic survey with explanatory research type. The samples comprised 40 childbearing women in private maternity clinics of Kasih Ibu, Kurnia, Tanjung, Wanda, and Mayana which were located in the working area of Delitua Puskesmas, Deli Serdang District, using accidental sampling technique. The data were gathered by using questionnaires and analyzed in the univariate analysis by using frequency distribution form, and bivariate analysis using Chi-Square test. The result of this study showed that the level of anxiety (p = 0.001) significantly related the length of the first stage of labor in which mothers who had severe anxiety. It is recommended that health providers should provide standardized services to childbearing women, especially to nulliparous women, so that their level of anxiety can be decreased facing the first stage of the labor process. It is also recommended that the husbands should support their wifes by positive behaviors so they will not think about negative things on their babies and on themselves.

Combination of dexmedetomidine and remifentanil for labor analgesia: A double-blinded, randomized, controlled study.

Background:Satisfactory analgesia is of great importance in the labor. The clinical efficacy and side effects of remifentanil in the management of labor pain had been evaluated. Dexmedetomidine (DMET) demonstrates an antinociceptive effect in visceral pain conditions. Aims of the study were to assess whether the combination of DMET with remifentanil would produce a synergistic effect that results in lower analgesic requirements. Furthermore, whether this combination would have less maternal and neonatal adverse effects.Patients and Methods:Sixty American Society of Anesthesiologists physical status I-II pregnant women had been enrolled into this study. All were full term (37-40 weeks’ gestation), singleton fetus with cephalic presentation in the first stage of spontaneous labor. They were divided into two groups group (I) Patient-controlled IV remifentanil analgesia (bolus dose 0.25 μg/kg, lockout interval 2 min) increased by 0.25 μg/kg to a maximum bolus dose 1 μg/kg in addition to a loading dose of DMET 1 μg/kg over 20 min, followed by infusion at 0.5 μg/kg/h group (II) Patient-controlled IV remifentanil analgesia (PCA) (bolus dose 0.25 μg/kg, lockout interval 2 min) increased by 0.25 μg/kg to a maximum bolus dose 1 μg/kg in addition to a the same volume of normal saline as a loading dose, followed by a continuous saline infusion. Visual analog scale score, maternal, and fetal complications and patients’ satisfaction were recorded.Results:Patients receiving a combination of PCA remifentanil and DMET had a lower pain score compared with remifentanil alone in the second stage of labor (P = 0.001). The Total consumption of remifentanil was reduced by 53.3% in group I. There was an increased incidence of maternal complications and a lower patient satisfaction score in group II.Conclusion:DMET has an opioid sparing effect; a combination of DMET and remifentanil produces a synergistic effect that results in lower analgesic requirements and less maternal and neonatal adverse events.

Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour

Slow progress in the first stage of spontaneous labour is associated with an increased caesarean section rate and fetal and maternal morbidity. Oxytocin has long been advocated as a treatment for slow progress in labour but it is unclear to what extent it improves the outcomes for that labour and whether it actually reduces the caesarean section rate or maternal and fetal morbidity. This review will address the use of oxytocin and whether it improves the outcomes for women who are progressing slowly in labour compared to situations where it is not used or where its administration is delayed. To determine if the use of oxytocin for the treatment of slow progress in the first stage of spontaneous labour is associated with a reduction in the incidence of caesarean sections, or maternal and fetal morbidity compared to situations where it is not used or where its administration is delayed. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 February 2013) and bibliographies of relevant papers. Randomised controlled trials which compared oxytocin with either placebo, no treatment or delayed oxytocin in the active stage of spontaneous labour in low-risk women at term. Two authors independently assessed studies for inclusion, assessed risk of bias and extracted data. We sought additional information from trial authors. We included eight studies in the review involving a total of 1338 low-risk women in the first stage of spontaneous labour at term. Two comparisons were made; 1) the use of oxytocin versus placebo or no treatment (three trials); 2) the early use of oxytocin versus its delayed use (five trials). There were no significant differences in the rates of caesarean section or instrumental vaginal delivery in either comparison. Early use of oxytocin resulted in an increase in uterine hyperstimulation associated with fetal heart changes. However, the early use of oxytocin versus its delayed use resulted in no significant differences in a range of neonatal and maternal outcomes. Use of early oxytocin resulted in a statistically significant reduction in the mean duration in labour of approximately two hours but did not increase the normal delivery rate. There was significant heterogeneity for this analysis and we carried out a random-effects meta-analysis; however, all of the trials are strongly in the same direction so it is reasonable to conclude that this is the true effect. We also performed a random-effects meta-analysis for the four other analyses which showed substantial heterogeneity in the review. For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernable difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.

Spontaneous Rupture of the Anterior Vaginal Wall during the First Stage of Labour

The risk of uterine rupture during attempted trial of labor after caesarean delivery (TOLAC) is well documented. However, vaginal rupture (in the absence of obstructed labour) is exceptionally uncommon. Below is described the rare case of a 37-year-old multiparous woman attempting TOLAC, who suffered a vaginal—rather than uterine—rupture, during the first stage of spontaneous labour. This case is an important reminder to obstetricians that concealed ruptures of both the vagina and uterus do occur and must be considered in clinical situations where another explanation is not apparent.

Oxytocin Versus No Treatment or Delayed Treatment for Slow Progress in the First Stage of Spontaneous Labour

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Changes in myometrial ‘perfusion’ during normal labor as visualized by three‐dimensional power Doppler angiography

Myometrial contractions are one of the most important aspects of effective labor. For cells within the myometrium to work efficiently they need to be well oxygenated and this requires an adequate blood supply. This study used quantitative three-dimensional (3D) power Doppler angiography to calculate the percentage change in myometrial blood flow during a relaxation-contraction-relaxation cycle of active labor. Transabdominal 3D power Doppler ultrasound imaging was used to acquire volumetric data during the first stage of spontaneous labor in 20 term, nulliparous women. 3D datasets were acquired during a single cycle of uterine relaxation, contraction and subsequent relaxation for each subject. The resultant datasets were analyzed independently by two investigators on two occasions using Virtual Organ Computer-aided AnaLysis to define a volume of interest within the myometrium; the power Doppler signal within this volume was quantified to provide 3D indices of vascularity: vascularization index (VI), flow index (FI) and vascularization flow index (VFI). The percentage change in these indices, during a uterine contraction, was calculated from the baseline value during the initial uterine relaxation phase (taken as a maximum of 100%). Myometrial blood flow fell significantly during the uterine contraction and returned during the subsequent relaxation phase of the cycle (P < 0.001 for VI and VFI, P = 0.002 for FI). From the initial baseline relaxation value, VI dropped to 43.9%, FI to 85.5% and VFI to 40.8% during uterine contraction, and returned to 86.7%, 98.1% and 89.1%, respectively, during the subsequent relaxation. The intraclass correlation coefficients in blood flow measurements of 0.982-0.999 between the two investigators were indicative of good interobserver reliability. This study confirms that myometrial perfusion, as measured by quantitative 3D power Doppler angiography, significantly falls during uterine contractions, returns during the subsequent relaxation phase, and can be quantified reliably from stored datasets. Further work is now required to establish clinical applicability for this non-invasive investigation.

Predicting the duration of the first stage of spontaneous labor using a neural network.

To create a neural network that predicts the length of the first stage of term labor. Two hundred patients with gestations > or = 36 weeks, in spontaneous active labor are the study group: 159 for training and 41 for testing; 4 training set patients had second-stage cesarean section for obstructed labor. The network is designed with Brainmaker MacIntosh 1.0 (California Scientific Software). Inputs are uterine activity, estimated fetal weight, position, station, and gestational age; maternal parity, age, height, weight, membrane status, and cervical dilatation. Actual first stages are regressed on those predicted by the network or by a standard partogram set. Differences between actual first stage lengths and those predicted by the neural network or partogram are compared with t-tests; while the proportions of first stages accurately predicted within 1 or 2 h are compared for both methods with chi-square tests. The network trained in 4 h (1388 runs) to a 0.15 tolerance. The network predictions have significantly higher correlation (r = 0.88) than do standard partograms (r = 0.35) with actual first stage durations. Mean differences between predicted and actual first stages are significantly lower for network output than with partograms; these differences increased with first stages exceeding 3 h; 100% of trained network values are within 2 h of actual first stage length. The network performs similarly for a new set of 41 previously unseen labors. This neural network predicts the length of the first stage of spontaneous labor and uses inputs readily available to obstetricians. It outperforms typical partograms for estimating this important feature of normal labor. Future application for intrapartum prognosis could be based on this successful design.

Predicting duration of the first stage of spontaneous labor in term parturients using a neural network: [formula omitted], S. Samuel BA x, P. Gardner RN x. Department of OBGYN, Medical College of Georgia, Augusta GA

Predicting duration of the first stage of spontaneous labor in term parturients using a neural network: [formula omitted], S. Samuel BA x, P. Gardner RN x. Department of OBGYN, Medical College of Georgia, Augusta GA

Chronic lead exposure and pregnancy

The objective of the study was to determine the effect of chronic lead exposure on pregnancy and the newborn. Cord blood was assayed for blood lead levels (PbB) in a randomly selected group of 82 Maltese newborns. Twenty-eight (34.1%) neonates had a PbB level greater than 200 μg/l. Two trends appeared with increasing blood lead levels suggesting a decrease in newborn birth weight (r=-0.1445, P=0.207) and an increase in the duration of the first stage of spontaneous labour (r=0.1385, P=0.3043). There appeared to be no mean differences in maternal third trimester haemoglobin, duration of gestation, and previous pregnancy loss in infants with high PbB levels compared to infants with low PbB. Through its properties of inhibiting enzymatic function and its competitiveness with other minerals, calcium and zinc, chronic sub-toxic lead exposure during pregnancy may cause adverse effects on the neonate and pregnancy.

Amniotic fluid prostaglandin D 2 in spontaneous and augmented labor

Prostaglandin D 2 (PGD 2) was quantified in human amniotic fluid obtained from women in various phases of the first stage of spontaneous labor, augmented labor, and induced labor. PGD 2 increased significantly only in late labor in the spontaneous and augmented labor groups.

Normal levels of uterine activity in primigravidae and women of high parity in spontaneous labour

SummaryUterine activity was measured in 30 primigravidae and 30 women of parity 5 or more. All were in the active phase of the first stage of spontaneous labour and were delivered spontaneously vaginally—without augmentation with oxytocin. The cumulative uterine activity integral values and the values at individual cervical dilatations were significantly lower with parity 5 or more than in primigravidae. The overall values (mean ± s.d.) of the integral were 1574 ± 468 KPa/15 min and 1139 ± 442KPa/15 min for primigravidae and high parity women respectively. A gradual rise in uterine activity as labour advanced from 3–10 cm cervical dilatation was observed.

Estimating the probability of spontaneous delivery conditional on time spent in the second stage.

The duration of second stage labour was studied, retrospectively, among 410 primigravidas who received epidural analgesia in the first stage of spontaneous labour at term (greater than 37 weeks). Survival analysis was used to investigate how the likelihood of a spontaneous delivery was related to time spent in the second stage, and how some maternal and fetal factors influenced this relationship. The proportion of spontaneous deliveries that had occurred by any given time was greatly influenced by maternal age and infant birthweight. However, the women who were least likely to have been delivered by any given time after full dilatation, were also the ones who were least likely to be delivered within any given subsequent time interval. If delivery had not occurred by 3 h, the probability that it would take place in the next 3 h was well under 30% in most cases. We conclude that second stage labour in excess of 3 h is likely to be beneficial only if certain criteria, which are defined in the paper, are met.

A rapid gas chromatographic determination of thiamphenicol in plasma and amniotic fluid

A rapid gas chromatographic method for the determination of thiamphenicol in plasma and amniotic fluid is described. The antibiotic is extracted from biological fluids with ethyl acetate and, after concentration of the extract, the trimethylsilyl derivative of the drug is determined by electron-capture gas chromatography using a 63Ni detector. After the intravenous administration of a single dose of 500 mg of thiamphenicol during the first stage of spontaneous labour to clinically normal gravidae at term, transmission of the drug across the placenta was demonstrated by a combination of gas chromatography and mass spectrometry.

Oxytocin release by infused prostaglandin.

Plasma oxytocin levels were measured serially in 22 women receiving prostaglandin E(2) or F(2alpha) intravenously for the induction of labour. Oxytocin was detected in the plasma of 19 of the 22 women; positive levels were found in 60 (43%) of 139 plasma samples, an incidence similar to that in the late first stage of spontaneous labour. Oxytocin was found in the maternal plasma even when the fetus was dead, and in the plasma of two men receiving prostaglandin infusions. This indicates that prostaglandins stimulate the pituitary directly and suggests that this mechanism may play a part in the oxytocic action of infused prostaglandins.

The fibrinolytic system in late pregnancy, labor, and the early puerperium

Controversy exists with regard to changes in the fibrinolytic system in late pregnancy, normal labor, and the puerperium, although it is generally thought that fibrinolytic activity is depressed in pregnancy and enhanced during the postpartum period. Twenty-one normal, pregnant patients were studied. The fibrinolytic system was investigated before labor, during the first stage of spontaneous labor, and then at intervals during the puerperium. Marked alterations in fibrinolytic activity were seen in the early puerperium. Plasma fibrinogen levels fell by 35 per cent, coincident with an increase in plasminogen activator activity. These and other changes tended to return to prelabor base-line values within the first 24 hours post partum. The results are interpreted as indicating that fibrinolytic activity is enhanced during the immediate puerperium but that prelabor levels are rapidly regained. The significance of these changes and their possible relationship to postpartum thromboembolic disease is discussed.