Slow Progress In Labour Research Articles

Fetal occiput-spine angle during the first stage of labour for predictor of progress and outcome of labour at Tanta university hospital

Background: Labor dystocia (LD) is defined by the slow and abnormal progress of labor. Failure to progress in labor is the leading indication for 1ry cesarean delivery approximately 80% of American women will eventually have at least one child, and the majority of these women will undergo labor. “Labor dystocia” encompasses a variety of concepts, ranging from “abnormally” slow dilation of the cervix or descent of the fetus during active labor to entrapment of the fetal shoulders after delivery of the head.Aim and objectives: To assess the relation between the fetal occiput-spine angle measured through transabdominal ultrasound during 1st stage, progress and outcome of labor.Subjects and methods: This cross sectional study was carried out on 150 pregnant ladies. who were recruited from the labor and delivery ward at Tanta University Hospitals and Desouq general Hospital during the period of research from August 2021 to August 2022.Result: As regard cut off value of angle to predict complication in predicting labour outcome either NVD or CS at an angle ≤133 the sensitivity specificity, PPV, NPV of angle to predict complication were 66.67%, 56.59%, 20%, 91.2% respectively. There was significant relation between angle ≤126 or >126 regarding Cervix position, Head station, Mode of delivery, Fetal and maternal complications.Conclusion: Occiput –spinal angle is a good predictor of operative delivery. Fetuses with a smaller occiput-spine angle (<126°) have a higher risk of cesarean delivery. We also found that the best OSA is 133 and below this angle the complication increased.

Clinical algorithms for identification and management of delay in the progression of first and second stage of labour

AimTo develop clinical algorithms for the assessment and management of slow progress of labour.PopulationLow‐risk singleton, term, pregnant women in labour.SettingInstitutional births in low‐ and middle‐income countries.Search strategyWe systematically reviewed the literature on normal labour progression, and guidance on clinical management of abnormally slow progression from 1 December 2015 to 1 October 2020 from relevant international guidelines, Cochrane reviews and primary research studies in PubMed by searching for international and national guidance documents, electronic databases and published systematic reviews using relevant keywords.Case scenariosWe developed two clinical algorithms: one for abnormally slow labour progression and arrest during first stage and one for the second stage. The algorithms provide definitions of suspected and confirmed slow progress of labour or arrest, initial assessment and ongoing monitoring, differential diagnosis, and management of the abnormalities, as well as links to other algorithms for labour management.ConclusionsIdentifying abnormal progress of labour is often challenging. These algorithms may help healthcare providers identify abnormal labour progress and institute prompt management or referral where needed but also reduce misdiagnosis and unnecessary use of interventions to accelerate labour.Tweetable abstractEvidence‐based clinical algorithms may help and standardize early identification and management of abnormally slow labour progress or arrest.

50 The labour progression study (LaPS): duration of labour following zhangs’s guideline and the who partograph – A cluster randomised trial

Introduction and aim: Traditionally, the progress of labour is measured by cervical dilatation. However, the expected progression varies between countries and there is no consensus regarding which guideline is best suited for clinical use. The applicability of stages, phases and time limits in labour is challenging, mainly because of variations in defining the onset of labour and transition of phases and stages. One concern is that women may undergo unnecessary interventions because slow progress of labour is poorly defined.

Disseminated Peritoneal Leiomyomatosis: A Case Report of an Incidental Finding During an Emergency Caesarean Section and a Review of the Literature

Aim: To present the case report of an incidental finding of disseminated peritoneal leiomyomatosis (DPL) found during an emergency caesarean section in a young Nigerian woman who presented with slow progress in labour and maternal exhaustion.&#x0D; Presentation of Case: We present the case of a 35-year-old unbooked primigravida with previous myomectomy who presented with maternal exhaustion and slow progress in labour and subsequently had an emergency lower segment caesarean section. At surgery, multiple firm to hard nodules of varying sizes were seen scattered throughout the peritoneum. Histological examination and immunohistochemical analysis of the nodules showed features consistent with disseminated peritoneal leiomyomatosis. Clinical and radiological follow-up for 1 year was uneventful.&#x0D; Discussion: DPL is a rare benign smooth muscle tumour that clinically and macroscopically simulates disseminated intra-abdominal or pelvic malignancy. It occurs predominantly in women of child bearing age and is mostly discovered incidentally. The occurrence of DPL in association with pregnancy and uterine leiomyomas was also corroborated in this index case as pedunculated and intramural uterine nodules were also seen during surgery.&#x0D; Conclusion: Disseminated peritoneal leiomyomatosis is a rare benign disease which may be misdiagnosed as disseminated or metastatic intra-abdominal malignancy. Therefore, a high index of suspicion is required for accurate diagnosis and proper management.

A myofibre model for the study of uterine excitation-contraction dynamics

As the uterus remodels in preparation for delivery, the excitability and contractility of the uterine smooth muscle layer, the myometrium, increase drastically. But when remodelling proceeds abnormally it can contribute to preterm birth, slow progress of labour, and failure to initiate labour. Remodelling increases intercellular coupling and cellular excitability, which are the main targets of pharmaceutical treatments for uterine contraction disorders. However, the way in which electrical propagation and force development depend on intercellular coupling and cellular excitability is not fully understood. Using a computational myofibre model we study the dependency of electrical propagation and force development on intercellular coupling and cellular excitability. This model reveals that intercellular coupling determines the conduction velocity. Moreover, our model shows that intercellular coupling alone does not regulate force development. Further, cellular excitability controls whether conduction across the cells is blocked. Lastly, our model describes how cellular excitability regulates force development. Our results bridge cellular factors, targeted by drugs to regulate uterine contractions, and tissue level electromechanical properties, which are responsible for delivery. They are a step forward towards understanding uterine excitation-contraction dynamics and developing safer and more efficient pharmaceutical treatments for uterine contraction disorders.

The association between induction of labour at 38 to 39weeks pregnancy and indication for caesarean delivery: An observational study.

Induction of labour is associated with a reduction in caesarean delivery, but the mechanism of action and which groups of women might benefit remain unknown. To assess the association between induction of labour at 38-39weeks pregnancy, and caesarean delivery: (i) overall; (ii) for slow progress in labour; and (iii) for suspected fetal compromise. Retrospective observational study in two Sydney hospitals from 2009 to 2016, among nulliparous women with induction of labour at 38 or 39 completed weeks pregnancy and a singleton, cephalic presenting fetus. The comparator was all planned vaginal births beyond 39(+1/7) weeks, whether or not labour was induced. Binary and multinomial multiple logistic regressions adjusting for multiple confounders were performed. There were 2388 and 15259 womenin the study and comparison groupsrespectively. Induction of labour was associated with caesarean delivery overall only for women <25years of age (adjusted odds ratio 1.63; 95% CI 1.17-2.27) and was not associated with caesarean delivery for slow progress. Induction of labour was positively associated with increased caesarean delivery for suspected fetal compromise among young women (<30years), with the association weakening as maternal age increased. The association between induction of labour and caesarean delivery was different for slow progress compared with suspected compromise (P=0.005). Induction of labour has different effects on the likelihood of caesarean delivery for slow progress and for suspected fetal compromise. Women <30years of age are at higher risk of caesarean delivery for suspected fetal compromise, potentially due to uterine hyperstimulation.

EFFECT OF ACUPRESSURE THERAPY POINT LI 4, SP 6, AND BL 60 ON DURATION OF THE FIRST STAGE OF LABOR IN PRIMIGRAVIDA AND NEWBORN’S APGAR SCORE

Background: The prolonged partus is one of the causes of maternal deaths marked by the slow progress of labor. Induction of labor and caesarean section is a common procedure performed on long-term partus events to end pregnancy. The birth acupressure technique is a complementary method to activate the hormone oxytocin at a certain point to use to soften the cervix and increase contraction.&#x0D; Objective: To examine the effect of acupressure point LI4, SP6 and BL60 on the duration of the first stage of labor and APGAR score of newborns in primigravida.&#x0D; Methods: This research employed a quasi-experimental study with posttest control group design. It was conducted at the Public Health Center of Trauma and Public Health Center of Palaran Samarinda, East Kalimantan, Indonesia. There were 40 respondents selected using purposive sampling, which 20 respondents assigned in the experiment and control group. The duration of the first stage of labor was assessed using partograph and APGAR score was assessed using APGAR score assessment sheets. Mann Whitney test was used for data analysis&#x0D; Results: Findings showed that the duration of the first stage of labor in the experiment group was 187 minutes and in the control group was 307 minutes. Mann Whitney test obtained p-value 0.001 (&lt;0.05), which indicated that there was a statistically significant difference of the duration of the first stage of labor between both groups. However, Mann Whitney test for APGAR score showed p-value 0.114 (&gt;0.05), which indicated that there was no significant difference of APGAR score in the experiment and control group.&#x0D; Conclusion: There was a significant effect of acupressure on the duration of the first stage of labor, but no effect of the APGAR score. Therefore, acupressure may be recommended to shorten the duration of the first stage of delivery in primigravida.

Is the policy of allowing a female labor companion feasible in developing countries? Results from a cross sectional study among Sri Lankan practitioners

BackgroundCompanionship during labor is known to have both physical and psychosocial benefits to mother and baby. Sri Lanka made a policy decision to allow a labour companion in 2011. However, implementation has been unsatisfactory. Given the leading role Obstetricians play in the implementation of policy, a study was undertaken to assess the knowledge, attitudes and practices among them.MethodA descriptive cross sectional study was conducted among consultant obstetricians working in the state hospitals using the platform ‘Survey Monkey’.ResultsOut of the 140 consultant obstetricians invited, 68(48.5%) participated. Among the study participants, 40 (58.8%) did not allow labour companions in their wards. Lack of space (n = 32; 80%) and the volume of work in the labor wards (n = 22; 55%) were the commonest reasons for not allowing a companion. Only 16.7% (n = 5) of the obstetricians handling more than 300 deliveries per month allowed a companion (p = 0.001). Less than 50% of the obstetricians were aware of the advantages associated with the practice such as shorter labor, lesser analgesic requirement, higher chances of a normal birth, improved neonatal outcome and reduced requirements for labor augmentation for slow progress of labor. Knowledge on advantages on breast feeding and reduced need of instrumental delivery also remained low.ConclusionIn an individual unit, the consultant often decides policy. The study points out the need to improve awareness among the practitioners.

P04.06: Fetal rotation during vacuum extraction

The main outcome of this study was to examine the rotation of the fetal head during vacuum delivery. We conducted a prospective cohort study including 222 nulliparous women with slow progress in the second stage of labour. The women were examined with ultrasound when the birth attended diagnosed slow progress in labour after 45 minutes of active pushing and a vacuum extraction was considered. The fetal head position was determined with transabdominal or transperineal ultrasound before vacuum extraction. They were categorised in occiput anterior (OA), occiput transverse (OT) and occiput posterior (OP). 150 vacuum extractions were performed. Before vacuum extraction 108 (76%) fetuses were in an OA position, 15 (11%) were in an OT position and 19 (13%) in an OP position. In 8 cases position before vacuum was not recorded. Of the fetuses in OA position 99% were delivered by vacuum extraction in OA position and 1% rotated into OP position. 80% of the fetuses in OT position rotated into OA position and 20% into OP position. Of the fetuses in OP position 69% rotated into OA position and 31% stayed in OP position at delivery. Supporting information can be found in the online version of this abstract Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Legal Briefs: Prolonged Labor and Ischemic Encephalopathy

A 4,232-g 40-3/7-week-gestation male infant was delivered by a 38-year-old gravida 1, para 0 woman after 4 days of uterine contractions. Eighteen hours before delivery when the cervix was 5 cm dilated, 100% effaced, and the fetus was at –2 station, the obstetrician artificially ruptured the membranes and placed an intrauterine pressure catheter (IUPC). The plaintiff obstetrical expert pointed out that the IUPC was not calibrated and this was below the standard of care. A caput was discovered at this point. The plaintiff obstetrical expert pointed out that much pressure must have been exerted on the fetal head thus far to have produced a caput before the second stage of labor. The presence of the caput did not allow the obstetrical team, which consisted of a midwife, a remotely distant supervising obstetrician, and several shifts of bedside nurses, to accurately assess the station and position of the fetus. The midwife noted variable decelerations with increasing frequency and severity 24 hours before delivery, prompting her to perform an amnioinfusion. The anesthesiologist provided an epidural. The plaintiff obstetrical expert maintained that because there were multiple and deep variables during the first stage of labor, it was very probable that the fetus would not be able to tolerate the contractions during the second stage. He further contended that delivery was remote, considering the slow progress of labor up to this point, and it was unlikely that a safe vaginal delivery could be reasonably expected. In fact, multiple attempts were made with intravenous boluses, position changes, and supplemental oxygen to help the fetus recover from the deep decelerations during the first stage of labor. The recovery to the prior baseline heart rate (HR) after decelerations initially was good. However, as time went on, by 16 hours before delivery, the fetus was not recovering well …

BJOG Editor's Choice

BJOG Editor's Choice

Rates and indicators for amniotomy during labor--a descriptive cross sectional study between primigravidas and gravida 2 and above.

ABSTRACTBackground:Artificial rupture of membranes (Amniotomy) is a common obstetric intervention. Its rates and indications had been subjected to criticism in medical literature. The current practices recommend to reduce its rate and keep the birthing process as natural as possible.Aim:This observational study aimed to describe the rates and indicators for practice of artificial rupture of membranes (Amniotomy) during normal labor and to determine if any significant differences existed between women who have had one pregnancy (PG) and women who have already delivered two or more children (G2 and above) on this obstetric interventions: artificial rupture of membranes (ARM).Results:There were no PG participants with ruptured membranes whereas slightly more than half of the G2 and above participants (n = 88) had ruptured membranes. The most frequent cause for ARM was active management of latent phase of labor (PG n = 20 and G2 and above n = 9). Furthermore, slow progress of labor (PG n = 17 and G2 and above n = 7) and concerns with fetal heart rate (PG n = 13 and G2 and above n = 5) had the next highest number of occurrences. Results from the proportions tests revealed that there was one significant difference between gravidity groups on the frequency of APH (p =0.039). That is, G2 and above participants had amniotomy done for APH (5 of 32 = 15.63%) significantly more often than PG participants (4 of 89 = 4.49%). And although not statistically significant (p =0.084), there were 21 cases within the PG group where ARM was performed for no specific reason (21 of 89 = 23.6%) compared to three cases within the G2 and above group (3 of 32 = 9.4%).Conclusions:Although ARM is a commonly performed procedure during labor, there is not much difference between its indications between PG and G2 and above. The only significantly different indication was antepartum hemorrhage which was higher in G2 and above. Amniotomy was also performed without any clear indication in 26.4% of PG and 9.4% of G2 and above. Considering ARM as obstetric intervention efforts should be done to reduce its rates. There is a need for arranging normal labor workshops to revise the indications and reviewing the rates after these workshops to reduce the rates of ARM.

Role of “Partograph” in Early Detection of Abnormal Progress of Labour

Background: The modified World Health Organisation (WHO) partograph is an inexpensive but valuable tool that provides a continuous pictorial overview of progress of labour. It guides the obstetrician to decide about the need for augmentation of labour and helps to recognize prolonged labour before she goes into obstructed labour. Objectives: To determine the role of partograph in early detection of prolonged labour and its complications; Identification of timing for intervention for any operative delivery. Materials and Methods: This prospective observational study was conducted with 800 women, 400 primigravida and 400 multigravida who were admitted in labour room with full term pregnancy in labour with vertex presentation. Monitoring was done by using ‘Modified WHO partograph.’ Results: Out of 400 patients, 82.25% primigravida and 95.25% of multigravida patients delivered vaginally, 13.75% of primigravida and 03.50% of multigravida patients required caesarean section and 04.00% of primigravida and 01.25% multigravida patients had to undergo operative vaginal deliveries. Commonest abnormal pattern in both primigravida (38.02%) and multigravida (31.58%) patients; was in the form of arrest of descent of labour. Commonest mode of delivery for abnormal labour pattern in this study; in both primigravida and multipara was caesarean section, followed by instrumental vaginal delivery. Conclusion: WHO partograph is an efficient tool for labour management. When labour is monitored graphically by using WHO partograph, it helps us in early identification of cases of slow or abnormal progress of labour.

Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour

Slow progress in the first stage of spontaneous labour is associated with an increased caesarean section rate and fetal and maternal morbidity. Oxytocin has long been advocated as a treatment for slow progress in labour but it is unclear to what extent it improves the outcomes for that labour and whether it actually reduces the caesarean section rate or maternal and fetal morbidity. This review will address the use of oxytocin and whether it improves the outcomes for women who are progressing slowly in labour compared to situations where it is not used or where its administration is delayed. To determine if the use of oxytocin for the treatment of slow progress in the first stage of spontaneous labour is associated with a reduction in the incidence of caesarean sections, or maternal and fetal morbidity compared to situations where it is not used or where its administration is delayed. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 February 2013) and bibliographies of relevant papers. Randomised controlled trials which compared oxytocin with either placebo, no treatment or delayed oxytocin in the active stage of spontaneous labour in low-risk women at term. Two authors independently assessed studies for inclusion, assessed risk of bias and extracted data. We sought additional information from trial authors. We included eight studies in the review involving a total of 1338 low-risk women in the first stage of spontaneous labour at term. Two comparisons were made; 1) the use of oxytocin versus placebo or no treatment (three trials); 2) the early use of oxytocin versus its delayed use (five trials). There were no significant differences in the rates of caesarean section or instrumental vaginal delivery in either comparison. Early use of oxytocin resulted in an increase in uterine hyperstimulation associated with fetal heart changes. However, the early use of oxytocin versus its delayed use resulted in no significant differences in a range of neonatal and maternal outcomes. Use of early oxytocin resulted in a statistically significant reduction in the mean duration in labour of approximately two hours but did not increase the normal delivery rate. There was significant heterogeneity for this analysis and we carried out a random-effects meta-analysis; however, all of the trials are strongly in the same direction so it is reasonable to conclude that this is the true effect. We also performed a random-effects meta-analysis for the four other analyses which showed substantial heterogeneity in the review. For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernable difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.

Feasibility of use of color-coded rings by nurse midwives: An appropriate technology based on partographic principles

Objectives:To study the feasibility of use of color-coded rings as a proxy for partograph for early identification of slow progress of labor.Materials and Methods:Color-coded rings were devised as a tool using appropriate technology to translate the partographic principles into simpler, easy to understand methodology. The rings were in pairs of 4 colors i.e., red, blue, yellow, and green, ranging from 3 cm to 10 cm in diameter with a difference of 4 cm between rings of the same color. The midwife performed p/v examination of the woman in labor to assess the initial cervical dilatation and identify corresponding ring. P/V was to be repeated after 4 hours to reassess the cervical dilatation and compare it with the bigger ring of the same color indicating expected cervical dilatation. If existing cervical dilatation measured lesser, it was interpreted as slow progress of labor indicating referral.Results:44 women [23 (22.1%) primis and 21 (13%) multis] showed delayed progress of labor as judged by use of color-coded rings. 20 women (4 primis and 16 multis) showed satisfactory progress or delivered by the time arrangements for referral were made.Conclusion:Use of color-coded rings may serve as a valuable tool based on appropriate technology to assess slow progress of labor not only in the hands of nurse midwives but it also can serve as a training tool for TBAs to help facilitate timely referral of such cases.

Patterns of transfer in labour and birth in rural New Zealand

For many women, and particularly rural women, birthing locally and within their own community is important for personal, social and/or cultural reasons. If concerns about the woman or her baby mean transfer to a secondary or tertiary facility is necessary, this can be disruptive and stressful, especially if road transfer is complicated by terrain, weather or distance, as is often the case in rural New Zealand. The objective of this study was to explore the number of and reason for transfers during labour and birth for well women, close to full term, from primary rural maternity facilities to specialist care in rural New Zealand. This retrospective survey of 45 rural maternity units in the North and South Islands of New Zealand was conducted over a 2 year period ending on 30 June 2006. The participants were the 4678 women who began labour in a rural facility during this time period. The survey response rate was 66.6%. The data revealed that 16.6% of women who commenced labour in a rural unit were transferred in labour or within 6 hours of birth; 3% of babies born in rural units were transferred after birth and up to 7 days post-birth. The primary reason for maternal transfer was slow progress in labour (49.67%). Of the 123 babies transferred, this was most often due to respiratory problems (43%). Key features of the rural context (times and distances to be travelled, geological and climatic characteristics, types of transport systems and availability of local assistance) influenced the timeliness of the decision to transfer. Within New Zealand's regionalised perinatal system, midwives make cautious decisions about transfer, taking into account the local rural local circumstances, and also the topography as it impacts on transport.

The Effect of Early Oxytocin Augmentation in Labor

To estimate the effects of early augmentation with oxytocin for slow progress of labor on the delivery method and on indicators of maternal and neonatal morbidity. We conducted electronic database searches of PubMed, MEDLINE, EMBASE, and the Cochrane Library for articles published through February 2009 using the keywords "oxytocin," "augmentation," "active management of labor," "cesarean section," and "labor." Primary authors were contacted directly if the data sought were unavailable. We included randomized controlled trials comparing early oxytocin augmentation with a more conservative approach to care in labor. We included only those studies in which membrane management was similar in the two groups. Early oxytocin augmentation was defined as immediate oxytocin administration when dystocia was identified. Data were extracted by two authors independently and evaluated for potential sources of bias. Relative risk (RR) and 95% confidence interval (CI) were calculated using fixed and random effects models. Nine trials with 1,983 women met the inclusion criteria. Early oxytocin was associated with an increase in the probability of spontaneous vaginal delivery (RR 1.09, 95% CI 1.03-1.17). For every 20 patients treated with early oxytocin augmentation, one additional spontaneous vaginal delivery is expected. Although the point estimate for the effect on cesarean delivery (RR 0.87, 95% CI 0.71-1.06) and on operative vaginal delivery (RR 0.84, 95% CI 0.70-1.00) showed modest protective effects, the CIs for both estimates included the null effect. A decrease in antibiotic use (RR 0.45, 95% CI 0.21-0.99) was observed with early intervention. Early oxytocin was associated with an increased risk of hyperstimulation (RR 2.90, 95% CI 1.21-6.94) without evidence of adverse neonatal effects. Women in the early oxytocin group reported higher levels of pain and discomfort in labor. Early oxytocin for augmentation in labor is associated with an increase in spontaneous vaginal delivery.

Does amnioinfusion reduce caesarean section rate in meconium-stained amniotic fluid

The purpose of our study was to evaluate the safety and efficacy of transcervical amnioinfusion during labour complicated by meconium-stained amniotic fluid, in a setting with limited peripartum facilities, to lower the incidence of caesarean section. A prospective study was conducted in a teaching hospital in north India, which enrolled 292 patients admitted in labour. Patients were randomly divided into two groups after taking their consent. One group received transcervical amnioinfusion, whilst in the other group amnioinfusion was not done. Caesarean sections were performed in either group if there were foetal heart rate abnormalities (bradycardia or irregularity for 10-20 min) or slow progress of labour. The outcomes studied were the incidence of caesarean sections, duration of maternal hospital stay, maternal febrile morbidity (temperature of >38 degrees C, 24 h after delivery), low Apgar score (at 1 and 5 min), respiratory death, MAS and perinatal mortality. There was a statistically significant reduction in the incidence of caesarean sections in the study group compared to the control group (31 vs. 61%). Amnioinfusion was associated with improved neonatal outcome as evidenced by statistically improved Apgar score at 1 min in newborns in the study group compared to the control group (10 vs. 37.2%). Amnioinfusion during labour was not associated with any significant maternal and neonatal complications. The mean hospital stay of the mother was decreased significantly in the study group patients compared to the control group. Transcervical amnioinfusion in labour for meconium-stained amniotic fluid is a simple, safe and easy-to-perform procedure. It can be performed safely in a setup with limited peripartum facilities, especially in developing countries, to decrease intrapartum operative intervention and reduce foetomaternal morbidity and mortality.

Fetal survival following posterior uterine wall rupture during labour with intact previous caesarean section scar

Posterior wall rupture of the uterus in presence of previous caesarean scar is an extremely rare and unpredictable event. A 26-year old lady in her second pregnancy went into spontaneous labour at 41 weeks gestation. She had emergency caesarean section in her previous pregnancy. She made slow progress in labour to full dilatation without augmentation, but was noted to have fresh vaginal bleeding and breakthrough pain despite an epidural. Uterine scar rupture was suspected and an emergency lower segment caesarean section was carried out. Fresh intraperitoneal bleeding was noted but with an intact previous scar. The baby was delivered in good condition. A vertical posterior uterine wall rupture of the lower segment, 5 cm in length, was found to be bleeding profusely and was successfully repaired. Uterine rupture is a rare but serious complication. Usually the rupture occurs through the previous uterine scar. There are only four reported cases in the literature of posterior uterine rupture in labour through "healthy" uterine tissue in women with previous caesarean section. This is the first instance of fetal survival. The exact mechanism is unknown but likely to be a combination of factors including prostaglandin use, element of obstruction and strong inelastic scar. Strict vigilance is required during labour in women with previous scar. Early recognition of imminent scar rupture should speed delivery and improve the outcome for mother and baby.

Obstetrical factors related to nuchal cord

To investigate the intrapartum factors related to umbilical cord nuchal loops (nuchal cord) with particular reference to shoulder dystocia. We studied all singleton pregnancies with a vertex presentation and a birth weight of at least 2500 g from 1 January 1978 to 31 March 1997 and the 13,717 pregnancies with nuchal cord were compared to the 44,136 without nuchal cord. When compared to pregnant women without nuchal cord, a greater proportion of pregnant women with nuchal cord underwent induction of labor (adjusted OR 1.09, 95% CI 1.04-1.15) and augmentation with oxytocin (adjusted OR 1.06, 95% CI 1.01-1.11). They had a longer second stage of labor (p=0.0013) and a greater proportion of primiparous women with tight nuchal cord had second stage of labor that lasted longer than two hours (adjusted OR 1.21, 95% CI 1.03-1.41). The proportion of abnormal fetal heart rate patterns was higher in the presence of nuchal cord (adjusted OR 1.61, 95% CI 1.55-1.68). Shoulder dystocia occurred more commonly in association with nuchal cord, especially when the nuchal cord was tight (adjusted OR 1.50, 95% CI 1.30-1.72 for all nuchal cord; adjusted OR 1.82, 95% CI 1.42-2.34 for tight nuchal cord). Umbilical cord nuchal loops are associated with induction of labor, slow progress of labor, and shoulder dystocia.