Outcomes In Nulliparous Women Research Articles

Timing of epidural analgesia intervention for labor pain in nulliparous women in Taiwan: A retrospective study

BackgroundLabor pain is probably the most painful event in a woman's life. By the present consensus, epidural analgesia is the most effective and least depressive treatment for labor pain. Recent systematic reviews concluded that the risk of cesarean delivery or instrumental vaginal delivery for women receiving early epidural analgesia has not increased. However, studies designed for discussing this topic in Taiwan are few. In this study, the association of the intervention timing with labor outcomes in nulliparous women in Taiwan is discussed. MethodsWe performed a retrospective chart review in parturients who underwent epidural analgesia for labor pain. Only nulliparae were included and divided into four groups based on the cervical dilatation width of 1, 2, 3, and 4 cm when they underwent epidural analgesia. We retrieved each patient's demographic characteristics, the course of labor and delivery, and the management of epidural analgesia from the medical chart. ResultsA total of 799 nulliparae was included. The numbers of parturients with cervical dilatation width of 1, 2, 3, and 4 cm were 119, 338, 258, and 84 respectively. There was no significant difference in demographic factors, regimen of epidural analgesia, loading volume, and anesthesiologist in charge among the four groups. The percentages of cesarean delivery in the four groups were 27.73%, 20.71%, 15.89%, and 20.24%, respectively, and there was no significant difference among these four groups (p = 0.0651). The incidences of instrumental delivery in four groups were 13.51%, 14.59%, 18.65%, and 21.43% respectively, and there was no significant difference among these four groups either (p = 0.2278). ConclusionOur results revealed that the timing of epidural intervention affects neither the cesarean delivery rate nor the instrumental delivery rate on nulliparae in Taiwan with the cervical dilatation width ranging from 1 cm to 4 cm. The fear of increasing cesarean section rate after early epidural analgesia is unfounded. Women in labor can choose pain relief at any time.

The Effect of Change in a Labour Management Protocol on Caesarean Section Rate in Nulliparous Women

ObjectiveTo investigate the impact on obstetric outcome in nulliparous women of changing labour management from an expectant approach to proactive support of labour. MethodsWe conducted a retrospective cohort study in a teaching hospital in the Netherlands among 858 women ≥ 37 weeks’ gestation with a singleton fetus in cephalic position and spontaneous labour who planned to have a vaginal birth in the hospital under the care of an obstetrician. Exclusion criteria were gestational age < 37 weeks, induction of labour, primary Caesarean section, non-cephalic position, and non-Caucasian ethnicity. Labour outcomes in the period 1999 to 2002 (using an expectant approach) were compared with labour outcomes in the period 2008 to 2010 (using proactive support of labour). The primary outcome measure was the relationship between the CS rate and the form of labour management (expectant approach vs. proactive support). The secondary outcome measure was to identify risk factors for repeat CS. ResultsThe overall prevalence of CS in the study population was 12.2%. The CS rate increased significantly from 9.7% between 1999 and 2002, to 15.4% between 2008 and 2010 (P < 0.001). Meanwhile, the assisted vaginal delivery rate decreased from 22.7% to 16.7% (P = 0.03).Multiple logistic regression showed that epidural analgesia (OR 4.6; 95% CI 2.6 to 8.4), occiput posterior position (OR 7.4; 95% CI 4.3 to 12.8), and advanced maternal age (OR 1.91; 95% 1.31 to 2.76) were risk factors for CS. ConclusionChanging labour management from an expectant approach to proactive support of labour did not decrease the Caesarean section rate.

Labour augmentation and fetal outcomes in relation to birth positions: A secondary analysis of an RCT evaluating birth seat births

Objectivethe aim of this study was to compare the use of synthetic oxytocin for augmentation, duration of labour and birth and infant outcomes in nulliparous women randomised to birth on a birth seat or any other position. Study designa randomised controlled trial in Sweden where 1002 women were randomised to birth on a birth seat (experimental group) or birth in any other position (control group). Data were collected between November 2006 and July 2009. The outcome measurements included synthetic oxytocin augmentation, duration of the second stage of labour and fetal outcome. Analysis was by intention to treat. Settingsouthern Sweden. Findingsthe main findings of this study were that women randomised to the experimental group had a statistically significant shorter second stage of labour than women randomised to the control group. There were no differences between the groups for use of synthetic oxytocin augmentation or for neonatal outcomes. Conclusionswomen allocated to the birth seat had a significantly shorter second stage of labour despite similar numbers of women subjected to synthetic oxytocin augmentation in the study groups. The adverse neonatal outcomes did not differ between groups. The birth seat can be suggested as non-medical intervention used to reduce duration of second stage labour and birth. The birth seat can be suggested as a non-medical intervention that may facilitate reduced duration of the second stage of labour. Furthermore it is recommended that caregivers, both midwives and midwifery students, should learn skills to assist women in using a variety of birth positions. Trial registrationunique Protocol ID: Dnr 2009/739 (register.clinicaltrials.gov).

Effect of Body Mass Index on Pregnancy Outcomes in Nulliparous Women Delivering Singleton Babies: Observational Study

To find out the effect of increasing body mass index (BMI) on pregnancy outcomes in nulliparous women delivering singleton babies. This was a hospital-based observation study, based on 300 nulliparous women delivering singleton babies in June 2009-Sept. 2010. Women were categorized into three groups. Underweight (BMI<20kg/m(2)), normal (BMI 20-24.9kg/m(2)), overweight (BMI 25-29.9kg/m(2)), and obese (BMI>30kg/m(2)) obstetric and perinatal outcomes were compared by univariate and multivariate analysis. Maximum patients who underwent LSCS were having BMI>30kg/m(2) [OR 9.558 (95% CI 5.82-17.27)]. As compared to women of normal BMI (20-24.9kg/m(2)), morbidly obese women faced the higher risk of PIH [OR 8.045 (95% CI 3.875-16.781)]. Obese women were more likely to have post partum hemorrhage [OR 5.11 (95% CI 1.76-14.79)] compared with women of normal BMI. Birth weight <2,500g was more common in women with BMI<25kg/m(2) (21.21%), while highest incidence of birth weight >4,000g (14.29%) is seen in women of the obese group. Increasing BMI is associated with increased incidence of cesarean delivery, PIH, post partum hemorrhage, and macrosomic babies.

Neuraxial analgesia versus intravenous remifentanil for pain relief in early labor in nulliparous women

To assess if there is a difference in duration of labor, the mode of delivery, average Visual Analog Scale (VAS) pain scores, maternal overall satisfaction with analgesia, side effects and neonatal outcomes in nulliparous women who received early labor analgesia with either epidural, patient-controlled IV analgesia (PCIA) with remifentanil or combined spinal-epidural (CSE) techniques. This is a prospective randomized interventional study. The study included 1,140 healthy nulliparous women (with term, singleton pregnancies) early in labor, requesting labor analgesia, during the period from September 2009 to August 2011 at TAIBA Hospital in Kuwait. The participants were randomized to receive either epidural analgesia (Group I), or PCIA with remifentanil (Group II) or CSE analgesia (Group III). The primary outcome was the rate of cesarean delivery. CSE analgesia was associated with a statistically highly significant decrease in labor duration (from analgesia to vaginal delivery), duration of latent and active phases of the first stage, and duration of the second stage of labor, average VAS pain scores, and a highest maternal overall satisfaction score with analgesia (P<0.01) as compared to epidural analgesia or PCIA with remifentanil. In terms of labor duration, average VAS pain scores, and maternal overall satisfaction score with analgesia, CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women. However, there were no differences in the mode of delivery, side effects or neonatal outcomes between the three techniques.

An Analysis of Second-Stage Labor beyond 3 Hours in Nulliparous Women

To analyze outcomes after second-stage labor beyond 3 hours and determine if prolonged second stages were intentional. Retrospective cohort analysis of maternal and neonatal outcomes in nulliparous women based on second-stage duration. Medical records were reviewed for management decisions in women with second stages ≥4 hours; all other outcomes were accessed via computerized obstetric database. Second stage exceeding 3 hours occurred in 1489 (7%) of 21,991 pregnancies analyzed. Of the 427 (2%) with second stages ≥4 hours, 315 (74%) reached 4 hours unintentionally, after a decision for operative delivery had been made. Only 34 (8%) women were intentionally allowed to continue second-stage labor beyond 4 hours, and half of these ultimately required cesarean. Indices of maternal and neonatal morbidity were significantly increased when second stages exceeded 3 hours. Most second stages reaching 4 hours are unintentional, occurring while awaiting an previously decided upon operative delivery. Maternal and neonatal morbidities are significantly increased with second stages beyond 3 hours.

Length of the First Stage of Labor and Associated Perinatal Outcomes in Nulliparous Women

OBJECTIVE:To estimate whether length of the first stage of labor is associated with adverse maternal and neonatal outcomes.METHODS:This is a retrospective cohort study of nulliparous women with term, singleton gestations delivered in one academic center between 1990 and 2008. The length of the first

Comparison of neonatal and maternal outcomes in nulliparous women 40 years or older with spontaneous versus IVF autologous egg or IVF donor egg singleton pregnancies

Comparison of neonatal and maternal outcomes in nulliparous women 40 years or older with spontaneous versus IVF autologous egg or IVF donor egg singleton pregnancies

Physicians' perspectives and practices regarding the fertility management of obese patients

To assess the practice patterns and personal beliefs of fertility physicians who care for obese patients seeking assisted reproduction, we conducted a national survey of fertility program directors from both private and academic practices and discovered that although few practices have firm guidelines regarding the management of obese patients, the overwhelming majority of providers believe that body mass index guidelines or cutoffs should exist.

Extreme Morbid Obesity and Labor Outcome in Nulliparous Women at Term

We examined the prevalence of cesarean delivery (CD) among women with morbid obesity and extreme morbid obesity. Using Kentucky birth certificate data, a cross-sectional analysis of nulliparous singleton gestations at term was performed. We examined the prevalence of CD by body mass index (BMI; in kg/m2) using the National Institutes of Health/World Health Organization schema and a modified schema that separates extreme morbid obesity (BMI ≥ 50) from morbid obesity (BMI ≥ 40 to < 50). Bivariate and multivariate analyses were performed. Multivariate modeling controlled for maternal age, estimated gestational age, birth weight, diabetes, and hypertensive disorders. Overall, 83,278 deliveries were analyzed. CD was most common among women with a prepregnancy BMI ≥ 50 (56.1%, 95% confidence interval 50.9 to 61.4%). Extreme morbid obesity was most strongly associated with CD (adjusted odds ratio 4.99, 95% confidence interval 4.00 to 6.22). Labor augmentation decreased the likelihood of CD among women with extreme morbid obesity, but this failed to reach statistical significance. We speculate a qualitative or quantitative deficiency in the hormonal regulation of labor exists in the morbidly obese parturient. More research is needed to better understand the influence of morbid obesity on labor.

No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome in nulliparous women giving birth on a birth seat: results of a Swedish randomized controlled trial.

BackgroundThe WHO advises against recumbent or supine position for longer periods during labour and birth and states that caregivers should encourage and support the woman to take the position in which she feels most comfortable. It has been suggested that upright positions may improve childbirth outcomes and reduce the risk for instrumental delivery; however RCTs of interventions to encourage upright positions are scarce. The aim of this study was to test, by means of a randomized controlled trial, the hypothesis that the use of a birthing seat during the second stage of labor, for healthy nulliparous women, decreases the number of instrumentally assisted births and may thus counterbalance any increase in perineal trauma and blood loss.MethodsA randomized controlled trial in Sweden where 1002 women were randomized to birth on a birth seat (experimental group) or birth in any other position (control group). Data were collected between November 2006 and July 2009. The primary outcome measurement was the number of instrumental deliveries. Secondary outcome measurements included perineal lacerations, perineal edema, maternal blood loss and hemoglobin. Analysis was by intention to treat.ResultsThe main findings of this study were that birth on the birth seat did not reduce the number of instrumental vaginal births, there was an increase in blood loss between 500 ml and 1000 ml in women who gave birth on the seat but no increase in bleeding over 1000 ml and no increase in perineal lacerations or perineal edema.ConclusionsThe birth seat did not reduce the number of instrumental vaginal births. The study confirmed an increased blood loss 500 ml - 1000 ml but not over 1000 ml for women giving birth on the seat. Giving birth on a birth seat caused no adverse consequences for perineal outcomes and may even be protective against episiotomies.Trial registration numberClinicalTrials.gov.ID: NCT01182038

Timing of operative vaginal delivery and associated perinatal outcomes in nulliparous women

Objective. To compare perinatal outcomes in nulliparous women who had operative vaginal delivery early during second stage (1–3 h) to those who delivered vaginally with a prolonged second stage (>3 h).Methods. This is a retrospective cohort study of nulliparas with term, singleton, vaginal deliveries beyond the first hour of second stage. Women who underwent operative vaginal deliveries (OVD) during 1–3 h of the second stage were compared to women who delivered vaginally but with a second stage duration of >3 h. Perinatal outcomes were examined using chi-square test, and potential confounders were controlled for using multivariable logistic regression analysis.Results. Nulliparas delivered vaginally beyond 3 h of second stage had lower odds of third or fourth degree perineal lacerations (aOR = 0.63, 95% CI 0.51–0.77), neonatal cephalohematoma (aOR = 0.48, 95% CI 0.28–0.83) and admissions to intensive care nursery (aOR = 0.70, 95% CI 0.49–0.99) compared to operative vaginal deliveries during 1–3 h of second stage.Conclusion. Compared to nulliparas who had operative vaginal deliveries performed early (1–3 h) in the second stage, women who delivered later (>3 h duration of second stage), either by spontaneous or operative vaginal delivery, had lower risk of third or fourth degree perineal lacerations without incurring risk of increased adverse neonatal outcomes.

Inherited Thrombophilia Polymorphisms and Pregnancy Outcomes in Nulliparous Women

Said, J.M.; Higgins, J.R.; Moses, E.K.; Walker, S.P.; Borg, A.J.; Monagle, P.T.; Brennecke, S.P. Author Information

The Influence of Maternal Age on Pregnancy Outcome in Nulliparous Women with Twin Gestation

We sought to determine if outcomes of nulliparous twin pregnancies differ based on maternal age. Nulliparous women with current twin pregnancies were identified from a database of women enrolled for outpatient nursing surveillance. Data were stratified into four groups by maternal age: less than 20, 20 to 34, 35 to 39, and greater than or equal to 40 years. Maternal and neonatal outcomes for women less than 20, 35 to 39, and 40 or more were compared with 20- to 34-year-old controls using Kruskal-Wallis, Mann-Whitney, and Pearson chi-square analyses. We analyzed 2144 nulliparous twin pregnancies. Patients ≥35 years (34 to 39, 78.5% or ≥40, 85.9%) were more likely to have cesarean deliveries compared with controls 20 to 34 years old (71.2%). Women aged 35 to 39 were less likely to deliver at <37 weeks, and women in the ≥40 group were less likely to deliver at <35 weeks due to spontaneous preterm labor compared with the controls. Neonates born to women aged 35 to 39 had a greater gestational age at delivery and larger average birth weight than controls. Maternal and neonatal outcomes were not adversely influenced by advanced maternal age in nulliparous women carrying twin gestations.

Length of the First Stage of Labor and Associated Perinatal Outcomes in Nulliparous Women

To estimate whether length of the first stage of labor is associated with adverse maternal and neonatal outcomes. This is a retrospective cohort study of nulliparous women with term, singleton gestations delivered in one academic center between 1990 and 2008. The length of the first stage was stratified into three subgroups: less than the 5th percentile, 5th to 95th percentile, and greater than the 95th percentile. Maternal and neonatal outcomes were compared using the χ test. Multivariable logistic regression models were used to control for confounders. Of the 10,661 nulliparous women meeting study criteria, the median (50th percentile) length of the first stage was 10.5 hours. Compared with women with a first stage between 2.8 and 30 hours (5th to 95th percentile thresholds), the risk of cesarean delivery was higher (6.1% compared with 13.5%; adjusted odds ratio [OR], 2.28, 95% confidence interval [CI], 1.92-2.72) in women with a first stage longer than 30 hours (greater than the 95th percentile). These women also had higher odds of chorioamnionitis (12.5% compared with 23.5%; adjusted OR, 1.58; 95% CI, 1.25-1.98) and neonatal admission to the neonatal intensive care unit (4.7% compared with 9.8%; adjusted OR, 1.53; 95% CI, 1.18-1.97) but no other associated adverse neonatal outcomes. Women with a prolonged first stage of labor have higher odds of cesarean delivery and chorioamnionitis, but their neonates are not at risk of increased morbidity. II.

Body mass index and obstetric outcomes in Saudi Arabia: a prospective cohort study

BACKGROUND AND OBJECTIVES:We examined the effect of body mass index in early pregnancy on pregnancy outcome since no study in Saudi Arabia has addressed this question.METHODS:This prospective cohort study involved women registered for antenatal care during the first month of pregnancy at primary health care centers in Al-Hassa, Saudi Arabia. Data was collected from records and by direct interview.RESULTS:The study included 787 women. Compared to normal weight women (n=307), overweight (n=187) and obese (n=226) women were at increased risk for pregnancy-induced hypertension (RR=4.9 [95% CI 1.6-11.1] and 6.1 [95% CI 2.1-17.8], respectively), gestational diabetes (RR=4.4 [95% CI 1.2-16.3] and 8.6 [95% CI 2.6-28.8]), preeclamptic toxemia (RR=3.8 [95% CI 1.1-14.6] and 5.9 [95% CI 1.7-20.4]), urinary tract infections (RR=1.4 [95% CI 0.5-3.9] and 3.7 [95% CI 1.7-6.2]), and cesarean delivery (RR=2.0 [95% CI 1.3-3.0] in obese women). Neonates born to obese women had an increased risk for postdate pregnancy (RR=3.7 [95% CI 1.2-11.6]), macrosomia (RR=6.8 [95% CI 1.5-30.7]), low 1-minute Apgar score (RR=1.9 [95% CI 1.1-3.6]), and admission to neonatal care units (RR=2.1 [95% CI 1.2-2.7]). On the other hand, low birth weight was less frequent among obese women (RR=0.5 [95% CI 0.3-0.9]) while the risk was high among underweight women (RR=2.3 [95% CI 1.4-3.8])CONCLUSION:Even with adequate prenatal care, overweight and obesity can adversely affect pregnancy outcomes.

Inherited Thrombophilia Polymorphisms and Pregnancy Outcomes in Nulliparous Women

Said, Joanne M. MBBS, FRANZCOG, CMFM, PhD; Higgins, John R. MRCOG, FRANZCOG, MD; Moses, Eric K. MSc, PhD; Walker, Susan P. MBBS, FRANZCOG, CMFM, MD; Borg, Anthony J. BSc; Monagle, Paul T. MBBS, FRCPA, FRACP, MD; Brennecke, Shaun P. MBBS, FRANZCOG, DPhil Author Information

Inherited Thrombophilia Polymorphisms and Pregnancy Outcomes in Nulliparous Women

Inherited Thrombophilia Polymorphisms and Pregnancy Outcomes in Nulliparous Women

Inherited Thrombophilia Polymorphisms and Pregnancy Outcomes in Nulliparous Women

To estimate the association between five commonly inherited thrombophilia polymorphisms and adverse pregnancy outcomes in women who had no prior history of adverse pregnancy outcomes or personal or family history of venous thromboembolism. Healthy nulliparous women (n=2,034) were recruited to this prospective cohort study before 22 weeks of gestation. Genotyping for factor V Leiden, prothrombin gene mutation, methylenetetrahydrofolate reductase enzyme (MTHFR) C677T, MTHFR A1298C, and thrombomodulin polymorphism was performed. Clinicians caring for women were blinded to the results of thrombophilia tests. The primary composite outcome was the development of severe preeclampsia, fetal growth restriction, placental abruption, stillbirth, or neonatal death. Complete molecular results and pregnancy outcome data were available in 1,707 women. These complications were experienced by 136 women (8.0%). Multivariable logistic regression demonstrated two statistically significant findings. Women who carried the prothrombin gene mutation had an odds ratio of 3.58 (95% confidence interval [CI] 1.20-10.61, P=.02) for the development of the composite primary outcome. Homozygous carriers of the MTHFR 1298 polymorphism had an odds ratio of 0.26 (95% CI 0.08-0.86, P=.03). None of the other polymorphisms studied showed a significant association with the development of the primary outcome in this cohort of women. Prothrombin gene mutation confers an increased risk for the development of adverse pregnancy outcomes in otherwise asymptomatic, nulliparous women, whereas homozygosity for MTHFR 1298 may protect against these complications. The majority of asymptomatic women who carry an inherited thrombophilia polymorphism have a successful pregnancy outcome. II.

Inherited Thrombophilia Polymorphisms and Pregnancy Outcomes in Nulliparous Women

Inherited Thrombophilia Polymorphisms and Pregnancy Outcomes in Nulliparous Women