Labor In Nulliparous Women Research Articles

Term Induction of Labour in Nulliparous Women: When to draw the line?

There exists uncertainty surrounding the most effective and efficient means of inducing labour, particularly in the setting of an unfavourable cervix. This study aims to determine the merit of repeating dinoprostone administration when a single application has failed to render the cervix favourable for amniotomy.

The administration of intravenous fluids to nulliparous women in labour: A retrospective clinical chart review and fluid balance documentation audit

BackgroundIn Australia, midwives are integral to providing safe and supportive care to women in labour. The administration of intravenous (IV) fluids is a frequent clinical intervention performed by midwives. At present, practices surrounding IV fluid administration to women during labour within Australia are largely undescribed and there is a limited amount of robust evidence available to guide practice. IV fluids do carry a risk of harm. To define and ensure safe IV fluid practices, research into practices surrounding the administration of IV fluids to women in labour is essential. AimsTo describe the current practice for registered midwives administering IV fluids to women during labour. DesignRetrospective clinical chart review and fluid balance documentation audit. MethodsA retrospective clinical chart review and audit of fluid balance documentation for 107 nulliparous women was conducted at a single metropolitan tertiary referral hospital in Sydney, New South Wales between 1 October 2016 and 22 March 2017. A 24-point tool was developed to audit fluid balance charts. ResultsEighty-eight percent of the 88 fluid balance charts available scored 50% or less using the 24-point fluid balance chart audit tool. Additionally, there was an estimated 18% completion rate for the NSW IV fluid order chart. ConclusionThis study found wide variation in clinical practice and incomplete fluid balance documentation at a single, metropolitan tertiary referral hospital. The findings highlight the difficulty of determining IV fluids practices in the context of incomplete fluid balance documentation. Additionally, there are patient safety and professional regulation concerns when fluid management documentation is missing and/or incomplete. Future research should examine barriers and facilitators for documentation.

Simultaneous use of high-volume Foley catheter (60ml) and misoprostol for labor induction in nulliparous women: Arandomized controlled trial.

To examine the simultaneous effect of high-volume Foley catheter (HVFC) (60ml) and vaginal misoprostol on labor induction in nulliparous women. A randomized, double-blind, controlled trial was conducted among nulliparous post-date (>40weeks) pregnant women between June and December 2019. At enrollment 100 women were randomized into each group (either HVFC and vaginal misoprostol or low-volume Foley catheter [LVFC] [30ml] and vaginal misoprostol), for labor induction. Demographic and clinical data were collected at enrollment and delivery. Women in the HVFC group had statistically significantly shorter induction to delivery interval (median 860min, interquartile range [IQR] 840-940min vs. 1160min, IQR 1080-1320min, P<0.001) and duration of labor (median 615min, IQR 600-680min vs. 750, IQR 692.5-800min, P<0.001). Mode of vaginal delivery (n=94 vs. n=78, P=0.002), number of doses of misoprostol required (median 2, IQR 1-2 vs. 2, IQR 1-3), and need of oxytocin augmentation (n=22 vs. n=39, P=0.014 and P<0.001), was significantly better in the HVFC group. However, there was no significant difference with respect to other maternal or neonatal outcomes. Simultaneous use of HVFC and vaginal misoprostol for labor induction significantly shortens the induction to delivery interval and duration of labor in nulliparous women. Clinical Trial Registry of India CTRI/2019/05/019394 (http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=31554&EncHid=&userName=Foley%20catheter).

Transvaginal sonographic assessment of the cervix for prediction of successful induction of labor in nulliparous women

Abstract Background Induction of labor is commonly performed in obstetric practice. Many methods have been suggested as good predictors of the outcome of labor induction, yet none of them is satisfactory enough. Objective To assess cervical length and uterocervical angle measured by transvaginal ultrasound as predictors of successful induction of labor. Methodology Prospective cohort study was conducted in a university-affiliated hospital over 150 nulliparous women undergoing induction of labor, in the period between May 2018 and August 2019. Transvaginal sonographic measurement of cervical length and uterocervical angle was done before induction of labor by prostaglandins. The patients were followed up till delivery and the outcome was recorded. Results The best cut-off value of cervical length for prediction of success of labor induction was 32.3 mm with 60% sensitivity and 56% specificity and the best cutoff value of uterocervical angle was 110.2 degrees with 87% sensitivity and 93% specificity. The cervical length showed a significant negative correlation while the uterocervical angle showed a significant positive correlation with the success of labor induction. Conclusion Cervical length and uterocervical angle are good predictors of successful labor induction.

Neonatal outcomes associated with obstetric interventions performed during labor in nulliparous women

Objective: to analyze neonatal outcomes associated with obstetric interventions performed during labor in low-risk nulliparous women. Methods: a cross-sectional observational study of 534 low-risk nulliparous women. Results: interruption of skin-to-skin contact after delivery was shown to be associated with obstetric interventions such as cardiotocography at admission, oxytocin in labor, amniotomy, and episiotomy. The need for positive pressure ventilation and oxygen therapy was associated with the encouragement of the Valsalva maneuver; the performance of this maneuver was also associated with interventions such as amniotomy, episiotomy and directed pulling. Conclusion: the study showed that the use of obstetric interventions during labor in low-risk women is associated with unfavorable neonatal outcomes that lead to the need for further interventions after delivery.

Efficacy and Safety of Epidural Analgesia versus Traditional Analgesia for Relief of Labour Pain

Background: Labour pain, a form of acute pain, intensity of the pain is perceived by many women as very severe or intolerable especially in nulliparous. Providing effective and safe analgesia during labour has remained an ongoing challenge. Multiple pharmacologic and non-pharmacologic options are available to manage labour pain. Epidural analgesia have reported nearly complete pain relief with effective labour conduction. Objective: Purpose of this study was to evaluate the effectiveness of epidural analgesia and pethidine during labour and delivery. Materials &amp; Methods: This cross sectional comparative study was conducted to compare the efficacy and safety between epidural and traditional analgesia on nulliparous women in labour. Subjects were grouped into two, group A received epidural &amp; group B received traditional analgesia, each group comprising with 40 patients. Then the subjects were followed up and outcomes were recorded in a preformed data collection sheet. Results: The two groups were almost identical. Maternal age, gestational age and preinduction pain score (p = 0.127, p = 0.454 and p = 0.186 respectively). Study demonstrated earlier onset, pain score at different time intervals and the time of delivery were lower in epidural group than traditional (p &lt; 0.001). No significant difference of complications (p = 0.431). Two(5%) patients in the epidural and five(12.5%) in the traditional group required caesarean delivery (p=0.455). No significance on neonatal outcome. Conclusion: Epidural analgesia induces a much earlier onset, intensity of pain reduced to a tolerable level and maintained up to delivery which not attained in the traditional method of analgesia. KYAMC Journal.2021;12(02): 66-70

COMPARISON OF MISOPROSTOLAND DINOPROSTONE FOR ELECTIVE INDUCTION OF LABOUR IN NULLIPAROUS WOMEN AT FULL TERM: A RANDOMIZED PROSPECTIVE STUDY

Background: The objective of this randomized prospective study was to compare the efcacy of 50 mcg vaginal misoprostol and 3 mg dinoprostone, administered every nine hours for a maximum of three doses, for elective induction of labor in nulliparous women with an unfavorable cervix and more than 40 weeks of gestation. Material And Methods: One hundred and sixty-three pregnant women with more than 285 days of gestation were recruited and analyzed. The main outcome measures were time from induction to delivery and incidence of vaginal delivery within 12 and 24 hours. Admission rate to the neonatal intensive care unit within 24 hours post delivery was a secondary outcome. Results: The induction-delivery interval was signicantly lower in the misoprostol group than in the dinoprostone group (11.9 h vs. 15.5 h, p &lt; 0.001). With misoprostol, more women delivered within 12 hours (57.5% vs. 32.5%, p &lt; 0.01) and 24 hours (98.7% vs. 91.4%, p &lt; 0.05), spontaneous rupture of the membranes occurred more frequently (38.8% vs. 20.5%, p &lt; 0.05), there was less need for oxytocin augmentation (65.8% vs. 81.5%, p &lt; 0.05) and fewer additional doses were required (7.5% vs. 22%, p &lt; 0.05). Although not statistically signicant, a lower Caesarean section (CS) rate was observed with misoprostol (7.5% vs. 13.3%, p &gt; 0.05) but with the disadvantage of higher abnormal fetal heart rate (FHR) tracings (22.5% vs. 12%, p &gt; 0.05). From the misoprostol group more neonates were admitted to the intensive neonatal unit, than from the dinoprostone group (13.5% vs. 4.8%, p &gt; 0.05). One woman had an unexplained stillbirth following the administration of one dose of dinoprostone. Conclusions: Vaginal misoprostol, compared with dinoprostone in the regimens used, is more effective in elective inductions of labor beyond 40 weeks of gestation. Nevertheless, this is at the expense of more abnormal FHR tracings and more admissions to the neonatal unit, indicating that the faster approach is not necessarily the better approach to childbirth

High-Dose Compared With Standard-Dose Oxytocin Regimens to Augment Labor in Nulliparous Women: A Randomized Controlled Trial.

High-Dose Compared With Standard-Dose Oxytocin Regimens to Augment Labor in Nulliparous Women: A Randomized Controlled Trial.

Impact of Early versus Late Amniotomy on Induction of Labor in Nulliparous Women after Vaginally Administered Misoprostol: A Randomized Clinical Trial

Abstract Objective: To investigate the effect of early versus late amniotomy after induction of labor (IOL) with vaginally administered misoprostol. Methods: This randomized clinical trial was conducted at the Department of Obstetrics and Gynecology, Menoufia University, from May 2019 to March 2020, and included 120 nulliparous women at term (≥ 37 weeks' gestation) undergoing IOL. Computer-generated randomization was used to randomize the participants into either the early amniotomy group (3 cm cervical dilatation; n = 60) or the late amniotomy group (7 cm cervical dilatation; n = 60). All participants received misoprostol (25 μg) vaginally to induce labor. The primary outcome was the induction-to-delivery interval, defined as the time from the initiation of IOL to the time of delivery. Results: Women in the early amniotomy group had a shorter duration of labor (12.60 ± 5.36 h) than those in the late amniotomy group (16.67 ± 7.26 h). The mean time from rupture of the fetal membrane to delivery was significantly shorter in the late (2.51 ± 0.36 h) than in the early amniotomy group (3.1 ± 0.89 h). There was no statistically significant difference between the groups in terms of maternal complications (fever, nausea, vomiting, and uterine hyperstimulation) or neonatal complications (meconium-stained liquor, APGAR score &lt;7 at 1 and 5 min, and neonatal intensive care unit admission). Conclusions: IOL using vaginally administered misoprostol followed by early amniotomy was accompanied by a shorter duration of labor and decreased use of oxytocin. There was no significant difference between the early and late amniotomy groups in terms of the rate of cesarean section or maternal and neonatal complications.

Maternal haemodynamics during labour epidural analgesia with and without adrenaline.

Labour is one of the most painful experiences in a woman's life. Epidural analgesia using low-concentration local anaesthetics and lipophilic opioids is the gold standard for pain relief during labour. Pregnancy in general, particularly labour, is associated with changes in maternal haemodynamic variables, such as cardiac output and heart rate, which increase and peak during uterine contractions. Adrenaline is added to labour epidural solutions to enhance efficacy by stimulating the α2-adrenoreceptor. The minimal effective concentration of adrenaline was found to be 2μgmL-1 for postoperative analgesia. The addition of adrenaline may also produce vasoconstriction, limiting the absorption of fentanyl into the systemic circulation, thereby reducing foetal exposure. However, adrenaline may influence the haemodynamic fluctuations, possibly adding to the strain on the circulatory system. The aim of this study was to compare the haemodynamic changes after application of labour epidural analgesia with or without adrenaline 2μgmL-1. This was a secondary analysis of a single-centre, randomised double-blind trial. Forty-one nulliparous women in labour requesting epidural analgesia were randomised to receive epidural solution of bupivacaine 1mgmL-1, fentanyl 2μgmL-1 with or without adrenaline 2μgmL-1. The participants were monitored using a Nexfin CC continuous non-invasive blood pressure and cardiac output monitor. The primary outcomes were changes in peak systolic blood pressure and cardiac output during uterine contraction within 30min after epidural activation. The effect of adrenaline was tested statistically using a linear mixed-effects model of the outcome variables' dependency on time, adrenaline, and their interaction. After excluding three patients due to poor data quality and two due to a malfunctioning epidural catheter, 36 patients (18 in each group) were analysed. The addition of adrenaline to the solution had no significant effect on the temporal changes in peak systolic blood pressure (p=0.26), peak cardiac output (0.84), or heart rate (p=0.91). Furthermore, no significant temporal changes in maternal haemodynamics (peak systolic blood pressure, p=0.54, peak cardiac output, p=0.59, or heart rate p=0.55) were associated with epidural analgesia during 30min after epidural activation in both groups despite good analgesia. The addition of 2μgmL-1 adrenaline to the epidural solution is not likely to change maternal haemodynamics during labour.

Maternal body mass index and oxytocin in augmentation of labour in nulliparous women: a prospective observational study

ObjectiveTo evaluate oxytocin use for augmentation of labour in relation to body mass index (BMI) on admission to the labour ward, focusing on cumulative oxytocin dose and maximum rate of...

Prolonged second stage effect on pelvic floor dysfunction: a follow up survey to a randomized controlled trial

Background Pelvic floor dysfunction is a group of disorders that can significantly impact quality of life due to persistent urinary and anal incontinence. Data evaluating the effect of prolonged second stage of labor and postpartum pelvic floor dysfunction is heterogenous and limited. Objective To evaluate whether extending the length of labor in nulliparous women with prolonged second stage affects the presence of self-reported pelvic floor dysfunction after a randomized controlled trial of prolonged second stage. Study design We conducted a planned follow up survey to our randomized controlled trial of prolonged second stage of labor using the Pelvic Floor Distress Inventory-20 (PFDI-20). The primary outcome was the PFDI-20 summary score. Secondary outcomes included urinary and fecal incontinence, prolapse, and patient satisfaction. Women surveyed were nulliparous patients with epidural anesthesia, previously enrolled in a randomized controlled trial that assigned them to extended labor, at least 1 additional hour in the second stage if they were undelivered after three hours, or to usual labor, defined as expedited delivery after three hours in the second stage. Women were surveyed at 12 − 36 months postpartum. Results Thirty-four of the seventy-eight women responded to the survey (43.6%). 17 women (50.0%) were from the extended labor group and 17 from the usual labor group (50.0%). Maternal demographic data were not significantly different between groups. The PFDI-20 summary score was 13.8 ± 23.3 in the extended labor group and 13.1 ± 20.9 in the usual labor group (p = 0.9). The Pelvic Organ Prolapse Distress Inventory-6 was 1.2 ± 2.9 in the extended labor group and 2.7 ± 6.4 in the usual labor group (p = 0.4). The Colorectal-Anal Distress Inventory-8 was 0.8 ± 2.8 in the extended labor group and 2.1 ± 4.0 in the usual labor group (p = 0.6). The Urinary Distress Inventory-6 was 11.8 ± 21.1 in the extended labor group and 8.3 ± 14.5 in the usual labor group (p = 0.6). Maternal and neonatal outcomes, as well as patient satisfaction, were not statistically significantly different between groups. Conclusion Extending the length of labor in nulliparas with singleton gestations, epidural anesthesia, and prolonged second stage did not have an impact on PFDI-20 scores at 12–36 months postpartum. However, our study was underpowered to detect small, but potentially clinically important, differences. Clinical Trial Number NCT02101515 (Study Registration Date March 28, 2014) https://clinicaltrials.gov/ct2/show/NCT02101515

117 Clinically defined active phase arrest of labor in nulliparous women

We sought to examine maternal and neonatal outcomes in women who achieved the active phase of labor and evaluated the duration of time to progress at least 1 cm. This was a retrospective cohort study of nulliparous women with term singleton in a cephalic presentation who presented with spontaneous labor and achieved active labor. Women were categorized based on the time interval it took to make at least 1 cm of cervical change (less than 4 hours, 4-5.9 hours, 6 hours or greater). Analyses were performed at cervical dilation of 6, 7, 8, and 9 cm. Outcomes that were examined included cesarean delivery, chorioamnionitis, and a composite of neonatal outcomes including intensive care unit admission, seizure, ventilator use, birth injury, or asphyxia. Adjusted odds ratios (aORs) with 95% confidence intervals (95%CIs) were calculated, controlling for predefined covariates. Of 31,505 nulliparous women, there were 13,142 (42%), 10,855 (34%), 11,761 (37%), and 17,049 (54%) who had documented cervical dilation of 6, 7, 8, and 9 cm, respectively (Figure). Rates of women who took 6 hours or greater to make at least 1 cm cervical change decreased as cervical dilation progressed. Overall, results were similar regardless of cervical dilation. For example, if we look at the time interval for women to make cervical change starting at 8 cm; women who took less than 4 hours to make cervical change from 8 cm compared to those who took 4-5.9 hours had lower rates of cesarean delivery (aOR 0.40; 95%CI 0.28-0.55), chorioamnionitis (aOR 0.42; 95%CI 0.29-0.60), and the neonatal composite outcome (aOR 0.51; 95%CI 0.36-0.72). However, women who took 6 hours or greater had similar rates of cesarean delivery (aOR 1.14; 95%CI 0.78-1.69), chorioamnionitis (aOR 1.30; 95%CI 0.83-2.03), and the neonatal composite outcome (aOR 1.18; 95%CI 0.70-2.00). While women who took less than 4 hours to make cervical change had lower rates of maternal and neonatal outcomes compared to those who took 4-5.9 hours, those who took 6 hours or greater did not have increased rates of maternal and neonatal outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

361 Elective induction of labor in nulliparous women of advanced maternal age: a meta-analysis

To ascertain whether elective induction of labor (eIOL) for nulliparous women of advanced maternal age (AMA, age at delivery ≥ 35yrs) leads to a higher rate of Cesarean delivery (CD) as compared to expectant management (EM). A literature search using Ovid MEDLINE, Ovid and The Cochrane Library identified articles based on keywords and phrases pertaining to the AMA population and intervention (eIOL). The reference lists from each article were reviewed to identify other articles. Studies included compared nulliparous women undergoing eIOL at 39 weeks with women undergoing EM and data on parity was available. The primary outcome was CD rate. Studies were assessed using a random effects model to incorporate between-study variation. Risk of bias was assessed with a modified Agency for Healthcare Research and Quality (AHRQ) scale for “Grading the strength of a Body of Evidence When Comparing Medical Interventions.” PROSPERO CRD42020159209 From 3500 titles and abstracts screened, 5 studies met inclusion criteria for data extraction. Data were extracted from 3 studies, one randomized trial and two observational studies. The authors for the other 2 studies were contacted but were unable to provide data. There were 4477 nulliparous women undergoing eIOL at 39 weeks and 58,268 nulliparous women undergoing EM. Elective IOL at 39 weeks was not associated with an increased risk of CD with high heterogeneity among the studies (RR 1.00, CI 0.74, 1.33; I2 = 93%, τ2 = 0.0610, p < 0.01) (Figure 1). There was also no difference in outcomes such as operative delivery, maternal hemorrhage or NICU admission. A significant reduction in severe maternal morbidity (RR 0.52, CI 0.28, 1.00; I 2 = 0%, τ 2 = 0, p = 0.49) and need for neonatal respiratory support (RR 0.75, CI 0.66 0.86; I 2 = 0%, τ 2 = 0, p = 0.70) was noted. All studies included were of moderate to high quality with low risk of bias and fair applicability. In nulliparous women who are AMA, eIOL at 39 weeks does not increase the CD rate, and may decrease severe maternal morbidity and need for neonatal respiratory support.

Propranolol for Induction of Labor in Nulliparas trial a double-blind, randomized, placebo-controlled trial

Propranolol hydrochloride is a nonselective beta-adrenergic antagonist that has a known activity in the myometrium. Small trials have shown that propranolol decreases the duration of induced labor, although those studies are limited by methodological variability. Our objective was to determine whether the addition of a single dose of propranolol to induce labor in nulliparous women would decrease total time to vaginal delivery. This study was a double-blind, randomized, placebo-controlled trial of nulliparous patients undergoing term induction of labor with a singleton, nonanomalous gestation. Subjects were randomized to 2 mg of intravenous propranolol hydrochloride or an identical-appearing saline placebo, administered 30 minutes after starting the induction of labor. Investigators, labor floor staff, and patients were blinded to the study drug allocation. The primary outcome was time to vaginal delivery. Secondary outcomes included mode of delivery, duration of the phases of labor, time to full dilation, composite maternal morbidity, and composite neonatal morbidity. Data were analyzed by intention-to-treat analysis with a P value of ≤.05 considered significant. In this study, 240 patients were enrolled from December 2017 to December 2018, with 121 patients randomized to the propranolol group and 119 to the placebo group. The 2 groups had similar baseline characteristics. Of the patients randomized, 154 (64.2%) delivered vaginally. There was no significant difference in time from the start of the induction of labor to vaginal delivery (13.8±5.4 hours for propranolol vs 14.3±5.3 hours for placebo; P=.58). There was also no difference in the rate of cesarean delivery (38% vs 33.6%; P=.48), time to active labor (11.0±5.0 vs 11.2±4.5 hours; P=.77), or time to full dilation (12.4±5.1 vs 12.8±5.2 hours; P=.60) in patients receiving propranolol compared with those receiving placebo. Subjects randomized to the propranolol group had a significantly lower rate of composite maternal morbidity (28.9% vs 41.2%; risk ratio, 0.70; 95% confidence interval, 0.49-1.00; P=.047). Rates of postpartum hemorrhage (12.4% vs 21.8%; P=.05) and transfusion (0% vs 4.2%; P=.03) were also lower in the treated group. There was no significant difference in neonatal outcomes or composite morbidity (risk ratio, 0.74; 95% confidence interval, 0.44-1.22). In this study, there is no evidence that the addition of a 1-time dose of propranolol to induce labor in nulliparous women decreases time to delivery or the rate of cesarean delivery. However, propranolol significantly reduced composite maternal morbidity without adverse neonatal effects.

Changes in the Frequency of Cesarean Delivery in Nulliparous Women in Labor in a Canadian Population, 1992-2018.

To examine the relative contribution of changes in patient demographics and physician management to changes in the cesarean delivery rate in labor among nulliparous women. We conducted a retrospective cohort study of 485,451 births to nulliparous women who experienced labor at or beyond 35 weeks of gestation in Alberta, Canada, from 1992 to 2018. The data were from a province-wide perinatal database. The primary outcome was cesarean delivery. Multivariate logistic regression and calculation of population attributable risk for identified risk factors were performed. The cesarean delivery rate increased from 12.5% in 1992 to 24% in 2018. The prevalence of maternal risk factors for cesarean delivery such as obesity, maternal age 35 years or older at delivery, and comorbidities increased over the study period. However, this did not account for the increase in cesarean delivery, because the frequency of cesarean delivery increased irrespective of risk status. Additionally, the population-attributable risk for each risk factor was stable across the study period. For example, for maternal age 35 years or older at delivery, the number of cesarean deliveries attributable to this factor (the population-attributable risk) was 0.9 per 100 deliveries in 1992-1998 and 1 per 100 in 2014-2018. The proportion of cesarean deliveries in which nonreassuring fetal status was the indication increased from 30.1% in 1992 to 51.1% in 2018. The absolute rate of cesarean delivery in the second stage of labor increased from 3.1% in 1992 to 5.9% in 2018. This was due to a significant increase, among those who entered the second stage, in cesarean delivery without a trial of forceps, from 2.5% in 1992 to 7.0% in 2018. The observed doubling of the rate of cesarean delivery in labor in first-time mothers was not driven by patient risk factors. Increases in the rate of cesarean delivery for nonreassuring fetal status and decreased operative vaginal deliveries were important factors.

Predicting cesarean delivery for failure to progress as an outcome of labor induction in term singleton pregnancy

Induction of labor is one of the most common interventions in modern obstetrics, and its frequency is expected to continue to increase. There is inconsistency as to how failed induction of labor is defined; however, the majority of studies define success as the achievement of vaginal delivery. Induction of labor in nulliparous women poses an additional challenge with a 15% to 20% incidence of failure, ending in emergency operative deliveries. The Bishop score has been traditionally used before decisions for induction of labor. Nonetheless, it is subjective and prone to marked interobserver variation. Several studies have been conducted to find alternative predictors, yet a reliable, objective method still remains to be introduced and validated. Hence, there is still a need for the development of new predictive tools to facilitate informed decision making, optimization of resources, and minimization of potential risks of failure. Furthermore, a peripartum transperineal ultrasound scan has been proven to provide objective, noninvasive assessment of labor. This study aimed to assess the feasibility of developing and validating an objective and reproducible model for the prediction of cesarean delivery for failure to progress as an outcome of labor induction in term singleton pregnancies. This was a prospective observational cohort study conducted in Cairo University Hospitals and University of Bologna Hospitals between November 2018 and November 2019. We recruited 382 primigravidae with singleton term pregnancies in cephalic presentation. All patients had baseline Bishop scoring together with various transabdominal and transperineal ultrasound assessments of the fetus, maternal cervix, and pelvic floor. The managing obstetricians were blinded to the ultrasound scan findings. The method and indication of induction of labor, the total duration of stages of labor, mode of birth, and neonatal outcomes were all recorded. Women who had operative delivery for fetal distress or indications other than failure to progress in labor were excluded from the final analysis, leaving a total of 344 participants who were randomly divided into 243 and 101 pregnancies that constituted the model development and cross-validation groups, respectively. It was possible to perform transabdominal and transperineal scans and assess all the required parameters on all study participants. Univariate and multivariate analyses were used for selection of potential predictors and model fitting. The independent predictive variables for cesarean delivery included maternal age (odds ratio, 1.12; P=.003), cervical length (odds ratio, 1.08; P=.04), angle of progression at rest (odds ratio, 0.9; P=.001), and occiput posterior position (odds ratio, 5.7; P=.006). We tested the performance of the prediction model on our cross-validation group. The calculated areas under the curve for the ability of the model to predict cesarean delivery were 0.7969 (95% confidence interval, 0.71-0.87) and 0.88 (95% confidence interval, 0.79-0.97) for the developed and validated models, respectively. Maternal age and sonographic fetal occiput position, angle of progression at rest, and cervical length before labor induction are very good predictors of induction outcome in nulliparous women at term.

Analysis of Caesarean Section Rates Using the Robson Ten-group Classification at a Tertiary Care Teaching Hospital in Eastern India: A Cross-sectional Study

Introduction: The Robson ten-group classification identifies the women’s groups that make the greatest contribution to the overall rate of Caesarean Section (CS), and thereby helps to optimise CS rates. It also helps to ensure optimum maternal and perinatal outcomes. Aim: This study was undertaken to examine the rates of CS using the Robson ten-group classification, and also to identify the women’s groups that contribute most to CS rates in a tertiary care teaching and referral hospital in Kolkata, India. Materials and Methods: This cross-sectional observational study was conducted over a period of one year from May 2012 to April 2013. All pregnant women admitted under the supervision of a particular unit of the Department of Obstetrics and Gynaecology and delivered in that hospital during the study period were included. Necessary data collection was done on the following parameters, i.e., previous obstetric history, category of pregnancy, course of labour and delivery, and gestational age. The women were categorised into the ten Robson groups. For each group, the CS rate, relative size of the group, and the percentage contribution made by the group to the overall CS rate were calculated and expressed in percentages. Chi-square test, Z-test and the trial version of Statistical Package for Social Sciences (SPSS) version 20.0 were used to analyse the data. Results: The CS rate in the present study was 43.13% (735 out of 1704 deliveries). Not only the largest group in terms of relative size 649 (38.08%), the Robson group 1 had a CS rate of 41.75% (271/649), as well as the largest absolute number of caesarean deliveries. The group 1 made the largest contribution (271) to the overall CS rate (15.9%). The group 5 was the second largest contributing group 155 (9.09%), followed by group 3 96 (5.63%) and group 2 69 (4.04%). In the present study group 5 showed the CS rate of 95.67%, group 3 with CS rate of 24.48% and group 2 with CS rate of 60.52%. Conclusion: The Robson groups 1, 2, 3 and 5 were found to be the major contributors to the overall CS rate. These groups may be targeted for effective interventions to reduce the CS rate. Active management of labour in a primigravida with spontaneous onset, reduction of primary caesarean delivery, promoting vaginal birth after CS, and careful assessment of cases before induction of labour in nulliparous women, are likely to be few effective strategies.

Transperineal ultrasound assessment of maternal pelvic floor at term and fetal head engagement.

To evaluate the association between pelvic floor dimensions in nulliparous women at term and fetal head engagement, as assessed by transperineal ultrasound. This was a prospective observational study of nulliparous women at term. Before the onset of labor, transperineal ultrasound was used to measure the anteroposterior diameter (APD) of the levator hiatus and the angle of progression (AoP) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver (before and after visual feedback). We assessed the correlation between pelvic floor static and dynamic dimensions (levator hiatal APD and levator ani muscle coactivation) and AoP, which is an objective index of fetal head engagement. In total, 282 women were included in the analysis. Among these, 211 (74.8%) women had a vaginal delivery while 71 (25.2%) had a Cesarean delivery. AoP was narrower in the Cesarean-delivery group at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva, whereas no differences in levator hiatal APD were found between the two groups. We found a negative correlation between levator hiatal APD at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva and the duration of the second stage of labor. There was a positive correlation between AoP and levator hiatal APD on maximum Valsalva maneuver after visual feedback (r = 0.15, P = 0.01). Women with levator ani muscle contraction on Valsalva maneuver (i.e. coactivation), both pre and post visual feedback, had a narrower AoP at rest and on maximum Valsalva. After visual feedback, women with levator ani muscle coactivation had a longer second stage of labor than did those without (80.8 ± 61.4 min vs 62.9 ± 43.4 min (P = 0.04)). Smaller pelvic floor dimensions and levator ani muscle coactivation are associated with higher fetal head station and with a longer second stage of labor in nulliparous women at term. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

When does fetal head rotation occur in spontaneous labor at term: results of an ultrasound-based longitudinal study in nulliparous women

Improved information about the evolution of fetal head rotation during labor is required. Ultrasound methods have the potential to provide reliable new knowledge about fetal head position. The aim of the study was to describe fetal head rotation in women in spontaneous labor at term using ultrasound longitudinally throughout the active phase. This was a single center, prospective cohort study at Landspitali - The National University Hospital of Iceland, Reykjavík, Iceland, from January 2016 to April 2018. Nulliparous women with a single fetus in cephalic presentation and spontaneous labor onset at ≥37 weeks' gestation were eligible. Inclusion occurred when the active phase could be clinically established by labor ward staff. Cervical dilatation was clinically examined. Fetal head position and subsequent rotation were determined using both transabdominal and transperineal ultrasound. Occiput positions were marked on a clockface graph with 24 half-hour divisions and categorized into occiput anterior (≥10- and ≤2-o'clock positions), left occiput transverse (>2- and <4-o'clock positions), occiput posterior (≥4- and ≤8 o'clock positions), and right occiput transverse positions (>8- and <10-o'clock positions). Head descent was measured with ultrasound as head-perineum distance and angle of progression. Clinical vaginal and ultrasound examinations were performed by separate examiners not revealing the results to each other. We followed the fetal head rotation relative to the initial position in the pelvis in 99 women, of whom 75 delivered spontaneously, 16 with instrumental assistance, and 8 needed cesarean delivery. At inclusion, the cervix was dilated 4 cm in 26 women, 5 cm in 30 women, and ≥6 cm in 43 women. Furthermore, 4 women were examined once, 93 women twice, 60 women 3 times, 47 women 4 times, 20 women 5 times, 15 women 6 times, and 3 women 8 times. Occiput posterior was the most frequent position at the first examination (52 of 99), but of those classified as posterior, most were at 4- or 8-o'clock position. Occiput posterior positions persisted in >50% of cases throughout the first stage of labor but were anterior in 53 of 80 women (66%) examined by and after full dilatation. The occiput position was anterior in 75% of cases at a head-perineum distance of ≤30 mm and in 73% of cases at an angle of progression of ≥125° (corresponding to a clinical station of+1). All initial occiput anterior (19), 77% of occiput posterior (40 of 52), and 93% of occiput transverse positions (26 of 28) were thereafter delivered in an occiput anterior position. In 6 cases, the fetal head had rotated over the 6-o'clock position from an occiput posterior or transverse position, resulting in a rotation of >180°. In addition, 6 of the 8 women ending with cesarean delivery had the fetus in occiput posterior position throughout the active phase of labor. We investigated the rotation of the fetal head in the active phase of labor in nulliparous women in spontaneous labor at term, using ultrasound to provide accurate and objective results. The occiput posterior position was the most common fetal position throughout the active phase of the first stage of labor. Occiput anterior only became the most frequent position at full dilatation and after the head had descended below the midpelvic plane.