Length Of Labor Research Articles

Effect of intrapartum vitamin D levels on labor pain.

Vitamin D has widespread receptor distribution in the body, and therefore it has vital roles in numerous pathophysiological conditions. It also affects pain manifestation through its functions at various stages of the pain pathways. This study aimed to investigate the effects of intrapartum vitamin D levels on pain experienced by women during the first stage of labor. A total of 127 term-nulliparous women at the early stage of labor were included in the study. Serum 25 (OH) vitamin D levels were measured at the beginning of labor to determine intrapartum vitamin D levels. Labor pain was assessed using the Visual Analog Scale at different stages of cervical dilation (VAS0 , VAS1 , VAS2 ). Postpartum pain (VASpp ) and women's birth satisfaction score (BSS) were also evaluated during the early postpartum period. There was a moderate negative correlation between vitamin D and VAS0 and VAS1 (r2 =0.4, p=0.000; r2 =-0.570, p=0.000, respectively), and a weak negative correlation between vitamin D and VAS2 (r2 =-0.373, p=0.000). No significant correlation was found between vitamin D and BSS and length of labor (p=0.127, p=0.126, respectively). In nulliparous women with low vitamin D levels, the first stage of labor and the early postpartum period may be more painful. To facilitate management of labor pain, during the antenatal period vitamin D levels should be monitored, and in cases where the levels are deficient, vitamin D supplementation should be started.

Risk analysis of poor wound healing in forceps delivery.

This study aims to explore the risk factors leading to poor wound healing after forceps delivery. In this retrospective study, 74 patients undergoing forceps delivery with poor wound healing were compared with contemporary randomly selected 74 patients undergoing forceps delivery but with normal wound healing. Compared to the normal healing group, the poor healing group had larger birthweight (p=0.01), longer labor length (805.9 ± 356.4min vs. 572.9 ± 306.3min, p < 0.001), more virginal checks (4.0 ± 1.5 vs. 3.4 ± 1.7, p=0.029), and more contaminated amniotic fluid (p=0.043). More patients in poor healing group suffered from postpartum fever (52.7% vs. 21.6%, p < 0.001), postpartum hemorrhage (p < 0.001), and anemia after delivery (p < 0.001). Labor length (odds ratio (OR) 1.125, 95% confidence interval [CI]=1.033-1.226), anemia after delivery (OR 3.621, 95% CI=2.077-6.314), postpartum fever (OR 7.100, 95% CI=2.505-20.124), and degree of laceration (OR 3.067, 95% CI=1.258-7.479) were the risk factors of poor healing of perineal wound after forceps delivery, while postpartum antibiotics (OR 0.303, 95% CI=0.098-0.937) and suture removal days (OR 0.272, 95% CI=0.133-0.556) were the protective factors. To promote the wound healing from the forceps delivery, obstetricians may consider to control the patient's labor length and degree of laceration, increase patient's nutrition, apply prophylactic antibiotics, and prolong the suture removal days.

Perbedaan Penggunaan Active Birth dengan Metode Birthball dan Hypnobirthing terhadap Lama Inpartu Kala I

Childbirth is a physiological process. In women giving birth, the time span is marked by uterine contractions characterized by pain, regularity, cervical dilatation and cervical effacement. One method of using active birth that has been carried out in Indonesia is the use of birth balls and hypnobirthing as a form of effort to provide maternal care in helping the birth process with evidence base The purpose of this study was to study the differences in the use of active birth with birthball and hypnobirthing methods on the length of the first stage of labor. This type of research is a quasi-experimental with a cross-sectional approach, the research design is Posttest Only Design. The research was conducted in May - December 2020 at the Independent Practice Midwife in Padang City. The sample of this study were primiparous mothers who had gestational age at term (37-42 weeks) and had no complications. The sampling technique used is non-probability sampling, namely purposive sampling. The sample is 20 people, with 10 samples using the birthball technique and 10 samples using the hypnobirthing technique. Data were obtained by using observation sheets. Data were analyzed by univariate and bivariate. Statistical test using Mann-Whitney test. The results showed that the average length of labor in the first stage using birthball was 3.15 ± 0.29 and the average length of labor in the first stage using hypnobirthing was 3.55 ± 0.27. The difference in the mean length of the first stage of labor between the 2 groups was 0.40. the results of statistical tests using the Mann Whitney test obtained p value 0.000 (p 0.05) which means that there is a significant difference in the use of active birth with the birthball method and hypnotherapy for the first stage of labor. It can be concluded that the difference in the the use of active birth with birthball and hypnobirthing methods on the length of the first stage of labor.

The Effect of Sundanese Instrumental Music Therapy and The Provision of Spicy Drinks on Pain Intensity and Labor Duration

The pain in labor due to contractions and the process of expelling the baby cannot be avoided by the mother. One way to reduce pain intensity non-pharmacologically is music therapy and the provision of spice drinks. music therapy can reduce stress and anxiety levels, especially during childbirth, while herbal drinks derived from ginger are analgesic, as well as cinnamon and cloves, can relieve pain. The research method is “Quasi experimental pre-post test with control group design. The intervention group was Sundanese instrumental music therapy with spice drinks and the control group was only given spice drinks, which was carried out on mothers giving birth during an active phase. The population is all mothers giving birth in BPM Bogor area. The sample size of the average difference test of two paired groups is 15 respondents in each group. The results showed a decrease in labor pain in the active phase of the first stage in the intervention group with p = 0.016. This shows that there is an effect of giving music therapy and spice drinks on the intensity of labor pain as assessed by the Visual Analog Scale (VAS), and there is no significant change in the decrease in labor pain during the active phase of labor, in the control group (p&gt;0.05). There was no significant result on the length of labor with p = 0.439 (p &gt; 0.05). This means that both the control and intervention groups did not show a difference in the time/length of labor

The effectiveness of a Pilates exercise program during pregnancy on childbirth outcomes: a randomised controlled clinical trial

BackgroundPerforming exercise with medium intensity has positive effects on the maternal health. The aim of this study was to investigate the effectiveness of Pilates exercise program during pregnancy on childbirth outcomes:MethodsThis clinical trial study was performed on 110 primiparous women who were randomly divided into two groups of intervention (n = 55) and control (n = 55). The intervention group performed Pilates exercises from 26 to 28 weeks of gestation for 8 weeks while the control group did not do any exercise. Data collection tools included Visual Analog Scale (VAS), Mackey Childbirth Satisfaction Rating Scale, and a checklist including demographic and obstetrics information.ResultsThe results of the study showed that Pilates exercise during pregnancy significantly reduces the labor pain intensity, length of the active phase and second stage of labor and increases maternal satisfaction of the labor process (p < 0.05). Based on the Kaplan Meyer analysis, the mean whole length of labor was shorter in Pilates exercise group than in the control group (P = .004). There was no statistically significant difference between the two groups in terms of Episiotomy, type of delivery, first and fifth Apgar score of neonates (p > 0.05).ConclusionAccording to the results of this study, Pilates exercise during pregnancy improved the labor process and increased maternal satisfaction of chidbirthprocess, without causing complications for the mother and baby. However, studies with larger sample sizes are recommended to prove the efficacy and safty of this practiceduring labor.Trial registrationIRCT registration number:IRCT20200126046266N1. Registration date: 2020-05-02 (retrospectively registered).

Mothers’ personal growth in the first year: the role of perceived childbirth experience and support

ABSTRACT Introduction: The study examined mothers’ personal growth in the first year after childbirth, investigating the contribution of several aspects of the childbirth experience (assisted delivery, length of labour, pain during labour, infant’s weight, gestation week, and two dimensions of the Hebrew BSS-R: perception of positive childbirth and of the quality of professional care), as well as the role of social support. Methods: Israeli mothers (n = 408) completed a set of self-report questionnaires up to one year following the birth of their first child/ren. Results: Positive correlations were found between mother’s growth and higher perception of the birth as positive, higher perceived care provided by the health team during labour, and higher perceived support from people close to her. Regression analysis indicated the significant contributions of the quality of care by the professional health team and the support provided by others to mothers’ personal growth in the first year of motherhood. Discussion: The results highlight the importance of receiving support during the various stages of the transition to motherhood. It is recommended that professionals encourage support for new mothers not only to ensure their adaptation to parenthood, but also to enhance their potential to thrive.

The Influence of Acupressure Li4 and Sp6 Techniques to the Endorphins Level And Progress of Labor in Period I Active Phase

Pain in labor is physiological because the pain comes from the cervical dilatation and uterine contractions that needed for labor (Potter &amp; Perry, 2005). Research conducted by Brown, Douglas and Flood (2001) using 10 nonpharmacological methods performed on 46 people found that acupressure technique is the most effective technique to reduce pain during labor through the increased of endorphins and shorten the length of labor. The purpose of this study is to know the influence of acupressure method on endorphin levels and the progress of labor in the first period. This type of research is quantitative research by using quasi experiment design with pretest approach and posttest design with control group by performing acupressure on primipara maternal mother during period I active phase. The study was conducted at Bidan Praktik Mandiri. The population of this study is primipara mother inpartu period I active phase using Non Probability sampling technique with Consecutive Sampling. The results showed a significant difference in endorphin levels before and after receiving acupressure in the intervention group (p = 0.048) and there was a significant difference in the progress of labor before and after receiving acupressure in the intervention group (p = 0.001). Acupressure can be used as a routine care in every care of normal childbirth thus mother's care and baby care can be created well.

Optimal antenatal corticosteroid exposure in women with history of preterm birth and asymptomatic short cervical length

A proposed benefit of cervical length assessment after 24 weeks' gestation in women with a history of preterm birth is to aid in the timing of antenatal corticosteroids in otherwise asymptomatic women. We sought to investigate whether the use of an ultrasonographic short cervical length as an indication for antenatal corticosteroids in asymptomatic women results in optimal exposure compared with women receiving antenatal corticosteroids for preterm labor symptoms. Retrospective cohort study of all women with a previous spontaneous preterm birth and a singleton gestation who underwent serial cervical length assessment at a large academic tertiary medical center from 2011 to 2016. Patients were included in the analysis if they received antenatal corticosteroids for either an asymptomatic short cervical length or symptoms of preterm labor. The primary outcome was optimal antenatal corticosteroids exposure (latency to delivery of ≤7 days). Poisson regression with robust error variance was used to calculate incidence rate ratios (IRR) and confidence intervals (CI) for primary and secondary outcomes adjusting for primary and secondary outcomes adjusting for race, earliest previous preterm birth, and current cerclage. There were 287 women meeting inclusion criteria, among whom 166 (57.8%) received antenatal corticosteroids for a short cervical length and 121 (42.2%) for preterm labor symptoms. Women who received antenatal corticosteroids for a short cervical length were less likely to have optimal exposure (1.2% vs 19.0%; incidence rate ratios, 0.06; confidence interval, 0.02-0.27) compared with women with preterm labor symptoms. They were also more likely to have exposure with eventual term delivery (43.2% vs 33.4%; incidence rate ratios, 1.6; confidence interval, 1.2-2.0). Importantly, women who received antenatal corticosteroids for a short cervical length were significantly less likely to receive either an initial or rescue antenatal corticosteroids course within 7 days of a preterm delivery of less than 34 weeks' gestation (42.9% vs 76.9%; incidence rate ratios, 0.52; confidence interval, 0.35-0.75). Women with a previous preterm birth who receive antenatal corticosteroids for an asymptomatic short cervical length are less likely to have optimal exposure than women with symptoms of preterm labor. These data challenge the practice of cervical length surveillance for the sole indication of timing antenatal corticosteroids administration.

The effect of stocking density and a blind on the behavior of Holstein dairy cows in group maternity pens. Part II: Labor length, lying behavior, and social behavior

In natural settings, dairy cows separate from the herd to give birth. When kept indoors, seeking isolation before calving may be restricted and may depend on space and resources provided in maternity housing. The effect of group maternity pens on behavior around calving and labor progress is unknown. Therefore, the objective of this study was to determine the effects of stocking density and provision of a blind in group bedded pack maternity pens on lying and social behavior as well as length of labor of preparturient dairy animals. The study was conducted as a complete randomized block design with a 2 × 2 factorial arrangement of treatments including stocking density and presence or absence of a blind, resulting in a total of 4 treatments: (1) high stocking density (7.7-12.9 m2 lying space/cow) with a blind, (2) low stocking density (15.4-25.8 m2) with a blind, (3) high stocking density without a blind, and (4) low stocking density without a blind. A total of 127 primiparous heifers and 247 multiparous cows were housed in mixed-parity groups from approximately 3 wk before and immediately after calving. During the 4 h before calving, lying behavior (lying time and bouts) was collected automatically using accelerometers, and social behavior (agonistic interactions, allogrooming, and attention from other cows), stage II labor duration, and frequency of position change during stage II labor were collected using video. Lying behavior was collected with accelerometers. Regardless of treatment, lying time and bouts increased as calving approached. Cows and heifers performed more lying bouts in low stocking density pens compared with high stocking density pens. Agonistic interactions and allogrooming were not different between treatments. Other cows spent more time paying attention to focal animals regardless of stocking density as calving approached, but time spent paying attention was reduced by the presence of a blind during h -2 before calving. The hazard of calving unassisted was greater for cows and heifers in low stocking density pens with a blind compared with all other treatments. Further, animals in pens with a blind tended to change positions fewer times during stage II labor. These results suggest that providing a blind in group maternity pens may improve the calving environment for cows and heifers and, in combination with low stocking density, may reduce the amount of time spent in labor.

Informed Consent for Epidural Analgesia at the Time of Labor Pain, Seems Too Late!

Pain in the process of childbirth is the phenomenon mostly feared by every woman in her pregnancy, and is a major cause of dissatisfaction and embarrassing memories of labor. Usage of lumbar epidural analgesia as a very effective pain management option has solved this problem to a great extent, and its utilization has turned to common practice in most of the women hospitals worldwide. The use of lumbar epidural analgesia in labor is widespread due to its benefits in terms of effective pain relief in comparison with other labor pain treatment options [1]. Vaginal delivery is an extremely painful process accompanied with great emotional disturbance, which may not be possible for the laboring mother to focus and concentrate to understand the anesthetist explanations at that moment and sign the epidural analgesia informed consent properly. On one hand, the laboring mother expresses doubts because of uncertainty on her decision and on the other hand she desperately wants to get rid of the excruciating labor pain by any means possible. Therefore, the decision to have a neuraxial analgesia (epidural, combined spinal epidural) sounds obligatory on this condition. Each of these analgesic methods beside desirable effectiveness in pain management may have some side effects and it is obvious that each complication takes lots of time and patiently concentration for the mother to be precisely understood and the decision making is even beyond of it. Decision making process cannot get precisely completed just in labor time, so free of any upcoming complication, informed consent may not be ethically verified on labor time. Decision making capacity is a complex mental process involving both cognitive and emotional components. Sometimes this complex action is reduced to “understanding” alone. There are uncertainties about decision-making capacity (mental competence) of women in labor in relation to giving informed consent to neuraxial analgesia. Considering these parameters, sufficient information about pain management methods (advantages, side effects, the way each procedure is conducted) should be provided as part of prenatal education and the consent process must be carefully conducted to enhance mothers’ autonomy [2]. To utilize effective methods for presenting the mothers with (like multimedia modules, recorded video of the sample procedure and so on) in late pregnancy should be considered to achieve better understanding and right decision. Patient decision aids are beneficial in clinical anesthesia and studies have shown that patients feel better informed, have better knowledge, and have less anxiety, depression and decisional conflicts after using this method [3]. It has been demonstrated that using decision aids prior to the procedure can significantly reduce the decision conflict, and improve both autonomy and outcome as a united benefit in favor of laboring mothers [4]. It seems that pain-relieving methods (neuraxial and other treatment options) should be described in details at the second and third trimester of pregnancy by a team consist of midwife, anesthesia provider and obstetrician. The more time is spent on this process; the better informed consent is achieved finally. Also high quality decision aids can increase women’s familiarity with medical terminology, options for care, and an insight into personal values, thereby decreasing decisional conflicts and increase knowledge [5]. Factors like parity, pain threshold, and estimated length of labor should be considered together in the decision process to individualize the best pain treatment option for mother [6].

Informed Consent for Epidural Analgesia at the Time of Labor Pain, Seems Too Late!

Pain in the process of childbirth is the phenomenon mostly feared by every woman in her pregnancy, and is a major cause of dissatisfaction and embarrassing memories of labor. Usage of lumbar epidural analgesia as a very effective pain management option has solved this problem to a great extent, and its utilization has turned to common practice in most of the women hospitals worldwide. The use of lumbar epidural analgesia in labor is widespread due to its benefits in terms of effective pain relief in comparison with other labor pain treatment options [1]. Vaginal delivery is an extremely painful process accompanied with great emotional disturbance, which may not be possible for the laboring mother to focus and concentrate to understand the anesthetist explanations at that moment and sign the epidural analgesia informed consent properly. On one hand, the laboring mother expresses doubts because of uncertainty on her decision and on the other hand she desperately wants to get rid of the excruciating labor pain by any means possible. Therefore, the decision to have a neuraxial analgesia (epidural, combined spinal epidural) sounds obligatory on this condition. Each of these analgesic methods beside desirable effectiveness in pain management may have some side effects and it is obvious that each complication takes lots of time and patiently concentration for the mother to be precisely understood and the decision making is even beyond of it. Decision making process cannot get precisely completed just in labor time, so free of any upcoming complication, informed consent may not be ethically verified on labor time. Decision making capacity is a complex mental process involving both cognitive and emotional components. Sometimes this complex action is reduced to “understanding” alone. There are uncertainties about decision-making capacity (mental competence) of women in labor in relation to giving informed consent to neuraxial analgesia. Considering these parameters, sufficient information about pain management methods (advantages, side effects, the way each procedure is conducted) should be provided as part of prenatal education and the consent process must be carefully conducted to enhance mothers’ autonomy [2]. To utilize effective methods for presenting the mothers with (like multimedia modules, recorded video of the sample procedure and so on) in late pregnancy should be considered to achieve better understanding and right decision. Patient decision aids are beneficial in clinical anesthesia and studies have shown that patients feel better informed, have better knowledge, and have less anxiety, depression and decisional conflicts after using this method [3]. It has been demonstrated that using decision aids prior to the procedure can significantly reduce the decision conflict, and improve both autonomy and outcome as a united benefit in favor of laboring mothers [4]. It seems that pain-relieving methods (neuraxial and other treatment options) should be described in details at the second and third trimester of pregnancy by a team consist of midwife, anesthesia provider and obstetrician. The more time is spent on this process; the better informed consent is achieved finally. Also high quality decision aids can increase women’s familiarity with medical terminology, options for care, and an insight into personal values, thereby decreasing decisional conflicts and increase knowledge [5]. Factors like parity, pain threshold, and estimated length of labor should be considered together in the decision process to individualize the best pain treatment option for mother [6].

Addition of vaginal isosorbide mononitrate for labor induction in pregnancies complicated by hypertensive diseases of pregnancy: a randomized controlled trial

Pregnancies complicated by hypertensive disease of pregnancy often require labor induction. Rates of cesarean delivery range from 15% to 60% in this population. Nitric oxide deficiency has been shown to underlay the pathophysiology of preeclampsia, and nitric oxide promotes cervical ripening. We hypothesized that addition of vaginal isosorbide mononitrate for labor induction could decrease the rate of cesarean delivery in pregnancies with hypertensive disease of pregnancy. This study was a double-blind, placebo-controlled, randomized trial of patients with singleton pregnancy at ≥24 weeks' gestation undergoing labor induction for hypertensive diseases of pregnancy between November 2017 and February 2020. Participants were eligible if their Bishop score was <6 and if their cervical dilation was ≤2 cm. In addition, participants received up to 3 doses of 40 mg isosorbide mononitrate in addition to misoprostol for labor induction. Labor management was per healthcare provider preference. The primary outcome was rate of cesarean delivery. Secondary outcomes included the length of labor and frequency of intrapartum adverse events, including the use of intrapartum antihypertensive agents. 89 women were randomized to the isosorbide mononitrate group, and 87 women were randomized to the placebo group. Cesarean delivery rates were similar in both groups (32.6% vs 25.3%; relative risk, 1.29; 95% confidence interval, 0.81-2.06; P=.39). Maternal headache was increased in patients exposed to isosorbide mononitrate (42.7% vs 31%; relative risk, 1.52; 95% confidence interval, 1.04-2.23; P=.04). Clinical chorioamnionitis was increased in the placebo group (0% vs 8%; P=.02). Secondary outcomes were similar between groups. The addition of vaginal isosorbide mononitrate for labor induction in pregnancies complicated by hypertensive disease of pregnancy did not result in fewer cesarean deliveries.

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

52 Vaginal isosorbide mononitrate for labor induction in pregnancies complicated by hypertensive diseases of pregnancy

Pregnancies with hypertensive diseases of pregnancy (HDP) often require induction of labor to minimize maternal and fetal risks. There is no superior method of labor induction and rates of cesarean delivery (CD) range from 15-60% in this population. Nitric oxide donors decrease maternal blood pressure and soften the cervix without inducing uterine contractions. We hypothesized that addition of vaginal isosorbide mononitrate (IMN) to vaginal misoprostol for labor induction may decrease the rate of CD and need for intrapartum emergent antihypertensive therapy in pregnancies complicated by HDP. This was a double-blind, placebo-controlled, randomized trial of women with singleton pregnancy ≥24 weeks gestation with an induction of labor for HDP between 11/2017-2/2020. Participants were eligible if Bishop score less than 6 and cervical dilation ≤2cm. They received up to 3 doses of 40mg IMN and 25mcg vaginal misoprostol in addition to standard interventions for induction - foley and oxytocin. Primary outcome was rate of cesarean delivery. Secondary outcomes included indication for CD, length of labor, use of intrapartum emergent antihypertensives, and maternal and neonatal morbidities. A sample size of 176 women was needed to detect at least a 20% difference in the primary outcome (Power 0.8). 89 women were randomized to the IMN group and 87 to the placebo group. GA at delivery were similar between groups (37 [34-38] vs 37 [35-38]). CD rates were similar with between both (32.6% vs 25.3%; RR, 1.29; 95% CI, 0.81 to 2.06; P=0.39). Neither length of labor nor use of intrapartum emergent antihypertensives was significantly different. Maternal headache was more common in IMN group than placebo group (47.2% vs 27.0%; RR, 1.52; 95% CI, 1.04 to 2.23; P=0.04), whereas clinical chorioamnionitis was less common in the IMN group (0% vs 8%; P=0.02). Adding vaginal IMN to vaginal misoprostol for labor induction in pregnancies complicated by HDP did not result in fewer CD.

47 A Double-Blinded Randomized Controlled Trial on Increased Intravenous Hydration in Nulliparous Women Undergoing Labor Induction

High-dose intravenous fluid (250cc/hr) has been previously demonstrated to shorten the time to delivery in nulliparous women in spontaneous labor. Whether or not this relationship ship exists in women undergoing induction of labor is unknown. Our study aimed to evaluate the effect of high-dose intravenous hydration (compared to standard dose) on time to delivery among nulliparous women undergoing induction of labor. Nulliparous women presenting for induction of labor with a Bishop score of less than or equal to 6 (with and without rupture of membranes) were randomized to receive either 125cc/hr or 250cc/hr of normal saline. The primary outcome was length of labor (defined as time from initiation of study fluids to delivery). Both time to overall delivery and vaginal delivery were evaluated. Secondary outcomes included the lengths of each stage of labor, the percentage of women delivering within 24 hours, and maternal and neonatal outcomes. 180 individuals meeting inclusion criteria were enrolled and randomized. Baseline demographic characteristics were similar between groups, however there was a higher incidence of maternal diabetes in the group receiving 125cc/hr. Average length of labor was similar between groups (27.6hr in 250cc/hr and 27.8hr in 125cc/hr) as was the length of each stage of labor. Cox regression analysis did not demonstrate an effect of fluid rate on time to delivery. Neither admission bishop score, BMI, nor other demographic characteristics impacted time to delivery or vaginal delivery. There were no differences in maternal or neonatal outcomes including overall cesarean rate, clinical iatrogenic intrapartum infection, Apgar scores, need for neonatal phototherapy, or neonatal intensive care unit stay. There are no observed differences in the length of labor or maternal or neonatal outcomes with the administration of an increased rate of intravenous fluids among nulliparous women undergoing induction of labor.

46 Length of labor and severe maternal morbidity in the NTSV population

To study the relationship between length of labor and the risk of severe maternal morbidity (SMM) using generalized additive models (GAMs). This retrospective cohort study included nulliparous term singleton vertex (NTSV) births in 17 US hospitals (2016-2019). Clinical data were abstracted from medical records. SMM included blood transfusion, DIC, hysterectomy, eclampsia, venous thromboembolism, and amniotic fluid embolism. Cesareans performed without labor were excluded. A multivariable GAM was trained to predict SMM from 40 demographic, pregnancy and labor characteristics. GAMs are an extension of logistic regression that allow non-linear effects of continuous variables and aid interpretability by plotting risk for each variable independently while correcting for other variables in the model. The cohort included 32,203 births. The rate of SMM was 1.2% (N=392). Characteristics of the study population are in Table 1. The strongest predictors of SMM were birthweight, time from admission to complete dilation, maternal height, pre-eclampsia/gestational hypertension, and 2nd stage duration. Induction was not a strong predictor of SMM when other variables (including cervical dilation on admission) were accounted for. SMM risk started to increase when admission to complete dilation duration was 12 hours and continued to increase smoothly up to 30 hours (Figure 1a). In contrast, SMM risk increased abruptly when 2nd stage duration reached 4 hours, a clinically relevant cut-off for prolonged 2nd stage in nulliparas (Figure 1b). Unlike the smooth increase in SMM during the first stage of labor, this abrupt increase likely reflects the impact of medical intervention. The relationship between length of labor and SMM in the NTSV population is non-linear. After accounting for other variables in the model, SMM starts to increase when the time from admission to complete dilation reaches 12 hours. In the 2nd stage, SMM increases abruptly at 4 hours, a clinically actionable cut-off for prolonged 2nd stage, and likely reflects the impact of operative delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

255 Chorioamnionitis rates in private versus resident-managed labor in term pregnancies

Intra-amniotic infection is associated with maternal and neonatal morbidity. We sought to determine if chorioamnionitis rates among private verses resident- managed services were different. This is a retrospective cohort study of women who labored at ≥37 weeks gestation from 2005 to 2018 at a single academic center. Women were identified as part of a “resident service” if their labor was primarily managed by OB/Gyn residents; “private service” patients were managed without resident involvement. The primary outcome of suspected chorioamnionitis was defined as maternal intrapartum fever (single oral temperature of >39°C or 38–38.9°C for 30 minutes) and one or more of the following: maternal leukocytosis, purulent cervical drainage, or fetal tachycardia. Rates of chorioamnionitis were analyzed using multivariate regression models while adjusting for potential confounders. 20,579 women were included: 3897 (18.9%) were managed by a resident service and 16681 (81%) were managed by a private service. Chorioamnionitis rates were higher among resident-managed patients after adjusting for confounders (relative risk [RR] 1.4, 95% confidence interval [CI] 1.2-1.6; p<0.001). Rates of chorioamnionitis remained higher after adjusting for public insurance and black race (RR 1.3, 95% CI 1.1-1.5; p<0.001). Duration of membrane rupture was significantly shorter among resident services (private service: 6hrs vs. resident service: 5hrs, p<0.001). There was no difference in the rates of unscheduled cesarean deliveries, length of labor, meconium or the number of cervical exams between the two services. This is the largest cohort comparing the rates of chorioamnionitis among women managed by a resident care model versus a private physician model. Women managed by a resident service were 30% more likely to develop chorioamnionitis despite shorter ruptured time and similar cervical exams. The etiology of infectious morbidity among resident services necessitates further investigation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1040 Doula support impact on maternal health outcomes for minority women: a meta-analysis of observational studies

Despite the available literature on the overarching positive impact of birth doulas on maternal health outcomes, little information pertains to their impact specifically on minority laboring populations. Thus, we aimed to assess the effect of doula care on maternal health outcomes in minority women populations. A systematic review of peer-reviewed, English language, observational studies was conducted using PubMed, CINAHL, Web of Science, PsycInfo, and SCOPUS databases. Observational trials that met our inclusion criteria were compiled, and studies were assessed for primary outcomes such as length of labor, cesarean section rate, epidural use, and breastfeeding initiation. Secondary outcomes included APGAR Score (>7), low birth weight, obstetric intervention, and preterm birth rate. All articles were assessed for risk of bias by two authors and a third author was consulted for any discrepancies. RevMan 5.3 was used to analyze the data. Odds ratios were estimated using random effect or fixed effects if applicable. Heterogeneity between studies was assessed using I2 > 50%. Our initial search resulted in 1074 articles, of which 8 observational studies (n= 799,775) were included for meta-analysis. Results showed that those who received doula care were 49% less likely to have a low birth weight baby as compared to those who did not receive doula care (OR=0.51, 95%CI= 0.36-0.71). Women who received doula care were also 22% less likely to deliver by cesarean section than those who did not receive doula care (OR=0.78, 95%CI= 0.59-1.02). Interestingly, breastfeeding initiation rates were much lower (OR=10.25, 95%CI= 1.82-57.72) amongst those who received doula care. No statistical differences were found in epidural use (OR=1.23, 95%CI= 0.94-1.63), preterm birth (OR=0.91, 95%CI= 0.57-1.44), APGAR Score (OR= 1.46, 95%CI= 0.97-2.20), or obstetric interventions (OR=0.76, 95%CI= 0.39-1.47). Our meta-analysis aligns with the available literature on the positive impact of doula support on cesarean delivery and low birthweight rates.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

960 Late vs. early amniotomy for preterm induction of labor: a randomized-controlled trial

Early amniotomy (AROM) during induction (IOL) shortens labor in term patients, but optimal timing of AROM has not been prospectively studied in preterm IOL. A prior retrospective study in preterm patients showed early AROM may be associated with increased risk of cesarean delivery (CD). We tested the hypothesis that late AROM compared to early decreases the risk of CD in preterm IOL. RCT (NCT03504670) of singleton pregnancies undergoing IOL between 23w0d and 35w6d gestation with reassuring fetal status and vertex presentation. Women were excluded for planned CD, labor contraindications, dilation >= 4cm, signs of spontaneous labor, ruptured membranes, chorioamnionitis, IUFD, major fetal anomaly, HIV, Hepatitis B or C, or plan for no fetal intervention. Women were randomized 1:1 to late (>= 4cm dilation) vs early (< 4cm) AROM. Both groups underwent IOL according to institutional protocol with combinations of cervical foley, oxytocin, and/or misoprostol. Primary outcome was CD. Secondary outcomes included labor duration, composite maternal morbidity and composite neonatal morbidity. Based on historical data, we powered to detect a 2.5-fold relative risk with a cross-over of 7.5% and a baseline CD risk of 62.5%. A sample size of 43 per group was required for 80% power and alpha=0.05. Intention-to-treat analysis was performed. Of 695 screened, 43 women were randomized per group (Figure). There were no differences in BMI (41.3 vs 39.1 kg/m2), gestational age (32.9 vs 32.8 wks), delivery indication (preeclampsia: 100% vs 95.4%), parity (1.05 vs 1.09), prior CD, comorbidities, cervical exam, or other baseline characteristics. CD did not significantly differ between groups (58.1 vs 53.5%, p=0.664; RR 1.11, 95% CI 0.69-1.79), nor did duration of labor (Table) or indications for CD. Composite maternal and neonatal morbidity did not differ based on timing of AROM (Table). In women undergoing preterm induction, late AROM did not reduce the risk of CD. Larger studies are needed to further evaluate whether early AROM reduces CD, length of labor, and maternal and neonatal morbidity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

249 Labor length and adverse cardiac outcomes among women with congenital heart disease

Women with congenital heart disease (CHD) are at high risk for peripartum morbidity, yet data is limited on the impact of labor on morbidity. Our objective was to evaluate whether exposure to labor and duration of labor were associated with rates of adverse maternal cardiac outcomes among women with CHD. This was a secondary analysis of a retrospective cohort study of women ≥18 years with CHD who received prenatal care and delivered at the Hospital of the University of Pennsylvania between 1998-2014 with a singleton gestation. Only the first pregnancy was counted for women who delivered more than once. Pregnancies that ended in termination or loss <24 weeks gestation were excluded. A composite adverse maternal cardiac outcome included any cardiac event during pregnancy or <6 months post-partum (specific outcomes listed in Figure), compared among women who did and did not labor. 168 women were included; 34 (20.2%) underwent planned cesarean delivery (CD) without labor and 134 (79.8%) labored. The overall rate of adverse cardiac outcome was 20.2%; 23.5% in the planned CD group and 19.4% in those that labored, regardless of mode of delivery (p=0.6). The most common adverse events were heart failure (13.7%) and arrhythmia (7.7%). As shown in the Figure, women who delivered in <24 hours (regardless of mode of delivery) had a lower rate of adverse cardiac outcome than those that delivered after ≥24 hours of labor, though not statistically significant (p=0.06). When adjusting for confounders including NYHA class, systemic ventricular dysfunction, and mode of delivery, women with labor length ≥15 hours had a 3.7-fold higher odds of adverse cardiac outcome (aOR 3.7 [1.1-12.9]). In this retrospective cohort of women with CHD, exposure to labor was not associated with an increased risk of adverse cardiac outcome. However, among those who labored, longer labor was associated with an increased risk, regardless of mode of delivery. Attention should be paid to the duration of labor in women with CHD, as achieving a vaginal delivery does not mitigate the risks of prolonged labor.View Large Image Figure ViewerDownload Hi-res image Download (PPT)