Women In Spontaneous Labor Research Articles

Динамика частоты кесарева сечения по тульской области за 2000-2010 гг.: мультицентровое ретроспективное исследование

Objectives. To study the trend of Caesarean section (CS) rate increase in the Tula region. Methods. A multicenter retrospective study of labor and delivery reports of women in Tula region, Russia who had CS procedures between the years 2000 and 2010. Robson’s Ten-Group Classification System (10-group classification) provides a clinically relevant classification of CS rates that provides a useful basis for internation-al comparisons and trend analyses. Results. In Tula region the total number of deliveries increased by 26.6% from the year 2000 as compared to 2010, the CS rate increased from 17.1 to 27.7%. The increase in CS deliveries was mostly attributed to three characteristic groups: multiparous women with uterine cicatrix; primaparous women who had medical conditions for a planned CS and these, who had labor induction; women with a gestational age less than 37 weeks. The largest Robson group was nulliparous women in spontaneous labor. Conclusions. Future efforts to reduce the overall CS rate should be focussed on reducing the primary CS rate.

Pregnancy outcomes of induced labor in women with previous cesarean section: a systematic review and meta-analysis.

To systematically review the literature about maternal and neonatal outcomes following induction of labor (IOL) and spontaneous labor (SL) in women with previous cesarean section (PCS). PubMed, Medline, EMBASE, Cochrane library searches; January 2000-February 2013. women attempting labor after PCS, singleton term pregnancies. Women undergoing IOL were compared with women in SL. Method for induction, mode of delivery, uterine rupture/dehiscence, post-partum hemorrhage, emergency hysterectomy and any maternal or neonatal morbidity and mortality were analyzed. MOOSE guidelines were followed. Interstudies heterogeneity was tested. A random effect model was generated if heterogeneity was >25 %. Pooled odds ratio with 95 % confidence interval (OR, 95 % CI) were calculated. Eight articles included 4,038 women with IOL (23.2 %) and 13,374 women with SL (76.8 %). IOL was associated with a lower incidence of vaginal delivery (OR 0.66; 95 % CI 0.55-0.80) and higher rates of cesarean section (OR 1.52; 95 % CI 1.26-1.83), uterine rupture/dehiscence (OR 1.62; 95 % CI 1.13-2.31), and post-partum hemorrhage (OR 1.57; 95 % CI 1.20-2.04), although hysterectomy was similar between the two groups (OR 2.60; 95 % CI 0.52-13.1). Neonatal morbidity was similar after IOL or SL (OR 1.13; 95 % CI 0.75-1.69). Induction of labor increases the risk of uterine rupture/dehiscence and of repeat cesarean section.

Fear of childbirth and emergency caesarean section in low-risk nulliparous women: a prospective cohort study

Objective: To assess the association between fear of childbirth (FOC) and emergency caesarean section.Design: A prospective cohort study of low-risk nulliparous women at term.Setting: Nine obstetric departments in Denmark, May 2004–July 2005.Population: A total of 2598 nulliparous women in spontaneous labor with a single fetus in cephalic presentation at term.Methods: Self-reported FOC was assessed at 37 weeks of gestation by the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) version A and at admission to the labor ward by the Delivery Fear Scale (DFS). Mode of delivery was recorded by the attending staff. Logistic regression analyses were used to estimate unadjusted and adjusted odds ratios (OR).Main outcome measures: Risk of emergency caesarean section in women who feared childbirth.Results: FOC (W-DEQ sum score ≥85 and DFS sum score ≥70) was not associated with emergency caesarean section: adjusted OR = 0.81 (95% CI: 0.48–1.36) and OR = 0.97 (95% CI: 0.55–1.71), respectively.Conclusion: In this prospective observational study, women with FOC did not have an increased risk of emergency caesarean section compared to women with no such fear.

Effect of intravenous hyoscine-N-butyl bromide on active phase of labor progress: a randomized double blind placebo controlled trial

Introduction: Appropriate cervical dilatation and effacement are essential for the progression of labor. With the active management of labor, number of cesarean deliveries reduces and the duration of labor shortens. Cervical dilatation can be facilitated by mechanical, pharmacological and non-pharmacologic methods. Cervix is richly supplied by autonomic nerves, which may play a role in the dilatation of cervix. Hyoscine-N-butylbromide (HBB) is a muscarinic antagonist and acts as a cervical spasmolytic agent. After intravenous administration it is rapidly distributed into the tissues. We aimed to study the effects and safety of a single dose 20 mg HBB injection during the active phase of labor in both primi- and multigravid women.Materials and method: A randomized, double-blinded, controlled trial, with healthy primigravid and multigravid women in spontaneous labor at term was considered in this study. Once the active phase of labor was achieved, either a single dose of 20 mg (1 mL) of HBB or placebo (1 mL saline) was given intravenously.Results: The mean duration of the first stage of labor was 191.1 ± 43.06 min in the primigravid patients of the HBB group, while it was 248.2 ± 66.1 min in the placebo group, a statistically significant difference of 57 min (p < 0.001). The mean duration of the first stage of labor was 170.1 ± 50.8 min in the multigravid patients of the HBB group, while it was 224.06 ± 53.7 min in the placebo group (difference of 54 min, p < 0.001). The mean duration of the first stage of labor was significantly different both for multigravida and primigravid patients. There was no significant change in the times for the second and third stages of labor. There were no significant differences in terms of APGAR scores noted at 1 and 5 min, prepartum and postpartum hemoglobin levels and birth weight. No adverse maternal and fetal effects were observed in both HBB and placebo groups.Conclusion: A single dose of 20 mg intravenous HBB is effective and safe in shortening the duration of the first stage of labor without any adverse effects on fetus and mother.

PLD.30 A 5-year review of maternal obesity and induction of labour on mode of delivery and risk of labour, anaesthetic and neonatal complications

IntroductionMaternal obesity is associated with adverse pregnancy outcomes. We routinely see women with a BMI >45 to discuss antenatal and intrapartum care including an early epidural recommendation.MethodsRetrospective analysis of women...

Women's perception of pre-hospital labour duration and obstetrical outcomes; a prospective cohort study.

BackgroundProgress during early labour may impact subsequent labour trajectories. Women admitted to hospital in latent phase (<3 cm cervical dilation) labour have been shown to be at higher risk of obstetrical interventions.MethodsWe conducted a secondary analysis of data from a randomized controlled trial of 1247 healthy nulliparous women in spontaneous labour at term with a singleton fetus in cephalic presentation at seven hospitals in Southwestern British Columbia. We computed relative risks and their 95% confidence intervals to examine our primary outcome of cesarean section and secondary outcomes including obstetrical interventions and maternal and newborn outcomes according to women’s perception of length of pre-hospital labour. Women were asked on admission to hospital how long they had been experiencing contractions prior to coming to hospital.ResultsWomen indicating that they had been in labour for 24 hours or longer at the time of hospital admission were at elevated risk for cesarean birth, relative risk (RR) 1.40, (95% Confidence Intervals 1.15-1.72), admission with a cervical dilation of 3 cm or less, RR 1.21 (1.07-1.36), more obstetrical interventions including continuous electronic fetal monitoring RR 1.11 (1.03-1.20), augmentation of labour RR 1.33 (1.23-1.44), use of narcotic RR 1.21 (1.06-1.37) and epidural analgesia RR 1.18 (1.09-1.28). Adverse neonatal outcomes did not differ apart from a significant increase in meconium-stained amniotic fluid RR 1.60 (1.09-2.35).ConclusionsA single question asked of women on presentation to hospital was an important predictor of cesarean birth and may have utility in identifying women who would benefit from close observation and more active management of labour.

Transcriptome interrogation of human myometrium identifies differentially expressed sense-antisense pairs of protein-coding and long non-coding RNA genes in spontaneous labor at term

Objective: To identify differentially expressed long non-coding RNA (lncRNA) genes in human myometrium in women with spontaneous labor at term.Materials and methods: Myometrium was obtained from women undergoing cesarean deliveries who were not in labor (n = 19) and women in spontaneous labor at term (n = 20). RNA was extracted and profiled using an Illumina® microarray platform. We have used computational approaches to bound the extent of long non-coding RNA representation on this platform, and to identify co-differentially expressed and correlated pairs of long non-coding RNA genes and protein-coding genes sharing the same genomic loci.Results: We identified co-differential expression and correlation at two genomic loci that contain coding-lncRNA gene pairs: SOCS2--AK054607 and LMCD1--NR_024065 in women in spontaneous labor at term. This co-differential expression and correlation was validated by qRT-PCR, an experimental method completely independent of the microarray analysis. Intriguingly, one of the two lncRNA genes differentially expressed in term labor had a key genomic structure element, a splice site, that lacked evolutionary conservation beyond primates.Conclusions: We provide, for the first time, evidence for coordinated differential expression and correlation of cis-encoded antisense lncRNAs and protein-coding genes with known as well as novel roles in pregnancy in the myometrium of women in spontaneous labor at term.

Secreted phospholipase A2 is increased in meconium-stained amniotic fluid of term gestations: potential implications for the genesis of meconium aspiration syndrome

Background: Meconium-stained amniotic fluid (MSAF) represents the passage of fetal colonic content into the amniotic cavity. Meconium aspiration syndrome (MAS) is a complication that occurs in a subset of infants with MSAF. Secreted phospholipase A2 (sPLA2) is detected in meconium and is implicated in the development of MAS. The purpose of this study was to determine if sPLA2 concentrations are increased in the amniotic fluid of women in spontaneous labor at term with MSAF.Materials and methods: This was a cross-sectional study of patients in spontaneous term labor who underwent amniocentesis (n = 101). The patients were divided into two study groups: (1) MSAF (n = 61) and (2) clear fluid (n = 40). The presence of bacteria and endotoxin as well as interleukin-6 (IL-6) and sPLA2 concentrations in the amniotic fluid were determined. Statistical analyses were performed to test for normality and bivariate analysis. The Spearman correlation coefficient was used to study the relationship between sPLA2 and IL-6 concentrations in the amniotic fluid.Results: Patients with MSAF have a higher median sPLA2 concentration (ng/mL) in amniotic fluid than those with clear fluid [1.7 (0.98–2.89) versus 0.3 (0–0.6), p < 0.001]. Among patients with MSAF, those with either microbial invasion of the amniotic cavity (MIAC, defined as presence of bacteria in the amniotic cavity), or bacterial endotoxin had a significantly higher median sPLA2 concentration (ng/mL) in amniotic fluid than those without MIAC or endotoxin [2.4 (1.7–6.0) versus 1.7 (1.3–2.5), p < 0.05]. There was a positive correlation between sPLA2 and IL-6 concentrations in the amniotic fluid (Spearman Rho = 0.3, p < 0.05).Conclusion: MSAF that contains bacteria or endotoxin has a higher concentration of sPLA2, and this may contribute to induce lung inflammation when meconium is aspirated before birth.

Effect of the presence of support person and routine intervention for women during childbirth in Isfahan, Iran: A randomized controlled trial.

Background:The aim of this study was to examine the effects of the presence of continuous support person and routine interventions during labor and delivery in Isfahan, Iran.Materials and Methods:One hundred pregnant women in spontaneous labor were assessed in four groups: Group 1; received routine intervention with a support person, Group 2; received routine intervention without support person, Group 3; received support person without routine intervention, Group 4; did not receive routine intervention or a support person. Sociodemographic, antenatal characteristics, length of stage of labor, instrumental delivery, the cervical laceration, perineal tear, labor pain, satisfaction and Apgar score collected and analyzed.Results:Based on the results there was no significant difference in regard to maternal age, BMI, maternal education and working statutes among the studied groups (P-value >0.05). Also, 1 and 5-min Apgar <7, cervical lacerations and instrumental delivery among studied groups were similar (P-value >0.05). Length of first and second stage of labor, perineal tear, satisfaction score and pain before and after labor were significant among studied groups (P-value <0.05).Conclusions:Presence of a support person and routine intervention during labor did not effect on incidence of cervical lacerations, instrumental delivery and Apgar <7. Labor pain and women's dissatisfaction, and number women with third and fourth degree of perineal tear among women who received routine intervention were increased compare to others. Interventions makes decreased the length of first and second stage of labor. In totally, the presence of a support person during labor in Iranian women decrease length of labor and improved labor outcomes.

548: Is a restrictive use of oxytocin during spontaneous labor associated with a change in obstetric or neonatal outcomes?

Oxytocin is used in France for 60-70 % of women in spontaneous labor, although according to current guidelines labor augmentation is required in less than 30% of the cases. Recently, the safety of oxytocin and its efficacy to reduce cesarean rates have been questioned. Therefore, we introduced a protocol of restrictive oxytocin use and investigated whether it was associated with changes in obstetric or neonatal outcomes.

Bacteria and endotoxin in meconium-stained amniotic fluid at term: could intra-amniotic infection cause meconium passage?

Background: Meconium-stained amniotic fluid (MSAF) is a common occurrence among women in spontaneous labor at term, and has been associated with adverse outcomes in both mother and neonate. MSAF is a risk factor for microbial invasion of the amniotic cavity (MIAC) and preterm birth among women with preterm labor and intact membranes. We now report the frequency of MIAC and the presence of bacterial endotoxin in the amniotic fluid of patients with MSAF at term.Materials and methods: We conducted a cross-sectional study including women in presumed preterm labor because of uncertain dates who underwent amniocentesis, and were later determined to be at term (n = 108). Patients were allocated into two groups: (1) MSAF (n = 66) and (2) clear amniotic fluid (n = 42). The presence of bacteria was determined by microbiologic techniques, and endotoxin was detected using the Limulus amebocyte lysate (LAL) gel clot assay. Statistical analyses were performed to test for normality and bivariate comparisons.Results: Bacteria were more frequently present in patients with MSAF compared to those with clear amniotic fluid [19.6% (13/66) versus 4.7% (2/42); p < 0.05]. The microorganisms were Gram-negative rods (n = 7), Ureaplasma urealyticum (n = 4), Gram-positive rods (n = 2) and Mycoplasma hominis (n = 1). The LAL gel clot assay was positive in 46.9% (31/66) of patients with MSAF, and in 4.7% (2/42) of those with clear amniotic fluid (p < 0.001). After heat treatment, the frequency of a positive LAL gel clot assay remained higher in the MSAF group [18.1% (12/66) versus 2.3% (1/42), p < 0.05]. Median amniotic fluid IL-6 concentration (ng/mL) was higher [1.3 (0.7–1.9) versus 0.6 (0.3–1.2), p = 0.04], and median amniotic fluid glucose concentration (mg/dL) was lower [6 (0–8.9) versus 9 (7.4–12.6), p < 0.001] in the MSAF group, than in those with clear amniotic fluid.Conclusion: MSAF at term was associated with an increased incidence of MIAC. The index of suspicion for an infection-related process in postpartum women and their neonates should be increased in the presence of MSAF.

Effect of Hydration on Spontaneous Labor Outcomes in Nulliparous Pregnant Women: A Multicenter Randomized Controlled Trial Comparing Three Methods

To evaluate the effect of mode and amount of fluid hydration during labor. The authors conducted a randomized controlled trial of uncomplicated nulliparous women in spontaneous labor at 36 weeks or more gestational age. Women were randomized to receive lactated Ringer solution with 5% dextrose at (1) 125 mL/h intravenously with limited oral intake, (2) 250 mL/h intravenously with limited oral intake, or (3) 25 mL/h intravenously with ad libitum oral intake of clear liquids. Results were analyzed by intent-to-treat analysis. A total of 311 out of 324 women were available for analysis. Groups 1 (n = 105), 2 (n = 105), and 3 (n = 101) above did not differ significantly for mean labor duration (11.6 ± 5.9, 11.4 ± 5.5, and 11.5 ± 5.9 hours, respectively; p = 0.998), proportion of women in labor > 12 hours (all groups 41%; p = 0.998), proportion receiving oxytocin augmentation (59, 60, and 57%, respectively; p = 0.923), or proportion delivered by cesarean (22, 17, and 17%, respectively; p = 0.309). Indications for cesarean were similar between groups. No cases of pulmonary edema, maternal aspiration, or perinatal mortality occurred. Although apparently safe, neither increased intravenous hydration nor oral hydration during labor improves labor performance.

Oxytocin augmentation of labour in women with epidural analgesia for reducing operative deliveries

The rate of operative deliveries (both caesarean sections, vacuum extractions and forceps), continues to rise throughout the world. These are associated with significant maternal and neonatal morbidity. The most common reasons for operative births in nulliparous women are labour dystocia (failure to progress), and non-reassuring fetal status. Epidural analgesia has been shown to slow the progress of labour, as well as increase the rate of instrumental deliveries. However, it is unclear whether the use of oxytocin in women with epidural analgesia results in a reduction in operative deliveries, and thereby reduces both maternal and fetal morbidity. To determine whether augmentation of women using epidural analgesia with oxytocin will decrease the incidence of operative deliveries and thereby reduce fetal and maternal morbidity. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013). All published and unpublished randomised and quasi-randomised trials that compared augmentation with oxytocin of women in spontaneous labour with epidural analgesia versus intent to manage expectantly were included. Cluster-randomised trials were eligible for inclusion but none were identified.Cross-over study designs were unlikely to be relevant for this intervention, and we planned to exclude them if any were identified. We did not include results that were only available in published abstracts. The two review authors independently assessed for inclusion the 16 studies identified as a result of the search strategy. Both review authors independently assessed the risk of bias for each included study. Both review authors independently extracted data. Data were checked for accuracy. We included two studies, involving 319 women. There was no statistically significant difference between the two groups in either of the primary outcomes of caesarean section (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.42 to 2.12) or instrumental delivery (RR 0.88, 95% CI 0.72 to 1.08). Similarly, there were no statistically significant differences between the two groups in any of the secondary outcomes for which data were available. This included Apgar score less than seven at five minutes (RR 3.06, 0.13 to 73.33), admission to neonatal intensive care unit (RR 1.07, 95% CI 0.29 to 3.93), uterine hyperstimulation (RR 1.32, 95% CI 0.97 to 1.80) and postpartum haemorrhage (RR 0.96, 95% CI 0.58, 1.59). There was no statistically significant difference identified between women in spontaneous labour with epidural analgesia who were augmented with oxytocin, compared with those who received placebo. However, due to the limited number of women included in the studies, further research in the form of randomised controlled trials are required.

Effect of partogram use on outcomes for women in spontaneous labour at term

The partogram (sometimes known as partograph) is usually a pre-printed paper form on which labour observations are recorded. The aim of the partogram is to provide a pictorial overview of labour, to alert midwives and obstetricians to deviations in maternal or fetal wellbeing and labour progress. Charts often contain pre-printed alert and action lines. An alert line represents the slowest 10% of primigravid women's labour progress. An action line is placed a number of hours after the alert line (usually two or four hours) to prompt effective management of slow progress of labour. To determine the effect of use of partogram on perinatal and maternal morbidity and mortality.To determine the effect of partogram design on perinatal and maternal morbidity and mortality. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013). Randomised and quasi-randomised controlled trials involving a comparison of partogram with no partogram, or comparison between different partogram designs. Three review authors independently assessed eligibility, quality and extracted data. When one review author was also the trial author, the two remaining authors assessed the studies independently. We have included six studies involving 7706 women in this review; two studies assessed partogram versus no partogram and the remainder assessed different partogram designs. There was no evidence of any difference between partogram and no partogram in caesarean section (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.24 to 1.70); instrumental vaginal delivery (RR 1.00, 95% CI 0.85 to 1.17) or Apgar score less than seven at five minutes (RR 0.77, 95% CI 0.29 to 2.06) between the groups. When compared to a four-hour action line, women in the two-hour action line group were more likely to require oxytocin augmentation (RR 1.14, 95% CI 1.05 to 1.22). When the three- and four-hour action line groups were compared, caesarean section rate was lowest in the four-hour action line group and this difference was statistically significant (RR 1.70, 95% CI 1.07 to 2.70, n = 613, one trial). When a partogram with a latent phase (composite) and one without (modified) were compared, the caesarean section rate was lower in the partograph without a latent phase (RR 2.45, 95% CI 1.72 to 3.50, n = 743, one trial). On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care. Given the fact that the partogram is currently in widespread use and generally accepted, it appears reasonable, until stronger evidence is available, that partogram use should be locally determined. Further trial evidence is required to establish the efficacy of partogram use.

Interinstitutional Variation of Caesarean Delivery Rates According to Indications in Selected Obstetric Populations: A Prospective Multicenter Study

The aim of the study was to identify which groups of women contribute to interinstitutional variation of caesarean delivery (CD) rates and which are the reasons for this variation. In this regard, 15,726 deliveries from 11 regional centers were evaluated using the 10-group classification system. Standardized indications for CD in each group were used. Spearman's correlation coefficient was used to calculate (1) relationship between institutional CD rates and relative sizes/CD rates in each of the ten groups/centers; (2) correlation between institutional CD rates and indications for CD in each of the ten groups/centers. Overall CD rates correlated with both CD rates in spontaneous and induced labouring nulliparous women with a single cephalic pregnancy at term (P = 0.005). Variation of CD rates was also dependent on relative size and CD rates in multiparous women with previous CD, single cephalic pregnancy at term (P < 0.001). As for the indications, “cardiotocographic anomalies” and “failure to progress” in the group of nulliparous women in spontaneous labour and “one previous CD” in multiparous women previous CD correlated significantly with institutional CD rates (P = 0.021, P = 0.005, and P < 0.001, resp.). These results supported the conclusion that only selected indications in specific obstetric groups accounted for interinstitutional variation of CD rates.

The Effect of Manipulation of the Programmed Intermittent Bolus Time Interval and Injection Volume on Total Drug Use for Labor Epidural Analgesia

BACKGROUND: Programmed intermittent bolus administration of epidural anesthetic solution compared with continuous infusion results in decreased anesthetic consumption and increased patient satisfaction. In this randomized and blinded study, we evaluated bupivacaine consumption and other analgesic outcomes when the programmed intermittent bolus time interval and volume were manipulated during the maintenance of epidural labor analgesia. METHODS: Healthy, term, nulliparous women in spontaneous labor had combined spinal-epidural labor analgesia initiated with intrathecal bupivacaine 1.25 mg and fentanyl 15 μg, followed by an epidural test dose (lidocaine 45 mg with epinephrine 15 μg). Subjects were randomized to 1 of 3 programmed intermittent bolus dose regimens for maintenance of analgesia: 2.5 mL every 15 minutes (2.5/15), 5 mL every 30 minutes (5/30), or 10 mL every 60 minutes (10/60). The maintenance epidural solution consisted of bupivacaine 0.625 mg/mL with fentanyl 1.95 μg/mL. Breakthrough pain was treated initially with patient-administered epidural bolus doses, followed by manual boluses administered by the anesthesiologist if necessary. The primary outcome was total bupivacaine consumption per hour of labor. A linear mixed-effects model was used to model each patient's overall bupivacaine consumption per hour; the fixed effect was basal bupivacaine administration rate and the random effect was the area under the pain score versus time curve. RESULTS: One hundred ninety women were studied. The median (interquartile range) adjusted bupivacaine consumption per hour of labor was 8.8 mg (8.0-9.7 mg) in group 10/60 compared with 10.0 mg (9.3-10.8 mg) in group 5/30 and 10.4 mg (9.6-11.2 mg) in group 2.5/15 (P = 0.005). There were no differences in area under the pain score versus time curve, pain scores at delivery, patient-controlled epidural analgesia requests or administrations, number of manual bolus doses for breakthrough pain, time to first patient-controlled epidural analgesia or manual bolus dose, or patient satisfaction with labor analgesia. CONCLUSIONS: Extending the programmed intermittent bolus interval and volume from 15 minutes to 60 minutes, and 2.5 mL to 10 mL, respectively, decreased bupivacaine consumption without decreasing patient comfort or satisfaction.

Oral Misoprostol for Labor Augmentation

In addition to artificial rupture of the membranes, intravenous oxytocin is essentially the sole medication for labor augmentation in the United States. Although misoprostol has been shown in numerous trials to be an effective agent for labor induction, there have been concerns with respect to its uterotonic properties and relatively long half-life, when used as a contractile agent for women in spontaneous labor who require augmentation. Limited data are available on the use of oral misoprostol as an augmentation agent. The aim of this randomized controlled trial was to compare the efficacy of oral misoprostol and intravenous oxytocin among women in spontaneous active labor who require augmentation. A total of 350 singleton women with spontaneous labor and cervical dilation between 4 and 8 cm were randomized to either oral misoprostol (n = 376) or intravenous oxytocin (n = 374). The main study outcome was the incidence of uterine tachysystole, hypertonus, or both. Secondary outcomes assessed included mode of delivery, duration of labor, presence of nonreassuring fetal heart rate, and selected maternal and neonatal outcomes. The admission-to-study drug interval was significantly shorter among women in the misoprostol group (330 minutes, range: 252–408) compared with those in the oxytocin group (402 minutes, range: 330–492; P < 0.001). However, no significant difference was found in the interval between initiation of the study drug and delivery (306 minutes in the misoprostol group vs. 276 minutes in the oxytocin group; P = 0.29). The incidence of uterine tachysystole, hypertonus, or both was higher in the misoprostol group (76%) compared with the oxytocin group (64%); P = 0.02. However, this increase appeared to be secondary to uterine hypertonus, as there was no difference between groups in the incidence of tachysystole (P = 0.74). There was no increased likelihood that women in the misoprostol group would experience a nonreassuring fetal heart rate or require a cesarean delivery (P = 0.20 and P = 0.78, respectively). No significant differences were noted between the groups in maternal or neonatal outcomes. The authors conclude that these findings suggest that oral misoprostol may be effective for augmentation of labor.

Epidural analgesia during labor vs no analgesia: A comparative study

Background:Epidural analgesia is claimed to result in prolonged labor. Previous studies have assessed epidural analgesia vs systemic opioids rather than to parturients receiving no analgesia. This study aimed to evaluate the effect of epidural analgesia on labor duration compared with parturients devoid of analgesia.Methods:One hundred sixty nulliparous women in spontaneous labor at full term with a singleton vertex presentation were assigned to the study. Parturients who request epidural analgesia were allocated in the epidural group, whereas those not enthusiastic to labor analgesia were allocated in the control group. Epidural analgesia was provided with 20 mL bolus 0.5% epidural lidocaine plus fentanyl and maintained at 10 mL for 1 h. Duration of the first and second stages of labor, number of parturients receiving oxytocin, maximal oxytocin dose required for each parturient, numbers of instrumental vaginal, vacuum-assisted, and cesarean deliveries and neonatal Apgar score were recorded.Results:There was no statistical difference in the duration of the active-first and the second stages of labor, instrumental delivery, vacuum-assisted or cesarean delivery rates, the number of newborns with 1-min and 5-min Apgar scores less than 7 between both groups and number of parturients receiving oxytocin, however, the maximal oxytocin dose was significantly higher in the epidural group.Conclusion:Epidural analgesia by lidocaine (0.5%) and fentanyl does not prolong labor compared with parturients without analgesia; however, significant oxytocin augmentation is required during the epidural analgesia to keep up the aforementioned average labor duration.

Oral Misoprostol for Labor Augmentation

To estimate the efficacy of oral misoprostol for labor augmentation. We performed a randomized, controlled trial comparing intravenous oxytocin to a 75-microgram dose of oral misoprostol. Women in spontaneous labor were eligible if they had cervical dilation of 4-8 cm and required labor augmentation. Primary outcome was the incidence of uterine tachysystole, hypertonus, or both. Secondary outcomes included labor durations, presence of nonreassuring fetal heart rate, mode of delivery, and select maternal and neonatal outcomes. Three hundred fifty women were randomized, 176 (50%) to oral misoprostol and 174 (50%) to intravenous oxytocin. Whereas the admission to study drug interval was significantly shorter in women randomized to misoprostol (median 330 minutes [252, 408] compared with 402 minutes [330, 492]; P<.001), there was no difference in the time interval between initiation of augmentation and delivery: 306 (150, 534) minutes in the misoprostol group compared with 276 (162, 462) in the oxytocin group (P=.29). Women in the misoprostol group were more likely to experience uterine tachysystole, hypertonus, or tachysystole and hypertonus compared with those in the oxytocin group (76% compared with 64%, respectively; P=.02). This increase was secondary to uterine hypertonus as the incidence of tachysystole did not differ between groups (P=.74). Women in the misoprostol arm were no more likely to experience a nonreassuring fetal heart rate (P=.20) or require a cesarean delivery for this indication (P=.78). There were no significant differences in maternal or neonatal outcomes. Oral misoprostol is an effective agent for augmentation of labor. : ClinicalTrials.gov, www.clinicaltrials.gov, NCT00906347. I.

Identification of a myometrial molecular profile for dystocic labor

BackgroundThe most common indication for cesarean section (CS) in nulliparous women is dystocia secondary to ineffective myometrial contractility. The aim of this study was to identify a molecular profile in myometrium associated with dystocic labor.MethodsMyometrial biopsies were obtained from the upper incisional margins of nulliparous women undergoing lower segment CS for dystocia (n = 4) and control women undergoing CS in the second stage who had demonstrated efficient uterine action during the first stage of labor (n = 4). All patients were in spontaneous (non-induced) labor and had received intrapartum oxytocin to accelerate labor. RNA was extracted from biopsies and hybridized to Affymetrix HuGene U133A Plus 2 microarrays. Internal validation was performed using quantitative SYBR Green Real-Time PCR.ResultsSeventy genes were differentially expressed between the two groups. 58 genes were down-regulated in the dystocia group. Gene ontology analysis revealed 12 of the 58 down-regulated genes were involved in the immune response. These included (ERAP2, (8.67 fold change (FC)) HLA-DQB1 (7.88 FC) CD28 (2.60 FC), LILRA3 (2.87 FC) and TGFBR3 (2.1 FC)) Hierarchical clustering demonstrated a difference in global gene expression patterns between the samples from dystocic and non-dystocic labours. RT-PCR validation was performed on 4 genes ERAP2, CD28, LILRA3 and TGFBR3ConclusionThese findings suggest an underlying molecular basis for dystocia in nulliparous women in spontaneous labor. Differentially expressed genes suggest an important role for the immune response in dystocic labor and may provide important indicators for new diagnostic assays and potential intrapartum therapeutic targets.