Strength Of Uterine Contractions Research Articles

Recognition of Chorioamnionitis on the Cardiotocograph (CTG): The role of the “Chorio Duck Score”

Chorioamnionitis refers to the inflammation of the chorion and amnion by the bacteria and their toxins as well as by the inflammatory cytokines. Therefore, it is a fetal disease with the bacteria, their toxins as well as the fetal immunological responses involving inflammatory cytokines (interleukins, interferons, and tumour necrosis factor-alpha) exerting their detrimental effects within the fetal compartment (i.e., amniotic fluid, fetal membranes, the placenta, and fetal tissues and organs). The vast majority of fetal inflammation occurs as a result of an ascending infection (i.e., entry of the bacteria from the maternal genital tract through the cervix). Therefore, maternal signs (tachycardia and pyrexia) may not be observed until the late stages of the disease. Cardiotocograph (CTG) trace was introduced into clinical practice in the 1960s as a tool to timely recognise ongoing fetal hypoxic stress so that immediate action could be taken to avoid hypoxic ischaemic encephalopathy (HIE) and/ or intrapartum hypoxia-related perinatal deaths. Unfortunately, the CTG was introduced into clinical practice without any prior randomised controlled trials, which resulted in panicking and reacting to the observed morphology of fetal heart rate decelerations, which reflect an ongoing fetal compensatory response to reduce the myocardial workload. A sudden and reflex reduction of the heart rate in response to ongoing intermittent hypoxic stress (i.e., repetitive compression of the umbilical cord or interruptions in uteroplacental oxygenation due to uterine contractions) would ensure a reduction in myocardial oxygen demand and maintenance of aerobic metabolism to avoid the onset of anaerobic metabolism and production of lactic acid within the myocardium. Lack of understanding of fetal compensatory responses resulted in the illogical approach of grouping arbitrary features into different categories and then randomly combining them to classify the CTG traces into “Normal, Suspicious, and Pathological”. The same parameters were used in fetuses with chorioamnionitis with an alternative, inflammatory pathway of neurological injury. The international consensus guidelines of physiological interpretation of CTG produced by 44 CTG experts from 14 countries in 2018 ensured a paradigm shift and recommended classification of CTG traces based on the type of fetal hypoxia and fetal response to stress, by applying the knowledge of fetal physiology whilst interpreting CTG traces. During the last 5 years, research has highlighted CTG features in fetal neuro-inflammation, which include an absence of fetal heart rate cycling, the ZigZag Pattern, and sinusoidal patterns. The proposed “Chorio Duck Score” is a scoring system based on recently published scientific evidence on CTG features in subclinical and clinical chorioamnionitis to enable timely diagnosis of fetal systemic inflammatory response syndrome (FIRS). This will help avoid the continuation of super-imposed hypoxic stress (i.e., progressive increasing frequency, duration, and strength of uterine contractions) on the background fetal inflammation, to prevent fetal neurological injury.

Impact of obesity on uterine contractile activity during labour: A blinded analysis of a randomised controlled trial cohort.

Tweetable abstractDespite higher strength of uterine contractions among obese parturients, they reach the active stage of labour less often than leaner ones. Linked article: This article is commented on by Mikko Tarvonen, pp. 1798 in this issue. To view this minicommentary visit https://doi.org/10.1111/1471-0528.17153

Comparative Characteristics of Pregnancy Course and Labour Outcomes in Pregnant Women, Depending on Observation Conditions and Location of Health Improvement Activities

Recurrent pregnancy loss (RPL) is quite an urgent problem in modern obstetric practice, as it has an important effect on perinatal morbidity and mortality, as well as on women's reproductive health. In the treatment of pregnancy loss, specialists have few attempts, and the doctor is responsible for diagnostic assessment, management and place of treatment. Purpose of study: To compare characteristics of pregnancy course and labour outcomes in pregnant women, depending on observation conditions and location of health improvement activities Materials and methods: Group I included 206 pregnant women, receiving in-patient treatment at the sanatorium; and 147 (group II), who were treated in the pathologic pregnancy department in the maternity hospital, were assigned to the risk group for pregnancy loss. At this, 45 patients in group I and 43 patients in group II 43 were treated for threatened miscarriage. Among women from the risk group of pregnancy loss in more than 70% of cases, a burdened obstetric and gynaecological history was revealed. Pregnant women with threatened pregnancy loss at the sanatorium received a complex therapeutic and preventive treatment, including consultations with a psychotherapist (auto-training), physiotherapy, vitamin therapy, herbal medicine, acupuncture. Pregnant women, belonging only to the risk group for pregnancy loss, received a preventive course of central electrical analgesia (CEA), psychophysiological training and general sanatorium regimen. The therapy was combined with test cardiac monitoring. The therapeutic measures in pathologic pregnancy department in the maternity hospital were limited to bed rest and medical therapy, vitamin therapy, prescription of sedatives and tocolytic therapy. Some pregnant women were treated using physical treatment methods - electric relaxation according to A.Z. Haskin on Amplipulse-4 device. Results: The performed study demonstrates that pregnant women, treated in the sanatorium, were less likely to suffer from gestational toxicosis, threatened miscarriage and anaemia of pregnant women. In women of group I, compared to group II, in a large percentage the delivery was in time and natural. In the pathologic pregnancy department, the following complications were recorded: poor uterine contraction strength and bleeding in the 3rd period. Conclusion: In women with RPL, it is recommended to include a sanatorium stage in the system of specialized care for such patients to prolong pregnancy, normalize psycho-emotional state and reduce the number of postnatal complications.

Fetal heart rate monitoring in labor: from pattern recognition to fetal physiology.

The journey of human labor involves hypoxic and mechanical stresses as a result of progressively increasing frequency, duration and strength of uterine contractions and resultant compression of the umbilical cord. In addition, occlusion of the spiral arteries during myometrial contractions also leads to repetitive interruptions in the utero-placental circulation, predisposing a fetus to progressively worsening hypoxic stress as labor progresses. The vast majority of fetuses are equipped with compensatory mechanisms to withstand these hypoxic and mechanical stresses. They emerge unharmed at birth. However, some fetuses may sustain an antenatal injury or experience a chronic utero-placental insufficiency prior to the onset of labor. These may impair the fetus to compensate for the ongoing hypoxic stress secondary to ongoing uterine contractions. Non-hypoxic pathways of neurological damage such as chorioamnionitis, fetal anemia or an acute fetal hypovolemia may potentiate fetal neurological injury, especially in the presence of a super-imposed, additional hypoxic stress. The use of utero-tonic agents to induce or augment labor may increase the risk of hypoxic-ischemic injury. Clinicians need to move away from pattern recognition guidelines (normal, suspicious, pathological), and apply the knowledge of fetal physiology to differentiate fetal compensation from decompensation. Individualization of care is essential to optimize outcomes.

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 < 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.

Fetal heart rate monitoring in labor: from pattern recognition to fetal physiology.

The journey of human labor involves hypoxic and mechanical stresses as a result of progressively increasing frequency, duration and strength of uterine contractions and resultant compression of the umbilical cord. In addition, occlusion of the spiral arteries during myometrial contractions also leads to repetitive interruptions in the utero-placental circulation, predisposing a fetus to progressively worsening hypoxic stress as labor progresses. The vast majority of fetuses are equipped with compensatory mechanisms to withstand these hypoxic and mechanical stresses. They emerge unharmed at birth. However, some fetuses may sustain an antenatal injury or experience a chronic utero-placental insufficiency prior to the onset of labor. These may impair the fetus to compensate for the ongoing hypoxic stress secondary to ongoing uterine contractions. Non-hypoxic pathways of neurological damage such as chorioamnionitis, fetal anemia or an acute fetal hypovolemia may potentiate fetal neurological injury, especially in the presence of a super-imposed, additional hypoxic stress. The use of utero-tonic agents to induce or augment labor may increase the risk of hypoxic-ischemic injury. Clinicians need to move away from "pattern recognition" guidelines ("normal," "suspicious," "pathological"), and apply the knowledge of fetal physiology to differentiate fetal compensation from decompensation. Individualization of care is essential to optimize outcomes.

Recognising Fetal Compromise in the Cardiograph during the Antenatal Period: Pearls and Pitfalls

There are several national and international guidelines to aid the interpretation of the cardiotocograph (CTG) trace during labour. These guidelines are based on assessing changes in the fetal heart rate (i.e. cardiograph) in response to mechanical and hypoxic stresses during labour secondary to ongoing frequency, duration and strength of uterine contractions (i.e. tocograph). However, during the antenatal period, uterine contractions are absent, and therefore, these intrapartum CTG guidelines cannot be used to reliably identify fetuses at risk of compromise. Computerised analysis of CTG using the Dawes-Redman Criteria could be used to detect fetal compromise. However, clinicians should be aware of the multiple pathways of fetal damage (i.e. inflammation, infection, intrauterine fetal stroke, chronic fetal anaemia, acute feto-maternal haemorrhage and fetal cardiac or neurological disorders) which can cause changes on the CTG trace which may not be recognised by using CTG guidelines.

A Broad Spectrum Chemokine Inhibitor Prevents Preterm Labor but Not Microbial Invasion of the Amniotic Cavity or Neonatal Morbidity in a Non-human Primate Model.

Leukocyte activation within the chorioamniotic membranes is strongly associated with inflammation and preterm labor (PTL). We hypothesized that prophylaxis with a broad-spectrum chemokine inhibitor (BSCI) would downregulate the inflammatory microenvironment induced by Group B Streptococcus (GBS, Streptococcus agalactiae) to suppress PTL and microbial invasion of the amniotic cavity (MIAC). To correlate BSCI administration with PTL and MIAC, we used a unique chronically catheterized non-human primate model of Group B Streptococcus (GBS)-induced PTL. In the early third trimester (128–138 days gestation; ~29–32 weeks human pregnancy), animals received choriodecidual inoculations of either: (1) saline (N = 6), (2) GBS, 1–5 × 108 colony forming units (CFU)/ml; N = 5), or (3) pre-treatment and daily infusions of a BSCI (10 mg/kg intravenous and intra-amniotic) with GBS (1–5 × 108 CFU/ml; N = 4). We measured amniotic cavity pressure (uterine contraction strength) and sampled amniotic fluid (AF) and maternal blood serially and cord blood at delivery. Cesarean section was performed 3 days post-inoculation or earlier for PTL. Data analysis used Fisher's exact test, Wilcoxon rank sum and one-way ANOVA with Bonferroni correction. Saline inoculation did not induce PTL or infectious sequelae. In contrast, GBS inoculation typically induced PTL (4/5, 80%), MIAC and fetal bacteremia (3/5; 60%). Remarkably, PTL did not occur in the BSCI+GBS group (0/4, 0%; p = 0.02 vs. GBS), despite MIAC and fetal bacteremia in all cases (4/4; 100%). Compared to the GBS group, BSCI prophylaxis was associated with significantly lower cytokine levels including lower IL-8 in amniotic fluid (p = 0.03), TNF-α in fetal plasma (p < 0.05), IFN-α and IL-7 in the fetal lung (p = 0.02) and IL-18, IL-2, and IL-7 in the fetal brain (p = 0.03). Neutrophilic chorioamnionitis was common in the BSCI and GBS groups, but was more severe in the BSCI+GBS group with greater myeloperoxidase staining (granulocyte marker) in the amnion and chorion (p < 0.05 vs. GBS). Collectively, these observations indicate that blocking the chemokine response to infection powerfully suppressed uterine contractility, PTL and the cytokine response, but did not prevent MIAC and fetal pneumonia. Development of PTL immunotherapies should occur in tandem with evaluation for AF microbes and consideration for antibiotic therapy.

COURSE PREGNANCY AND ITS OUTCOME IN WOMEN AT THE HIGH RISK GROUP FOR PREECLAMPSIA

Introduction. Preeclampsia constitutes a significant proportion of maternal and prenatal morbidity and mortality. The rate of prenatal mortality in severe preeclampsia is 18-30 ‰, and for prenatal morbidity it is 640-780 ‰. The aim of the research was to study the clinical efficacy of early prognosis of preeclampsia and secondary prevention of this pathology. Materials and methods. Selection of the subjects at the risk group for the development of preeclampsia was performed on the basis of reduced blood flow in the spiral arteries of the uterus in the area of the placental site at 18-20 (+6 days) weeks of pregnancy. 30 healthy pregnant women and 91 pregnant women at risk for preeclampsia were examined; 32 pregnant women with the risk for preeclampsia refused advanced secondary prevention of preeclampsia, 59 pregnant women received the secondary prevention of preeclampsia (vitamin D3, metformin and corvitin) we proposed. We collected data on general and reproductive history, conducted objective clinical and laboratory examination, analyzed the course of the present pregnancy, the course and outcome of childbirth, their complications, the condition of the foetuses and newborns. Results. Reduced blood flow in the spiral arteries of the uterus located in the area of the placental site during the second ultrasound screening at 18-20 (+6 days) weeks of pregnancy is an informative prognostic sign of a high risk for preeclampsia. Pregnant women who consented to the secondary prevention of preeclampsia (vitamin D3, metformin, corvitin) as compared with the group of women who refused such prevention had fewer complications of pregnancy (preeclampsia, delayed foetal development, foetal distress and premature placental abruption, preterm birth) and childbirth (premature bursting of amniotic fluid was in 2.6 times less frequent, poor uterine contraction strength – in 1.8 times less, obstetric bleeding – in 2.8 times less, neonatal asphyxia – in 2.9 times less, no preterm infants with extremely low birth weight, intrauterine mortality occurred in 1.8 times less frequent).

MATERNAL PSYCHOSOCIAL STRESS AND LABOR DYSTOCIA

The aim: to study the possible role of psychosocial stressors in the emergence of anomalies of childbirth, as well as to examine their nature using the example of pregnant women who have been forcefully displaced from Donetsk and Luhansk regions of Ukraine. Materials and methods: 115 internally displaced pregnant women from Donetsk and Luhansk regions, were surveyed. All women underwent a comprehensive neuropsychological examination of their psycho-emotional status via interviews, questioning, and psychological testing (Spielberg-Haning's Situational and Personal Anxiety Scale). The following analysis of the childbirth process' nature was conducted. Results: The prevalence of high level of situational and personal anxiety by the Spielberg-Haning's test were determined in the internally displaced women. This indicates a high level of social anxiety (stress) in these pregnant women. Labours in women in this group can be characterized by 3 main features: rapid (precipitated) labour with high levels of obstetric traumatism (tear of perineum) and labour medicalization (EDA). The characteristics described above are due to such labour activity anomalies as hypertensive uterine dysfunction - the cases when the speed and strength of uterine contractions significantly exceed the normative parameters. The reasons for the high level of pain in labour in displaced women could be objecttive and subjective factors: excessive nociceptor irritation due to cervical-uterine dysfunction and impaired individual perception of pain. Conclusions: Chronic psychosocial stress has an impact on labour activity in displaced women. A mandatory standard for managing such pregnancy is psychological counselling and correction of the identified disorders.

Effect of Heat Compresses Hydrotherapy to Reduction of Pain Labor Stage 1st

Labor pain is an unpleasant stimulus that causes fear and worry. This situation will be stimulate an increase in catecholamineswhich can be cause interference with the strength of uterine contractions so that uterine insertion occurs if not corrected, which will be cause prolonged labor, so that’s necessary to prevent maternal care in the form of methods of pain transfer The One non-pharmacological method is heat compresshydrotherapy. The type of research was used Quasi Experimental withcross sectional approach one group pretest-posttest design. The results of data analysis stated that sig (p) = 0,000 where α = 0.05, p &lt;α, means that therewas an effect of giving heat compress hydrotherapy to the reduction of labor pain in the active phase. Correlation or influence using Wilcoxon Correlation =-0.382.

Expert perspectives on essential parameters to monitor during childbirth in low resource settings: a Delphi study in sub-Saharan Africa

ObjectiveThere is no consensus on the essential parameters to monitor during childbirth, when to start, and the rate of monitoring them. User disagreement contributes to inconsistent use of the twelve-item modified World Health Organization partograph that is started when the cervix is at least 4 cm dilated. The inconsistent use is associated with poor outcomes at birth. Our objective was to identify the perspectives of childbirth experts on what and when to routinely monitor during childbirth in low resource settings as we develop a more acceptable childbirth clinical decision support tool.MethodWe carried out a Delphi study with two survey rounds in early 2018. The online questionnaire covered the partograph items like foetal heart, cervical dilation, and blood pressure, and their monitoring rates. We invited panellists with experience of childbirth care in sub-Saharan Africa. Consensus was pre-set at 70% panellists rating a parameter and we gathered some qualitative reasons for choices.ResultsWe analysed responses of 76 experts from 13 countries. There was consensus on six important parameters including foetal heart rate, amniotic fluid clearness, cervical dilation, strength of uterine contractions, maternal pulse, and blood pressure. Two in three experts expressed support for changing the monitoring intervals for some parameters in the partograph. 63% experts would raise the partograph starting point while 58% would remove some items from it. Consensus was reached on monitoring the cervical dilation at 4-hourly intervals and there was agreement on monitoring the foetal heart rate one-hourly. However, other parameters only showed majority intervals and without reaching agreement scores. The suggested intervals were two-hourly for strength of uterine contractions, and four-hourly for amniotic fluid thickness, maternal pulse and blood pressure. The commonest reason for their opinions was the more demanding working conditions.ConclusionThere was agreement on six partograph items being essential for routine monitoring at birth, but the frequency of monitoring could be changed. To increase acceptability, revisions to birth monitoring guidelines have to be made in consideration of opinions and working conditions of several childbirth experts in low resource settings.

Efficacy of iron sulfate with ascorbic acid in pregnant women with iron deficiency of varying degrees of severity

Iron deficiency anemia (IDA) is one of the most common diseases in the world, characterized by hemoglobin synthesis disorder due to iron deficiency and manifested by anemia. According to WHO, the rate of IDA in pregnant women in different countries ranges from 21 to 80%, judging by the level of hemoglobin, and from 49 to 99% - by serum iron. Lack of treatment of iron-deficient pregnant women with varying degrees of iron deficiency leads to an increase in the frequency of complicated pregnancy, such as the threat of termination of pregnancy, placental insufficiency, delay in intrauterine development and hypoxia of the fetus, premature delivery, poor uterine contraction strength, pathological bleeding, infectious complications. Aim of the study: study of the efficacy of the drug containing iron sulfate (Ferrous sulfate) and ascorbic acid in pregnant women with latent and manifest forms of iron deficiency. Patients and methods: 66 pregnant women were examined. Group 1 consisted of 36 pregnant women with latent iron deficiency, Group 2–30 pregnant women with manifest iron deficiency and moderate anemia. Pregnant women in the 1st group were prescribed the drug only for 1 month due to the fact that there were no manifestations of anemia in this category of patients. Blood parameters were monitored dynamically after 1 month of treatment and after 2 months, which means after 1 month of absence of the drug intake. Patients of the 2nd group received treatment during 2 months, dynamic treatment after laboratory parameters was carried out after 1 and 2 months of treatment. Results of the study. Analyzing the data obtained, it was found that all laboratory parameters differ significantly from those before treatment. Pregnant women of the 1st group have no reliable changes between the parameters after 1 and 2 months of observations, as during this period the patients did not receive iron medication. And even a slight decrease in some indicators is noted, but when compared with laboratory data before treatment, the results differ significantly. Conclusion: Ferrous sulfate and ascorbic acid can be recommended to compensate iron deficiency in pregnant women with LID to prevent the development of anemia, in patients with MID to treat anemia and prevent the development of possible complications in pregnant women associated with this condition. Thus, earlier detection and elimination of LID leads to prevention of anemia later on.

Correlation of Calcium Levels With The Strenght of Uterus Contraction on The Active Phase of First Stage Labor

Contributing factor to uterus contraction mechanism is the imbalance of the extracellular calcium level. When extracellular calcium level is inadequate, response of the myometrium to oxytocin decreased and the calcium influx inter-cell membranes are suppressed, thus inhibit uterine contractions. The aim of this research is to know the correlation between levels of calcium and the strength of uterine contraction in the active phase of first stage labor. This was a cross-sectional analytic correlative study in the Dr. Rasidin Hospital Padang and UPTD Health Laboratory in West Sumatra province, in was conducted from November 1st, 2014 till February 2016. Sampling was takes by using non probability sampling with consecutive sampling. Subjects of this research were the active phase of first stage labor of 62 people. Kolmogorof Smirnov normality test was used to the normality of the data. Pearson correlation test was conducted to examine the correlation between dependent and independent variables. Mean levels of calcium in the the stage I of labor respondents active phase (8.94 ±0,71), while mean strength of uterine contractions in active phase of first stage labor(56.77±11,84), there was positive correlation (r = 0,62) between the levels of calcium in the strength of uterine contractions (p &lt; 0.05). The conclusion of the study there was a significant correlation between the levels of calcium in the strength of uterine contractions.

INTEGRATED MODEL FOR THE PREDICTION OF ORGANIC DYSFUNCTIONS DEVELOPMENT IN NEWBORNS WITH ASPHYXIA AND APPLIED POINTS OF ITS IMPLEMENTATION

Relevance of the research. The causes of asphyxia are well known, but the debates about the importance of antenatal and intranatal factors in its development are still ongoing. Identification of clear predictors for the development of the dysfunction in vital and non-vital organs will improve the existing algorithms for monitoring neonates who are subject to hypoxia/asphyxia, and will enable the doctors to make decisions on the timely use of personalized therapeutic and diagnostic measures aimed at reducing mortality, morbidity, childhood disability and enhancing the quality of their life.The aims of the research are substantiation and development of the integrated model for prediction of organ dysfunctions, and improvement of the algorithm for monitoring newborns with asphyxia in the early neonatal period.Materials and methods. The study included 72 full-term infants with asphyxia and 35 healthy newbornswho were born at the perinatal centre of M.V. Sklifosovsky Poltava Regional Clinical Hospital and Poltava City Clinical Maternity Hospital in 2011-2013. We studied the associations between the development of organ dysfunction and risk factors characterizing the somatic, obstetric, antenatal/intranatal history of the mother, the condition of the infant, the volume of primary resuscitation, as well as the metabolic, inflammatory and vascular biomarkers. The prediction of lesions of organs and systems of the newborn is considered from the point of view of pathophysiological mechanisms of circulatory and non-circulatory adaptation reactions in newborns with asphyxia, when against the background of increased cerebral, coronary and adrenal blood flow, there is a decrease in perfusion in the kidneys, lungs, gastrointestinal tract, liver and their dysfunctions.Results of the research. The proposed integrated model for the prediction of lesions of vital and non-vital organs demonstrates the insignificant role of ante and intranatal factors in the prognosis of multiorgan dysfunction development. It was determined that the prognostic model for the development of hypoxic and ischemic encephalopathy, which includes poor uterine contraction strength (odds ratio 13.2), administering 0.9% solution of sodium chloride during primary intensive care (OR 9.2), LDH level &gt;1700 units/l (OR 7.4) and creatinine&gt;110 mmol/l (OR 15.9) for 1 day of life has an area under the ROC curve of 0.8711. The development of myocardial dysfunction is reliably associated with glucose levels &lt;3.3 mmol/l (OR 11.6), urea &gt;7.0 mmol/l (OR 21.3) and NO2¯+ NO3¯ &lt;21 mmol/l in urine (OR 15.2) and the prognostic model of its development has an area under the ROC curve of 0.8368. The prognostic models for the development of lesions of non-vital organs, in particular, the dysfunction of the gastrointestinal tract (Apgar score of &lt;5 points on the 5th min., administering 4% NaHCO3 solution during the course of reanimation measures, glucose level &lt;3.3 mmol/l, urea &lt;6.0 mmol/l) and acute myocardial infarction (Apgar score &lt;4 points on the 5th min. of life, meconial aspiration), have the corresponding areas under the ROC curves − 0.8424 and 0.8054.Taking into account the pathophysiological mechanisms of organ dysfunction development in newborns with asphyxia, 4 possible clinical scenarios were suggested for the aforementioned disease, which allow to assume the time hypoxic / asphyxial episode.The algorithm for monitoring infants with possible or present hypoxic episode has been improved, in particular, if a child has at least one of the following symptoms: sentinel event, Apgar score less than 7 points on the 5th min. of life, pH of umbilical cord blood less than 7.25, use of artificial lung ventilation during resuscitation. In addition to the recommendations provided by the Order of the Ministry of Healthcare No. 255 as of 2014, it is advisable to prescribe the following studies: complete blood count, blood glucose level, creatinine, urea in blood serum at the obstetrical inpatient establishments of the 2nd level, and in addition to the abovesaid − NO2¯ + NO3¯ in the urine − for obstetric hospitals of the 3rd level.Conclusions. The integrated model for the prediction of organ dysfunctions development in newborns with asphyxia has been substantiated; the applied points of its implementation have been determined; and the algorithm for monitoring the newborns with a score less than 7 points on the 5th min. of life has been suggested.

High-dose versus low-dose oxytocin infusion regimens for induction of labour at term.

When women require induction of labour, oxytocin is the most common agent used, delivered by an intravenous infusion titrated to uterine contraction strength and frequency. There is debate over the optimum dose regimen and how it impacts on maternal and fetal outcomes, particularly induction to birth interval, mode of birth, and rates of hyperstimulation. Current induction of labour regimens include both high- and low-dose regimens and are delivered by either continuous or pulsed infusions, with both linear and non-linear incremental increases in oxytocin dose. Whilst low-dose protocols bring on contractions safely, their potentially slow induction to birth interval may increase the chance of fetal infection and chorioamnionitis. Conversely, high-dose protocols may cause undue uterine hyperstimulation and fetal distress. To determine the effectiveness and safety of high- versus low-dose oxytocin for induction of labour at term We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014) and the reference lists of relevant papers. Randomised controlled trials and quasi-randomised controlled trials that compared oxytocin protocol for induction of labour for women at term, where high-dose oxytocin is at least 100 mU oxytocin in the first 40 minutes, with increments delivering at least 600 mU in the first two hours, compared with low-dose oxytocin, defined as less than 100 mU oxytocin in the first 40 minutes, and increments delivering less than 600 mU total in the first two hours. Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. Data were checked for accuracy. We have included nine trials, involving 2391 women and their babies in this review. Trials were at a moderate to high risk of bias overall.Results of primary outcomes revealed no significant differences in rates of vaginal delivery not achieved within 24 hours (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.78 to 1.14, two trials, 1339 women) or caesarean section (RR 0.96, 95% CI 0.81 to 1.14, eight trials, 2023 women). There was no difference in serious maternal morbidity or death (RR 1.24, 95% CI 0.55 to 2.82, one trial, 523 women), and no difference in serious neonatal morbidity or perinatal death (RR 0.84, 95% CI 0.23 to 3.12, one trial, 781 infants). Finally, no trials reported on the number of women who had uterine hyperstimulation with fetal heart rate changes.Results of secondary outcomes revealed no difference between time from induction to delivery (mean difference (MD) -0.90 hours, 95% CI -2.28 to +0.49 hours; five studies), uterine rupture (RR 3.10, 95% CI 0.50 to 19.33; three trials), epidural analgesia (RR 1.03, 95% CI 0.89 to 1.18; two trials), instrumental birth (RR 1.22, 95% CI 0.88 to 1.66; three trials), Apgar less than seven at five minutes (RR 1.25, 95% CI 0.77 to 2.01, five trials), perinatal death (RR 0.84, 95% CI 0.23 to 3.12; two trials), postpartum haemorrhage (RR 1.08, 95% CI 0.87 to 1.34; five trials), or endometritis (RR 1.35, 95% CI 0.53 to 3.43; three trials). Removal of high bias studies reveals a significant reduction of induction to delivery interval (MD -1.94 hours, 95% CI -0.99 to -2.89 hours, 489 women). A significant increase in hyperstimulation without specifying fetal heart rate changes was found in the high-dose group (RR 1.86, 95% CI 1.55 to 2.25).No other secondary outcomes were reported: unchanged/unfavourable cervix after 12 to 24 hours, meconium-stained liquor, neonatal intensive care unit admission, neonatal encephalopathy, disability in childhood, other maternal side-effects (nausea, vomiting, diarrhoea), maternal antibiotic use, maternal satisfaction, neonatal infection and neonatal antibiotic use. The findings of our review do not provide evidence that high-dose oxytocin increases either vaginal delivery within 24 hours or the caesarean section rate. There is no significant decrease in induction to delivery time at meta-analysis but these results may be confounded by poor quality trials. High-dose oxytocin was shown to increase the rate of uterine hyperstimulation but the effects of this are not clear. The conclusions here are specific to the definitions used in this review. Further trials evaluating the effects of high-dose regimens of oxytocin for induction of labour should consider all important maternal and infant outcomes.

Successful IT Initiative to Reduce the Rate of Excessive Uterine Contractions During Labor

Introduction/aims Oxytocin, an effective drug to increase the rate and strength of uterine contractions, is used in more than half of all labors. Intravenous infusions are adjusted frequently at the bedside because the uterine response can vary greatly. Clinical protocols recommend discontinuing oxytocin in the presence of overly frequent contractions because they can decrease oxygen delivery to the fetus and result in brain injury. Despite well-established guidelines, incautious use of oxytocin is reported in 45-71% of births with severe asphyxia and subsequent litigation. In 2011 Medstar Franklin Square Medical Center introduced specialized obstetrical software (PeriCALM Patterns V2.01 PeriGen, Cranbury, NJ) with electronic fetal monitor (EFM) pattern recognition and display features specifically designed to assist in the prompt recognition of uterine tachysystole. Uterine tachysystole (UT) is defined as the presence of more than 5 contractions per 10 minutes, averaged over a 30-minute period. The objective of this study was to compare the rates of UT in the periods “Before” and “After” the introduction of this software in women with induction or augmentation of labor. Methods/process/procedures Inclusion criteria were labors with live singleton cephalic-presenting babies at term with EFM recordings. The “Before” group comprised 6728 births (3869 with induction or augmentation) from February 2006 to February 2010. The “After” group included 3790 births (1988 with induction or augmentation) from January 2012 to December 2013. Induction or augmentation status was ascertained by automated review of the electronic medical record database searching for evidence of interventions or oxytocin use to induce or enhance labor. Each EFM record was analyzed by PeriCALM Patterns software to determine contraction counts in 30 minute segments. Results As a result of early detection and prompt remediation, very substantial reductions were observed in a variety of UT-related measures. In women with induction or augmentation the rate of tachysystole fell from 22.7% to 17.3% (p<0.0001). When UT did occur, the average duration fell from 64 minutes to 54 minutes (p=0.0039). In those who experienced UT, the total percentage of time spent in UT decreased by 36.5% over the course of this study (p<0.0001). There were also decreases in the percentages of babies with severe neonatal depression, but the small numbers precluded statistical significance. Discussion/outcomes This is the first report of a large and systematic review on the effect of efforts to reduce uterine tachysystole. We observed a very substantial and sustained reduction in both the incidence and duration of UT in patients with augmentation or induction of labor. The 36.5% reduction in the total percentage of time spent in UT reflects a marked changed in clinical behavior. We attribute this marked improvement to the coexistence of several essential factors present in IT initiatives that actually change behavior: 1. Objective computations at the point of care that are personalized to the individual patient; 2. Continuous trend analysis and feedback showing the patient’s situation related to expected norms; 3. Clearly established clinical policies regarding expected therapeutic actions; 4. Active quality improvement follow up.

662: Association of Montevideo units with uterine rupture in women undergoing a trial of labor after cesarean delivery

662 Association of Montevideo units with uterine rupture in women undergoing a trial of labor after cesarean delivery Lindsay Maggio, Joanna Forbes, Haleh Sangi-Haghpeykar, Christina Davidson Baylor College of Medicine, Obstetrics and Gynecology, Houston, TX OBJECTIVE: To investigate if there is a threshold of uterine contraction strength, as measured by Montevideo units (MVUs), at which catastrophic uterine rupture always occurs and/or never occurs, as well as to determine if the rate of uterine rupture increases as MVUs increase. STUDY DESIGN: Retrospective chart review of women who underwent a trial of labor after cesarean (TOLAC) at a tertiary care academic hospital in Houston, TX, between January 2007 and June 2010. We included women with one prior cesarean delivery (CD) attempting TOLAC at 36 0/7 weeks gestational age or greater with a singleton gestation who had an intrauterine pressure catheter placed during their labor. Cases were those women who experienced a catastrophic uterine rupture during their TOLAC and controls had a successful vaginal birth after cesarean (VBAC). For each case, 6 controls were randomly selected. MVUs were calculated in 10 minute intervals for a total of 120 minutes prior to either delivery (controls) or to the time of planned CD for suspected uterine rupture (cases). Time zero was that time of delivery or planned CD. Cases and controls were compared via chi-square/fisher exact test for grouped variables and t-test for continuous outcomes. Ability of MVU time points to predict uterine rupture was assessed via logistic regression models and the corresponding Area Under the Curve (AUC) and Receiver Operative Characteristic (ROC). RESULTS: Eight cases were identified during the study time period and compared against 48 controls. When comparing MVUs, there was no statistically significant difference between the two groups at any time period except in the zero to ten minute interval (the 10 minutes immediately prior to successful VBAC or planned CD for uterine rupture). At this time point, the mean MVUs in the control group were actually higher than in the cases (271.2 vs. 151.9, p 0.0008), which remains true for almost every other time point, although not statistically significant. CONCLUSION: We did not find a correlation between MVUs and risk of uterine rupture in women undergoing a TOLAC. 663 Predicting cesarean delivery in the second stage of labor: a classification & regression tree (CART) analysis Lorie Harper, Anthony Odibo, George Macones, Alison Cahill Washington University in St. Louis, Department of Obstetrics and Gynecology, St. Louis, MO OBJECTIVE: While uncommon, cesarean delivery (CD) performed in the second stage is associated with increased maternal and neonatal morbidity compared to CD in the first stage of labor. We aimed to develop a prediction model for CD in the second stage of labor using a classification and regression tree (CART) analysis. STUDY DESIGN: A retrospective cohort study of all consecutive women admitted for labor 37.0 weeks gestation from 2004-2008 who reached the second stage of labor. The primary outcome was CD after reaching 10-cm dilation. Univariate and multivariate analyses were used to identify candidate risk factors for CD in the second stage of labor, and CART analysis was performed to identify risk factor scenarios that best discriminate between women who undergo a second stage CD and those who do not. Only factors known at the time a patient reaches 10-cm dilation were used in the analysis. RESULTS: Of 5,388 subjects who reached 10-cm dilation, 88 (1.6%) required CD. The logistic regression model identified 4 risk factors for CD and produced a receiver operator characteristic (ROC) curve with an area under the curve of 0.75. The ROC curve identified no optimal trade-off between sensitivity and specificity for predicting CD. CART analysis identified 6 dominant risk factors applied in 4 specific pathways to predict CD. The most important variable in predicting CD in the second stage was a station higher than 0 at complete dilatation. Pathways predicting no CD resulted in CD rates of 0-0.6%. Pathways that predicted CD had CD rates of 2.5-5.1%. Using this prediction model, 1,791 (34%) of women who delivered vaginally would have been misclassified as requiring CD. CONCLUSION: Despite being able to identify risk factors associated with need for cesarean in the second stage of labor, cesarean delivery in the second stage of labor cannot be reliably predicted based on antenatal and intrapartum characteristics by logistic regression or CART techniques. PosterSessionIV Epidemiology, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics, Obstetric Quality & Safety, Public Health-Global Health www.AJOG.org

42: Trans-abdominal uterine electromyography (EMG) vs. clinical parameters as predictors of preterm delivery

EMG correlates strongly with strength of uterine contractions & can predict true labor. Cervical dilation and contraction frequency are not good predictors of true preterm labor (PTL). Our aim was to compare EMG to clinical parameters in predicting delivery time in PTL.

Effect of short-term hypothyroidism on reproduction in the bitch

Hypothyroidism in bitches has been reported to cause a variable interestrus interval, infertility, abortion, and stillbirth. The objective of this study was to evaluate the effect of experimentally induced hypothyroidism in bitches on fertility, pregnancy, parturition, and neonatal health. Eighteen healthy multiparous bitches were used; hypothyroidism was induced (by radioiodine administration) in nine bitches and the remaining nine served as untreated controls. After breeding, bitches were evaluated for pregnancy, fetal resorption, gestation length, litter size, duration and strength of uterine contractions (during parturition), interval between delivery of pups, viability of pups at birth, periparturient survival, and weight of pups at birth through 4 weeks of age. Bitches were bred a median of 19 weeks after induction of hypothyroidism. All bitches became pregnant and delivered term litters. There was no difference in the interestrus interval, litter size, or gestation length between hypothyroid and control bitches. Duration of uterine contractions was longer, but contraction strength was weaker in hypothyroid than control bitches; however, the interval between delivery of pups was not affected. Periparturient puppy mortality was significantly higher in litters from hypothyroid bitches. Viability scores and weight at birth were significantly lower in pups from hypothyroid bitches than controls. There was no difference between groups in pup weight gain during the first 4 weeks, in the interval from birth to the eyes opened, or to the onset of walking. Although hypothyroidism of relatively short duration did not affect fertility, it prolonged parturition and reduced pup survival in the periparturient period.