[Influence of ACTH-depot doses on neuroendocrine gestosis treatment]

OBJECTIVE OF THE STUDY

Two dosing methods of ACTH-depot therapy were compared dependently on gestational age and sequence of applied injections. It has been concluded that better efficacy was observed in single doses method comparing to serial doses in 2nd trimester.

MATERIAL AND METHODS

Retrospectively, 380 pregnancies were analyzed, in which ACTH-depot therapy was applied using 0,5 mg doses. In 140 subjects (Group I, 1990-1991) 3 injection series every 2nd day with additional antibiotic (i.e. Monural 3g) were administrated. In the rest 240 (Group II, 1997-2002) single doses were applied during the whole period of pregnancy due to recurrent vomiting or decreased CAP1 serum levels under 0,8 micromol/l/min and CAP2 under 1,4 micromol/l/min in 1st trimester and compulsory in ACTH serum levels under 5,0 pg/ml.

RESULTS

Clinical results can be compared with oxytocinase and ACTH serum levels, what allows to understand enzymatic control of internal maternal state. Role of ACTH not only in lung maturation, but also in onset of labor was proved in the mechanism of influence on immunologic tolerance. In hormonal threatening pregnancies enzymatic component is less helpful in predicting birth date because of common irregular oxitocinase pattern in such patients. On the other hand constant enzymatic increase proves effectiveness of ACTH-depot therapy in neurendocrine-gestoses, or in insulin-requiring pregnant patients.

CONCLUSIONS

Acquired results of neonatal state proved that: 1. in pregnancies after infertility treatment early application of substitutional hormonotherapy wsith single doses of 0,5 mg ACTH-depot in early gestational weeks is more efficient method of ACTH dosing than 3 injections method in 2nd trimester 2. serum prelabour oxitocinase levels were precise factors of clinical results.

Longitudinal changes in serum paraoxonase-1 activity throughout normal pregnancy

The aim of this study was to investigate the longitudinal changes in serum paraoxonase-1 (PON1) activity from preconception throughout normal pregnancy and their relationships with maternal dietary vitamin C and E intake. The study was performed in 35 women (studied at preconception, at 8, 20 and 32weeks of pregnancy, and at labour). PON1 activity decreased significantly from 145.8 (109.8–198.8) U/L at preconception to 111.1 (85.3–179.9) U/L (p<0.01) at 32weeks and 100.4 (54.7–171.4) U/L (p<0.001) at labour. There was a direct association between vitamin C intake and PON1 at week 32 (p=0.018). We conclude that adequate vitamin C intake in pregnant women may merit consideration, since vitamin C supplementation has proved beneficial in the prevention of preeclampsia in women at increased risk of this condition.

Clin Chem Lab Med 2006;44:880–2.

Influence of Partus Induction on the pH Value in the Blood of Newborn Piglets

Partus induction is an important integrative component of reproduction management in the swine industry. In this context, the question is to what extent the application of uterotonic substances may influence the vitality of piglets. The blood pH value is used as a laboratory objective diagnostic parameter of neonatal acidosis. This parameter of the acid-base balance was examined in piglets born spontaneously at the 115th to 116th day of gestation (group 1, n = 57) and after two different partus induction protocols starting at the 114th day of gestation (group 2: combination of 175 microg of cloprostenol and 20 IU of oxytocin, n = 55; group 3: 175 microg of cloprostenol and 35 microg of carbetocin, n = 56). Initial blood samples were taken from each piglet at birth and 2 h later. The results show that the different protocols have no negative influence on the initial pH value and the compensation of neonatal acidosis until the second hour post-natum.

[Epidural analgesia and the course of delivery in term primiparas]

OBJECTIVES

Epidural analgesia provides the most effective pain control during labor. Of great concern is its influence on the course of delivery and perinatal complications.

DESIGN

The aim of the study was to assess the effect of epidural analgesia on the course of delivery and perinatal outcome.

MATERIALS AND METHODS

609 deliveries among 1334 (323 women with epidural analgesia (53%) and 548 without epidural analgesia (47%)) met the following criteria: primipara, singleton, live pregnancy, > =37 weeks' gestation, cephalic presentation of a fetus, lack of contraindication for vaginal delivery. The incidence of instrumental deliveries and fetal distress, duration of the first, second and third stage of labor, perinatal outcome, perinatal complications and perinatal blood loss and were analyzed.

RESULTS

The incidence of fetal distress during second stage of labor was significantly higher in the epidural group (12.69 vs. 6.99%, P=0.02). The incidence of fetal distress during first stage of labor did not differ in both groups (10.53% vs. 8.74%, NS). Cesarean sections rate was similar in epidural and non-epidural group (17.7 vs. 18.2%, NS). Among vaginal deliveries duration of the first and second stage of labor was longer in epidural group (6.5+/-2.4 vs. 5.4+/-2.5 godz., P=0,000003 and 47.3+/-34.8 vs. 29.1+/-25.8 min., P=0.000003) and this was independent of period of time between onset of first stage of labor and epidural analgesia. Oxitocin use was significantly more frequent in the epidural group (20.6 vs. 10.3%, P<0.004). There were no statistically significant differences in the rates of instrumental vaginal deliveries, 1 and 5-minute Apgar scores, length of third stage of labor and perinatal blood loss in patients with and without epidural analgesia. Perinatal outcome did not depend on previous use of epidural analgesia or mode of analgesia for the operation in cesarean section subgroup.

CONCLUSION

Epidural labor analgesia is associated with slower progress of labor but has no adverse effect on perinatal outcome and perinatal complications.

Lower epidural anesthesia use associated with labor support by student nurse doulas: Implications for intrapartal nursing practice

Interventions of baccalaureate nursing students, trained as doulas, were examined for their association with epidural anesthetic use. Doulas, trained to support laboring mothers, are associated with shorter labors and fewer medical interventions. Data from a convenience sample of 89 vaginal births attended between 1999 and 2002 were analyzed. Analysis showed an association of lower epidural use with increased complementary doula interventions (.62 OR, P=.003) and an association of higher epidural use with longer labors (1.22 OR, P=.004). No significant association was found between epidural use and parity, income, education and type of health care provider. These findings support previous research of decreased analgesia use by doula-supported women and suggest benefits of the interventions by student nurse doulas. Students trained in providing low-tech supportive care may change the environment for intrapartum nursing practice. Institutional changes may be required to allow greater opportunity for intrapartal nurses to provide support to laboring women.

A randomized trial of prostaglandin E2 gel and extra-amniotic saline infusion with high dose oxytocin for cervical ripening

BACKGROUND

Our purpose was to compare the efficacy of extra-amniotic saline infusion plus high dose oxytocin with prostaglandin E2 intracervical gel (Dinoprostone) for preinduction cervical ripening.

MATERIAL/METHODS

166 nulliparous women with term pregnancies, vertex presentation, intact membranes and a Bishop score < or = 4 referred for labor induction were randomly assigned to receive a 0.5 mg PGE2 intracervical gel and extra-amniotic saline infusion (EASI) plus high-dose oxytocin. Changes in the Bishop scores, labor progress, various labor end points and outcomes of labor were assessed. Data were analyzed using chi2 analysis or the Student t-test.

RESULTS

151 women were studied after 15 exclusions, 75 were assigned to PGE2, and 76 to EASI. The groups were similar in age, race, indication for induction and gestational age. The EASI group had a significant improvement in Bishop score and greater dilation. The mean time to vaginal delivery was 11.4+/-4.8 hours and 18.9+/-6.4 hours for the EASI and PGE2 groups respectively (P=0.001). The cesarean delivery rate was not significantly different between the two groups (25% for the EASI group; 34.6% for the PGE2 group). The cesarean rate due to failure to progress, fetal labor intolerance, and maternal and neonatal outcomes were similar in the two groups.

CONCLUSIONS

Preinduction cervical ripening with EASI plus high dose oxytocin resulted in greater changes in Bishop score, and shorter time to normal vaginal delivery than with PGE2 gel in nulliparous women, without increasing the cesarean rate due to failure to progress or fetal labor intolerance.

Neurobehavioral functioning and breastfeeding behavior in the newborn

OBJECTIVE

To determine whether central nervous system functioning has an effect on the normal, term infant's ability to breastfeed in the first day following birth.

DESIGN

Breastfeeding behaviors and neurobehaviors were evaluated at birth and at 24 hrs of age in two groups of neonates. One group of neonates was born to mothers who received epidural analgesia during labor, and one group was born to mothers who received no pain medication. Breastfeeding behavior was evaluated using the Preterm Infant Breastfeeding Behavior Scale, and the infant's neurobehaviors were evaluated using the Neurologic and Adaptive Capacity Score.

PARTICIPANTS

Fifty-six breastfeeding mother-newborn dyads. All mothers were healthy multiparae who gave birth vaginally to normal, full-term, healthy newborns.

MAIN OUTCOME MEASURES

Newborns were observed for rooting, latch-on, sucking, swallowing, activity state, and neurobehavior.

RESULT

Analysis of the data indicated that the higher the infant scored in relation to neurobehavioral functioning, the higher the infant scored on breast-feeding behaviors.

CONCLUSION

When determining physiologically what is important for the infant to successfully latch on and feed, it appears that an intact and functioning central nervous system may be one of the crucial elements.

Phloroglucinol for acceleration of labour: double blind, randomized controlled trial

OBJECTIVES

To determine the effects of Phloroglucinol in acceleration of labour and its adverse effects on mother and foetus.

METHODS

A double blind randomized, placebo controlled trial was conducted on 100 patients in active phase of uncomplicated labour selected by convenient sampling. Patients were given Phloroglucinol or Placebo (distilled water) intravenously. Progress of labour was plotted on Partogram. Any adverse effects of the drug on mother and fetus were noted. Student's t-test was applied for statistical analysis.

RESULTS

In patients receiving Phloroglucinol there was a mean 34% reduction in duration of 1st stage of labour and a mean 23% reduction in 2nd stage as compared to Placebo group respectively. Blood loss >500ml was observed in 2% patients. Otherwise there were no adverse effects on mother or foetus.

CONCLUSION

Phloroglucinol shortens the duration of labour, is non toxic to both mother and fetus and does not cause primary post partum haemorrhage.

Outcomes of labours augmented with oxytocin

OBJECTIVE

To highlight the differences in mode of delivery between women augmented with intravenous oxytocin because of failure to progress in labour with those who labour without the need for augmentation.

STUDY DESIGN

An incidence study over a 5-year-period in a tertiary referral hospital comparing 1097 nulliparous women who were augmented in labour with 2745 nulliparous women who did not need augmentation. Only labours of spontaneous onset in the pregnancies of women at term were studied. The incidence of pregnancy outcomes were assessed by presenting estimates of relative risk (RR) and their 95% confidence intervals (CI).

RESULTS

Only 51.1% of women who received augmentation achieved a normal vaginal delivery compared with 76.5% of women who did not need augmentation (RR 0.67; CI 0.63-0.71). Contributory factors to this disparity included a greater number of Caesarean sections (14.4% versus 6.6%; RR 2.18 CI 1.74-2.67), forcep deliveries (12.8% versus 5.3%; RR 2.41 CI 1.93-3.01) and ventouse deliveries (21.7% versus 11.5%; RR 1.89 CI 1.62-2.21) being performed among augmented labours as compared to normal progressive labours.

CONCLUSION

Significant improvements in the management of labours which fail to progress are needed if normal vaginal delivery rates are to approach those seen in labours which progress without the need for augmentation.

[Influence of combined spinal-epidural analgesia and epidural analgesia on the progress of labor]

OBJECTIVE

To investigate the influence of combined spinal-epidural analgesia (CSEA) and epidural analgesia (EA) and patient-controlled epidural analgesia (PCEA) on labor progress.

METHODS

The partograms of 722 healthy vaginal delivery nulliparas were retrospectively analyzed in Department of Obstetric and Gynecology, First Hospital of Peking University. Three groups were divided among all subjects: CSEA group (259 cases) receiving CSEA + PCEA, EA group (215 cases) receiving EA + PCEA and control group (248 cases) without any analgesia method.

RESULTS

The duration of active phase in the first stage and the second stage in the CSEA group [(272 +/- 127) min and (57 +/- 36) min] and in the EA group [(305 +/- 133) min and (59 +/- 39) min] were significantly longer than that of control group [(188 +/- 110) min and (45 +/- 32) min]. No significant difference was found in the three groups in the duration of the third stage [CSEA: (9 +/- 6) min; EA: (8 +/- 6) min;

CONTROL

(9 +/- 6) min. P > 0.05]. The dilatation curve of the cervix in CSEA group and EA group was plotted on the right side of the Friedman curve while that of the control group on the left, reflecting a slower progress in the former two groups than the control during the active phase. The average speed of cervical dilatation in CSEA and EA groups (1.5 cm and 1.4 cm) was significantly slower than that of the control (1.8 cm) in the active phase (P < 0.01).

CONCLUSIONS

CSEA + PCEA or EA + PCEA during labor might slow down the progress of the active phase and lead to a prolonged labor in the end. Therefore, the management of these parturients may vary based on Friedman partogram.

[Effect of different analgesia on pain relief during labor]

OBJECTIVE

To evaluate the effect of spinal-epidural and epidural anesthesia for pain relief in labor.

METHODS

Totally 6671 cases selected from pregnant women delivered from Aug. 2001 to Oct. 2004 in our hospital were reviewed retrospectively. All cases were divided into three groups, 1482 cases in spinal-epidural group (combined epidural) and 1111 in epidural group (epidural) who received pain relief during labor; 4078 as control group without any pain relief during labor. Delivery method and maternal, fetal complications among three groups were compared.

RESULTS

(1) Delivery methods were significantly different (P < 0.01) among the three groups. The cesarean section (CS) rate in combined epidural was 423 (28.5%); in epidural: 351 (31.6%); and in control, 1847 (45.3%). The forceps delivery rate was 231 (15.6%), 207 (18.9%) and 357 (8.8%) in combined epidural, epidural and control, respectively, demonstrating significant difference (P < 0.01) among three groups. There was significant difference among spinal epidural 828 (55.9%) vs epidural 553 (49.8%) vs control 1874 (46.0%) in the rate of normal delivery. (2) Maternal and fetal complication existed significant difference (P < 0.01) among combined epidural, epidural vs control in the rate of fetal distress 33.7% (499/1482), 29.8% (331/1111), 28.5% (1163/4078), arrested active phase 17.3% (256/1482), 18.1% (201/1111), 8.3% (337/4078), prolonged active phase 1.8% (27/1482), 1.7% (19/1111), 0.8% (34/4078), and prolonged second stage 6.1% (91/1482), 5.4% (60/1111), 3.0% (124/4078). While no difference (P > 0.05) in postpartum hemorrhage and neonatal asphyxia between spinal epidural 4.3% (63/1482) 1.0% (15/1482), epidural 4.1% (45/1111), 0.8% (9/1111), and control 3.9% (159/4078), 1.4% (56/4078).

CONCLUSIONS

Anesthetic pain relief in labor may reduce the CS rate, but increase the rate of forceps delivery. Pain relief is associated with arrested and prolonged active phase, prolonged second stage. However, pain relief in labor does not enhance the rate of postpartum hemorrhage and neonatal asphyxia.

[Effects of epidural ropivacaine labor analgesia on duration of labor and mode of delivery]

OBJECTIVE

To study the effects of ropivacaine on the duration of labor and mode of delivery in the primigravidas using patient-controlled epidural analgesia (PCEA).

METHODS

Retrospective analysis was performed. The 190 healthy, full-term, and single-fetus parturient primigravidas who received PCEA with 0.1% ropivacaine + fentanyl (1 microg/ml) were in the epidural analgesia group. Another 222 primigravidas who did not receive PCEA were in the control group. The duration of labor and modes of delivery, and the neonatal Apgar scores in both two groups were recorded and evaluated.

RESULTS

Those in the epidural analgesia group experienced a significantly longer first stage [(426 +/- 161) minutes], longer second stage [(54 +/- 27) minutes] and longer full duration of delivery [(489 +/- 166) minutes] than those in the control one [(409 +/- 170) minutes, (364 +/- 167) minutes and (37 +/- 22) minutes]. The rate of using pitocin in the epidural analgesia group (30.2%) was significantly higher than that in the control group (4.1%). The cesarean section rate in epidural analgesia group (20.0%) was lower than that in the control one (28.4%); while the rate of instrumental delivery in the epidural analgesia group (20.0%) was significantly higher than that in the control one (6.3%). In summary, there were significant differences between two groups in the duration of labor, the rate of using pitocin, the rate of instrumental delivery and the rate of cesarean section. But there were no differences found for those newborn who had Apgar scores less than 7 at the point of both one and five minutes (7.9% and 4.5%, 2.6% and 0.5% respectively).

CONCLUSION

Epidural ropivacaine labor analgesia lengthens the duration of labor and increases the rate of instrumental delivery, but it has no significant negative effects on the neonates.

Expression of α5 Integrin (Itga5) Is Elevated in the Rat Myometrium During Late Pregnancy and Labor: Implications for Development of a Mechanical Syncytium1

The underlying mechanisms controlling uterine contractions during labor are still poorly understood. Integrins are heterodimeric, transmembrane receptors composed of alpha and beta subunits that can be found in focal adhesions. Because these structures play an important role in the regulation of smooth muscle contractility and cell adhesion, we hypothesized that alpha5 integrin mRNA (Itga5) and protein (ITGA5) expression would be induced in the rat myometrium during late pregnancy and labor. Itga5 mRNA expression was significantly increased (P < 0.05) from Day 17 to labor, noticeably decreasing 1 day postpartum (PP). Immunoblot analysis illustrated a continual increase in ITGA5 levels during pregnancy, labor, and PP, with levels reaching significance at labor (P < 0.05). Analysis of ITGA5 expression by immunocytochemistry demonstrated that it is primarily localized to myometrial cell membranes in the longitudinal muscle layer of the myometrium from before pregnancy to Day 6, and in both the longitudinal and circular muscle layers from Day 15 to PP. Treatment of late-pregnant rats with progesterone blocked labor and resulted in sustained expression of Itga5 mRNA expression to Day 24. In addition, immunocytochemistry experiments showed ITGA5 was detectable at higher levels in cell membranes of both myometrial layers in progesterone-treated animals on Days 23 and 24, compared with vehicle controls. We propose that ITGA5, with its sole known partner, ITGB1, may be important in promoting cellular cohesion during late pregnancy. This process may aid the development of a mechanical syncytium for efficient force transduction during the sustained, coordinated, and powerful contractions of labor.

[Changes of matrix metalloproteinase-9 and effect of diazepam on its expression in uterine lower segment during delivery]

OBJECTIVE

To investigate the role of matrix metalloproteinases (MMPs) in onset of labor, and the mechanism of diazepam in promoting cervical ripening.

METHODS

Concentrations of MMP-9 in lower segment of uterus from the group of cesarean section with (56 cases) and without (16 cases) uterine contraction were measured by enzyme linked immunosorbent assay (ELISA) method. Human cervical mechanocytes were cultured respectively with different concentrations of diazepam (0, 0.1, 10, 100 micromol/L). Semi-quantitative RT-PCR was used to study the expression of MMP-9 mRNA, and MMP-9 contents in culture supernatant were measured by ELISA methods.

RESULTS

The concentration of MMP-9 in uterine lower segment tissue in the group of cesarean section with uterine contraction, (3.1 +/- 2.6) ng/mg, was significantly higher than that in the group of cesarean section without uterine contraction, (0.8 +/- 0.4) ng/mg (P < 0.05). In the 1st-stage-labour group from the 44 cases of cesarean section with uterine contraction, MMP-9, (2.2 +/- 2.0) ng/mg, tended to increase with the dilatation of cervix. MMP-9 in the 12 cases of 2nd-stage-labour group was (6.1 +/- 2.5) ng/mg, which was significantly higher than that in the 1st-stage-labour group (P < 0.05). The relative expressions of MMP-9 mRNA in the cells of the blank control group and those with diazepam at final concentrations of 0.1, 10 micromol/L were all time dependent, in another word, the expressions gradually increased over time. There was a remarkable difference between the two groups and blank control group (P < 0.05). In the blank control group and group with diazepam at final concentration of 0.1 micromol/L, the MMP-9 contents in supernatant showed a time dependent increase, with a significant difference between the two groups (P < 0.05).

CONCLUSIONS

MMPs are key mediator in the onset of labor, maturation and dilatation of uterine cervix. Our studies suggest that human cervical mechanocytes play a role in synthesizing and secreting MMP-9 naturally; and diazepam might promote those activities of mechanocytes, thus in part accelerating the degradation of collagen fibers and cervical ripening.

Acute tocolysis

PURPOSE OF REVIEW

Emergency uterine relaxation may decrease the morbidity and mortality of the mother and her fetus. Obstetricians need to be aware of the indications, pharmacological methods, efficacy and complications of acute tocolysis.

RECENT FINDINGS

A variety of pharmacological agents are used to suppress uterine contractions. Newer agents like cyclo-oxygenase-2 inhibitors (Celecoxib) and oxytocin antagonists (atosiban) have been introduced into clinical practice with the hope of reducing the complications of betasympathomimetic drugs. Calcium-channel blockers are used but there are recent case reports of acute pulmonary oedema with the use of these agents. Most of the trials on tocolytics have been for suppression of preterm labour. Nitroglycerin has been used successfully as an acute tocolytic during Caesarean sections and manual removal of placenta. A recent randomized trial has suggested that atosiban may be an option for acute intrapartum tocolysis. This article will review the recent literature on the use of pharmacological agents used to suppress uterine contractions in emergency obstetric situations.

SUMMARY

Acute tocolysis may be indicated in antepartum, intrapartum and postpartum periods for a variety of indications. It may help reduce maternal and fetal morbidity and mortality. The ideal tocolytic is yet to be developed. Research is needed to develop a drug which has a greater uterospecificity with no effect on other organs with a rapid onset and a short duration of action.

Labor epidurals and outcome

The use of epidural analgesia for labor continues to increase dramatically. It has been suggested that epidural analgesia increases the risk of cesarean section, operative vaginal delivery, and prolonged labor. These issues have been extensively investigated. The use of epidural analgesia does not increase the risk of cesarean section. It may affect the incidence of forceps delivery, but it depends on the medications used. Epidural analgesia does prolong labor, although the clinical significance of this prolongation has not been shown.

The risk of cesarean delivery with neuraxial analgesia given early versus late in labor

BACKGROUND

Epidural analgesia initiated early in labor (when the cervix is less than 4.0 cm dilated) has been associated with an increased risk of cesarean delivery. It is unclear, however, whether this increase in risk is due to the analgesia or is attributable to other factors.

METHODS

We conducted a randomized trial of 750 nulliparous women at term who were in spontaneous labor or had spontaneous rupture of the membranes and who had a cervical dilatation of less than 4.0 cm. Women were randomly assigned to receive intrathecal fentanyl or systemic hydromorphone at the first request for analgesia. Epidural analgesia was initiated in the intrathecal group at the second request for analgesia and in the systemic group at a cervical dilatation of 4.0 cm or greater or at the third request for analgesia. The primary outcome was the rate of cesarean delivery.

RESULTS

The rate of cesarean delivery was not significantly different between the groups (17.8 percent after intrathecal analgesia vs. 20.7 percent after systemic analgesia; 95 percent confidence interval for the difference, -9.0 to 3.0 percentage points; P=0.31). The median time from the initiation of analgesia to complete dilatation was significantly shorter after intrathecal analgesia than after systemic analgesia (295 minutes vs. 385 minutes, P<0.001), as was the time to vaginal delivery (398 minutes vs. 479 minutes, P<0.001). Pain scores after the first intervention were significantly lower after intrathecal analgesia than after systemic analgesia (2 vs. 6 on a 0-to-10 scale, P<0.001). The incidence of one-minute Apgar scores below 7 was significantly higher after systemic analgesia (24.0 percent vs. 16.7 percent, P=0.01).

CONCLUSIONS

Neuraxial analgesia in early labor did not increase the rate of cesarean delivery, and it provided better analgesia and resulted in a shorter duration of labor than systemic analgesia.

Raised dietary n-6 polyunsaturated fatty acid intake increases 2-series prostaglandin production during labour in the ewe

Preterm labour is the major cause of perinatal morbidity and mortality in humans. The incidence is around 10% and the causes are often unknown. Consumption of dietary n-6 polyunsaturated fatty acids (PUFAs) in western societies is increasing. These are metabolized to arachidonic acid, the precursor for 2-series prostaglandins (PGs), major signalling molecules during labour. This study investigated the effect of dietary supplementation with linoleic acid (LA, 18: 2, n-6) on parturition. Ewes were fed a control or LA-supplemented diet from 100 days gestation. Labour was induced using a standardized glucocorticoid challenge (dexamethasone, Dex) to the fetus, starting on day 139. Electromyographic (EMG) activity and fetal and maternal circulating PG concentrations were monitored. One third of LA-fed ewes delivered early (pre-Dex) although basal uterine EMG activity preceding Dex was higher in control ewes (P < 0.05). A steep increase in EMG activity occurred 18-38 h after the start of Dex infusion. Twice basal EMG activity (defined as established labour) occurred on average 7 h earlier in the LA-supplemented ewes (P < 0.05). The basal concentrations of maternal and fetal PGFM and fetal PGE(2) were approximately doubled in LA-supplemented ewes before the start of Dex infusion (P < 0.01). The rise in fetal PGE(2) and maternal oestradiol concentrations post-Dex occurred earlier in the LA-supplemented ewes. All PG measurements remained significantly higher in the LA-supplemented ewes during labour onset. This study suggests that consumption of a high LA diet in late pregnancy can enhance placental PG production and may thus increase the risk of preterm labour.

High- versus Low-Dose Oxytocin for Augmentation or Induction of Labor

OBJECTIVE:

To compare the use of high- and low-dose oxytocin for augmentation or induction of labor.

DATA SOURCES:

Clinical trials were accessed through MEDLINE (1966–November 2003). Published literature relevant to the use of oxytocin for augmentation or induction of labor was evaluated.

STUDY SELECTION AND DATA EXTRACTION:

Articles identified from the data sources were evaluated and included if they were clinical trials comparing high- versus low-dose oxytocin for augmentation or induction of labor.

DATA SYNTHESIS:

Oxytocin is a treatment of choice for augmentation and induction of labor; however, no consensus exists regarding optimal dosing. Relevant studies comparing high-dose (2–6 mU/min) and low-dose (1–2 mU/min) therapy for labor augmentation and induction were evaluated.

CONCLUSIONS:

High-dose oxytocin decreases the time from admission to vaginal delivery, but does not appear to decrease the incidence of cesarean sections when compared with low-dose therapy.

Obstetric anesthesia: changes and choices

This article is a review of analgesics and anesthetics offered to laboring women, including intravenous drugs, epidural and spinal agents, and inhalational anesthetics. An overview of the uses, risks, and benefits is provided for each anesthetic alternative. To provide the most effective care to women in labor, clinicians have a responsibility to have current knowledge of the best evidence for safety and efficacy of these pharmacologic agents and techniques and be able to effectively communicate this information to clients.

Patient-controlled epidural analgesia for labor pain: effect on labor, delivery and neonatal outcome of 0.125% bupivacaine vs 0.2% ropivacaine

The objective was to evaluate the influence of patient-controlled epidural analgesia (PCEA) using low doses of bupivacaine vs. ropivacaine, on labor pain, motor blockade, progression of labor, delivery and neonatal outcome. This randomized double blind study included 565 parturients. All received a 5-mL/h infusion and PCEA (5-mL boluses with a 20-min lockout, maximum volume 20 mL/h) of either 0.125% bupivacaine (n = 313: 165 nulliparous, 148 parous) or 0.2% ropivacaine (n = 252: 113 nulliparous, 139 parous). Pain score, lower limb motor block, sensory levels, local analgesic doses required, hemodynamic parameters, side effects and complications were assessed. Obstetric variables included cervical dilation at epidural insertion, incidence of ruptured membranes and their duration, use of oxytocin, fetal heart rate changes, duration of labor, mode and outcome of delivery, and use of invasive and non-invasive fetal monitoring. Neonatal characteristics included birth weight, Apgar scores, umbilical artery pH, serum bilirubin, hypoglycemia, need for assisted ventilation, sepsis or sepsis study, feeding difficulties and respiratory distress syndrome. Ropivacaine 0.2% was equianalgesic with 0.125% bupivacaine, but produced less motor block (P < 0.0001). There were no significant differences, however, in duration of labor, delivery type or neonatal outcome.

Induction of labor with oxytocin increases cesarean section rate as compared with oxytocin for augmentation of spontaneous labor in nulliparous parturients controlled for lumbar epidural analgesia

STUDY OBJECTIVES

To study labor outcomes in parturients receiving oxytocin for augmentation or induction of labor, in the presence of labor epidural analgesia.

DESIGN

Retrospective study of data from a continuous quality improvement database.

SETTING

Tertiary-care hospital with more than 8000 deliveries per annum.

MEASUREMENTS AND MAIN RESULTS

Of the 1671 healthy nulliparous women with singleton pregnancies and who requested labor epidural analgesia at our institution, 675 patients received oxytocin during elective induction of labor, whereas 996 patients received oxytocin for augmentation of spontaneous labor. Measured variables were cervical dilatation at time of epidural analgesia request, epidural insertion to 10-cm time, duration of stage 2 of labor, normal spontaneous vaginal delivery rate, cesarean section rate, operative vaginal delivery rate, and baby weight. Women admitted for induction of labor requested epidural analgesia sooner than those who had their labor augmented (p < 0.001). The incidence of cesarean section was higher in the induced group (p = 0.008).

CONCLUSION

Patients who have their labor induced request analgesia sooner and are at a higher risk of cesarean section than are patients who go into labor spontaneously. Any study that purports to assess the effects of epidural analgesia in labor should distinguish between induced and augmented/spontaneous labor.

Geburtseinleitung mit Misoprostol: eine effektive, sichere und kostengünstige Alternative

Misoprostol is a prostaglandin E1 analogue marketed for use in the prevention of peptic ulcer disease. It is inexpensive and has few side-effects. Although not registered misoprostol has been widely used for obstetric and gynaecologic indications, such as induction of labour at term. In our clinic misoprostol has been use since April 15, 2003. The data of 70 women, who had been treated with misoprostol for induction of labour at term form April 15 to August 15, 2003, were analysed retrospectively and compared with the data of those women treated with dinoprostin in the same period 2002. The time to active labour was longer with dinoprostin compared to misoprostol (19.2 h vs. 15.5 h). Parity did not influence the time to active labour. The rate of cesarean sections was lower with misoprostol (17.2 vs. 25.8 %). The induction of labour with Misoprostol caused costs of 58.80 euro. If dinoprostin had been used, it would have cost 4 368.00 euro. Although not registered, misoprostol is a safe, effective and inexpensive alternative for induction of labour with few side-effects. However, patients accept the off-label use.

Patient-controlled epidural technique improves analgesia for labor but increases cesarean delivery rate compared with the intermittent bolus technique

BACKGROUND

We tested the hypothesis that patient-controlled epidural analgesia for labor (PCEA) provides better analgesia and satisfaction than the intermittent bolus technique (bolus) without affecting the mode of delivery.

METHODS

We randomized 187 parturients to receive labor analgesia using either the PCEA or bolus technique. The PCEA group received a starting bolus of 14 mg of bupivacaine and 60 micro g of fentanyl in a 15-ml volume, followed by a background infusion (bupivacaine 0.08% and fentanyl 2 microg ml(-1)) 5 ml h(-1) with a 5-ml bolus and 15-min lock-out interval. The bolus group received boluses of 20 mg of bupivacaine and 75 micro g of fentanyl in a 15-ml volume.

RESULTS

Parturients in the PCEA group had significantly (P < 0.05-0.01) less pain during the first and second stages of labor. There was no difference in the spontaneous delivery rate between the groups, but the cesarean delivery rate was significantly (P < 0.05) higher (16.3% vs. 6.7%) in the PCEA group than in the bolus group. Bupivacaine consumption was significantly (P < 0.01) higher (11.2 mg h(-1) vs. 9.6 mg h(-1)) and the second stage of labor was significantly (P < 0.01) longer (70 min vs. 54 min) in the PCEA group than in the bolus group. Patient satisfaction was equally good in both groups.

CONCLUSION

The PCEA technique provided better pain relief. This was associated with higher bupivacaine consumption, prolongation of the second stage of labor, and an increased rate of cesarean section.

Mifepristone: effect on plasma corticotropin-releasing hormone, adrenocorticotropic hormone, and cortisol in term pregnancy

OBJECTIVE

To compare the effects of in vivo mifepristone with placebo on plasma corticotropin-releasing hormone (CRH), adrenocorticotropic hormone (ACTH), and cortisol levels concentrations in term human pregnancies.

STUDY DESIGN

In all, 24 women participating in a randomized controlled trial of mifepristone for preinduction cervical ripening were enrolled in this ancillary study. Participants with uncomplicated singleton pregnancies beyond 41 weeks gestation and undilated, uneffaced cervices were randomized to either placebo or mifepristone 200 mg orally and observed for 24 hours prior to receiving either intravaginal misoprostol and/or intravenous oxytocin. Blood samples were obtained before medication administration, 3 and 6 hours later, and then every 6 hours until delivery. Plasma hormone levels were measured by radioimmunoassay.

RESULTS

Basal levels of CRH, ACTH, and cortisol were similar in the placebo (n=13) and mifepristone groups (n=11). Compared to placebo treatment, exposure to mifepristone resulted in significant elevation of plasma cortisol within 18 hours. Plasma CRH and ACTH were unaffected. Progression of labor was associated with significant increases in cortisol in both groups, while CRH and ACTH levels were not altered. Compared to basal levels within each group, plasma cortisol at delivery was significantly elevated within both the mifepristone (156.8+/-17.7 vs 332.6+/-48.5 ng/ml, p=0.008) and the placebo (166.6+/-34.3 vs 342.4+/-46.4 ng/ml, p=0.003) groups. However, plasma CRH, ACTH, and cortisol levels at delivery did not differ between the groups.

CONCLUSION

Mifepristone exposure and induced labor were associated with significant increases in plasma cortisol without alterations of systemic CRH or ACTH levels.

Pressure Sore as a Complication of Labor Epidural Analgesia

Lumbar epidural analgesia has become a common mode of pain control for laboring patients. Side effects, such as hypotension, motor blockade, respiratory depression, dural puncture, and urinary retention, are well described. Although pressure sores have been thought of as a complication limited to elderly, emaciated, unconscious, or bedridden patients, we describe the occurrence of pressure sores in a young and healthy parturient after lumbar epidural analgesia.

IMPLICATIONS

We report a pressure sore that resulted from lumbar epidural analgesia for labor.

Intrathecal Midazolam II: Combination with Intrathecal Fentanyl for Labor Pain

Recent investigations have sought to improve intrathecal analgesia by combining opioids with other classes of analgesics. In this study we assessed the ability of intrathecal midazolam to increase the potency and duration of the analgesic effects of intrathecal fentanyl without causing adverse effects. Thirty parturients with cervical dilations 2-6 cm were randomized to receive either intrathecal midazolam 2 mg, fentanyl 10 micro g, or both combined to initiate analgesia. Pain scores were recorded before and at 5-min intervals for 30 min after the injection and then every 30 minutes until the patient requested further analgesia. The presence and severity of nausea, emesis, pruritus, headache, and sedation, in addition to arterial blood pressure, heart rate, respiratory rate, sensory changes to ice, motor impairment, cardiotocograph, and Apgar score were also recorded. The parturients were assessed after 2 days and 1 mo for neurologic impairment. Preinjection pain scores were unaltered by intrathecal midazolam alone and moderately decreased by fentanyl. Intrathecal midazolam increased the analgesic effect of fentanyl. No treatment altered cardiorespiratory variables or caused motor impairment. The addition of intrathecal midazolam to fentanyl did not increase the occurrence of any maternal adverse event or abnormalities on the cardiotocograph. We conclude that intrathecal midazolam enhanced the analgesic effect of fentanyl without increasing maternal or fetal adverse effects.

IMPLICATIONS

Treatment of labor pain with epidural injections of local anesthetic is complicated by decreases in arterial blood pressure and leg weakness. This study showed that a mixture of two drugs, fentanyl and midazolam, could provide powerful pain relief when the drugs were given together spinally without such side effects.

Subarachnoid catheter placement after wet tap for analgesia in labor: influence on the risk of headache in obstetric patients

BACKGROUND AND OBJECTIVES

The incidence of postdural puncture headache (PDPH) after epidural wet tap for obstetric patients may be as high as 75%. We have studied how subsequent placement of a subarachnoid catheter immediately after confirmation of a wet tap, and leaving the catheter in place for 24 hours affects the incidence of PDPH.

METHODS

Over a 5-year interval, 115 consecutive patients who had unintentional dural puncture were divided into 3 groups by consecutive assignment. Group A had an epidural catheter placed at another interspace. Group B had a subarachnoid catheter placed for labor analgesia that was removed immediately after delivery. Group C had a subarachnoid catheter that was left in place for 24 hours after delivery. Data were collected retrospectively. The incidence of PDPH and blood patch was compared between groups.

RESULTS

The overall incidence of PDPH was 46.9% and need for blood patch 36.5%, significantly less in both subarachnoid catheter groups, 31% in B and 3% in group C, compared with group A (PDPH 81%) (P <.001).

CONCLUSION

Subarachnoid catheter placement after wet tap in obstetric patients reduces the PDPH rate and does so to a greater extent if left in place for 24 hours after delivery.

[Clinical effects and pharmacokinetics of ropivacaine and bupivacaine for epidural analgesia during labor]

OBJECTIVE

To compare the analgesic efficacy, pharmacokinetics and histamine release of ropivacaine and bupivacaine with fentanyl in continuous epidural perfusion during labor and childbirth.

MATERIAL AND METHODS

Prospective study of 40 women at full-term pregnancy who requested epidural analgesia. The patients were randomly assigned to 2 groups of 20: group R received an initial bolus dose of 10 mL of 0.25% ropivacaine and group B received 0.25% bupivacaine, followed in both groups by epidural infusion of the assigned drugs at a concentration of 0.125% plus 0.30 mg of fentanyl at a rate of 5 mL/h through a patient-controlled analgesia device that allowed additional bolus doses. The studied variables were age, weight, height, sensory and motor block, mean blood pressure and maternal-fetal heart rates, number of bolus doses, total local anesthetic administered, duration and type of delivery, oxytocin increase, Apgar at 1 and 5 minutes, plasma levels of local anesthetic (30 minutes after the initial dose, at the end of dilation, in the umbilical vein, and 30 minutes after switching off the perfusion pump), time to clearance, elimination half-life, and a test of histamine release by radioimmunoassay.

RESULTS

No significant differences were observed in the course of labor or in Apgar scores. The plasma concentrations of ropivacaine were higher than those of bupivacaine (p<0.03). Clearance of both drugs was similar. The elimination half-life of ropivacaine was significantly less than that of bupivacaine (5.2 +/- 0.7 h vs. 10.8 +/- 1.06 h).

CONCLUSIONS

Analgesia was equally effective in both groups, without adverse maternal-fetal effects, with spontaneous micturition and absence of motor blockade in both groups. The plasma concentrations were higher with ropivacaine but were not toxic.

[Obstetric epidural analgesia: relationship between obstetric variables and the course of labor]

OBJECTIVES

To analyze the relationship between epidural analgesia and diverse obstetric and fetal variables as well as the impact of epidural analgesia on the rates of instrumental and cesarean delivery.

PATIENTS AND METHODS

Observational study of women who gave birth at Fundación Hospital Alcorcón over a period of 3 years. All the women were offered obstetric epidural analgesia based on 0.0625% bupivacaine plus 2 microg/mL of fentanyl. The following data were recorded: age, nulliparity (yes/no) administration of epidural analgesia (yes/no), induction of labor (yes/no), stimulation of uterine activity with oxytocin (yes/no), type of delivery, fetal weight, duration of dilation, duration of expulsion, cause of cesarean.

RESULTS

The records of 4364 women were gathered. The percentages of inductions, nulliparas, oxytocin stimulation, and fetal weight greater than 4 kg and less than 2.5 kg were higher among women taking epidural analgesia. The age of women who received epidurals was significantly lower. The durations of dilation and expulsion were longer among women receiving epidural analgesia, and epidural analgesia was associated with greater risk of instrumental and cesarean deliveries. The significant increase in administration of epidural blocks over the 3-year period of the study was not accompanied by an increased rate of instrumentally assisted deliveries or cesareans.

CONCLUSIONS

It is difficult to evaluate the real influence of epidural analgesia on certain aspects of labor and its evolution. The strength of the association between epidural analgesia and greater risk of increased rates of instrumental and cesarean deliveries may be influenced by factors not considered in the present study.

Effect of deslorelin implants on follicular development, parturition and post-partum oestrus in the tammar wallaby (Macropus eugenii)

The effect of treatment with slow release implants containing the GnRH agonist, deslorelin, was investigated in female tammar wallabies. Pouch young were removed from 16 wallabies presumed to be carrying quiescent blastocysts. Eight received a 5 mg deslorelin implant and eight received a placebo implant. Animals were caught daily from day 25 to day 30 and their pouches inspected for newborn young and their urogenital sinus checked for a copulatory plug. Treatment with deslorelin did not affect reactivation of a dormant blastocyst and subsequent birth in 4/8 animals, but post-partum mating was inhibited in these animals. Five control and five treated animals were killed within 0–48 h post partum and their reproductive tracts analysed. At autopsy, all five control animals had large preovulatory follicles but only one deslorelin-treated animal showed signs of follicular development. These differences were also reflected in the weights of the lateral vaginae, with treated animals showing no evidence of oestrogenic stimulation. The remaining three control and three treated animals were monitored for approximately 2 years. The long-term contraceptive effects of a single 5 mg deslorelin implant lasted for just under one year. These results indicate that slow release deslorelin implants inhibit follicular development in the female tammar wallaby for extended periods of time and may have potential application in reproductive management of captive marsupials in the kangaroo family.

Effects of in vivo administration of epidermal growth factor (EGF) on uterine contractility, prostaglandin production and timing of parturition in rats

Prostaglandins synthesized by cyclooxygenases elicit uterine contractions during labour. Nitric oxide synthases (NOS) produce nitric oxide (NO), which maintains uterine quiescence during pregnancy. Epidermal growth factor (EGF) interacts with prostaglandins and NO in many biological systems. The aim of this work was to study the effect of the in vivo administration of EGF on uterine contractility, prostaglandin production and timing of parturition in rats. EGF was injected into the uterine lumen of pregnant rats on day 20, 21 or 22 of gestation. Intra-uterine administration of 500 ng EGF on day 21 of gestation delayed parturition for 18 h compared with control rats. Administration of EGF was able to: (i) reduce cyclooxygenase expression in the uterus (determined by western blot analysis) and production of prostaglandins by the uterus (evaluated by conversion of [(14)C]arachidonate to labelled prostaglandins); (ii) decrease prostaglandin concentrations in amniotic fluid (radioimmunoassay); (iii) increase NO production (evaluated by conversion of [(14)C]arginine into [(14)C]citrulline); (iv) increase serum progesterone concentrations to more than control concentrations (P<0.05; radioimmunoassay); and (v) reduce the amplitude of the uterine contractions. The overall effect was a delay in the onset of delivery. This in vivo effect raises the question of whether exogenous EGF plays a role in the initiation of parturition.

Induction of labor with RU 486 (mifepristone) in relaxin-deficient rats: antepartum administration of relaxin facilitates delivery and increases pup survival

OBJECTIVE

This study was conducted to determine whether antepartum administration of relaxin improves RU 486-induced delivery at term in rats that lack circulating endogenous relaxin.

STUDY DESIGN

Pregnant rats were modified two ways to obtain circulating levels of relaxin and progesterone that resemble those of pregnant humans: relaxin was immunoneutralized throughout the second half of the 23-day pregnancy and high progesterone levels were sustained until term by inserting progesterone implants on day 20. Porcine relaxin was administered subcutaneously from 8 AM on day 20 until delivery. Labor was induced by administering RU 486 subcutaneously at 4 AM on day 22.

RESULTS

After induction of labor with RU 486, labor and delivery were faster, and the incidence of live births was higher when rats were also administered relaxin during the antepartum period.

CONCLUSION

Antepartum administration of relaxin in combination with RU 486 has beneficial effects on delivery in relaxin-deficient rats.

Omega 3 oils and pregnancy

Women can safely commence omega 3 intake in early pregnancy to allow the full benefits to be incorporated into the body. Pregnant women should consider the intake of omega 3 oils and evening primrose oil throughout pregnancy in order possibly to prevent preterm delivery, promote an easier birth, assist the baby's brain and eye health and preprogram the baby's cell membranes for optimum lifelong wellness. Benefits to the mother may include prevention of postnatal depression and the comfort of knowing that she is giving her baby a healthy start in life.

Labor Analgesia for the Parturient With an Uncommon Disorder:

There appears to be an absence of uniform guidelines for management of labor analgesia in pregnant patients with uncommon medical conditions such as Marfan's syndrome, Ehlers-Danlos syndrome, achondroplastic dwarfism, previous back surgery, and kyphoscoliosis. A Medline search for articles highlighting considerations for obstetric anesthesia in parturients with these disorders was performed. Because of the multiorgan involvement and varied presentations of these disorders, no uniform or routine obstetric anesthetic recommendations can be made. In the absence of uniform obstetric anesthesia guidelines for pregnant patients with Marfan's syndrome, Ehlers-Danlos syndrome, achondroplastic dwarfism, previous back surgery, and kyphoscoliosis, the decision whether to administer regional anesthesia (epidural labor analgesia) should be based on an individual risk-to-benefit ratio on a case-by-case basis.

Reduced duration of intrathecal sufentanil analgesia in laboring cocaine users

On the basis of our previous clinical experience, we hypothesized in this study that the duration and/or quality of labor analgesia produced by intrathecal sufentanil was less in cocaine-abusing parturients compared with nonabusing parturients. Ten micro g of sufentanil was given intrathecally as part of a combined spinal-epidural (CSE) technique to two groups of laboring parturients: 1). those whose urine tested positive for cocaine (cocaine group), and 2). those whose urine tested negative for cocaine (control group). The epidural catheter was not injected with local anesthetic until the patient requested additional pain relief. The time from injection of intrathecal sufentanil until patient request for additional pain relief was defined as duration of analgesia. Baseline visual analog pain score (VAPS) and cervical dilation were measured before the CSE was performed. After injection of intrathecal sufentanil, VAPS was recorded at specific intervals. Cervical dilation was again documented when the patient requested additional analgesia. We found that both groups reported high baseline VAPS and a marked decrease in VAPS after injection of sufentanil that did not differ between groups. Geometric mean duration of pain relief with adjustment for cervical dilation was 87 min in the cocaine group compared with 139 min in the control group (P = 0.019). All patients experienced itching. We conclude that intrathecal sufentanil produces a similar quality but shorter duration of analgesia in cocaine-abusing parturients compared with nonabusing parturients.

IMPLICATIONS

Intrathecal sufentanil administered as part of a combined spinal-epidural technique produces similar quality but reduced duration of labor analgesia in cocaine-abusing parturients compared with nonabusing parturients.

Analgesia and Anesthesia During Labor and Birth: Implications for Mother and Fetus

Labor and birth, although viewed as a normal physiological process, can produce significant pain, requiring appropriate pain management. Systemic analgesia and regional analgesia/anesthesia have become less common, whereas the use of newer neuraxial techniques, with minimal motor blockade, have become more popular. Low- and ultra-low-dose epidural analgesia, spinal analgesia, and combination spinal-epidural analgesia have replaced the once traditional epidural for labor. The shift from regional anesthesia during labor, in which the woman became a passive participant during the labor and birth, to a collaborative approach for pain management, in which the woman becomes an active participant, has resulted in a new philosophy of labor analgesia. This article provides a review of the current systemic analgesics and regional and neuraxial analgesia/anesthesia techniques for pain management in labor and birth. Also addressed are implications for perinatal nurses who participate in pain management choices during labor and birth.