Nulliparous Women In Spontaneous Labor Research Articles

Impact of Walking Epidural Analgesia on Obstetric Outcome of Nulliparous Women in Spontaneous Labour

Impact of Walking Epidural Analgesia on Obstetric Outcome of Nulliparous Women in Spontaneous Labour

Midwives’ perception of the intrapartum risk of healthy nulliparae in spontaneous labour, in The Flanders, Belgium

Objective to explore midwives’ perception of intrapartum risk for healthy nulliparous women in spontaneous labour at term of a healthy singleton pregnancy, in the Belgian Flanders, and to compare these results with those of a previous study undertaken in England. Design survey of the care midwives would advocate and their perception of intrapartum risk using a standardised scenario. This study replicates part of a survey undertaken with British midwives ( Mead & Kornbrot 2004b). With an added section to capture the particulars of the Belgian situation and explore the likelihood of midwives being fully responsible for the whole intrapartum care of healthy women, including their delivery. The questionnaire was translated into Dutch by MR and distributed by the Flemish Midwives’ Association (Vlaamse Organisatie van Vroedvrouwen—VLOV). Participants all 845 midwives and 143 student midwives who were members of VLOV were sent a questionnaire with their invitation to take part in their annual conference. Two hundred and seventy-five midwives and 107 students attended the conference, and 128 questionnaires were returned at the conference: 99 midwives (36% of the attendees), 26 students (24% of attendees), with three unidentified respondents. This convenience sample represented 12% of all midwives and 18% of all students. Analysis SPSS for Windows was used for the statistical analysis. Descriptive statistics were used and differences between categorical variables were analysed using χ 2 and Fisher's Exact tests, and differences between continuous variables were analysed by analysis of variance. Findings midwives generally described a more medicalised approach to intrapartum care on admission and during the first stage of labour than their British counterparts, but were much more optimistic about the chances of healthy women in spontaneous labour achieving a normal delivery within 12 hours. However, Belgian midwives had only a limited ability to undertake normal deliveries because of the high proportion of obstetricians who fulfil this responsibility. This contravenes the European Union (EU) directive on the activities of the midwife. Key conclusions despite much greater involvement of obstetricians in the care, of women suitable for full midwifery care, and a more medicalised approach to intrapartum care, the Belgian Flanders have a significantly lower caesarean section rate than the UK. The inability of Belgian midwives to fulfil the activities of the midwives as identified by the EU directives raises questions about the migration of midwives trained in Belgium to other EU member states.

Impact of walking epidural analgesia on obstetric outcome of nulliparous women in spontaneous labour

To explore the effects of walking epidural analgesia on obstetric and neonatal outcomes, we performed a case-control study. Each nulliparous woman receiving walking epidural analgesia using 0.0625% bupivacaine (n = 44) was matched to two nulliparous historical controls receiving 0.125% or 0.25% bupivacaine (n = 88 each) for epidural analgesia while recumbent. Maternal and obstetric parameters, fetal status and presentation, and oxytocin use were comparable among groups. Those receiving walking epidural analgesia walked for a mean of 60 min (range: 20-75 min). In the control groups the mean total durations of labour were shorter (58 min in the 0.125% group and 99 min in the 0.25% group, P < 0.05). Significantly fewer walking epidural analgesia cases than controls required instrumental vaginal delivery (P < 0.05). No other differences in obstetric or fetal outcome were observed and no mother fell or stumbled while walking. Although it was associated with a prolonged first stage of labour, walking epidural analgesia appeared safe for nulliparous women and their babies.

Dystocia increases with advancing maternal age

Human physical performance peaks before 25 years of age. Demographic trends in western countries indicate an increasing maternal age at first childbirth. We have examined the relationship between age and indices of uterine efficiency in nulliparous women in spontaneous labor at term to assess whether labor performance is affected by age.

The Risk of Cesarean Delivery With Neuraxial Analgesia Given Early versus Late in Labor

The recommendation that epidural anesthesia be delayed in nulliparous women until there is 4–5 cm of cervical dilatation rests on an increased risk of cesarean delivery at less than 4.0 cm. It is not clear whether this is a result of the analgesia or other factors. The authors postulated that neuraxial analgesia administered early in labor using intrathecal opioid, as part of a low-dose local anesthetic technique, would not increase the risk of operative delivery. A randomized trial enrolled 728 nulliparous women at term who either were in spontaneous labor or had spontaneous rupture of membranes and whose cervical dilatation was less than 4.0 cm. The participants received either intrathecal fentanyl, with bupivacaine added as needed, or systemic (intravenous and intramuscular) hydromorphone when they first asked for analgesia. Epidural analgesia was started at the second request for analgesia in the intrathecal group, and at cervical dilatation of 4.0 or more, or at the third request for pain relief in the systemic group. Rates of cesarean delivery did not differ significantly between the 2 groups, and there also were no significant differences in the rate of instrumental vaginal delivery or indications for operative delivery. The maximum rate of oxytocin infusion was, however, higher in women given systemic analgesia. Neither type of insurance (private or public) nor different obstetric providers made a difference. Times from initial analgesia to complete dilatation and vaginal delivery were significantly shorter when intrathecal analgesia was used. The intrathecal group had less nausea and vomiting, and neuraxial analgesia lasted longer in this group than in women given systemic analgesia. There was no significant group difference in worrisome fetal heart rate tracings. The findings in this randomized trial indicate that nulliparous women in spontaneous labor, or having spontaneous membrane rupture, may receive neuraxial analgesia early in the course of labor without adverse effects. Early neuraxial analgesia does not appear to increase the number of cesarean deliveries compared with systemic opioid analgesia, and it may shorten labor.

The continuing effectiveness of active management of first labor, despite a doubling in overall nulliparous cesarean delivery

The purpose of this study was to determine the continuing effectiveness of active management of labor, a protocol that involves early detection and correction of dystocia with oxytocin in spontaneous cephalic nulliparous labor, by analysis of the contribution of this cohort to a doubled overall nulliparous cesarean delivery rate. This was a retrospective analysis of annually collated institutional data on cesarean delivery and perinatal outcome. From 1989 to 2000, 81,855 women were delivered at the National Maternity Hospital, of whom 34,201 women (42%) were nulliparous; the annual proportion of nulliparous women in spontaneous labor decreased progressively from 83% to 60%; the overall nulliparous cesarean rate increased from 8.1% to 16.6%. Cesarean birth rate among nulliparous women in spontaneous labor, although showing a significant upward trend between 1989 and 2000 (2.4%-4.8%; P = .001), was stable, averaging 5% for the last 8 years (P = .705); the peripartum death rate in this group fell significantly (P = .024). Comparing results for 1989 with results for 2000, nulliparous women in spontaneous labor accounted for 14% of the overall increase in cesarean deliveries (dystocia, 5%), compared with 51% for nulliparous women with induced labor. The perinatal mortality rate in term infants was unchanged. Active management of spontaneous first labors remains an effective protocol for the promotion of vaginal delivery with low peripartum mortality rates; factors other than dystocia in spontaneous labor account for the progressive increase in the nulliparous cesarean delivery rate.

Active management of labour revisited: the first 1000 primiparous labours in 2000

This was a prospective observational study in a tertiary referral obstetric unit in Dublin to ascertain the delivery outcome in the first 1000 nulliparous women in 2000. The initial diagnosis of labour was confirmed in the first 1000 consecutive nulliparous women in spontaneous labour with cephalic presentation at term. All patients underwent active management of labour. Active management included strict criteria for the diagnosis of labour, early amniotomy, 2-hourly vaginal examinations, oxytocin augmentation where progress of labour was slow and the presence of a companion (personal nurse) in labour. Epidural analgesia was freely available. Mode of delivery, duration of labour, analgesia usage and maternal and perinatal complications were the main outcome measures. All patients presented with painful uterine contractions, 75% with show in addition, and 36% had spontaneous rupture of membranes on admission. Eighty per cent presented with a cervical dilatation of h 2 cm; 72.2% had epidural for pain relief. In 81.8% of cases electronic fetal monitoring was used to monitor the baby. Oxytocin was used in 51.8% to augment labour and a further 6.4% required its use for the first time in the second stage of labour. Fetal blood sampling was performed in 20.8%. The spontaneous vaginal delivery rate was 71.8%, 4.2% were delivered by caesarean section and the operative vaginal delivery rate was 24%. The incidence of prolonged labour (labour duration >12 hours) was 4.3%. Postpartum haemorrhage occurred in 3.8% of mothers and 1.6% of babies were admitted to the special care baby unit. Our study suggests that active management of labour is associated with a low incidence of prolonged labour and a low caesarean section rate.

▪ Graphic Analysis of Actively Managed Labor: Prospective Computation of Labor Progress in 500 Consecutive Nulliparous Women in Spontaneous Labor at Term

▪ Graphic Analysis of Actively Managed Labor: Prospective Computation of Labor Progress in 500 Consecutive Nulliparous Women in Spontaneous Labor at Term

Graphic analysis of actively managed labor: Prospective computation of labor progress in 500 consecutive nulliparous women in spontaneous labor at term

Objective: Active management has been shown to shorten the length of labor and reduce the incidence of prolonged labor. We examined the influence of this protocol on the rate of cervical dilatation by calculating a mean partogram to explain how this acceleration is achieved. Study Design: We retrospectively analyzed partograms of cervical dilation in 500 consecutive nulliparous women in spontaneous labor at term with a singleton fetus in a cephalic presentation; cesarean deliveries were not excluded. Mean cervical dilations at admission and mean time intervals to reach 2, 3, 4, 6, 8, and 10 cm of dilatation and delivery were calculated, with 95% confidence intervals, both for the whole cohort and specifically in women with cervical dilatations <3 cm at admission. These data were used to construct mean partograms. Results: The mean duration of labor was 6.1 hours. The mean cervical dilatation at admission was 1.7 cm; all but 2.8% were delivered within 12 hours. The cesarean rate was 5.4%. The mean partogram, with narrow 95% confidence intervals, shows a rapid active phase after a much shorter latent phase than reported in other analyses of labor. Conclusion: Active management reduces the duration of first labor mainly by shortening the latent phase in association with amniotomy at very early cervical dilatations and does not delay the diagnosis of labor until the active phase has begun. (Am J Obstet Gynecol 2000;183:438-43.)

Effect of epidural analgesia on fetal head malpositioning at vaginal delivery

Objective: To determine if nulliparous women receiving labor epidural analgesia (LEA) with combined local anesthetic/narcotic infusions are more likely to have malpositioning of the fetal vertex at delivery when compared with women not receiving epidural analgesia.Study design: Retrospective cohort analysis of nulliparous women with spontaneous labor delivered during a 12-month period immediately before the availability of on-demand LEA (Before group), and a similar group of nulliparas delivered during the 12 months after LEA was available on request (After group). The primary outcome variable was a nonocciput anterior position of the fetal head at vaginal delivery.Results: The frequency of LEA increased from 1.2% in the Before period to 83.6% in the After period. Fetal head malpositioning (occiput transverse or posterior position) at vaginal delivery occurred in 29 of 422 (6.9%) women delivered in the Before period, compared with 21 of 346 (6.1%) in the After period (P = NS). There was no statistically significant difference in the incidence of fetal head malpositioning between the Before and After periods after patients were stratified according to mode of delivery (Mantel–Haenszel weighted relative risk = 0.94, 95% CI 0.6–1.4). The sample size was sufficient to exclude a doubling in the incidence of fetal head malpositioning associated with on-request labor epidural analgesia.Conclusions: Providing on-request labor epidural analgesia with combined local anesthetic/narcotic to nulliparous women in spontaneous labor does not result in a clinically significant increase in the frequency of fetal head malpositioning at vaginal delivery.

Controversies of Labor Epidural Analgesia

Controversies of Labor Epidural Analgesia

Epidural Analgesia Compared with Combined Spinal-Epidural Analgesia During Labor in Nulliparous Women

NAGEOTTE, MICHAEL P.; LARSON, DAVID; RUMNEY, PAMELA J.; SIDHU, MOHAN; HOLLENBACH, KATHERINE Author Information

Does epidural analgesia cause dystocia?

Study Objective: To analyze the effects of epidural analgesia for labor when dystocia occurs. Design: Retrospective cohort study. Setting: Academic health center. Patients: 641 low risk, nulliparous women in spontaneous labor. Interventions: 406 (63%) women received epidurals analgesia and 253 (37%) did not. Sixty women (9.4%) required an abdominal delivery for dystocia. Measurements and Main Results: Women receiving epidural analgesia were more likely to be white, receive care from an attending physician, need labor augmentation, and deliver a heavier infant. Multivariate analysis identified five variables predictive of dystocia and abdominal delivery: pitocin augmentation odds ratio (O.R.) = 3.9 (2.0 to 7.6), duration of labor more than 20 hours O.R. = 2.4 (1.3 to 4.4), high epidural dose O.R. = 2.2 (1.2 to 4.1), birthweight over 4,000 grams O.R. = 2.0 (1.0 to 4.2), and early placement of epidural O.R. = 1.9 (1.0 to 3.5). Repeating the regression after excluding the 20 women who developed abnormal labor prior to epidural placement (18 of 20 women had protracted dilatation) demonstrated that pitocin augmentation O.R. = 4.0 (1.8 to 4.), high epidural dose O.R. = 3.0 (1.9 to 6.2), duration of labor greater than 20 hours O.R. = 2.7 (1.3 to 5.7), and birthweight over 4,000 grams O.R. = 2.1 (0.9 to 4.8) were associated with dystocia. Conclusion: Epidural analgesia appears to be a marker of abnormal labor rather than a cause of dystocia. High concentration anesthetics and epinephrine should be avoided, as they may influence labor. Randomized, controlled trials of this technique will be difficult to do; our work should reassure patients and their clinicians that epidural analgesia does not adversely affect labor.

The association of fetal sex with the rate of cesarean section

OBJECTIVE: Our purpose was to evaluate the rate of cesarean deliveries according to fetal sex. STUDY DESIGN: We evaluated method of delivery, indication for cesarean section, and infant outcome according to fetal sex in 2439 low-risk nulliparous women in spontaneous labor. Crude odds ratios and 95% confidence intervals were calculated. Confounding was controlled with use of logistic regression. RESULTS: The overall cesarean section rate was 13.2% among 1246 women carrying male fetuses compared with 9.6% among 1193 women carrying female fetuses (odds ratio 1.4, 95% confidence interval 1.1 to 1.8). There was a 30% increase in cesarean sections for failure to progress (odds ratio 1.3, 95% confidence interval 1.0 to 1.8) and a 70% increase in those for fetal distress (odds ratio 1.7, 95% confidence interval 1.0 to 3.0). When adjusted for gestational age and fetal size, male fetal sex no longer predicted the risk of cesarean delivery for failure to progress (adjusted odds ratio 1.04, 95% confidence interval 0.8 to 1.4) but continued to predict the risk of cesarean section for fetal distress (adjusted odds ratio 2.2, 95% confidence interval 1.3 to 4.0). Among infants delivered by cesarean section for fetal distress, males were more than three times as likely than females to have an Apgar score ≤7 at both 1 and 5 minutes. CONCLUSION: Increased cesarean deliveries for failure to progress among women with male fetuses is related to the larger size of males, whereas the increase for fetal distress is not, and may relate to other developmental differences between male and female fetuses. (Am J Obstet Gynecal 1997;176:667-71.)

A Multicentre Randomised Trial of Amniotomy in Spontaneous First Labour at Term

Objective To measure the effect of a policy of routine amniotomy on nulliparous labour. Design A multicentre randomised controlled trial. Subjects One thousand four hundred and sixty-three nulliparous women in spontaneous labour at term with intact membranes and a single cephalic fetus. Interventions To have the membranes ruptured routinely early in labour or left intact for as long as possible. Main outcome measures Duration of labour, operative and instrumental delivery rates, use of analgesia, perinatal death, neonatal convulsions and admission to special care. Results Median duration of labour was 8-4 h in the early rupture group and 9-4 h in the late group

Effect of early amniotomy on the risk of dystocia in nulliparous women

Background Early amniotomy has been advocated as a means of preventing dystocia, but its efficacy has not been studied prospectively. The purpose of this multicenter study was to determine whether routine early amniotomy reduces the risk of dystocia for nulliparous women in spontaneous labor. Methods We studied 925 nulliparous women in labor, who were stratified according to the degree of cervical dilatation (<3 cm vs. ≥ 3 cm) and randomly assigned to either early rupture of the membranes (amniotomy group) or conservative management of labor (conservative-management group). Dystocia was defined as a period of at least four hours after dilatation of the cervix to 3 cm had been reached during which the mean rate of cervical dilatation was less than 0.5 cm per hour. Results Dystocia was significantly less frequent in the amniotomy group than in the conservative-management group (34 percent vs. 45 percent; relative risk, 0.8; 95 percent confidence interval, 0.6 to 0.9). The median length of time from randomiz...

RUPTURE OF MEMBRANES BEFORE THE ONSET OF SPONTANEOUS LABOUR INCREASES THE LIKELIHOOD OF INSTRUMENTAL DELIVERY

We studied obstetric outcome in 350 consecutive nulliparous women in spontaneous labour and term pregnancy. Women who presented with rupture of membranes before the onset of contractions were more likely to deliver by forceps compared with those in whom contractions preceded rupture of membranes. This increased likelihood of instrumental delivery was significant with and without the use of extradural analgesia in labour (P less than 0.05 and P less than 0.001, respectively). Furthermore, significantly more women with premature rupture of membranes received extradural analgesia in labour (P less than 0.01). We conclude that any study which aims to examine the influence of extradural analgesia on the outcome of delivery should include premature rupture of membranes as a bias factor.

A Controlled Trial of a Program for the Active Management of Labor

Over the past two decades, the rate of cesarean section in the United States has risen from 5 percent to 25 percent of deliveries, primarily because of the increased frequency of dystocia (arrest of labor). One strategy that has been proposed for increasing the rate of vaginal delivery is a program of active management of labor that encourages early amniotomy, early diagnosis of slow progress in labor, and the use of higher than usual doses of oxytocin; the efficacy and safety of this approach are uncertain, however. We conducted a randomized trial in which nulliparous women in spontaneous labor at term were randomly assigned to either active management of labor or traditional management. With active management, amniotomy was performed within one hour of the diagnosis of labor, and when the rate of cervical dilation was less than 1 cm per hour, oxytocin was infused at an initial rate of 6 mU per minute. The dose was increased by 6 mU per minute every 15 minutes (to a maximum of 36 mU per minute) until there were seven contractions every 15 minutes. For the women assigned to active management (n = 351), the cesarean-section rate was 10.5 percent, as compared with 14.1 percent for those assigned to traditional management (n = 354, P = 0.18). The 26 percent reduction in the cesarean-section rate was due primarily to a decrease in dystocia. After we controlled for potential confounding variables, the reduction in the rate of delivery by cesarean section was statistically significant (odds ratio for women given active as compared with traditional management, 0.57; 95 percent confidence interval, 0.36 to 0.95). With active management, the average length of labor was shortened by 1.66 hours, principally because of earlier amniotomy and earlier use of oxytocin. There was no increase in maternal or neonatal morbidity, and there were significantly fewer infectious complications in the mothers. The program we studied for the active management of labor reduces the incidence of dystocia and increases the rate of vaginal delivery without increasing maternal or neonatal morbidity.

Intervention Rates in Spontaneous Term Labour in Low Risk Nulliparous Women

This study analyses retrospectively the outcome of labour in 3,058 consecutive low risk nulliparous women in spontaneous labour at term in public and private care at the Mater Mothers' Hospital, Brisbane, Queensland. Differing rates of spontaneous, instrumental or Caesarean deliveries were found between the public and private cohorts (spontaneous vaginal delivery 73.7% public, 48.6% private; instrumental 17.9% public, 35.4% private; Caesarean section 8.4% public, 16% private). These differences were all highly statistically significant (p less than .001). Other statistically significant differences were evident in durations of labour and second stage of labour. Demographically the 2 groups were dissimilar, illustrated by differences in age distribution. Correcting for age difference failed to account for the differences in frequency of delivery methods between the private and public groups.

Active management of labor and operative delivery in nulliparous women

There has been a fourfold increase in cesarean births in Canada in the last 20 years. The two main indications are dystocia and repeat cesarean section. Of all primary cesarean sections, about half are due to dystocia. This is largely confined to nulliparous women. Work from Ireland suggests that a policy of active management of labor may reduce dystocia. This involves a uniform policy of amniotomy once a diagnosis of labor is established, followed by oxytocin augmentation if labor is nonprogressive (< 1 cm/hr). From October 1, 1985, to December 31, 1986, this policy was carried out on 552 consecutive normal nulliparous women in spontaneous labor at ≥37 weeks' gestation with a single fetus in vertex presentation with no fetal distress. These results were compared with a control group of 533 similar nulliparous women delivered between January 1, 1984 and March 31, 1985. The cesarean section rate dropped to 4.3% from 13% (p < 0.005) and the forceps delivery rate dropped to 19.4% from 29% (p < 0.005). The duration of labor > 12 hours dropped to 7% from 20% (p < 0.005). There was no increase in fetal morbidity or mortality.