Nulliparous Deliveries Research Articles

Prevention of prolonged labour in term nulliparas with oxytocin alone versus with oxytocin and an antispasmodic

Background: Poor progress of labour is a common problem with nulliparous deliveries. It occurs when the cervical dilatation rate in the active phase of the first stage of labour is <1cm/hr, and is mainly due to poor uterine contractions or slow cervical dilatation. Without interventions, poor progress could degenerate into prolonged labour which is associated with increased maternal and perinatal morbidity and mortality. Augmentation of labour with oxytocin is the traditional management for poor progress as it enhances uterine contractions. At times, despite adequate uterine contractions poor progress will persist due to cervical smooth muscle spasms. Antispasmodics can relieve smooth muscle spasms. Aim/objective: This study compared the duration of labour in term nulliparous parturients with poor progress following augmentation with oxytocin alone versus with oxytocin and an antispasmodic (drotaverine). Methods: The study was a single-blinded randomized controlled trial involving 156 term nulliparous parturients with poor progress of labour, that were randomized into two groups in eight months. Each group had 78 parturients which were augmented with either oxytocin with placebo or oxytocin with drotaverine. They were monitored until delivery and the duration of labour in both groups after the intervention was compared. Data obtained were analysed using SPSS version 23 software. The level of significance was set at 0.05. Results: The two groups were similar in their sociodemographic characteristics, and the mean pre-intervention duration of labour was also similar (6.02 ±2.04 vs. 6.09± 2.07hr p=0.23). In this study 135(86.5%) parturients had vaginal delivery while 21(13.5%) had emergency caesarean section. Among those who had a vaginal delivery, the mean duration of labour following augmentation was significantly shorter in the oxytocin-drotaverine group than in the oxytocin-placebo group (6.20 ±0.40hrs vs. 6.64±0.34hrs, MD- 26.4minutes, p<0.01). There was no difference in the duration of the second stage of labour in both groups. Conclusion: The use of drotaverine with oxytocin in managing poor progress of labour in term nulliparous women leads to a significantly shorter duration of the first stage of labour than oxytocin alone.

Race and obstetrical practices for low-risk nulliparous patients after the ARRIVE trial

Overall, labor inductions and 39 week deliveries have been increasing for low-risk, nulliparous patients while cesarean deliveries have been decreasing. These trends were accelerated after the ARRIVE trial publication in 2018. Given that these obstetrical practices are known to vary by race, we wanted to evaluate whether the findings of ARRIVE were applied uniformly among patients of all races. This was a population-based cohort study of low-risk, nulliparous deliveries between 39+0 to 41+6 weeks using US Natality Data. Outcomes were obstetrical practices: labor induction (IOL) and delivery by 39 weeks and cesarean delivery (CD). These were stratified by self-reported race recorded in the dataset. Using multivariate and stratified logistical regression models, we compared the years following ARRIVE (2019-2020) with the three years prior (2015-2017) for changes in the rates of these practices by race. There were 1,804,474 patients with self-reported race in the pre-ARRIVE group and 1,099,027 in the post-ARRIVE group. IOL plus 39 week delivery increased significantly for all races in the post ARRIVE period (Table 1). The rate of IOL plus 39 week delivery remained highest among Blacks in the post ARRIVE period, but the greatest increase was among Whites (+7.1%) and the highest odds was among Asians (aOR 1.70, 95% CI 1.65, 1.76). Though the CD rate remained the lowest for Whites in the post ARRIVE period, there were larger decreases in CD rates among the non-White races (Figure 1). All races appeared to have changes in obstetrical practices after the ARRIVE trial. While the overall rate of IOL plus 39 week delivery was highest among Blacks in both periods, the rate of change was highest among Whites. However, regarding CD rates, the largest changes were seen in non-White groups. Despite persistent racial differences, this data suggests that the changes in obstetrical practices that occurred post-ARRIVE might have helped to close pre-existing racial gaps.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Cervical dilatation rate following augmentation of dysfunctional labour with oxytocin alone versus oxytocin and drotaverine among term nulliparas in the Rivers State University Teaching Hospital, Port Harcourt, Nigeria

Background: Dysfunctional labour is the commonest abnormality of the first stage of labour. It complicates 50% of nulliparous deliveries and is associated with increased perinatal morbidity and mortality. Dysfunctional labour occurs when the progress in the active phase of labour is abnormally slow (<1 cm/hr). It is largely due to ineffective uterine contractions or slow cervical dilatation. Augmentation of labour with oxytocin is the standard management of dysfunctional labour as it enhances uterine contractions. In many cases, despite good uterine contractions slow progress persists due to cervical smooth muscle spasms. Drotaverine a smooth muscle relaxant can be used to relieve cervical smooth muscle spasms. Aim/objective: This study compared the cervical dilatation rate in term nulliparas following augmentation of dysfunctional labour with oxytocin versus oxytocin and drotaverine. Methods: The study was a single-blinded randomized clinical trial involving 156 term nulliparous women with dysfunctional labour, who were randomized into two groups. Each group had 78 participants and received either oxytocin with a placebo or oxytocin with drotaverine. They were monitored until delivery and the cervical dilatation rates in both groups were compared. Data obtained were analysed using SPSS version 23 software. The level of significance was set at 0.05. Results: The two groups were similar in their baseline characteristics, the mean pre-intervention cervical dilatation rate were also similar (0.53 cm/hr vs. 0.52 cm/hr, p = 0.85). Following augmentation, the cervical dilatation rate in the oxytocin-drotaverine group was significantly faster than in the oxytocin-placebo group (1.60 cm/hr vs. 1.20 cm/hr, p < 0.01). Conclusion: The use of drotaverine with oxytocin in managing dysfunctional labour in term nulliparous women leads to a faster cervical dilatation rate.

Obstetrical outcomes of labor with and without analgesia in Robson classification groups 1 and 2a: a single-center retrospective study.

This study aimed to elucidate the effects of neuraxial analgesia on labor in women classified based on the Robson classification system. We retrospectively reviewed the clinical data of singleton cephalic nulliparous deliveries in labor at term between January 2018 and December 2021 and compared obstetrical outcomes between deliveries with and without neuraxial analgesia in women of Robson group 1 (spontaneous labor) and group 2a (induced labor). Statistical analyses were performed using the Wilcoxon ranked-sum test, Fisher's exact test, and logistic regression model. Statistical significance was set at p < 0.05. We identified 2726 deliveries during the period, of which 387 deliveries (215 with analgesia and 172 without analgesia) were in Robson group 1 and 502 deliveries (258 with analgesia and 244 without analgesia) in Robson 2a. In Robson group 1 pregnancies, the cesarean section (CS) rate was higher in those who received analgesia (15%) than in those who did not (3%) (p = 0.0001). Multivariate analysis revealed that labor with analgesia was a significant risk factor for CS (p < 0.0001). Similarly, in Robson group 2a pregnancies, we observed a higher CS rate in those with analgesia than in those without analgesia (18 vs. 11%, p = 0.042). A higher CS rate was observed in deliveries with analgesia than in those without analgesia both in the Robson group 1 and group 2a pregnancies.

Effect of the COVID-19 Pandemic on Well-Baby Nursery.

The coronavirus disease 2019 (COVID-19) pandemic is associated with fewer deliveries and premature births; however, the impact of this pandemic on the well-baby nursery (WBN) is unknown. The aim of the study is to evaluate the impact of the COVID-19 pandemic on infants admitted to the WBN by comparing pandemic and pre-pandemic cohorts. We performed a retrospective study of infants admitted to a WBN during the pandemic period (March 18, 2020 to March 17, 2021) and compared them to those during the pre-pandemic period (March 18, 2019 to March 17, 2020). Maternal (age, parity, gestation, method of delivery, and COVID-19 status) and neonatal (sex, weight, Apgar score, feeding pattern, urine toxicology, and neonatal intensive care unit [NICU] admission) data were collected and compared between the two periods. The results were statistically analyzed, and significance was set at p <0.05. There were 824 and 859 WBN admissions during the pandemic and pre-pandemic periods, respectively, a 4% decrease in WBN admissions during the pandemic period. During the pandemic period, the number of deliveries among nulliparous women increased (From 40.3% to 45.1% p = 0.01), and deliveries among multiparous women decreased (From 59.2% to 53.1% p = 0.01). The number of infants exposed to marijuana in utero increased (From 8.2% to 16.1% p = 0.035), and transfers from WBN to NICU decreased (From 9% to 6.3% p = 0.044) during the pandemic period. Compared with the pre-pandemic period, the number of WBN admissions, multiparous deliveries, and NICU admissions decreased, while the number of nulliparous deliveries and infants exposed to marijuana in-utero increased during the pandemic period. · COVID-19 Pandemic is associated with decreased number of deliveries, preterm births, and NICU admissions.. · We observed decreased admissions to WBN, deliveries by multiparous women, and transfers from WBN.. · More nulliparous women delivered, and more infants were exposed to marijuana in-utero during the Pandemic..

Risk factors for obstetric anal sphincter injuries (OASIS) during vacuum extraction delivery in a university affiliated maternity hospital

Introduction: Instrumental delivery is a well-known risk factor for obstetric anal sphincter injuries (OASIS). The specific characteristics among patient undergoing vacuum extraction delivery (VE) are less studied. Therefore, we aimed to evaluate risk factors for OASIS among parturient that underwent a VE delivery in a large university affiliated maternity hospital.Material and methods: The study population contained 9116 women who delivered by VE in tertiary medical center from 1988 to 2015. Inclusion criteria included deliveries beyond 24-week gestation. Multiple gestations and pregnancies complicated with stillbirth were excluded from the analysis. Maternal obstetric variables were compared between parturient with and without OASIS. Independent risk factors for OASIS were assessed by multivariable logistic regression modeling.Results: OASIS was diagnosed in 94 women (1.03%) following vacuum extraction. Among patients who underwent a VE delivery, gravidity and parity were found to be significantly lower in patients with OASIS. A multivariable logistic regression model with OASIS as the outcome variable revealed that among women who underwent VE, while episiotomy and delivery of a macrosomic neonate were not independently associated with OASIS, a strong association between nulliparity and OASIS was found (OR 3.34; 95% CI 1.93–5.78; p < .001).Conclusions: OASIS is uncommon in our population. Vacuum extraction in nulliparous parturient is a significant risk factor for OASIS. Our results should be taken into account when managing nulliparous deliveries.

Lactate in Amniotic Fluid: Predictor of Labor Outcome in Oxytocin-Augmented Primiparas' Deliveries.

BackgroundOne of the major complications related to delivery is labor dystocia, or an arrested labor progress. Many dystocic deliveries end vaginally after administration of oxytocin, but a large numbers of women with labor dystocia will undergo a long and unsafe parturition. As a result of the exertion required in labor, the uterus produces lactate. The uterine production of lactate is mirrored by the level of lactate in amniotic fluid (AFL).ObjectivesTo evaluate whether the level of AFL, analysed in a sample of amniotic fluid collected vaginally at arrested labor when oxytocin was needed, could predict labor outcome in nulliparous deliveries.MethodsA prospective multicentre study including 3000 healthy primiparous women all with a singleton pregnancy, gestational age 37 to 42 weeks and no maternal /fetal chronic and/or pregnancy-related conditions. A spontaneous onset of labor, regular contractions and cervical dilation ≥ 3 cm were required before the women were invited to take part in the study.ResultsAFL, analysed within 30 minutes before augmentation, provides information about delivery outcome. Sensitivity for an acute cesarean section according to high (≥10.1mmol/l) or low (< 10.1mmol/l) AFL values was 39.0% (95% CI; 27–50), specificity 90.3% (95% CI; 87–93) PPV 37.3% (95% CI; 27–48) and NPV was 91.0% (95% CI; 88–93). The overall percentage of correct predictions of delivery outcome when the AFL level was used was 83.7%. Deliveries with a high AFL-level correlated with delivery time >12h (p = 0.04), post-partum fever (>38°C, p = 0.01) and post-partum haemorrhage >1.5L (p = 0.04).ConclusionThe AFL is a good predictor of delivery outcome in arrested nulliparous deliveries. Low levels of AFL may support the decision to continue a prolonged vaginal labor by augmentation with oxytocin. A high level of AFL correlates with operative interventions and post-partum complications.

A Comparison of Vaginal Pressures and Abdominal Muscle Thickness According to Childbirth Delivery Method during the Valsalva Maneuver.

[Purpose] The purpose of this study was to compare the effect of childbirth delivery method on vaginal pressure and abdominal thickness during the Valsalva maneuver (VAL). [Subjects] Thirty healthy female volunteers (26–39 years of age) were selected for this research. Their delivery histories were: nulliparous 10, vaginal delivery 10, and Cesarean delivery 10. None of the participants had a history of incontinence. [Methods] In the crook-lying position, a perineometer probe was inserted into the vagina and the transducer was placed transversely on the right side of the body during the Valsalva maneuver. [Results] There were significant differences in the thickness of the transverses abdominis (TrA) between in all the groups rest and the Valsalva maneuver, and there were significant differences in the internus oblique (IO) in the nulliparous group. During the Valsalva maneuver, there were significant differences in the TrA between the nulliparous group and the vaginal delivery group, and there were significant differences in the IO between the nulliparous delivery group and the vaginal delivery group, and between the nulliparous group and the Cesarean section group. Delivery history changed vaginal pressure, and there were significant differences between the nulliparous group and the vaginal delivery group, and between the nulliparous group and the Cesarean delivery group. [Conclusion] Pregnancy and delivery method may affect pelvic floor and abdominal muscles during the Valsalva maneuver.

Maternal and neonatal morbidity during off peak hours in a busy obstetric unit. Are deliveries after midnight more complicated?

We sought to compare maternal and neonatal outcomes in deliveries occurring overnight with those in daylight hours. Prospective observational study. Large national tertiary referral center. All singleton laboring nulliparous parturients delivering infants >500 g over a 2-year period, 1 January 2008 to 31 December 2009. Details of intrapartum characteristics and neonatal outcomes of deliveries occurring between midnight and 08.00 h were compared with deliveries occurring outside of these hours. Maternal and neonatal morbidity. During the study period there were 8450 nulliparous deliveries. 2668 (31.6%) delivered between midnight and 08.00 h, and 5782 (68.4%) outside of these hours. There was a significant difference between the time periods in the number of babies born with a cord pH <7.1: 10.8% (44/406) of babies were born between midnight and 08.00 h, and 6.3% (63/1007) of babies were born outside these hours (p = 0.003). There was no significant difference in terms of Apgar score <7 at 5 min (p = 0.17). There was a trend toward a larger number of anal sphincter injuries occurring between midnight and 08.00 h (3% vs. 2.3%; p = 0.05). Our findings suggest that infants are more likely to be born with a pH <7.1 and there was a trend toward an increased rate of anal sphincter injury during time periods when staffing levels are low and clinician fatigue may play a role in decision-making and patient management. This may play a role in service provision planning and staff recruitment.

Placental Site Trophoblastic Tumor: A Case Report.

Patient K.N., age 30, nulliparous deliveries and with one miscarriage, was admitted to the Institute of Gynecology and Obstetrics, Clinical Center of Serbia, in December 2000 with the following diagnosis: Uterine myoma and adnexal mass.

Emergency peripartum hysterectomy in the nulliparous patient

Objective To find out the incidence, indications and outcomes of emergency peripartum hysterectomy in the nulliparous woman. Method Retrospective study at the Korle Bu Teaching Hospital in Accra, Ghana, between January 1995 and December 2003. Results During the eight-year study period there were 92,966 deliveries out of which 36,550 (39.5%) were for the nulliparous. Peripartum hysterectomy was performed for 39 nulliparous women, thus giving an incidence of 1 per 1000 nulliparous deliveries. The indications for the hysterectomy were: atonic uterus 28 (71.8%), ruptured uterus 8 (20.5%) and placenta praevia/accreta 3 (7.7%). The perinatal losses were 8 (20.5%) and the total blood loss ranged from 1 to 4.5 l. There were no maternal deaths but there were 7 near-missed fatalities. Conclusion Though rare, peripartum hysterectomy in the nulliparous patients carries high maternal morbidity and perinatal mortality.