Nulliparous Women In Spontaneous Labor Research Articles

Validating a predictive model for caesarean section in low-risk nulliparous pregnancies

ProblemCaesarean birth (CS) rates are steadily increasing. BackgroundIn 2017 Janssen et al. developed a model which could predict CB in nulliparous healthy woman with 71 % accuracy based on factors measurable on admission to the hospital. AimTo validate the predictive model for risk of caesarean birth among low-risk, nulliparous women in a new setting. MethodsA retrospective chart study in Abbotsford Regional Hospital (British Columbia, Canada) of healthy nulliparous women in spontaneous labour, at term, with a singleton fetus in cephalic position. Sociodemographic, pregnancy and labour-related characteristics were collected and independent predictors of CS were determined using multivariate logistic regression. The Janssen model was tested in the Abbotsford sample and additionally novel predictors were tested in an effort to improve the model. The area under the ROC curve (C-statistic) was computed and model calibration, sensitivity and specificity evaluated for the final model. Findings and discussionOf 348 women, 106 (30.5 %) had a CB. Applying the Janssen predictive model to the Abbotsford data resulted in a C-statistic of 0.77. No new predictors were added to the model. The mean predicted risk score for CS in the cohort was 0.30 ± 0.20. A risk score cut-off of 0.32 was determined resulting in a sensitivity and specificity of 69 %. The model had acceptable calibration. ConclusionA model with variables easily accessible at admission can predict caesarean birth in nulliparous women. The results from this study can guide provision of more intensive care during labour to women at higher risk, with the overall goal of reducing CB rates.

Machine Learning Prediction of risk for Cesarean delivery among nulliparous women in spontaneous labor

Machine Learning Prediction of risk for Cesarean delivery among nulliparous women in spontaneous labor

Hands-on vs hands-off technique for the prevention of perineal injury: a randomized clinical trial

Perineal trauma after vaginal delivery is common and is associated with severe morbidity, including incontinence, pelvic pain, and sexual dysfunction. Morbidity is mainly related to third- or fourthdegree lacerations. This study aimed to test the hypothesis that in nulliparous women with singleton pregnancies at term, hands-off technique during spontaneous vaginal delivery could reduce the rate of perineal laceration. This was a parallel-group, nonblinded, randomized clinical trial. Nulliparous women in spontaneous labor with singleton pregnancies and vertex presentation admitted to the labor and delivery room between 37 0/7 and 42 0/7 weeks of gestation were eligible, and were randomized in a 1:1 ratio to receive hands-off technique (intervention group) or hands-on technique during pushing in the second stage of labor. The primary outcome was perineal laceration (any degree). The effect of hands-off technique on each outcome was quantified as relative risk with 95% confidence interval. A total of 70 women were enrolled in the trial. Perineal lacerations (any degree) occurred in 15 of 35 (42.9%) women in the intervention group and 33 of 35 (94.3%) women in the control group (relative risk, 0.45; 95% confidence interval, 0.31-0.67). Hands-off technique was also associated with significantly decreased incidence of episiotomy (relative risk, 0.36; 95% confidence interval, 0.14-0.88), first-degree lacerations (relative risk, 0.41; 95% confidence interval, 0.20-0.87), and second-degree lacerations (relative risk, 0.43; 95% confidence interval, 0.19-0.99). There was no significant between-group difference in third- and fourth-degree lacerations, but the trial was not powered for these outcomes. In nulliparous women with singleton pregnancies at term, hands-off technique reduces the rate of perineal lacerations.

Room4Birth – The effect of giving birth in a hospital birthing room designed with person-centred considerations: A Swedish randomised controlled trial

ObjectiveTo evaluate if a birthing room designed with person-centred considerations improves labour and birth outcomes for nulliparous women when compared to regular birthing rooms. MethodsA randomised controlled trial was conducted at a Swedish labour ward between January 2019 and October 2020. Nulliparous women in spontaneous labour were randomised either to a birthing room designed with person-centred considerations (New room) or a Regular room. The primary outcome was a composite of four variables: vaginal non-instrumental birth; no oxytocin augmentation; postpartum blood loss < 1000 ml; and a positive childbirth experience. To detect a difference of 8% between the groups, 1274 study participants were needed, but the trial was terminated early due to consequences of the Covid-19 pandemic. ResultsA total of 406 women were randomised; 204 to the New room and 202 to the Regular room. There was no significant difference in the primary outcome between the groups (42.2% versus 35.1%; odds ratio: 1.35, 95% Confidence Interval 0.90–2.01; p = 0.18). Participants in the New room used epidural analgesia to a lower extent (54.4% versus 65.3%, relative risk: 0.83, 95% Confidence Interval 0.71–0.98; p = 0.03) and reported to a higher degree that the room contributed to a sense of safety, control, and integrity (p=<0.001). ConclusionsThe hypothesis that the New room would improve the primary outcome could not be verified. Considering the early discontinuation of the study, results should be interpreted with caution. Nevertheless, analyses of our secondary outcomes emphasise the experiential value of the built birth environment in improving care for labouring women.

Comparing compliance with commencement and use of two partograph designs for women in active labour: A randomised controlled trial

BackgroundDocumentation and assessment of progress in labour using a partograph is recommended by the World Health Organisation to assist in the timely recognition of labour dystocia. Recent studies have tested new designs of partographs that aim to account for more variable rates of labour progress. However, other studies have suggested that poor compliance in the completion of partographs affects utility. The objective of this study was to compare two types of partographs for compliance in documentation and use for managing labour. MethodsLow-risk nulliparous women in spontaneous labour (n = 228) were randomised to either an Action Line (control) (n = 114) or Dystocia Line partograph (intervention) (n = 114). Primary outcome was compliance with instructions for commencement of the partograph following a multifaceted training strategy. Secondary outcomes included compliance with the accompanying clinical management protocol for each partograph; and labour and birth outcomes. ResultsThe compliance rate for commencing the Action line partograph was 43.2% compared to 67.0% (p = 0.02) for the Dystocia line partograph. Other than a reduction in artificial rupture of membranes in the Dystocia Line group there were no other differences in labour management or birth outcomes. The use of centralised electronic display of labour progress may be a contributing factor. ConclusionsCompliance with the commencement and use of either partograph was low. There was little indication that the partograph was being utilized in the assessment and management of prolonged labour. Further studies are needed to explore the current utility of partographs in labour management and the effect of centralised monitoring of progress in high resource settings

Analysis of cesarean section rates and its indications using robson's classification at a tertiary care hospital, Manipur.

The World Health Organization proposed the Robson's classification system as a global standard for assessing and comparing cesarean section (CS) rates within health-care facilities over time and between facilities. This study aims to assess the frequency and indications of CS and to identify the groups within the obstetric population contributing to CS using Robson's classification. A retrospective chart review was conducted in a Tertiary Care Teaching Hospital in Imphal, Manipur. All women who delivered between January and December 2019 were classified using the Robson's Ten Group Classification System. The overall CS rate and the CS rate in each Robson's group were calculated. The indications for CS were also recorded. Descriptive statistics, such as frequency, percentage, mean, and standard deviation, was used. A total of 10,282 births were reported. The overall CS rate was 35.2%. Group 3 (multiparous women without previous CS in spontaneous labor) (27.6%) and Group 1 (nulliparous women in spontaneous labor) (23.7%) contributed to most of the obstetric populations. The majority of CS belonged to the women in Group 5 (multiparous women with previous lower segment CS) (11%), followed by Group 2 (nulliparous women with labor induced or prelabor CS) (8.6%) and Group 4 (multiparous women without previous CS were induced or taken for prelabor CS) (5.5%). The study revealed that Groups 5, 2, and 4 contributed to the high CS rate. Efforts to reduce the overall CS rate should be directed at increasing vaginal births after CS, performing effective pelvic examinations, and encouraging obstetricians to perform versions when indicated.

Can the Robson 10 Group Classification System help identify which groups of women are driving the high caesarean section rate in major private hospitals in eastern Ethiopia? A cross-sectional study

ObjectiveThe rates of caesarean section (CS) in Ethiopian private hospitals are high compared with those in public facilities, and there are limited descriptions of groups of women contributing to these...

Does giving birth in a "birth environment room" versus a standard birth room lower augmentation of labor? - Results from a randomized controlled trial.

In the last decade, there has been an increased interest in exploring the impact of the physical birth environment on midwifery practice and women's birth experiences. This study is based on the hypothesis that the environment for birth needs greater attention to improve some of the existing challenges in modern obstetric practice, for example the increasing use of augmentation and number of interventions during delivery. A randomized controlled trial was carried out to study the effect of giving birth in a specially designed "birth environment room" on the use of augmentation during labor. The study took place at the Department of Obstetrics and Gynecology, Herning Hospital, Denmark and included 680 nulliparous women in spontaneous labor at term with a fetus in cephalic presentation. Women were randomly allocated to either the "birth environment room" or a standard birth room. The primary outcome was augmentation of labor by use of oxytocin. Secondary outcomes were duration of labor, use of pharmacological pain relief, and mode of birth. Differences were estimated as relative risks (RR) and presented with 95% confidence intervals. No difference was found on the primary outcome, augmentation of labor (29.1% in the "birth environment room" versus 30.6% in the standard room, RR 0.97; 0.89-1.08). More women in the "birth environment room" used the bathtub (60.6% versus 52.4%, RR 1.18; 1.02-1.37), whereas a tendency to lower use of epidural analgesia (22.6% versus 28.2%) did not reach statistical significance (RR 0.87; 0.74-1.02). The chance of an uncomplicated birth was almost similar in the two groups (70.6% in the "birth environment room" versus 72.6% in the standard room, RR 0.97; 0.88-1.07) as were duration of labor (mean 7.9 hours in both groups). Birthing in a specially designed physical birth environment did not lower use of oxytocin for augmentation of labor. Neither did it have any effect on duration of labor, use of pharmacological pain relief, and chance of birthing without complications. We recommend that future trials are conducted in birth units with greater improvement potentials.

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.

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

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

Fetal descent in nulliparous women assessed by ultrasound: a longitudinal study

Ultrasound measurements offer objective and reproducible methods to measure the fetal head station. Before these methods can be applied to assess labor progression, the fetal head descent needs to be evaluated longitudinally in well-defined populations and compared with the existing data derived from clinical examinations. This study aimed to use ultrasound measurements to describe the fetal head descent longitudinally as labor progressed through the active phase in nulliparous women with spontaneous onset of labor. This was a single center, prospective cohort study at the Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland, from January 2016 to April 2018. Nulliparous women with a single fetus in cephalic presentation and spontaneous labor onset at a gestational age of ≥37 weeks, were eligible. Participant inclusion occurred during admission for women with an established active phase of labor or at the start of the active phase for women admitted during the latent phase. The active phase was defined as an effaced cervix dilated to at least 4 cm in women with regular contractions. According to the clinical protocol, vaginal examinations were done at entry and subsequently throughout labor, paired each time with a transperineal ultrasound examination by a separate examiner, with both examiners being blinded to the other's results. The measurements used to assess the fetal head station were the head-perineum distance and angle of progression. Cervical dilatation was examined clinically. The study population comprised 99 women. The labor patterns for the head-perineum distance, angle of progression, and cervical dilatation differentiated the participants into 75 with spontaneous deliveries, 16 with instrumental vaginal deliveries, and 8 cesarean deliveries. At the inclusion stage, the cervix was dilated 4 cm in 26 of the women, 5 cm in 30 of the women, and ≥6 cm in 43 women. One cesarean and 1 ventouse delivery were performed for fetal distress, whereas the remaining cesarean deliveries were conducted because of a failure to progress. The total number of examinations conducted throughout the study was 345, with an average of 3.6 per woman. The ultrasound-measured fetal head station both at the first and last examination were associated with the delivery mode and remaining time of labor. In spontaneous deliveries, rapid head descent started around 4 hours before birth, the descent being more gradual in instrumental deliveries and absent in cesarean deliveries. A head-perineum distance of 30 mm and angle of progression of 125° separately predicted delivery within 3.0 hours (95% confidence interval, 2.5-3.8 hours and 2.4-3.7 hours, respectively) in women delivering vaginally. Although the head-perineum distance and angle of progression are independent methods, both methods gave similar mirror image patterns. The fetal head station at the first examination was highest for the fetuses in occiput posterior position, but the pattern of rapid descent was similar for all initial positions in spontaneously delivering women. Oxytocin augmentation was used in 41% of women; in these labors a slower descent was noted. Descent was only slightly slower in the 62% of women who received epidural analgesia. A nonlinear relationship was observed between the fetal head station and dilatation. We have established the ultrasound-measured descent patterns for nulliparous women in spontaneous labor. The patterns resemble previously published patterns based on clinical vaginal examinations. The ultrasound-measured fetal head station was associated with the delivery mode and remaining time of labor.

Effect of music on labor and delivery in nulliparous singleton pregnancies: a randomized clinical trial

Women's experience of pain during labor varies greatly, and pain control is a major concern for obstetricians. Several methods have been studied for pain management for women in labor, including drug and non-drug interventions. To test the hypothesis that in nulliparous women with singleton pregnancies at term, listening to music would reduce the pain level during labor. Parallel group non-blinded randomized clinical trial conducted at a single center in Italy. Nulliparous women in spontaneous labor with singleton pregnancies and vertex presentation admitted in labor and delivery room between 37 0/7 and 42 0/7weeks of gestation for active phase of labor were eligible, and were randomized in a 1:1 ratio to receive music during labor or no music during labor. Music in labor was defined listening to music from the randomization until the delivery of the baby. The primary endpoint was the pain level during the active phase of labor, recorded using the visual analogue scale (VAS) for pain, ranging from 0 (no pain) to 10 (unbearable pain). The effect of music use during labor on each outcome was quantified as the mean difference (MD) with 95% confidence interval (CI). During the study period, 30 women agree to take part in the study, underwent randomization, and were enrolled and followed up. 15 women were randomized in the music group, and 15 in the control group. No patients were lost to follow up for the primary outcome. Pain level during the active phase of labor was scored 8.8 ± 0.9 in the music group, and 9.8 ± 0.3 in the control group (MD - 1.00 point, 95% CI - 1.48 to - 0.52; P < 0.01). Music during labor and delivery was also associated with a decreased pain at 1h postpartum (MD - 2.40 points, 95% CI - 4.30 to - 0.50), and decreased anxiety level during active phase of labor (MD - 19.90 points, 95% CI - 38.72 to - 1.08), second stage of labor (MD - 49.40 points, 95% CI - 69.44 to - 29.36), and at 1h postpartum (MD - 27.00 points, 95% CI - 47.37 to - 6.63). In nulliparous women with singleton pregnancies at term, listening to music reduces the pain level, and the anxiety level during labor. Clinicaltrials.gov NCT03779386.

1039: Determining the risk of cesarean delivery in the nulliparous population stratified by age and BMI

The rising cesarean delivery (CD) rate is a complex issue, particularly in a nulliparous population of advancing maternal age and increasing body mass index (BMI). The objective of this study was to stratify the CD rate in nulliparous women by age and BMI to determine if there was any significant difference within this cohort. This was a retrospective review of CD procedures of nulliparous women in Galway University Hospital, Galway and The Rotunda Hospital, Dublin, Ireland, over 4 years (from 2014 through 2017), with Institutional Review board approval from both hospitals. Data were obtained from hospital databases including details on mode of delivery, maternal age and BMI. The number of CD procedures and percentage was determined for each age and BMI category and graphed for analysis. Statistical analysis was performed using SPSS software. Sub-analysis was performed on nulliparous women in spontaneous labor (Robson Group 1). A total of n=17,474 nulliparous women were included for analysis. N=6,257 (35.8%) had CD procedures. Results are presented in Table 1. A trend can be seen emerging showing increasing CD rates for increasing age and BMI categories. Women under 20 years with a BMI of < 18.5kg/m2 had a CD rate of 9%, while those with a BMI of 30-34.9kg/m2 had a 29% CD rate. Women 35-39 years of BMI < 18.5 kg/m2 and 30-34.9kg/m2 had CD rates of 36% and 62% respectively. For women over 45 years the CD rates ranged from 80-100% in all BMI groups. The higher CD rates in women of higher BMI and advanced maternal age when compared with younger women of lower BMI was significant (P< 0.05). Similar results were obtained when analyzing the CD rates of women in Robson Group 1. We observed significant differences within the nulliparous population in the CD rates when stratified by age and BMI. The development of customized charts subdivided by age and BMI may aide to more accurately estimate a women’s risk of CD In a first pregnancy, provide a useful counseling tool to women and their clinicians and may also assist in the comparison of CD rates between obstetric units.

Mode of delivery among nulliparous women with single, cephalic, term pregnancies: The WHO global survey on maternal and perinatal health, 2004-2008.

To determine risk factors associated with cesarean delivery among nulliparous women in spontaneous labor with a single, cephalic, term pregnancy (Robson group 1). Data were assessed from the WHO Global Survey of Maternal and Perinatal Health conducted in 2004-2008. Among 82280 women in Robson group 1, 67698 (82.3%) had vaginal and 14578 (17.7%) had cesarean delivery. In adjusted analyses, maternal factors associated with cesarean included age older than 18years, being overweight or obese, being married or cohabitating, attending four prenatal visits or more, and being medically high risk (P<0.001). Women who were obstetrically high risk, referred during labor, or at 39 gestational weeks or more were also more likely to undergo cesarean (all P<0.001). Facility-level factors associated with cesarean were availability of an anesthesia service 24/7, being a teaching facility, requirement of fees for cesarean, availability of electronic fetal monitoring, and having providers skilled in operative vaginal delivery (all P<0.01). The analysis highlights the importance of maintaining a healthy pre-pregnancy and pregnancy weight, optimizing management of women with medical problems, and ensuring clear referral mechanisms for women with intrapartum complications. The association between fees and cesarean delivery warrants further exploration.

Evaluating Fundal Dominant Contractions on Spatiotemporal Electrohysterography as a Marker for Effective Labor Contractions.

To evaluate if fundal (F) dominance of the electrohysterogram is associated with vaginal delivery and lack of F dominance is associated with cesarean for labor dystocia. We conducted a prospective cohort study of nulliparous women in spontaneous labor at ≥36 weeks. Clinicians were blinded to electrohysterography data which were in addition to standard cardiotocography. All contractions in the hour preceding diagnosis of complete cervical dilation (for women delivering vaginally) or the hour preceding the decision for cesarean were analyzed. Of 224 patients, 167 had evaluable data. The proportion of F dominant contractions was not different for women undergoing cesarean for labor dystocia (n = 11) compared with all others (n = 156)-88.7 ± 10.2 versus 86.0 ± 11.4%; p = 0.44. Results were similar when comparing the cesarean for labor dystocia group to those undergoing cesarean for other indications (n = 10) and vaginal deliveries (n = 146)-88.7 ± 10.2 versus 86.5 ± 10.0 versus 85.9 ± 11.5%; p = 0.74. We were unable to confirm our earlier finding that F dominance of the electrohysterogram is associated with vaginal delivery and lack of F dominance is associated with cesarean for dystocia.

Comparing Different Partograph Designs for Use in Standard Labor Care: A Pilot Randomized Trial.

Backgound Partographs are used in many labour settings to provide a pictorial overview of a woman's cervical dilation pattern in the first stage of labor and to alert clinicians to slow progress possibly requiring intervention. Recent reviews called for large trials to establish the efficacy of partographs to improve birth outcomes whilst highlighting issues of clinician compliance with use. Previous studies have also reported issues with participant recruitment related to concerns regarding the possibility of a longer labour. Objectives We sought to compare a standard partograph with an action line, to a newly designed partograph with a stepped line, to determine the feasibility of recruitment to a larger clinical trial. Methods A pragmatic, single-blind randomised trial wherein low-risk, nulliparous women in spontaneous labour at term were randomized to an action-line or stepped-line partograph. First stage labour management was guided by the allocated partograph. Primary outcomes included the proportion of eligible women recruited, reasons for failed recruitment and compliance with partograph use. Secondary outcomes included rates of intervention, mode of birth, maternal and neonatal outcomes. Results Of the 384 potentially eligible participants, 38% (149/384) were approached. Of these 77% (116/149) consented, with 85% (99/116) randomized, only nine women approached (6%) declined to participate. A further 9% (14/149) who were consented antenatally were not eligible at onset of labor and 7% (10/149) of women approached in the birth suite but did not meet the inclusion criteria. Compliance with partograph completion was 65% (action) versus 84% (dystocia line). Conclusions for Practice Participant recruitment to a larger randomized controlled trial comparing new labour management guidelines to standard care is feasible. Effective strategies to improve partograph completion compliance would be required to maintain trial fidelity.

Management of Spontaneous Labor in Primigravidae: Labor Scale versus WHO Partograph (SLiP Trial) Randomized Controlled Trial

We aimed to compare maternal and neonatal outcomes of spontaneous term labor among primigravidae who were monitored by the novel labor scale versus the World Health Organization (WHO) partograph. A single center, double-blinded randomized trial had been conducted between July 2015 and June 2016. Nulliparous women in spontaneous labor with singleton term pregnancies were randomized to either labor scale or the WHO partograph for management of labor. Primary outcome was successful vaginal delivery. Secondary outcome included low APGAR scores, birth injuries, postpartum hemorrhage, and infection. One hundred ten patients were randomized (55 in each arm). Women managed with labor scale had significantly lower rate of cesarean deliveries than women managed with the partograph arm (3.6% versus 18.2%, P=0.03). There was a significant reduction in the rate and duration of oxytocin administration for augmentation of labor (21.8% versus 69.1%, P < 0.0001) and a significant increase in average 1-minute APGAR score in the labor scale group. Labor monitoring with the labor scale is associated with lower rate of cesarean section, less and shorter use of oxytocin for augmentation of labor. Monitoring of labor progress starting at 5 cm or more is also associated with lower rate of cesarean delivery.

Intravenous fluid rate for reduction of cesarean delivery rate in nulliparous women: a systematic review and meta-analysis.

The National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine have emphasized the need to promote vaginal delivery and have offered recommendations to safely prevent primary cesarean delivery. However, there has been limited discussion regarding management of intravenous fluids and other aspects of labor management that may influence mode of delivery. Therefore the aim of our study was to determine whether an intravenous fluid rate of 250 vs. 125 mL/h is associated with a difference in cesarean delivery rate. Searches were performed in MEDLINE, OVID, Scopus, ClinicalTrials.gov, the PROSPERO International Prospective Register of Systematic Reviews, Embase, Web of Science, and the Cochrane Library for randomized controlled trials. We included all randomized controlled trials comparing intravenous fluid rates of 250 vs. 125 mL/h in nulliparous women in spontaneous labor at term with singleton pregnancies at ≥36 weeks. Studies were included regardless of the type of intravenous fluids used and regardless of whether oral intake was restricted during labor. Studies including multiparous women or women whose labor was induced were excluded. The primary outcome was the incidence of cesarean delivery. We planned to assess a subgroup analysis according to type of fluids used and according to restriction of oral fluid intake. Seven trials including 1215 nulliparous women in spontaneous labor at term were analyzed; 593 (48.8%) in the 250 mL/h group, and 622 (51.2%) in the 125 mL/h group. Five studies used lactated Ringer's solution, one used normal saline in dextrose water, and in one study it was unclear which intravenous fluid was used. Women who received intravenous fluids at 250 mL/h had a significantly lower incidence of cesarean delivery for any indication (12.5 vs. 18.1%; RR 0.70, 95% CI 0.53-0.92; seven studies, 1215 participants; I2 = 0%) and for dystocia (4.9 vs. 7.7%; RR 0.60, 95% CI 0.38-0.97; five studies, 1093 participants; I2 = 18%), a significantly shorter mean duration of labor of about one hour (mean difference -64.38 min, 95% CI -121.88 to -6.88; six studies, 1155 participants; I2 = 83%) and a significantly shorter mean length of second stage of labor (mean difference -2.80 min, 95% CI -4.49 to -1.10; 899 participants; I2 = 22%) compared with those who received intravenous fluid at 125 mL/h. No differences were found in the other secondary outcomes. There were no maternal or perinatal deaths and only one woman, in the 125 mL/h group, developed pulmonary edema. The findings persisted regardless of the type of intravenous fluid used. No significant reduction in the incidence of cesarean delivery was demonstrated in women with unrestricted oral intake; however, this was limited to only two studies evaluating 254 women. Our findings provide evidence that the duration of labor in low-risk nulliparous women may be shortened by a policy of intravenous fluids at a rate of 250 mL/h rather than 125 mL/h. A rate of 250 mL/h seems to be associated with a reduction in the incidence of cesarean delivery compared to 125 mL/h. The number needed to treat to prevent one cesarean delivery is 18 women. Our data support increased hydration among nulliparous women in labor when oral intake is restricted. Further study is needed regarding risks and benefits of increased hydration among women with unrestricted oral intake, those undergoing induction of labor, and those with medical comorbidities.

First stage of labour management practices: A survey of Australian obstetric providers.

To report on the opinions and reported practices of Australian obstetricians and general practice (GP) obstetricians, in the definition and management of spontaneous first stage of labour, in low-risk nulliparous women. Cross-sectional survey sent electronically to all Australian Specialist obstetricians (FRANZCOG) and Diplomates. Respondents answered questions regarding care of nulliparous women in spontaneous labour at term across three domains: (i) practitioners' characteristics; (ii) current practice; (iii) opinion regarding joint statement by ACOG/SMFM (Society of Maternal Fetal Medicine) 'Safe prevention of primary caesarean section'. The dataset included responses from 664 participants, representing 29% of Specialists and 11% of Diplomates. Responses varied in the criteria used to define normal labour, and the diagnosis and management of prolonged labour. Clinicians with more post-qualification experience considered the minimal acceptable progress to be faster than those with fewer years of experience (P = 0.02). Clinicians working in higher acuity hospitals were more likely to augment labour for longer prior to recommending a caesarean section for active phase arrest, compared to those in lower acuity hospitals (P = 0.025). The majority of respondents (58.2%) already based their practice on the ACOG/SMFM 'Safe prevention of primary caesarean section' statement, or would now consider changing their practice. There is a lack of consensus among Australian obstetricians and GP obstetricians regarding definition of normal progress in first stage of labour and how to manage abnormal progress; however, many are open to new recommendations for practice.

Evolution of cesarean categories in a modified Robson classification in a single center from 2002 to 2012 due to high rate of maternal pathology.

To study the evolution in cesarean section (CS) categories in a single center from 2002 to 2012. We performed a retrospective study on all live births from 2002, 2007, and 2012 using a modified Robson classification accounting for cervical ripening in the induction groups, post-term pregnancies, and the number of uterine scars. We recorded 2162, 2105 and 2380 deliveries with caesarean delivery rates of 23.2%, 24.9%, and 30.4% in 2002, 2007, and 2012 respectively. Nulliparous women in spontaneous labor (group 1) decreased from 36.3% to 27.4% of the total population, but CS rates in this group increased from 14.1% to 19.5% (P < 0.05). Labor induction and CS before labor in nulliparous women category (group 2) increased from 6.7% to 14.2% but with stable CS rates. Induction of labor and cervical ripening in this group increased from 91 and nine in 2002 to 119 and 240 in 2012, respectively. In the same period, maternal pathology increased from 11% to 33%. Scarred uterus remained the major source of CS (almost 30% of all CS in 2012). CS rates increased throughout the studied period, associated with an increase in rates of maternal pathology, induction by cervical ripening, and scarred uterus.