Prolonged First Stage Of Labor Research Articles

Intrapartum transperineal ultrasound: angle of progression to evaluate and predict the mode of delivery and labor progression.

Intrapartum ultrasonography serves as a valuable tool for the objective evaluation of labor progression and effectively identifies underlying factors, such as asynclitism, in cases of abnormal labor progression. Among the various ultrasound measurement techniques, the angle of progression (AOP) demonstrates favorable reproducibility and accuracy in assessing fetal head descent. In the context of abnormal labor, interventions differ across different stages of labor, emphasizing the importance of investigating the utility of AOP according to labor stages in this review article. Pre-labor assessment of AOP can be beneficial in terms of counseling for the timing of induction of labor, while a wider AOP value during the prolonged first stage of labor has demonstrated a positive correlation with successful vaginal delivery and shorter time to delivery. In the second stage of labor, the AOP has exhibited efficacy in predicting the mode of delivery and complicated operative deliveries. Furthermore, it has assisted in predicting the duration of labor, thereby highlighting its potential as a decision-making model for labor progression. However, further research is needed to investigate aspects, such as the determination of cutoff values, of AOP, considering the multifaceted characteristics of labor progression, which are influenced by complex interactions among maternal, fetal, and other contributing factors.

The husband as a labor companion has a good influence on the duration of labor

Birth support can prevent prolonged labor. The husband can carry out this support as a delivery companion. This study aims to assess the effect of the husband's role as a labor companion on the duration of labor. This research is an observational analytic study with a cross-sectional design. The samples in this study were 60 pairs of mothers and their husbands who met the inclusion and exclusion criteria. Data were obtained using the observation sheet on the husband's role and partograph. The analysis used in this study was the chi-square test and logistic regression. Mothers in labor will have an increased risk of 2.85 to experience a prolonged first stage of labor if the husband does not provide sufficient support as a birth companion during labor (OR=2.8, 95% CI=1.52-5.16). Good labor companion by the husband will be able to prevent mothers from experiencing a long second stage of labor (OR = 0.34, 95% CI = 0.18-0.62). The role of a good husband as a birth companion is to maintain the expected time for the first and second stages of labor and prevent the long duration of labor.

Predictive Value of MRI Pelvimetry in Vaginal Delivery and Its Practicability in Prolonged Labour-A Prospective Cohort Study.

Pelvic dimensions are crucial variables in the labour process. We used magnetic resonance imaging (MRI) pelvimetry to predict the probability of vaginal delivery and distinguish the cephalopelvic disproportion risk in women with prolonged active labour. This prospective cohort study enrolled term nulliparous women willing to undergo MRI pelvimetry and a trial of labour. A nomogram, with vaginal birth as the outcome, was developed and evaluated by calibration curve and decision curve analyses. The pairwise association between maternal and fetal parameters and a prolonged first stage of labour was quantified. Head circumference (HC), abdominal circumference (AC), intertuberous distance (ITD), interspinous diameter (ISD), and body mass index (BMI) were introduced to develop a nomogram with good diagnostic performance (area under the curve = 0.799, sensitivity = 83%, and specificity = 73%). The cephalopelvic index of diameter (CID) in 54 women with a prolonged first stage of labour was much smaller in those who delivered via cesarean section compared with those who delivered vaginally (18.09 ± 1.14 vs. 21.29 ± 1.06; p = 0.046). An MRI pelvimetry-based nomogram may predict the probability of vaginal delivery. Practitioners should reassess the pelvimetry parameters to decide whether the trial of labour should be continued if it is prolonged.

Adoption of Consensus Guidelines for Safe Prevention of the Primary Cesarean Delivery by Freestanding Birth Centers.

Slow or arrested progress in labor is the most frequent (64%) indication for nonemergent transfer of laboring people from freestanding birth centers to the hospital. After the 2014 publication of the Consensus Statement on Safe Prevention of Primary Cesarean Delivery (Consensus Statement), many freestanding birth centers changed their clinical practice guidelines to allow more time for active labor in the birth center prior to hospital transfer. The result of these changes has not been evaluated in birth centers. Evaluation of adoption of guidelines based on the Consensus Statement in hospitals has shown inconsistent results. Birth centers were contacted to determine whether they changed clinical practice guidelines in response to the Consensus Statement. A before-after analysis compared outcomes for the 2 calendar years before and the 2 calendar years after adoption of new guidelines with a retrospective analysis of deidentified client-level data collected in the American Association of Birth Centers Perinatal Data Registry. A third of responding birth centers (11 of 33) changed their clinical practice guidelines, mostly redefining the onset of active labor as beginning at 6 cm cervical dilatation and allowing 4 hours of arrest of dilatation in active labor before transfer to the hospital. These changes were associated with fewer diagnoses of prolonged first stage of labor (13.8% vs 8.0%, P < .01) but not with fewer intrapartum transfers (14.0% vs 14.7%, P = .55) or cesarean births (5.0 vs 4.1%, P = .26.) DISCUSSION: We found no evidence that making these practice changes was associated with better outcomes. Two hours of a lack of documented cervical change in active labor is likely long enough to diagnose arrested progress in labor. Research on proportion of morbidity and mortality associated with prolonged labor could inform practice guidelines for transfers.

Assessing maternal thyroid function and its relationship to duration of the first stage of labor.

IntroductionMaternal thyroid function plays a critical role in the normal labor process. Whether maternal thyroid function affects the duration of the first stage of labor is still unknown.MethodsMaternal serum levels of free thyroxine (FT4), thyroid-stimulating hormone (TSH) and thyroid peroxidase antibody (TPOAb) were detected in 31,382 pregnant women. A multiple linear regression model was applied to investigate the effect of maternal thyroid function on the duration of the first stage of labor.ResultsFT4 level in the second trimester and in the third trimester was found to be negatively associated with duration of the first stage of labor (β = −1.30 h, 95% CI: −2.28, −0.32, P < 0.01; β = −0.35 h, 95% CI: −0.61, −0.10, P < 0.01). TSH level in the third trimester was found to be positively associated with the duration of the first stage of labor (β = 0.12 h, 95% CI: 0.06, 0.18, P < 0.001). Per unit increase in TPOAb (IU/mL) in the second trimester and in the third trimester was significantly associated with prolonged first stage of labor (β = 0.08 h, 95% CI: 0.01, 0.14, P = 0.02; β = 0.09 h, 95% CI: 0.02, 0.15, P = 0.01). For pregnant women suffering from subclinical hypothyroidism combined without TPOAb, TSH level in the third trimester exhibited a significant positive association with the length of the first stage of labor (β = 2.44 h, 95% CI: 0.03, 4.84, P = 0.04).ConclusionsThese findings suggest that maternal FT4, TSH and TPOAb might be important predictors of the first stage of labor.

FAKTOR PERSALINAN KALA 1 LAMA DI PUSKESMAS KETUWAN BLORA

The first stage of labor includes a prolonged latent phase and a prolonged active phase. Long-term delivery always poses risks and complications for both the mother and the fetus in her womb and can be fatal if not treated properly. Based on data from Ketuwan Health Center from January 2020 to December 2020, there were 37 cases of prolonged first stage labor out of 159 cases of labor. The purpose of this study was to determine the factors associated with the incidence of prolonged first stage of labor at the Ketuwan Health Center, Blora Regency which included maternal age, education, parity, his and the weight of the fetus. This type of research is quantitative analytic with a case control research design, using a retrospective approach and using a proportional random sampling technique. The number of samples was 37 cases and 37 controls. Data analysis was carried out univariate and bivariate using the Odds Ratio test. The results showed that the factors associated with the incidence of prolonged first stageof labor were Age (p=0.403; OR=2.121), Education (p=0.627; OR=0.789), Parity (p=0.011; OR=3.544), Contraction (p= 0.000; OR=0.072), Fetal Weight (p=1,000; OR=1,000). The conclusion of this study is that the factors associated with the incidence of prolonged first stage labor include parity and his, while age), education, and fetal weight do not have a significant relationship with the incidence of prolonged first stage labor. The advice given is to establish a definite diagnosis and make the right decisions to reduce the risk to the mother and fetus

Management of prolonged first stage of labour in a low-resource setting: lessons learnt from rural Malawi

BackgroundCaesarean sections without medical indication cause substantial maternal and perinatal ill-health, particularly in low-income countries where surgery is often less safe. In presence of adequate labour monitoring and by appropriate use of evidence-based interventions for prolonged first stage of labour, unnecessary caesarean sections can be avoided. We aim to describe the incidence of prolonged first stage of labour and the use of amniotomy and augmentation with oxytocin in a low-resource setting in Malawi.MethodsRetrospective analysis of medical records and partographs of all women who gave birth in 2015 and 2016 in a rural mission hospital in Malawi. Primary outcomes were incidence of prolonged first stage of labour based on partograph tracings, caesarean section indications and utilization of amniotomy and oxytocin augmentation.ResultsOut of 3246 women who gave birth in the study period, 178 (5.2%) crossed the action line in the first stage of labour, of whom 21 (11.8%) received oxytocin to augment labour. In total, 645 women gave birth by caesarean section, of whom 241 (37.4%) with an indication ‘prolonged first stage of labour’. Only 113 (46.9%) of them crossed the action line and in 71/241 (29.5%) membranes were still intact at the start of caesarean section. Excluding the 60 women with prior caesarean sections, 14/181 (7.7%) received oxytocin prior to caesarean section for augmentation of labour.ConclusionThe diagnosis prolonged first stage of labour was often made without being evident from labour tracings and two basic obstetric interventions to prevent caesarean section, amniotomy and labour augmentation with oxytocin, were underused.

480 Intrapartum sonographic features of cephalopelvic disproportion in non-occiput posterior fetuses: prospective multicenter study

To describe the intrapartum sonographic characteristics of cephalopelvic disproportion (CPD) in labor arrest in non-occiput posterior (OP) position. Prospective study conducted across three tertiary maternity Units and including women with prolonged first stage of labor and fetuses lying in non-OP position. In the recruited cases transabdominal ultrasound was performed in order to evaluate the degree of flection of the fetal head by means of the occiput-spine angle (OSA), while the sonographic indicators of head station – i.e. the angle-of-progression (AoP) and the head-perineum distance (HPD) – and additional signs of CPD were assessed at transperineal ultrasound. Obstetric intervention performed solely based on suspected fetal distress represented exclusion criteria for the study. Overall, 86 women were included. Spontaneous vaginal delivery, instrumental delivery and cesarean section were recorded in 45 (52.3%), 11 (12.8%) and 30 (34.9%) cases, respectively. A wider OSA (126.2+14.4 vs 114.5+23.6 degrees, p=0.006) and AoP (117.5+12.7 vs 104.0+10.7 degrees, p<0.001) and a shorter HPD (39.7+5.2 vs 49.0+9.4 mm, p<0.001) were measured in women who had vaginal delivery compared to those delivered by cesarean section. When investigating the correlation between the OSA and the sonographic indices of head station, the OSA showed a direct correlation with the AoP (Pearson’s correlation 0.449, p<0.01) but no correlation with the HPD (p=0.15); 9 cases showing a narrow AoP, a long HPD and a wide OSA and all delivered by cesarean section were labelled as outliers. Such cases showed a lower maternal height (p<0.01) and a higher ratio between the birthweight and the maternal height (p=0.04) compared to the non-outlier cases. Caput succedaneum and moulding were also noted at transperineal ultrasound in all the outlier cases. Findings from this study suggest that a discrepancy between the width of the OSA and the expected AoP and HPD represent sonographic indicators of CPD in non-OP fetuses diagnosed with labor arrest.

Features of labor course upon with preterm rupture of membranes and "mature" cervix at gestation of 37 weeks or higher

Introduction. Management and the prevalence of labor complications in patients with premature rupture of the membranes (PROM) is a pressing issue. Aim: to assess the features of childbirth course in patients with PROM during a full-term pregnancy and a favourable cervix. Materials and methods. А prospective analysis of labor course and the postpartum period was performed in 189 patients with a singleton pregnancy with occipital presentation, at least 37-week gestation, of low and moderate risk groups, without contraindications for vaginal delivery. PROM as complicated pregnancy was found in 89 subjects (main group), whereas 100 having labor onset with intact fetal membranes were enrolled into comparison group. The features of labor course were analyzed. Results. Primiparous patients dominated in the main group (66.7 %). The latent period between amniotic fluid discharge to labor onset comprised 4.15 ± 3.48 hours and 3.40 ± 2.13 hours in primiparous and multiparous women, respectively, whereas labor activity in 19 % of women did not develop after 6 hour-latent period. The average duration of labor did not depend on the patient parity and was longer in the group with PROM: 8.06 ± 3.51 hours – in primiparous females, 7.21 ± 2.56 hours – in comparison group (T = –1.99; p = 0.04) due to prolonged first stage of labor. In patients with and without PROM, rate of poor uterine contraction strength was 24.7 % and 18.3 % (p = 0.29), cervical dystocia – 2.25 % and 0 % (p = 0.13), use of oxytocin in childbirth – 35.9 % and 18.3 % (p = 0.007), respectively. Caesarean sections in the main group were recorded in 15 cases (16.85 %), fetal vacuum extraction – 6 cases (6.74 %), whereas in the comparison group – per 2 (2,0 %) cases, respectively (χ2 = 16.13; p &lt; 0.001). Conclusion. Patients with PROM and favourable cervix were shown to have duration of labor, occurrence of operative delivery, rupture of the cervix, and use of oxytocin lasting substantially longer compared to those with the rupture of membranes after onset of the labor. PROM with a favourable cervix occurs more often in primiparous females, which is also coupled to peak rate complications. A 6-hour expectant management is considered as insufficient, because an onset of labor activity in 15.7 % of patients developed after latent period lasting more than 6 hours.

OC13.04: Intrapartum sonographic assessment of the fetal head position and flection in prolonged first stage of labour: prospective multicentre study

OC13.04: Intrapartum sonographic assessment of the fetal head position and flection in prolonged first stage of labour: prospective multicentre study

Association of abnormal first stage of labor duration and maternal and neonatal morbidity

Contemporary guidelines for labor management do not characterize abnormal labor on the basis of maternal and/or neonatal morbidity. In this study, we aimed to evaluate the association of abnormal duration of the first stage of term labor and the risk of maternal and neonatal morbidity. We conducted a retrospective analysis of prospectively collected data of all consecutive women admitted for delivery at a single center at ≥37 weeks and 0 to 7 days of gestation with singleton, nonanomalous, vertex infants from 2010 to 2015, who reached 10 cm cervical dilation. Multivariable logistic regression compared odds ratios for maternal and neonatal outcomes among women above and below the 90th, 95th, and 97th percentiles for first stage of labor duration. Receiver operating characteristic curves estimated the association between first stage of labor duration and maternal morbidity. Maternal morbidity was a composite of maternal fever, hemorrhage, transfusion, or endomyometritis; prolonged second stage of labor duration; and third- or fourth-degree perineal laceration. Neonatal morbidity was a composite of hypothermic therapy, need for mechanical ventilation, respiratory distress syndrome, meconium aspiration syndrome, birth injury or trauma, and neonatal seizure or sepsis. Of 6823 women included in this study, 682 were anticipated to have first stage of labor duration above the 90th percentile cutoff point, which was associated with an increased risk of composite maternal morbidity, maternal fever, postpartum transfusion, prolonged second stage of labor duration, third- or fourth-degree perineal laceration, and cesarean or operative vaginal delivery (P≤.02) and an increased risk of composite neonatal morbidity, respiratory distress syndrome, need for mechanical ventilation, and neonatal sepsis (P≤.03). Composite maternal morbidity was 2.2 (95% confidence interval, 1.8-2.7), 1.9 (95% confidence interval, 1.4-2.4), and 1.8 (95% confidence interval, 1.3-2.5) times more likely to occur among women above the 90th, 95th, and 97th percentile, respectively, for first stage of labor duration from 4 to 10 cm. Composite neonatal morbidity was 2.6 (95% confidence interval, 2.1-3.2), 2.2 (95% confidence interval, 1.7-2.9), and 1.9 (95% confidence interval, 1.3-2.8) times more likely to occur among infants delivered by women above the 90th, 95th, and 97th percentiles for first stage of labor duration from 4 to 10 cm. Receiver operating characteristic curves among all women from 4 to 10 cm and 6 to 10 cm, including when stratified by parity and type of labor onset, had an area under the curve of 0.51 to 0.62 and 0.53 to 0.71 for maternal and neonatal morbidity, respectively. Thus, duration of labor has moderate predictive ability, at best, for composite maternal or neonatal morbidity. No curve demonstrated a clear point at which adverse maternal or neonatal outcomes increased that could be used to define abnormal labor. The benefit of expectantly managing a prolonged first stage of labor with duration above the 90th percentile in anticipation of vaginal delivery must be weighed against the increased risk of composite maternal and neonatal morbidity. Risks associated with performing cesarean delivery as an alternative management for women with prolonged first stage of labor duration must also be considered.

32: Second stage of labor outcomes in nulliparous patients with prolonged first stage of labor

Contemporary labor curves suggest that a wide variation in first stage duration may be normal. We tested the hypothesis that a prolonged first stage of labor in nulliparas who reach complete cervical dilation is associated with a lower likelihood of spontaneous vaginal delivery (SVD). Planned secondary analysis from the Optimizing Management of the Second Stage (OMSS) multicenter randomized trial in which nulliparas with term pregnancies and neuraxial analgesia were assigned at complete dilation to immediate or delayed pushing. The primary outcome was SVD. Secondary outcomes were operative vaginal delivery, cesarean, 3rd/4th degree lacerations, postpartum hemorrhage, 2nd stage chorioamnionitis, duration of 2nd stage and pushing, shoulder dystocia, and composite neonatal morbidity defined as occurrence of one or more of: death, birth injury, acidemia, respiratory distress, transient tachypnea, meconium aspiration with pulmonary hypertension, hypoxic-ischemic encephalopathy, hypoglycemia, hypothermia treatment, or suspected neonatal sepsis. Multivariable logistic regression was used to estimate aOR for outcomes with prolonged first stage of labor, defined as first stage duration >90th percentile of the cohort. First stage duration was determined by the interval between admission and completion dilation. Of the 2404 patients in the trial, 2349 had data on first stage duration and were included in this analysis. The 90th percentile for first stage duration was 12.7 hours. Rates of immediate and delayed pushing were similar between groups. Patients with a prolonged first stage were less likely to have a SVD compared to those without a prolonged first stage (aOR 0.65, 95% CI 0.46, 0.94). Patients with a prolonged first stage were at higher risk for cesarean (aOR 2.14, 95%CI 1.40, 3.26) and chorioamnionitis (aOR 1.86, 95% CI 1.22, 2.84). Other secondary outcomes were similar between groups. A prolonged first stage of labor in nulliparous women is associated with a lower likelihood of SVD even when patients reach complete cervical dilation.

1106: Can we define abnormal first stage of labor duration by maternal morbidity?

Current guidelines for labor management do not define abnormal labor based on maternal morbidity. We aim to define abnormal duration of the first stage of term labor based on the risk of maternal morbidity. We conducted a secondary analysis of a single-center prospective cohort study of all consecutive women admitted for delivery at ≥37 0/7 weeks’ gestation with singleton, nonanomalous, vertex infants from 2010-2015 who reached 10cm cervical dilation. Multivariable logistic regression compared maternal outcomes among women above and below the 90th, 95th, and 97th percentiles for first stage of labor duration. Receiver-operator characteristic (ROC) curves estimated the association between first stage of labor duration and maternal morbidity. Maternal morbidity was a composite of postpartum fever, hemorrhage, transfusion or endomyometritis; prolonged second stage duration; and cesarean or operative vaginal delivery. Of 6,823 included women, 681 had first stage of labor duration above the 90th percentile, which was associated with an increased risk of composite maternal morbidity, postpartum fever or transfusion, prolonged second stage duration, and cesarean or operative vaginal delivery (p< 0.01). The odds of composite maternal morbidity; postpartum fever, hemorrhage or transfusion; prolonged second stage; and cesarean or operative vaginal delivery were significantly increased by 1.5-2.5 times among women above the 90th percentile for first stage of labor duration. ROC curves among all women from 3-10cm and 6-10cm, including when stratified by parity and type of labor onset, had an area under the curve of 0.51-0.62, demonstrating that duration of labor has moderate predictive ability, at best, for composite maternal morbidity. No curve demonstrated a clear point at which adverse maternal outcomes increased that could be used to define abnormal labor. The benefit of expectantly managing a prolonged first stage of labor with duration above the 90th percentile in anticipation of vaginal delivery must be weighed against the increased risk of maternal morbidity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Does third trimester cervical length predict duration of first stage of labor?

To examine the association between third trimester cervical length (CL) measurement and duration of the first stage of labor. This prospective cohort study included women with asingleton pregnancy who had routine CL measurements taken by transvaginal ultrasonography between 37 and 39weeks gestation. Subjective duration of the first stage of labor was defined as the duration of contractions that the women subjectively had from the onset of regular contractions to full effacement of the cervix. Objective duration of first stage of labor was defined as 3 cm cervical dilation independent of cervical effacement until full effacement of the cervix. Associations between variables were analyzed using nonparametric correlations coefficients. Amodel relating the duration of labor to predictors was built using linear regression. In this analysis a total of 129 women were included. There was no significant correlation between CL and subjective duration of labor (ρ = -0.037, p = 0.695); however, areduction in CL increased the objective duration of the first stage of labor (ρ = -0.269, p = 0.013). In univariate analysis parity (p = 0.018), hypertensive disorders (p = 0.013) and induction of labor (p = 0.022) were significantly associated with subjective duration of the first stage of labor. Along cervix in the third trimester is not associated with a prolonged first stage of labor. Induction of labor and multiparity were associated with a shorter first stage of labor while hypertension was associated with a longer duration of labor.

The Correlation of the Level of Anxiety of Nulliparous Women to the Length of First Stage of Spontaneous Labor at Private Maternity Clinics in the Working Area of Delitua Puskesmas, Deli Serdang District in 2013

Abnormal length of first stage of labor in nulliparous women (first pregnancy) can be related by severe anxiety during labor. Based on the preliminary survey in several private maternity clinics at the working area of Delitua Puskesmas, Deli Serdang District, it was found that there was a prolonged first stage of labor (27.65%) in nulliparous women. The purpose of this study was to analyze the influence of anxiety level to the lenght of first stage of labor. The type of this study was an analytic survey with explanatory research type. The samples comprised 40 childbearing women in private maternity clinics of Kasih Ibu,Kurnia,Tanjung,Wanda,and Mayana which were located in the working area of Delitua Puskesmas , Deli Serdang District,using accidental sampling technique. The data were gathered by using questionnaires and analyzed in univariet analysis by using frequency distribution form, and bivariate analysis using Chi Square test. The result of this study showed that the level of anxiety (p = 0.001) significantly related the lenght of first stage of labor in which mothers who had severe anxiety. It is recomended that health providers should provide standardized services to childbearing women, especially to nulliparous women, so that their level of anxiety can be decreased facing the first stage of labor process. It is also recommended that the husbands should support their wives by positive behaviors so they will not think about bad things on their babies and on themselves.

786: Prior prolonged first stage of labor is associated with prolonged first stage in subsequent pregnancies

Limited data exists regarding the impact of a history of a prior prolonged first stage of labor (PPFSL) on labor curves in subsequent pregnancies. We hypothesized that patients with PPFSL were more likely to have an abnormal labor curve in subsequent pregnancies, and ultimately have a higher cesarean section rate. The aim of this study was to explore if a PPFSL is associated with prolonged labor in subsequent pregnancies. This was a retrospective cohort study of all women with two consecutive singleton term pregnancies that reached 10 cm cervical dilation in the first pregnancy (regardless of mode of delivery), at tertiary care center from 2004 to 2014. Labor curves and pregnancy outcomes were compared between patients with and without a history with a PPFSL (greater than 12 hours). T-tests & Mann Whitney U tests were used for continuous variables and chi- square/Fisher’s exact tests for categorical variables. Interval-censored regression was used to estimate median times for cervical change. 2,150 patients had at least two pregnancies during the study, and 204 (9.5%) had a PPFSL. Besides women with a PPFSL to be less likely to have interpregnancy interval (IPI) less than 6 months or an IPI less than 12 months, the groups were similar, with similar rates of spontaneous labor and no significant difference in mode of delivery. Patients with PPFSL were more likely to have another prolonged first stage (OR 2.06, 95%CI 1.35-3.13). There was no difference in the second stage. Patients with PPFSL had significantly longer first stage in the current pregnancy, including a longer time to dilate from 4 to 10 cm (median 5.25 vs 4.01 hrs, p=.01). A PPFSL in a previous term pregnancy was associated with a prolonged first stage in a subsequent pregnancy, but was not predictive of a prolonged second stage. However, even with the increased risk of a prolonged subsequent first stage, there was no association with an elevated risk of cesarean or operative delivery. This suggests that natural history of the first stage of labor may be longer in some women, but that may not preclude a vaginal delivery.

804: Large-for-gestational age infants – when is it truly labor dystocia?

Labor dystocia is a diagnosis often given to women with large-for-gestational age (LGA) infants with a prolonged first stage of labor, ultimately leading to cesarean delivery. However, normative standards for the first stage of labor when fetal macrosomia is suspected have not been clearly defined. This study aimed to evaluate labor progress of women with LGA infants compared to appropriate-for-gestational age (AGA) infants. We conducted a retrospective cohort study of patients admitted for labor at our institution from 2004 -2014 with a vertex singleton at term who achieved 10cm cervical dilation. Labor curves were constructed with repeated measures regression and were compared between patients who delivered LGA infants (actual birthweight [BW] >90th percentile) and those who delivered AGA infants (actual BW 10-90th percentile). Interval-censored regression estimated median duration of labor stratified by actual infant BW, and further stratified by parity (nulliparity vs. multiparity) and labor type (spontaneous vs. induction of labor). Among all 17,097 women, 15843 (92.7%) had AGA infants, of whom 6194 (39.1%) were nulliparous and 5351 (33.8%) were induced; 1,254 (7.3%) had LGA infants, of whom 387 (30.9%) were nulliparous and 464 (37.0%) were induced. After adjustment for obesity, epidural and prior cesarean delivery, AGA infants progressed to 10cm significantly faster than LGA infants, even when stratified by maternal parity and labor type (p<0.01). Patients with LGA infants progressed from 4-10cm more slowly than with AGA infants (median 7.4 hours [5th-95th percentile, 2.2-5.8] vs. 4.9 hours [1.4-16.9], p<0.01). LGA infants also progressed in active labor from 6-10cm more slowly than with AGA infants (2.4 [0.4, 13.5] vs. 1.7 [0.3, 9.2], p<0.01). In the LGA group, nulliparous women dilated 4-10cm more slowly than multiparous women (8.3 hours [2.5-27.7] vs. 5.9 hours [1.6-21.4]). Women in spontaneous labor also dilated 4-10cm faster than induced women in the LGA group (6.2 hours [1.8-21.5] vs. 7.3 hours [2.0-26.7]). Women with LGA infants experience relatively slowed labor progression compared to women with AGA infants, particularly in nulliparous and induced women. Clinicians should consider fetal size and make labor dystocia diagnoses cautiously in women with suspected fetal macrosomia.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Delivery outcomes of large-for-gestational-age newborns stratified by the presence or absence of gestational diabetes mellitus.

To evaluate separate and combined contributions of gestational diabetes mellitus (GDM) and large-for-gestational age (LGA) on delivery outcomes. In a retrospective cohort study of term singleton deliveries between 2007 and 2014 in Tel Aviv, Israel, outcomes were compared between non-GDM/AGA pregnancies (reference) and three study groups: non-GDM/LGA, GDM/appropriate for gestational age (AGA) and GDM/LGA. Overall, there were 62102 deliveries, of which 53201 (85.7%) were eligible for inclusion. Of these, 43775 (82.3%) were non-GDM/AGA, 6441 (12.1%) non-GDM/LGA, 2351 (4.4%) GDM/AGA, and 634 (1.2%) GDM/LGA. Compared with the reference group, the study groups had higher mean maternal age and higher rates of previous cesarean delivery, polyhydramnios, induction of labor, and cesarean delivery. Considering only women attempting vaginal delivery, the three groups were independently associated with adverse outcomes including cesarean delivery (adjusted odds ratio [aOR], 1.5, 1.6, and 2.6 for non-GDM/LGA, GDM/AGA, and GDM/LGA, respectively), mainly for prolonged first stage of labor, and hypoglycemia (aOR, 1.9, 2.5, and 4.6, respectively). LGA with and without GDM was associated with shoulder dystocia (aOR, 14.5 and 6.9, respectively), prolonged second stage, and jaundice. GDM and LGA share similarities in pregnancy complications. The presence of both has a cumulative impact.

Dysfunctional Uterine Activity in Labour and Premature Adverse Cardiac Events: Population-Based Cohort Study

BackgroundThere exist structural and physiological commonalities between myometrial and myocardial tissue, and each can become dysfunctional, such as in the presence of cardiometabolic factors. MethodsThis population-based cohort study was comprised of 1,608,720 women with ≥ 1 singleton hospital live birth at 24-41 weeks' gestation in Ontario, from 1992 to 2016. The main exposure was prolonged first stage of labour; secondary exposure was prolonged second stage of labour. The main outcome was a composite of heart failure, cardiomyopathy or dysrhythmia ≥ 1 day after the index delivery. Cox proportional hazard regression was used to generate a hazard ratio (HR), adjusted for maternal age, parity, obstructed labour or fetal malposition, preeclampsia, income quintile, rural residence, preterm birth, and infant birth weight—each at the time of delivery; time-varying drug/tobacco use, obesity, diabetes mellitus, chronic hypertension, kidney disease, dyslipidemia—each diagnosed before or at time of delivery; as well as newly diagnosed coronary artery disease or congenital heart disease arising ≥ 1 day after the index delivery. ResultsAfter a median follow-up of 10.5 and 14.0 years, respectively, there were 78 composite cardiac events (2.33 per 10,000 person-years) among women with prolonged first stage of labour vs 4114 events (2.30 per 10,000 person-years) among those without prolonged labour—a crude HR of 1.07 (95% confidence interval [CI], 0.86-1.34) and an adjusted HR of 1.09 (95% CI, 0.87-1.36). Women with prolonged second stage of labour had an adjusted HR of 0.86 (95% CI, 0.75-0.99) for the composite outcome. ConclusionsWomen with prolonged labour do not appear to be at a higher short-term risk of cardiac outcomes.

Delivery outcomes of term pregnancy complicated by idiopathic polyhydramnios

ObjectivePolyhydramnios is associated with an increased risk of cesarean section. The aetiology of polyhydramnios and the characteristics of the labour may be confounding factors. The objective was to study the characteristics and mode of delivery in case of pregnancy complicated with idiopathic polyhydramnios. MethodsThis retrospective matched and controlled study included all pregnant women with idiopathic polyhydramnios (amniotic index>25cm or single deepest pocket>8cm) diagnosed at the 2nd or 3rd trimester and persistent at term delivery (>37weeks of pregnancy) in our institution. We excluded pregnancies in which the polyhydramnios could be explained by infection, gestational diabetes, congenital malformation, abnormal karyotype, placental anomalies, alloimmunization as well as pregnancies in which an amniocentesis for the purpose of diagnosis had not been performed. Data were gathered from a tertiary care university hospital register from 1998–2015. Cases of polyhydramnios were matched with the following two women who presented for labour management with spontaneous cephalic presentation, matching for delivery date, maternal age, parity, body mass index. The main outcome measure was the risk of cesarean section. Univariate and multivariate adjusted analysis were performed. ResultsWe identified 108 women with idiopathic polyhydramnios and compared them with 216 matched women. Among them, 94 and 188 attempted a trial of labour. Maternal age, mean term delivery and birthweight were 31 years, 39+5weeks gestation and 3550 g. We did not observe differences in maternal characteristics, epidural analgesia and rate of abnormal fetal heart tracing. Induced labour and non-vertex presentations (forehead, bregma, face) were more frequent in the polyhydramnios group (respectively 57.9% versus 27.8%, P<0.05 and 7.8% versus 1%, P<0.05). Cesarean section rate was higher in the case of polyhydramnios in the overall population (45.4% versus 8%, P<0.05) and remained higher after exclusion of cases of induced labour and non-vertex presentation (38.4% versus 3.8%, P<0.05). Amniotomy was more frequent in pregnancies with polyhydramnios (55.8% versus 39.1%, P<0.05). After adjustment for matching and confounding variables, polyhydramnios was found to be a risk factor for cesarean section (OR 21.02; CI 95% 8.004–55.215, P<0.01). ConclusionIdiopathic polyhydramnios increased the risk of prolonged first stage of labour, non-vertex presentation and cesarean section.