Protracted Labor Research Articles

Home birth in Croatia - a medico-legal perspective today.

In Croatia, the model of obstetrics-midwifery management of childbirth in maternity hospitals is still in effect, and this is how > 99% of Croatian women give birth. However, in my view, midwives are still not sufficiently educated for completely independent work notwithstanding their university education. The Law on Midwifery defined the role of the midwife in home birth without, however, setting out other organisational-communication and professional provisions. Then it began with sporadic midwifery home births of a few per year, which grew quite rapidly, especially with the impact of the Covid-19 virus pandemic, to about 100 out of a total of about 38,000 births that are performed annually in the Republic of Croatia in maternity hospitals. Since the start of planned home births many bad perinatal outcomes have been recorded in hospital maternity wards who have admitted women after such deliveries. These include puerperal sepsis, protracted labour of several days, neglected protracted labour with perinatal asphyxia and aspiration of meconium amniotic fluid and resuscitation of the newborn (who later developed cerebral palsy), severe postpartum haemorrhage with obstetric shock and postpartum hysterectomy, episiotomy infection, and stillbirth at term pregnancy. Therefore, planned home birth in Croatia should now be regarded as an unsafe birth in extraordinary circumstances and the person who takes charge of it must be professionally prepared, educated and have numerous social skills. Most Croatian gynaecologists and obstetricians give support to midwives in their efforts to be professional and independent when at work, including the controlled and legal implementation of the planned home birth. We unreservedly support self-aware midwives to maintain their profession as highly ethical and professional as possible above the wishes of non-professionals who call for autonomy, so that we do not have to discuss such problems of malpractice of Croatian midwifery in the 21st century.

Efficacy of Foley Catheter Bulb with Intracervical Dinoprostone Gel versus Dinoprostone Gel Alone for Cervical Ripening and Induction of Labour: An Observational Study

Introduction: One of the most common obstetrical interventions is the induction of labour. Cervical ripening drugs are typically used before conventional methods of induction since they are linked to an increased risk of protracted labour, chorioamnionitis, and Caesarean Sections (CS) during labour induction when an unfavourable cervix is present. The two major techniques for cervical ripening are mechanical interventions, such as the insertion of balloon catheters, and the application of pharmacologic agents, such as prostaglandins. It is widely accepted that the induction of labour, which ultimately leads to vaginal delivery, is largely dependent on the condition of the uterus’ cervix. Aim: To compare the efficacy of a combination of Foley bulb catheter and intracervical Dinoprostone and intracervical Dinoprostone alone for the induction of labour. Materials and Methods: A prospective observational study was performed over 150 pregnant mothers from May 2018 to April 2019. in the labour room of North Bengal Medical College and Hospital, a tertiary care institution in Darjeeling, West Bengal, India. The pregnant women were divided into two groups: intracervical Dinoprostone gel alone (Group-1) and a combination of intracervical Foley catheter and intracervical Dinoprostone gel (Group-2) with n=75 patients in each group. Group-1 received intracervical Dinoprostone gel 0.5 mg, which was repeated every 6 hours, a maximum of three doses, or until she went into active labour, whichever occurred earlier. In Group-2, a 16 F Foley catheter was inserted into the cervix, inflated, and a single dose of intracervical Dinoprostone gel 0.5 mg was given alongside it. Participant demographic characteristics, medical and pregnancy history, indication for labour induction, labour course, and outcomes were collected. The collected data were analysed with the mean and standard deviation for numerical variables and counts and percentages for categorical variables. Odds ratio was calculated where deemed relevant. Results: The induction to delivery time was considered the primary outcome and was shorter in Group-2 by 28 minutes (p=0.342). Among the secondary outcomes, the duration of the latent phase of labour was shorter in Group-2 by 57 minutes, and the proportion of patients delivering within 12 hours was also higher (28%) but statistically insignificant (p>0.05). The rates of CS were unaffected by the mode of induction. None of the two methods were found to be inferior to the other in respect to neonatal outcomes or complications of labour like chorioamnionitis and postpartum haemorrhage. Conclusion: The combination of Foley catheter with intracervical Dinoprostone gel did not prove to be more efficient than intracervical Dinoprostone alone for labour induction in the current study

Protracted Labor Complicated by Pneumomediastinum and Subcutaneous Emphysema: A Rare Case Report and Management Considerations.

BACKGROUND Spontaneous pneumomediastinum and subcutaneous emphysema (Hamman's syndrome) presents with sudden and life-threatening symptoms. Clinical signs include crackles that synchronize with the heartbeat on chest auscultation (Hamman's sign). This report describes the case of a 29-year-old woman with a protracted second stage of labor at 40 weeks of pregnancy with postpartum dyspnea, acute chest pain, and surgical emphysema due to pneumomediastinum (Hamman's syndrome). CASE REPORT This case report describes the case of a 29-year-old primigravida admitted to the hospital ward for spontaneous labor at 40 weeks of pregnancy. Due to a protracted second stage of labor, the delivery was assisted by Thierry's spatulas. Shortly after delivery, the patient developed dyspnea associated with subcutaneous emphysema in the inferior part of the face, neck, and anterior chest wall. As the clinical evaluation showed no signs of severity, we performed a chest X-ray, which confirmed the diagnosis of pneumomediastinum (Hamman's syndrome), excluded any other life-threatening condition, and led to a conservative treatment approach. CONCLUSIONS This report presents a rare association between protracted labor and Hamman's syndrome and highlights the importance of rapid diagnosis and management. In this case, the postpartum presentation was distinguished from pulmonary embolism, and emergency life-saving management was initiated.

Terra Incognita: California Transit Agency Perspectives on Demand, Service, and Finance in the Age of COVID-19

The COVID-19 pandemic upended transit use, finance, and management. To investigate these effects two years into the pandemic, we conducted 21 semi-structured interviews with senior managers at transit agencies in the most populous U.S. state, California. We found that the pandemic generated many operational and managerial challenges for transit agencies. Ridership plummeted, then slowly recovered, but is still well below pre-pandemic levels at most agencies. Commuter trips to and from major job centers were especially slow to return. In response to decreased demand, public health concerns, and uncertain finances, many agencies cut services and spending early on. As a result, fare revenues declined, in some cases precipitously. However, federal pandemic relief funds proved essential in filling budgetary gaps, stabilizing finances, preventing layoffs, and maintaining services. Other transit subsidies mostly bounced back robustly. Our interviews suggest that, though California transit agencies experimented with free fares, few fareless programs were made permanent. Their challenges include considerable uncertainty associated with future travel demand, looming financial shortfalls at systems that formerly had high farebox recovery and are still drawing on federal pandemic funds to backfill their fare revenue losses, and protracted labor shortages of drivers and mechanics that are preventing many systems from providing desired levels of service.

Chorioamnionitis Is an Independent Risk Factor for Third- and Fourth-Degree Perineal Lacerations in the United States [ID: 1377609

INTRODUCTION: The objective was to determine the effect chorioamnionitis has on the risk of third- and fourth-degree perineal lacerations (3/4 PL). METHODS: This represents a retrospective cohort based on the Centers for Disease Control and Prevention Natality Live Birth database (2016–2020). We compared the rates of 3/4 PL in term, singleton vaginal births across the United States based on diagnosed intrapartum chorioamnionitis. We used Pearson chi-square and multivariate logistic regression to control for confounding variables. Statistical significance was determined as P<.05, and results were displayed as adjusted odds ratios (aORs) with 95% CI. RESULTS: Of the 11,677,671 who met inclusion criteria, 139,174 (1.2%) women experienced 3/4 PL. Intrapartum chorioamnionitis was associated with a staggering 3.96% rate of 3/4 PL compared to a 1.15% rate in women without chorioamnionitis (aOR 1.85, 95% CI 1.80–1.90). CONCLUSION: Based on this current U.S. database we identified chorioamnionitis as a major risk factor for 3/4 PL. The potential explanation may be due to dysfunctional labor, increased perineal edema secondary to protracted labor, or increased friability of tissue. Understanding this association may assist in better counseling and potentially reduce the rates of 3/4 PL in gravidas with chorioamnionitis.

Modern features of the delivery complicated premature rupture of membrane at term

Premature rupture of membranes (PROM) is diagnosed in 6–26.5% of full-term pregnancies. An analysis of the characteristics of labor and the frequency of complications in tPROM could allow us to identify «weak» points and optimize the managing this category of patients.The aim of the study was to assess the characteristics of labor during full-term pregnancy (at 37.0–41.0 weeks), complicated by premature rupture of the membranes.Materials and methods. A prospective analysis of the course of labor and the postpartum period was carried out in 425 patients with singleton pregnancy in cephalic presentation, 37,0–41,0 weeks of gestation, women of low and moderate risk groups, without contraindications to vaginal delivery.. As a complication of the pregnancy, 310 of them had PPROM (main group) and 115 women in labor went into labor with intact fetal membrane (comparison group). The features of the delivery and postpartum complications were analyzed.Results: The features of delivery patients with PROM was the longer duration of rupture – 4.7 times higher than in the comparison group (p<0.001), the second stage of labor – in the main group more an average of 7 minutes (p=0.008). The frequency of abnomally labor activity in the main group, such as abnormally slow or protracted labor (primary and secondary), was 2 times higher than it was in the comparison group. The diagnosis of «cervical dystocia» was observed in 27 cases (8.7%) only in the group with PROM. In the main group, oxytocin was used in 165 patients (53.2%), which is more than 2 times higher than in the comparison group – 25 (21.7%, p<0.001), respectively, the total dose of oxytocin used was higher at vaginal delivery: 8 .06 (0.44) U and 1.06 (0.46) U (p<0.001). The differences in this parameter at patents of both group with C-section were not signifcant. Medical analgesia in the main group was required 2 times more often than in the comparison group (83.5 and 43.5%; <0.001).The problem of tPROM is a higher percentage of operative delivery and obstetric trauma. Thus, in our study, the incidence of C-section was 54 cases (17.4%) compared with the another group – 2 cases (1.7%), vaginal operative delivery – 20 cases (6.5%) and 3 (2.6%)%) respectively (Xi=21.88; Df=2; p<0.001), cervical ruptures: 11.3% (p=0.002), episiotomies: 8.3% (p=0.099). The frequency of postpartum septic complications was comparable in groups, but high level of leukocyts and antibiotic therapy were more often in patients with PROM.Conclusion: the management of labor in patients with PROM is associated with a high percentage of the use of oxytocin, antibacterial therapy, various methods of medical analgesia, and operative delivery.

The effect of anti-pandemic measures on some aspects of obstetric care in a single obstetric unit in the Slovak Republic.

< pre style="margin-bottom: 6.0pt; line-height: 150%;" > < span lang="EN-GB" style="font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif;" > Objectives: < /span > < span lang="EN-GB" style="font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif;" > In many countries, various anti-pandemic interventions were adopted in 2020, which also affected obstetric practices. The aim of this study is to determine their effect on the frequency of caesarean section (CS) according to Robson classification (RC). < /span > < /pre > < pre style="margin-bottom: 6.0pt; line-height: 150%;" > < span lang="EN-GB" style="font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif;" > Material and methods: < /span > < span lang="EN-GB" style="font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif;" > Deliveries in 2019 and 2020 were retrospectively analysed. Mothers were grouped according to RC, and the frequency of CR in the different groups were compared. < /span > < /pre > < pre style="margin-bottom: 6.0pt; line-height: 150%;" > < span lang="EN-GB" style="font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif;" > Results: < /span > < span lang="EN-GB" style="font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif;" > We found a statistically significant increase in the frequency of CR in the pandemic year (20.0% vs 17.8%, p = 0.0242). When classified into RC groups, the increase in the different groups lost statistical significance. Nevertheless, the increase was most important in Robson group 5 due to maternal rejection of vaginal delivery after CR and in Robson group 2b with elective CR. In spite of our expectations, the frequency of caesarean section performed due to indication of protracted labour was not increased. < /span > < /pre > < pre style="margin-bottom: 6.0pt; line-height: 150%;" > < span lang="EN-GB" style="font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif;" > Conclusions: < /span > < span lang="EN-GB" style="font-size: 12.0pt; line-height: 150%; font-family: 'Times New Roman',serif;" > Interventions that were implemented during the first and second waves of the pandemic were associated with increased frequency of planned caesarean sections. < /span > < /pre >.

Macrosomia: A Serious Complication of Diabetes in Pregnancy

Gestational diabetes mellitus (GDM) and its associated complication, macrosomia, pose significant challenges during pregnancy. This review explores the epidemiological aspects, pathophysiology, complications, and long-term consequences of these conditions, with a focus on the need for early detection and advanced management strategies. The prevalence of GDM varies globally, with particular attention to India, where the correlation between macrosomia and GDM is evident. Early prenatal monitoring and glycemic control have been identified as effective strategies to reduce macrosomia incidence. Understanding the pathophysiology of GDM reveals a complex interplay of β-cell dysfunction and chronic insulin resistance, resulting in elevated blood sugar levels. This disruption contributes to macrosomia, characterized by the birth of abnormally large infants. Complications associated with macrosomia are not limited to childbirth; mothers may experience protracted labor, uterine atony, and an increased risk of tears, while newborns face the challenge of shoulder dystocia and neonatal jaundice. Additionally, the enduring significance of exposure to GDM in utero is concerning, with evidence linking it to childhood obesity and metabolic syndrome. The review also discusses promising research directions. The study of glycation markers aims to improve macrosomia prediction, enabling better management and care for affected pregnancies. Moreover, the integration of mobile technology, such as the GDm health smartphone solution, offers remote monitoring of blood glucose levels and tailored feedback, potentially revolutionizing GDM management. In tackling the challenges presented by GDM and macrosomia, a multifaceted approach is essential. Early and effective prenatal care, coupled with vigilant glycemic control, is critical for the well-being of both mothers and their infants. Continued research into innovative screening and management methods will further enhance pregnancy outcomes and long-term health. Healthcare professionals, armed with a comprehensive understanding of these conditions and their extensive effects, play a pivotal role in supporting expectant mothers and ensuring a brighter and healthier future for both mother and child.

Outpatient Foley Catheter for Induction of Labor in Obese Nulliparous Patients: A Secondary Analysis of OFFSITE II Randomized Controlled Trial.

In the OFFSITE II randomized controlled trial, outpatient cervical ripening with a Foley catheter (CF) in nulliparous patients undergoing elective induction of labor (eIOL) shortened the time from admission to delivery. Given that patients with obesity have protracted labor and higher rates of failed IOL, we sought to determine if outpatient ripening with a CF may be even more beneficial for this high-risk group. We performed a secondary analysis of the OFFSITE II randomized controlled trial. For this analysis, all patients from the primary trial were classified by their intervention assignment (inpatient vs. outpatient) and also by their admission body mass index (BMI) class (BMI ≥ 30 and BMI < 30 kg/m2). The primary outcome was time from labor and delivery (L&D) admission to delivery. Secondary outcomes included cesarean delivery, time from admission to hospital discharge, and rates of clinically diagnosed chorioamnionitis and endometritis. In patients with BMI ≥ 30, the primary outcome, time from admission to delivery, (18.0 [13.5-20.9] vs. 20.4 [16.6-31.3] hours, p = 0.01), as well as total hospitalization length (3.2 [2.5-3.3] vs. 3.4 [3.1-4.3] days, p = 0.02) were shorter in the outpatient group. There were no differences in rates of chorioamnionitis or endometritis in outpatient compared with inpatient CF. Furthermore, in those with a BMI ≥ 30, the cesarean rate was significantly lower with outpatient CF (19.4% vs. 44.7%, p = 0.03); it was not statistically different in patients with BMI < 30. In this exploratory retrospective secondary analysis of the OFFSITE II randomized control trial, we found that in patients with BMI ≥ 30 undergoing eIOL, outpatient CF was associated with a lower time from L&D admission until delivery. This was also associated with a shorter time of total hospital duration and decreased the rate of cesarean, a benefit not detected in the overall analysis presented in the primary study. In nulliparas undergoing induction of labor, ripening with outpatient cervical Foley may even more significantly reduce labor duration, total hospital duration, and the rate of cesarean in patients with obesity. · Outpatient CF was associated with a lower time from L&D admission until delivery in obese nulliparas.. · Outpatient CF was associated with a shorter time of total hospital duration in obese nulliparas.. · Outpatient CF was associated with a decreased rate of cesarean birth in obese nulliparas..

Synchronization as Musical Labor in Italian Silent Cinemas

Abstract This article examines a series of lawsuits that consumed Italy’s legal establishment between approximately 1924 and 1933. Resulting from a protracted labor dispute between instrumental musicians who worked in cinemas and the exhibitors who employed them, the lawsuits turned on a question of employment law: whether musicians ought to be considered full-time employees—entitled to various benefits and protections against unfair termination—or more precariously situated freelancers whom exhibitors could hire and fire at will. As a consequence of the vagaries of existing Italian labor law and new Fascist legislation governing labor relations, musicians were already at a disadvantage in this dispute. Unexpectedly, their situation was further undermined by the judiciary, as Italy’s highest court made their employee status conditional on the perceived aesthetic value of cinema and its associated music making. That is, musicians had to prove that their musical abilities were integral to the artistic outcome of any given film screening—a tall order in the context of silent cinematic exhibition, where musical accompaniment was materially distinct from the projected film. Precisely because the courts valorized the fusion of music and image, however, the Italian musicians’ lawsuits illuminate a fundamental parameter of cinematic aesthetics—synchronization—and reveal something significant about the nature of film music. Public recognition for effecting music-image synchronization in film conferred symbolic, but also literal, capital; thus I contend that synchronization ought to be understood as a form of musical labor, both in the silent era and beyond.

Maternal mortality in modern world

Aim: to analyze the causes and level of global maternal mortality (MM) according to the data published within the last 7 years.Materials and Methods. Search for publications in the PubMed/MEDLINE database was conducted according to the criteria: metaanalysis, free full-text, English, 2015–2021 period. The PICO principle (Patient/Problem, Intervention, Comparison, Outcome) and the keywords "maternal mortality causes", "maternal death causes", "maternal outcomes" were used. The search was finished on October 13, 2021 after retrieving 137 results.Results. The rate of MM and cause pattern has been changing during COVID-19 pandemic. The first weeks of the COVID-19 lockdown showed that in-hospital mortality among pregnant women increased from 0.13 up to 0.20 % (p = 0.01) and in MM the proportion of respiratory diseases elevated up to 32 % versus 5.6%. Certain geographic regions of the world showed that MM due to COVID-19 reached extremely high values extending 3399 per 100,000 live births as well as increased general MM rate. Heart and vascular diseases (pericarditis, myocardial infarction, thromboembolism) have a significant position among the causes of MM. The rate of MM due to cardiovascular disease was inversely related to the population income level. Cardiomyopathy is the cause of death in 4 % (95 % confidence interval (95 % CI) = 2–7) of mothers in developed countries and 14 % (95 % CI = 10–18) in developing countries. The mortality rate 6 weeks after delivery among women with pregnancy-related myocardial infarction was 5.03 % (95 % Cl = 3,78–6,27), whereas it associated with thromboembolism among women with a mechanical heart valve was related to the agent used to prevent thrombosis, ranging from 0.9 (95 % CI = 0.1–1.6) for vitamin K antagonists up to 3.4 (95 % CI = 0–7.7) for unfractionated heparin per 100 pregnancies with a mechanical heart valve. After 2000, the proportion of anesthesia among immediate MМ causes decreased from 3.5 % (95 % CI = 2.9–4.3) down to 2.4 % (95 % CI = 1.9–2.9) in low- and middleincome countries. High MM odds due to maladjusted pregnancy are still observed: OR (odds ratio) = 17 (95 % CI = 9.6–28.8) for hypertension, OR = 3.70 (95 % CI = 1.72–7.99) for HELLP syndrome with acute kidney injury. Severe obstetric complications cause MM in sub-Saharan Africa and South Asia: bleeding (OR = 28.8; 95 % CI = 20.3–40.7), preeclampsia or eclampsia (OR = 9.13; 95 % CI = 6.10–13.7), maternal infections in antenatal period (OR = 2.80; 95 % CI = 1.63–4.80). About 67 % of pregnant women in such countries obtain no antenatal care (OR = 2.80; 95% CI = 1.63–4.80), predominantly giving birth at home in sub-Saharan Africa. In Ethiopia, ММ results from obstructed home delivery resulting in maternal death in 17.27 %, where uterine rupture is cause of death in 7.75 % of women.Conclusion. The COVID-19 pandemic contributed a lot to MM. Diseases of the cardiovascular system markedly elevate the MM risk and long-term mortality after delivery. For countries with traditionally home births in the absence of medical care, a high MM remains due to complicated and protracted labor complicated by uterine rupture.

Study of Women in Labor with Artificial Rupture of Membranes and its Effect on the Duration of Labor

In a venture to reduce maternal mortality especially by post-partumhemorrhage and prolonged and protracted labor many labor room procedures are in practice. The purpose of this study is to compare laborers with and without amniotomy concerning the duration of admission to delivery interval, mode of delivery (vaginal or cesarean), and fetal compromise in form of Apgar score.In the background of augmentation of labor by routine amniotomy in normally progressing labor, this study was carried out on 156 parous women in the Department of Obstetrics and Gynaecology at C. R. Gardi Hospital, Ujjain, Central India from January 2017 to January 2018. Doing artificial rupture of membranes at 3-4 cm dilatation was the main procedure. Results showed a definite reduction in admission to a delivery interval in primigravida and multipara (p=0.00). There was no effect on mode of delivery, the requirement of addition of oxytocin, and poor Apgar score (&lt; 7); p-value being more than 0.05. Concluding our result findings, amniotomy as a routine procedure in the labor room helps reduce the length of labor.

A brief history and indications for cesarean section

Cesarean section (CS) is one of the oldest surgical operations. Originally, this surgery was performed post-mortem by cutting open the woman’s abdomen to remove a dead or alive fetus. It was therefore not intended for saving the mother in ancient times. Roman law and religious rituals shaped the procedure until the Middle Ages. At that time, the indication of CS was only post-mortem. Although CS became a medical procedure in the Renaissance, maternal mortality was extremely high, mainly due to hemorrhage and puerperal infection. The reason for performing CS was to rescue the mother and fetus from protracted labor as a last resort. Since the late 19th century, with the introduction of chloroform and the developments of surgical techniques, and the availability of blood transfusion in the early twentieth century, CS became a relatively safe procedure, further helped by the introduction of antibiotics after World War II. Then, CS was increasingly an intervention to preserve the health and safety of both mother and fetus. During the 21st century, CS has been performed even without medical indication, such as maternal choice. Advancement of obstetric practice technologically and professionally during the period as well as changing attitudes of both obstetricians and childbearing women meant indications for CS are no longer limited to medical/obstetric indications. CS is perceived as a safer mode of childbirth. Therefore, the indications of CS have been changed drastically from ancient times (rescuing a baby from dying or dead mother) to the 21st century (maternal choice/reproductive rights).

Dysfunctional labor and hemoperitoneum secondary to an incidentally discovered dysgerminoma: a case report

BackgroundOvarian dysgerminoma, a subtype of malignant germ cell tumor (GCT), is a rare ovarian neoplasm that is infrequently found in the gravid patient. When dysgerminomas do occur in pregnancy, the rapidly growing tumors can have a heterogeneous presentation and lead to peripartum complications and morbidity. Due to the rarity of this condition, diagnostic and therapeutic strategies are not well described in the literature.Case presentationA healthy multigravida with an uncomplicated antenatal history presented for elective induction of labor. She had a protracted labor course, persistently abnormal cervical examinations, and eventually developed a worsening Category II tracing that prompted cesarean birth. Intraoperatively, a 26 cm pelvic mass later identified as a Stage IA dysgerminoma was discovered along with a massive hemoperitoneum. The mass was successfully resected, and the patient remains without recurrence 6 months postoperatively.ConclusionAlthough rare and generally indolent, dysgerminomas can grow rapidly and cause mechanical obstruction of labor and other complications in pregnancy. Pelvic masses, including malignant neoplasms, should be included in as part of a broad differential diagnosis when evaluating even routine intrapartum complications such as abnormal labor progression. Additionally, we demonstrate that adnexal masses can be a source of life-threatening intraabdominal hemorrhage.

Normal labor curve in twin gestation

Failure to progress is one of the leading indications for cesarean delivery in trials of labor in twin gestations. However, assessment of labor progression in twin labors is managed according to singleton labor curves. This study aimed to establish a partogram for twin deliveries that reflects normal and abnormal labor progression and customized labor curves for different subgroups of twin labors. This was a multicenter, retrospective cohort analysis of twin deliveries that were recorded in 3 tertiary medical centers between 2003 and 2017. Eligible parturients were those with twin gestations at ≥34 weeks' gestation with cephalic presentation of the presenting twin and ≥2 cervical examinations during labor. Exclusion criteria were elective cesarean delivery without a trial of labor, major fetal anomalies, and fetal demise. The study group comprised twin gestations, whereas singleton gestations comprised the control group. Statistical analysis was performed using Python 3.7.3 and SPSS, version 27. Categorical variables were analyzed using chi-square tests. Student t test and Mann-Whitney U test were applied to analyze the differences in continuous variables, as appropriate. A total of 1375 twin deliveries and 142,659 singleton deliveries met the inclusion criteria. Duration of the active phase of labor was significantly longer in twin labors than in singleton labors in both nulliparous and multiparous parturients; the 95th percentile duration was 2 hours longer in nulliparous twin labors and >3.5 hours longer in multiparous twin labors than in singleton labors. The cervical dilation progression rate was significantly slower in twin deliveries than in singleton deliveries with a mean rate in twin deliveries of 1.89 cm/h (95th percentile, 0.51 cm/h) and a mean rate of 2.48 cm/h (95th percentile, 0.73 cm/h) in singleton deliveries (P<.001). In addition, epidural use further slowed labor progression in twin deliveries. The second stage of labor was also markedly longer in twin deliveries, both in nulliparous and multiparous women (95th percentile, 3.04 vs 2.83 hours, P=.002). Twin labors are characterized by a slower progression of the active phase and second stage of labor compared with singleton labors in nulliparous and multiparous parturients. Epidural analgesia further slows labor progression in twin labors. Implementation of these findings in clinical management might lower cesarean delivery rates among cases with protracted labor in twin gestations.

341 Outpatient cervical ripening with foley catheter for elective induction of labor (eIOL) in obese nulliparas

Outpatient cervical ripening with a Foley catheter (CF) in nulliparas undergoing eIOL shortens L&D admission to delivery time. As obese women (BMI ≥ 30) have protracted labor, we evaluated if outpatient ripening with a CF may be even more beneficial in this population than in those with BMI < 30. Secondary analysis of an RCT (NCT03472937) in which nulliparas with singletons and modified Bishop score <5 undergoing eIOL ≥ 39wks were randomized to outpatient CF (with scheduled L&D admission the next day) vs inpatient CF. In both groups, oxytocin was initiated on admission. The primary outcome was duration of labor (L&D admission to delivery time); secondary outcomes included rate of cesarean and infections. Outcomes were compared between inpatient and outpatient groups, stratified by BMI ≥ 30 and BMI < 30 after evaluating statistical interactions between randomization group and obesity. Of 126 women in the parent RCT, 69 (55%) had a BMI ≥30. In women with BMI ≥30, women in the outpatient group (vs. inpatient) had lower BMI, decreased GBS+ status, and higher randomization modified Bishop score (p<0.01). Duration of labor and total hospitalization were significantly shorter in the outpatient group (Table). Furthermore, cesarean rate was lower and admission modified Bishop score was higher (3 [2-3] vs. 1 [0-1], p<0.001) with outpatient CF. Adjusting for BMI, labor was on average 6 hours shorter with outpatient CF (mean difference/OR -6.3 [95% CI -10.3, -2.4]). There was no difference in chorioamnionitis (inpatient 13% vs outpatient 29%, p=0.10) or endometritis (inpatient 5% vs outpatient 0%, p=0.50). Tests for interaction between CF group and obesity group were significant–demonstrating an increased beneficial effect with outpatient CF in the obese strata (Table). In obese nulliparas undergoing eIOL, outpatient ripening with CF significantly decreases labor duration, total hospitalization, and the cesarean rate more so than in non-obese women. Given the protracted labor course in these women, a larger study evaluating both safety and efficacy of outpatient CF is warranted.

49 Normal Labor Curve in Twin Gestations

Failure to progress is the leading indication for cesarean delivery in trials of labor of twin gestations. However, assessment of labor progression in twin labors is managed according to singleton labor curves. This study aims to establish a partogram for twin deliveries that reflects normal and abnormal labor progress, as well as customized labor curves for different subgroups of twins. A multi-center retrospective cohort analysis of twin deliveries recorded in three tertiary medical centers between the years 2003-2017 was conducted. Eligible parturients were twin gestations ≥34 weeks with cephalic presentation of the presenting twin and ≥2 documented cervical examinations during labor. Exclusion criteria were elective cesarean delivery without trial of labor, major fetal anomalies, and fetal demise. Twin gestations comprised the study group while singletons counterparts formed the comparison group. Statistical analysis was performed with Python 3.7.3. A total of 1,375 twin deliveries and 142,659 singleton deliveries met the inclusion criteria. Parturients with twins used epidural analgesia more frequently (74.2% vs. 54.8%, p<0.001) and underwent more labor inductions (24.2% vs. 15.3%, p<0.001) as compared to singletons. Active phase duration was significantly longer in twins as compared to singletons in both nulliparous and multiparous parturients (p=0.005, p<0.001 respectively) (Figure 1). Epidural use and labor induction further slowed labor progression in twins as compared with singletons (p=0.02, p<0.001 respectively) (Figure 2). Twin labors are characterized by slower progression of the active phase of labor as compared with singletons. Nulliparity, epidural analgesia and induction of labor slow labor progression further. Implementation of these findings to clinical management might lower cesarean delivery rate due to protracted labor in twin gestations.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Maternal and Neonatal Morbidity After 4 and 6 Hours of Protracted Active Labor in Nulliparous Term Pregnancies.

Maternal and Neonatal Morbidity After 4 and 6 Hours of Protracted Active Labor in Nulliparous Term Pregnancies.

Maternal and Neonatal Morbidity After 4 and 6 Hours of Protracted Active Labor in Nulliparous Term Pregnancies.

Maternal and Neonatal Morbidity After 4 and 6 Hours of Protracted Active Labor in Nulliparous Term Pregnancies.

Proactive versus standard support of labour in nulliparous women; study protocol for a randomized, controlled trial

BackgroundProlonged latent phase of labour often results in a traumatic birth experience. Prolonged labour is associated with more operative deliveries, haemorrhage, fetal asphyxia and poor birth experience. Women with prolonged labour in a former pregnancy more often demand caesarean section in the next, due to their negative birth experience. “Proactive support of labour” is an alternative method, developed to counteract prolonged labour. There are little research and no randomized controlled study that compare proactive to standard labour support.Methods/DesignA prospective, non-blinded, randomized, single-centre, clinical trial where we compare proactive support to standard support of labour in a university hospital setting.Inclusion criteria: latent phase of labour, non-pathologic pregnancy. Robson group 1, with painful contractions, and fully effaced cervix, with 1–3 cm dilatation. Exclusion criteria: induction of labour, breech presentation, twin pregnancy, multi-parity, conditions that require extended surveillance before and/or during labour.Primary outcome: spontaneous, uncomplicated vaginal delivery. After inclusion, women randomized to proactive support of labour will stay at the hospital and have one-to-one midwife support. If no progression during the next 1–2 hours, amniotomy and/or oxytocin stimulation will be started. The control group will adhere to the standard procedures for labour support: expectance until established regular contractions and 4–5 cm cervical dilatation, and then one-to-one midwife support.DiscussionThe idea of proactive support of labour is to initiate early intervention when there are signs of slow progress in order to avoid protracted labour with exhaustion of the mother, the uterus and prolonged stress of the foetus. Proactive support of labour may represent a useful method to improve labour support in nulliparous women. However, evidence based on randomized controlled trials are needed in order to know whether proactive support of labour is comparable or superior to standard care. A randomized, controlled trial is described; challenges and possible clinical implications are discussed.Trial registrationThe Proactive Support of Labor Study (PAF) ClinicalTrials, NCT03056313. Registered on February 17, 2017.