Nulliparous Women In Spontaneous Labor Research Articles

Elevated amniotic fluid lactate predicts labor disorders and cesarean delivery in nulliparous women at term

We sought to assess amniotic fluid lactate (AFL) at diagnosis of spontaneous labor at term (≥37 weeks) as a predictor of labor disorders (dystocia) and cesarean delivery (CD). This was a single-institution, prospective cohort study of 905 singleton, cephalic, term (≥37 weeks) nulliparous women in spontaneous labor. A standard management of labor (active management of labor) including a standard oxytocin regimen up to a maximum dose of 30 mU/min was applied. AFL was measured using a point-of-care device (LMU061; ObsteCare, Stockholm, Sweden). Labor arrest in the first stage of labor was defined as the need for oxytocin when cervical dilatation was <1 cm/h over 2 hours and in the second stage of labor by poor descent and rotation over 1 hour. Standard statistical analysis included analysis of variance, Pearson correlations, and binary logistic regression. Unsupervised decision tree analysis with 10-fold cross-validation was used to identify AFL thresholds. AFL was normally distributed and did not correlate with age, body mass index, or gestation. Unsupervised decision tree analysis demonstrated that AFL could be divided into 3 groups: 0-4.9 mmol/L (n = 118), 5.0-9.9 mmol/L (n = 707), and ≥10.0 mmol/L (n = 80). Increasing AFL was associated with higher total oxytocin dose (P = .001), labor disorders (P = .005), and CD (P ≤ .001). Multivariable regression analysis demonstrated that women with AFL ≥5.0-9.9 mmol/L (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.06-2.39) and AFL ≥10.0 mmol/L (OR, 1.72; 95% CI, 1.01-2.93) were independent predictors of a labor disorder. AFL ≥5.0-9.9 mmol/L did not predict CD but multivariable analysis confirmed that AFL ≥10.0 mmol/L was an independent predictor of CD (OR, 3.35; 95% CI, 1.73-6.46). AFL ≥5.0-9.9 mmol/L had a sensitivity of 89% in predicting a labor disorder and a sensitivity of 93% in predicting CD with a 97% negative predictive value. AFL ≥10.0 mmol/L was highly specific but lacked sensitivity for CD. There was no difference in birthweight of infants according to labor disorder and delivery method. AFL at diagnosis of labor in spontaneously laboring single cephalic nulliparous term women is an independent predictor of a labor disorder and CD. These data suggest that women with AFL between 5.0-9.9 mmol/L with a labor disorder may be amenable to correction using the active management of labor protocol.

Stabilising the caesarean rate: which target population?

Caesarean rate increased in France between 1995 and 2003, but remained stable between 2003 and 2010. Our objective was to analyse these trends by identifying the groups of women who contributed to the increase and those who contributed to the stabilisation. Cross-sectional population-based study from the French national perinatal surveys. All maternity units in France. Representative samples of women delivering in 1995 (n = 13 147), 2003 (n = 14 482), and 2010 (n = 14 681). Robson classification, based on pregnancy and delivery characteristics, was used for each group. Caesarean rate for each group, its contribution to the overall caesarean rate, and the differences (Δ) in these contributions between 1995 and 2003 and between 2003 and 2010. Overall caesarean rates were 15.4% in 1995, 19.7% in 2003 and 20.5% in 2010. Between 1995 and 2003, the contribution to the overall caesarean rate of all groups but one rose. Between 2003 and 2010, the contribution of all groups but three stabilised or decreased: nulliparous women in spontaneous labour with singleton cephalic fetuses at term (Δ = + 0.5%, 95% CI 0.1-0.9%), an increase explained by their higher caesarean rate; nulliparous women with induced labour at term (Δ = + 1.1%, 95% CI 0.8-1.4%) caused by an increase in both the caesarean rate and the relative size of this group; and women with previous caesarean (Δ = + 0.8%, 95% CI 0.3-1.3%), because of the growing size of this group. Proposing and evaluating interventions for improving the management of labour in nulliparous women could help to maintain caesarean rates and mitigate increases among multiparous women in the future.

Динамика частоты кесарева сечения по тульской области за 2000-2010 гг.: мультицентровое ретроспективное исследование

Objectives. To study the trend of Caesarean section (CS) rate increase in the Tula region. Methods. A multicenter retrospective study of labor and delivery reports of women in Tula region, Russia who had CS procedures between the years 2000 and 2010. Robson’s Ten-Group Classification System (10-group classification) provides a clinically relevant classification of CS rates that provides a useful basis for internation-al comparisons and trend analyses. Results. In Tula region the total number of deliveries increased by 26.6% from the year 2000 as compared to 2010, the CS rate increased from 17.1 to 27.7%. The increase in CS deliveries was mostly attributed to three characteristic groups: multiparous women with uterine cicatrix; primaparous women who had medical conditions for a planned CS and these, who had labor induction; women with a gestational age less than 37 weeks. The largest Robson group was nulliparous women in spontaneous labor. Conclusions. Future efforts to reduce the overall CS rate should be focussed on reducing the primary CS rate.

Fear of childbirth and emergency caesarean section in low-risk nulliparous women: a prospective cohort study

Objective: To assess the association between fear of childbirth (FOC) and emergency caesarean section.Design: A prospective cohort study of low-risk nulliparous women at term.Setting: Nine obstetric departments in Denmark, May 2004–July 2005.Population: A total of 2598 nulliparous women in spontaneous labor with a single fetus in cephalic presentation at term.Methods: Self-reported FOC was assessed at 37 weeks of gestation by the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) version A and at admission to the labor ward by the Delivery Fear Scale (DFS). Mode of delivery was recorded by the attending staff. Logistic regression analyses were used to estimate unadjusted and adjusted odds ratios (OR).Main outcome measures: Risk of emergency caesarean section in women who feared childbirth.Results: FOC (W-DEQ sum score ≥85 and DFS sum score ≥70) was not associated with emergency caesarean section: adjusted OR = 0.81 (95% CI: 0.48–1.36) and OR = 0.97 (95% CI: 0.55–1.71), respectively.Conclusion: In this prospective observational study, women with FOC did not have an increased risk of emergency caesarean section compared to women with no such fear.

Women's perception of pre-hospital labour duration and obstetrical outcomes; a prospective cohort study.

BackgroundProgress during early labour may impact subsequent labour trajectories. Women admitted to hospital in latent phase (<3 cm cervical dilation) labour have been shown to be at higher risk of obstetrical interventions.MethodsWe conducted a secondary analysis of data from a randomized controlled trial of 1247 healthy nulliparous women in spontaneous labour at term with a singleton fetus in cephalic presentation at seven hospitals in Southwestern British Columbia. We computed relative risks and their 95% confidence intervals to examine our primary outcome of cesarean section and secondary outcomes including obstetrical interventions and maternal and newborn outcomes according to women’s perception of length of pre-hospital labour. Women were asked on admission to hospital how long they had been experiencing contractions prior to coming to hospital.ResultsWomen indicating that they had been in labour for 24 hours or longer at the time of hospital admission were at elevated risk for cesarean birth, relative risk (RR) 1.40, (95% Confidence Intervals 1.15-1.72), admission with a cervical dilation of 3 cm or less, RR 1.21 (1.07-1.36), more obstetrical interventions including continuous electronic fetal monitoring RR 1.11 (1.03-1.20), augmentation of labour RR 1.33 (1.23-1.44), use of narcotic RR 1.21 (1.06-1.37) and epidural analgesia RR 1.18 (1.09-1.28). Adverse neonatal outcomes did not differ apart from a significant increase in meconium-stained amniotic fluid RR 1.60 (1.09-2.35).ConclusionsA single question asked of women on presentation to hospital was an important predictor of cesarean birth and may have utility in identifying women who would benefit from close observation and more active management of labour.

Effect of Hydration on Spontaneous Labor Outcomes in Nulliparous Pregnant Women: A Multicenter Randomized Controlled Trial Comparing Three Methods

To evaluate the effect of mode and amount of fluid hydration during labor. The authors conducted a randomized controlled trial of uncomplicated nulliparous women in spontaneous labor at 36 weeks or more gestational age. Women were randomized to receive lactated Ringer solution with 5% dextrose at (1) 125 mL/h intravenously with limited oral intake, (2) 250 mL/h intravenously with limited oral intake, or (3) 25 mL/h intravenously with ad libitum oral intake of clear liquids. Results were analyzed by intent-to-treat analysis. A total of 311 out of 324 women were available for analysis. Groups 1 (n = 105), 2 (n = 105), and 3 (n = 101) above did not differ significantly for mean labor duration (11.6 ± 5.9, 11.4 ± 5.5, and 11.5 ± 5.9 hours, respectively; p = 0.998), proportion of women in labor > 12 hours (all groups 41%; p = 0.998), proportion receiving oxytocin augmentation (59, 60, and 57%, respectively; p = 0.923), or proportion delivered by cesarean (22, 17, and 17%, respectively; p = 0.309). Indications for cesarean were similar between groups. No cases of pulmonary edema, maternal aspiration, or perinatal mortality occurred. Although apparently safe, neither increased intravenous hydration nor oral hydration during labor improves labor performance.

Interinstitutional Variation of Caesarean Delivery Rates According to Indications in Selected Obstetric Populations: A Prospective Multicenter Study

The aim of the study was to identify which groups of women contribute to interinstitutional variation of caesarean delivery (CD) rates and which are the reasons for this variation. In this regard, 15,726 deliveries from 11 regional centers were evaluated using the 10-group classification system. Standardized indications for CD in each group were used. Spearman's correlation coefficient was used to calculate (1) relationship between institutional CD rates and relative sizes/CD rates in each of the ten groups/centers; (2) correlation between institutional CD rates and indications for CD in each of the ten groups/centers. Overall CD rates correlated with both CD rates in spontaneous and induced labouring nulliparous women with a single cephalic pregnancy at term (P = 0.005). Variation of CD rates was also dependent on relative size and CD rates in multiparous women with previous CD, single cephalic pregnancy at term (P < 0.001). As for the indications, “cardiotocographic anomalies” and “failure to progress” in the group of nulliparous women in spontaneous labour and “one previous CD” in multiparous women previous CD correlated significantly with institutional CD rates (P = 0.021, P = 0.005, and P < 0.001, resp.). These results supported the conclusion that only selected indications in specific obstetric groups accounted for interinstitutional variation of CD rates.

The Effect of Manipulation of the Programmed Intermittent Bolus Time Interval and Injection Volume on Total Drug Use for Labor Epidural Analgesia

BACKGROUND: Programmed intermittent bolus administration of epidural anesthetic solution compared with continuous infusion results in decreased anesthetic consumption and increased patient satisfaction. In this randomized and blinded study, we evaluated bupivacaine consumption and other analgesic outcomes when the programmed intermittent bolus time interval and volume were manipulated during the maintenance of epidural labor analgesia. METHODS: Healthy, term, nulliparous women in spontaneous labor had combined spinal-epidural labor analgesia initiated with intrathecal bupivacaine 1.25 mg and fentanyl 15 μg, followed by an epidural test dose (lidocaine 45 mg with epinephrine 15 μg). Subjects were randomized to 1 of 3 programmed intermittent bolus dose regimens for maintenance of analgesia: 2.5 mL every 15 minutes (2.5/15), 5 mL every 30 minutes (5/30), or 10 mL every 60 minutes (10/60). The maintenance epidural solution consisted of bupivacaine 0.625 mg/mL with fentanyl 1.95 μg/mL. Breakthrough pain was treated initially with patient-administered epidural bolus doses, followed by manual boluses administered by the anesthesiologist if necessary. The primary outcome was total bupivacaine consumption per hour of labor. A linear mixed-effects model was used to model each patient's overall bupivacaine consumption per hour; the fixed effect was basal bupivacaine administration rate and the random effect was the area under the pain score versus time curve. RESULTS: One hundred ninety women were studied. The median (interquartile range) adjusted bupivacaine consumption per hour of labor was 8.8 mg (8.0-9.7 mg) in group 10/60 compared with 10.0 mg (9.3-10.8 mg) in group 5/30 and 10.4 mg (9.6-11.2 mg) in group 2.5/15 (P = 0.005). There were no differences in area under the pain score versus time curve, pain scores at delivery, patient-controlled epidural analgesia requests or administrations, number of manual bolus doses for breakthrough pain, time to first patient-controlled epidural analgesia or manual bolus dose, or patient satisfaction with labor analgesia. CONCLUSIONS: Extending the programmed intermittent bolus interval and volume from 15 minutes to 60 minutes, and 2.5 mL to 10 mL, respectively, decreased bupivacaine consumption without decreasing patient comfort or satisfaction.

Epidural analgesia during labor vs no analgesia: A comparative study

Background:Epidural analgesia is claimed to result in prolonged labor. Previous studies have assessed epidural analgesia vs systemic opioids rather than to parturients receiving no analgesia. This study aimed to evaluate the effect of epidural analgesia on labor duration compared with parturients devoid of analgesia.Methods:One hundred sixty nulliparous women in spontaneous labor at full term with a singleton vertex presentation were assigned to the study. Parturients who request epidural analgesia were allocated in the epidural group, whereas those not enthusiastic to labor analgesia were allocated in the control group. Epidural analgesia was provided with 20 mL bolus 0.5% epidural lidocaine plus fentanyl and maintained at 10 mL for 1 h. Duration of the first and second stages of labor, number of parturients receiving oxytocin, maximal oxytocin dose required for each parturient, numbers of instrumental vaginal, vacuum-assisted, and cesarean deliveries and neonatal Apgar score were recorded.Results:There was no statistical difference in the duration of the active-first and the second stages of labor, instrumental delivery, vacuum-assisted or cesarean delivery rates, the number of newborns with 1-min and 5-min Apgar scores less than 7 between both groups and number of parturients receiving oxytocin, however, the maximal oxytocin dose was significantly higher in the epidural group.Conclusion:Epidural analgesia by lidocaine (0.5%) and fentanyl does not prolong labor compared with parturients without analgesia; however, significant oxytocin augmentation is required during the epidural analgesia to keep up the aforementioned average labor duration.

Identification of a myometrial molecular profile for dystocic labor

BackgroundThe most common indication for cesarean section (CS) in nulliparous women is dystocia secondary to ineffective myometrial contractility. The aim of this study was to identify a molecular profile in myometrium associated with dystocic labor.MethodsMyometrial biopsies were obtained from the upper incisional margins of nulliparous women undergoing lower segment CS for dystocia (n = 4) and control women undergoing CS in the second stage who had demonstrated efficient uterine action during the first stage of labor (n = 4). All patients were in spontaneous (non-induced) labor and had received intrapartum oxytocin to accelerate labor. RNA was extracted from biopsies and hybridized to Affymetrix HuGene U133A Plus 2 microarrays. Internal validation was performed using quantitative SYBR Green Real-Time PCR.ResultsSeventy genes were differentially expressed between the two groups. 58 genes were down-regulated in the dystocia group. Gene ontology analysis revealed 12 of the 58 down-regulated genes were involved in the immune response. These included (ERAP2, (8.67 fold change (FC)) HLA-DQB1 (7.88 FC) CD28 (2.60 FC), LILRA3 (2.87 FC) and TGFBR3 (2.1 FC)) Hierarchical clustering demonstrated a difference in global gene expression patterns between the samples from dystocic and non-dystocic labours. RT-PCR validation was performed on 4 genes ERAP2, CD28, LILRA3 and TGFBR3ConclusionThese findings suggest an underlying molecular basis for dystocia in nulliparous women in spontaneous labor. Differentially expressed genes suggest an important role for the immune response in dystocic labor and may provide important indicators for new diagnostic assays and potential intrapartum therapeutic targets.

Obstetric outcomes and maternal satisfaction in nulliparous women using patient-controlled epidural analgesia

The purpose of this study was to compare obstetric outcomes and maternal satisfaction in nulliparous women in spontaneous labor who used patient-controlled epidural analgesia (PCEA) vs continuous epidural infusion (CEI). We conducted a double-masked trial of 270 nulliparous women who were assigned randomly to 3 groups (with a concentration 0.1% bupivacaine and 2 μg/mL fentanyl): group I, CEI-only (10 mL/h); group II, CEI + PCEA (CEI 10 mL/h plus PCEA 10 mL, at 20 minutes); group III, PCEA-only (10 mL, at 20 minutes). A PCEA bolus button was given to each subject. The primary outcome was the dosage of local anesthetic that was used. The total milligrams of bupivacaine that were used was less in the PCEA-only group compared with CEI: group I. 74.8 ± 36 mg; group II, 97.3 ± 53 mg; group III, 52.4 ± 42 mg (P < .001). Pain with pushing, however, was worse in the PCEA-only group. Median satisfaction scores were similar (scale, 0 [best] to 100 [worst]: group I, 0; group II, 0; group III, 0 (P = .23). PCEA results in less anesthetic used, and maternal satisfaction remains high without a continuous infusion. Pain with pushing, however, was worse with the PCEA alone.

The Effect of Manipulation of the Programmed Intermittent Bolus Time Interval and Injection Volume on Total Drug Use for Labor Epidural Analgesia

Programmed intermittent bolus administration of epidural anesthetic solution compared with continuous infusion results in decreased anesthetic consumption and increased patient satisfaction. In this randomized and blinded study, we evaluated bupivacaine consumption and other analgesic outcomes when the programmed intermittent bolus time interval and volume were manipulated during the maintenance of epidural labor analgesia. Healthy, term, nulliparous women in spontaneous labor had combined spinal-epidural labor analgesia initiated with intrathecal bupivacaine 1.25 mg and fentanyl 15 μg, followed by an epidural test dose (lidocaine 45 mg with epinephrine 15 μg). Subjects were randomized to 1 of 3 programmed intermittent bolus dose regimens for maintenance of analgesia: 2.5 mL every 15 minutes (2.5/15), 5 mL every 30 minutes (5/30), or 10 mL every 60 minutes (10/60). The maintenance epidural solution consisted of bupivacaine 0.625 mg/mL with fentanyl 1.95 μg/mL. Breakthrough pain was treated initially with patient-administered epidural bolus doses, followed by manual boluses administered by the anesthesiologist if necessary. The primary outcome was total bupivacaine consumption per hour of labor. A linear mixed-effects model was used to model each patient's overall bupivacaine consumption per hour; the fixed effect was basal bupivacaine administration rate and the random effect was the area under the pain score versus time curve. One hundred ninety women were studied. The median (interquartile range) adjusted bupivacaine consumption per hour of labor was 8.8 mg (8.0-9.7 mg) in group 10/60 compared with 10.0 mg (9.3-10.8 mg) in group 5/30 and 10.4 mg (9.6-11.2 mg) in group 2.5/15 (P = 0.005). There were no differences in area under the pain score versus time curve, pain scores at delivery, patient-controlled epidural analgesia requests or administrations, number of manual bolus doses for breakthrough pain, time to first patient-controlled epidural analgesia or manual bolus dose, or patient satisfaction with labor analgesia. Extending the programmed intermittent bolus interval and volume from 15 minutes to 60 minutes, and 2.5 mL to 10 mL, respectively, decreased bupivacaine consumption without decreasing patient comfort or satisfaction.

316: The maternal demographics and intrapartum characteristics associated with epidural analgesia in spontaneous nulliparous labor

To examine the maternal demographics and labor characteristics associated with epidural use in spontaneous nulliparous term labors in a setting where the management of labor is standardized. This is a prospective observational study of all term nulliparous women in spontaneous labor with a singleton cephalic pregnancy who delivered from January 1st 2008 until December 31st 2008. In our institution the management of women in labor is standardized; all spontaneous nulliparous labors are actively managed. This standardization of care has permitted an effective examination of the influence of epidural analgesia on labor outcomes. The study cohort consisted of 2,442 consecutive deliveries. The overall epidural rate was 64% (n=1559). The onset of labor occurred at a later gestational age (282 vs. 280 days p=0.01) in women who received epidural analgesia and the duration of labor was significantly longer (416 vs.190 mins. p<0.001). These women also had a significantly higher body mass indices (BMI) at first antenatal consultation (24.8 vs. 24.1 kg/m2 p<0.001), though there was no significant difference in maternal age. Women who required oxytocin to augment spontaneous labor were also significantly more likely to require epidural analgesia (69% vs. 18%, p<0.001) The overall caesarean section rate was 7 % (n=177). The overall operative vaginal delivery rate was 24% (n= 585). The incidence of both caesarean (10% vs. 2%, p<0.001) and operative vaginal (31% vs. 11% p<0.001) delivery was significantly higher in those women who received epidural analgesia in labor compared to those that did not. The mean birthweight was also significantly higher in those receiving epidural analgesia (3550 vs. 3336g, p<0.001). The use of epidural analgesia was significantly more common in women with higher BMIs, laboring at later gestational ages. These results, in a contemporary cohort of actively managed spontaneous nulliparous labors, confirm the higher incidence of operative delivery with epidural use.

28: Obstetric outcomes and maternal satisfaction using patient controlled epidural analgesia in nulliparous women

Patient-controlled epidural analgesia (PCEA) has been shown to reduce local anesthetic use during labor. It is unclear if obstetric outcomes and maternal satisfaction are improved with the use of PCEA. Our aim was to compare obstetric outcomes and maternal satisfaction in nulliparous women in spontaneous labor using PCEA vs continuous epidural infusion (CEI).

172: The impact of epidural timing on mode of delivery in nulliparous women at term

To determine if epidural placement in early labor (≤3 cm dilation) compared to late labor (>5 cm dilation) alters the rates of cesarean or operative vaginal delivery in nulliparous women in spontaneous labor at term.

Trends and determinants of caesarean sections births in Queensland, 1997–2006

The determinants of Queensland's rising caesarean section (CS) rate remain poorly understood because of the historical absence of standard classification methods. We applied the Robson Ten Group Classification System (RTGCS) to population-based data to identify the main contributors to Queensland's rising CS rate. The RTGCS was applied retrospectively to the Queensland Perinatal Data Collection. CS rates were described for all ten RTGCS groups using data from 2006. Trends were evaluated using data for the years 1997-2006. Public and private sector patients were evaluated separately. In Queensland, in 2006, CS rates were 26.9 and 48.0% among public and private sector patients, respectively. Multiparous women with a previous caesarean birth (Group 5) made the greatest contribution to the CS rate in both sectors, followed by nulliparous women who had labour induced or were delivered by CS prior to the onset of labour (Group 2) and nulliparous women in spontaneous labour (Group 1). CS rates have risen in all RTGCS groups between 1997 and 2006. The trend was pronounced among multiparous women with a previous caesarean delivery (Group 5), among women with multiple pregnancies (Group 8) and among nulliparous women who had labour induced or were delivered by CS prior to the onset of labour (Group 2). The CS rate in Queensland in 2006 was higher than in any other Australian state. The increase in Queensland's CS rates can be attributed to both the rising number of primary caesarean births and the rising number of repeat caesareans.

A randomised controlled trial of early versus delayed oxytocin augmentation to treat primary dysfunctional labour in nulliparous women

Oxytocin is widely used to speed up slow labour, especially in nulliparous women, but randomised trials, apart from one reported only in abstract, have been too small to exclude important effects. To test the hypothesis that early use of oxytocin reduces the need for caesarean delivery. A randomised controlled trial. Twelve obstetric units within the Northern and Yorkshire regions in the North East of England. A total of 412 low-risk nulliparous women in spontaneous labour at term, who had been diagnosed with primary dysfunctional labour were recruited from January 1999 to December 2001. Immediate oxytocin administration (active group) or oxytocin withheld for up to 8 hours (conservative group). Caesarean section and operative vaginal delivery rates. The length of labour measured from the time of randomisation to delivery. The rate of maternal Edinburgh Postnatal Depression Scale (EPDS) greater than 12 (major depression) within 48 hours of delivery. The caesarean section rates were 13.5% active versus 13.7% controls (OR 0.98, 95% CI 0.6-1.7). Operative delivery, 24.5% versus 30.9% (OR 0.73, 95% CI 0.5-1.1). The median (interquartile range) randomisation to delivery interval in the active group was 5 hours 52 minutes (3:57-8:28) and in the conservative group 9 hours 8 minutes (5:06-13:16) (P < 0.001). The rate of EPDS >12 was 20% in the active arm versus 15% among controls (OR 1.26, 95% CI 0.7-2.2). There was one perinatal death in each group and no major differences in perinatal outcomes. Among nulliparous women with primary dysfunctional labour, early use of oxytocin does not reduce caesarean section or short-term postnatal depression. However, it shortens labour considerably and may reduce operative vaginal deliveries.

The incidence of maternal fever during labor is less with intermittent than with continuous epidural analgesia: a randomized controlled trial

Background This prospective, randomized study was performed to see if intermittent labor epidural analgesia was protective against maternal intrapartum fever, compared to continuous epidural infusion. Methods Ninety-two healthy, term, nulliparous women in spontaneous labor were assigned to either intermittent (ILEA) or continuous labor epidural analgesia (CLEA), 46 in each group. In both groups, epidural analgesia was established with fentanyl 100 μg, and 8 mL of either 0.125% bupivacaine with fentanyl 0.0002%, or 0.1% ropivacaine with fentanyl 0.0002%. Maintenance in the CLEA group was with the same bupivacaine/fentanyl or ropivacaine/fentanyl solutions at 10-15 mL/h. In the ILEA group, additional boluses of the same solution were given as needed. Maternal tympanic temperature was measured before epidural insertion, 4-hourly during labor and 4 h post partum. Fever was defined as a temperature of ⩾38 °C. Newborn temperature was noted within 60 min of birth. Results The incidence of fever in ILEA was significantly lower at four hours (2/42, vs. 10/44 in CLEA, P = 0.036). No significant differences were detected at other time periods. Mean maternal temperatures did not differ between groups at any time. There were no differences in neonatal temperature or neonatal sepsis evaluation rate (CLEA vs. ILEA 0/46 vs. 2/43, P = 0.45). Conclusions Intermittent epidural injections appear to protect against intrapartum fever in the first 4 hours of labor analgesia, compared to continuous infusion. This may be due to intermittent partial recovery of heat loss mechanisms between injections. Neonatal sepsis evaluation rates were similar in the two groups.

Maternal Body Mass Index in the First Trimester and Risk of Cesarean Delivery in Nulliparous Women in Spontaneous Labor

Maternal Body Mass Index in the First Trimester and Risk of Cesarean Delivery in Nulliparous Women in Spontaneous Labor

Maternal body mass index in the first trimester and risk of cesarean delivery in nulliparous women in spontaneous labor

To evaluate the effect of maternal body mass index (BMI) on the incidence of cesarean delivery. Prospective observational cohort study of 4341 consecutive nulliparous women with a single cephalic presentation, and spontaneous onset of labor between 37 and 42 weeks gestation at High Wycombe General Hospital, London, between January 1, 1995, and December 31, 2000. The incidence of cesarean delivery rose significantly with an increase in BMI. Women in labor with a BMI > 35 had a 3.8 times greater chance of a cesarean delivery than women with a BMI < 25 (after adjustment for variables such as maternal height and age, gestational age, fetal birthweight, and use of oxytocin and epidural analgesia during labor). This was true for cesarean deliveries performed for suspected fetal distress as well as for failure to progress. A high BMI significantly increased the risk of cesarean delivery, but the reasons are not certain.