On predicting time to completion for the first stage of spontaneous labor at term in multiparous women

Who is most vulnerable? Factors associated with presenting to antenatal care without a male partner in Northern Tanzania

OBJECTIVE

Male engagement in pregnancy care can be beneficial for maternal and child health outcomes. In Tanzania, pregnant women are strongly encouraged to present to their first antenatal care (ANC) appointment with a male partner, where they jointly test for HIV. For some, this presents a barrier to ANC attendance. The objectives of this study were to identify factors associated with presenting to ANC with a male partner using a cross-sectional design and to assess whether women presenting without partners had significantly delayed presentation.

METHODS

Pregnant women (n = 1007) attending a first ANC appointment in Moshi, Tanzania were surveyed. Questions captured sociodemographic characteristics and measures of psychosocial constructs.

RESULTS

Just over half (54%) of women presented to care with a male partner. Women were more likely to present with a male partner if they were younger than 25 years old, married, Muslim, attending ANC for their first pregnancy, and testing for HIV for the first time. Women presenting to ANC with a male partner were significantly more likely to attend ANC earlier in their pregnancy than those presenting without male partners.

CONCLUSION

Policy change allowing women to present to care with other supportive family members could promote earlier presentation to first ANC. Unmarried women may be at a disadvantage in presenting to ANC when policies mandate attendance with a male partner. Male partners of multiparous women should be encouraged to provide pregnancy support even after first pregnancies, and a wholistic emphasis (beyond HIV testing) on first ANC could encourage male engagement beyond the initial appointment.

Assessing Continuous Epidural Infusion and Programmed Intermittent Epidural Bolus for Their Effectiveness in Providing Labor Analgesia: A Mono-Centric Retrospective Comparative Study

Background and Objectives: Local anesthetics administered via epidural catheters have evolved from intermittent top-ups to simultaneous administration of continuous epidural infusion (CEI) and patient-controlled epidural analgesia (PCEA) using the same device. The latest programmed intermittent epidural bolus (PIEB) model is believed to create a wider and more even distribution of analgesia inside the epidural space. The switch from CEI + PCEA to PIEB + PCEA in our department began in 2018; however, we received conflicting feedback regarding workload from the quality assurance team. This study aimed to investigate the benefits and drawbacks of this conversion, including the differences in acute pain service (APS) staff workload, maternal satisfaction, side effects, and complications before and after the changeover. Materials and Methods: Items from the APS records included total delivery time, average local anesthetic dosage, and the formerly mentioned items. The incidence of side effects, the association between the duration of delivery and total dosage, and hourly medication usage in the time subgroups of the CEI and PIEB groups were compared. The staff workload incurred from rescue bolus injection, catheter adjustment, and dosage adjustment was also analyzed. Results: The final analysis included 214 and 272 cases of CEI + PCEA and PIEB + PCEA for labor analgesia, respectively. The total amount of medication and average hourly dosage were significantly lower in the PIEB + PCEA group. The incidences of dosage change, manual bolus, extra visits per patient, and lidocaine use for rescue bolus were greater in the PIEB + PCEA group, indicating an increased staff workload. However, the two groups did not differ in CS rates, labor time, maternal satisfaction, and side effects. Conclusions: This study revealed that while PIEB + PCEA maintained the advantage of decreasing total drug doses, it inadvertently increased the staff burden. Increased workload might be a consideration in clinical settings when choosing between different methods of PCEA.

The success of vaginal birth by use of trans-labial ultrasound plus vaginal examination and vaginal examination only in pregnant women with labor induction: a comparative study

BACKGROUND

Predicting the success of vaginal delivery is an important issue in preventing adverse maternal and neonatal outcomes. Thus, this study aimed to compare the success rate of vaginal birth by using trans-labial ultrasound and vaginal examination, and vaginal examination only in pregnant women with labor induction.

METHODS

This was a comparative study including 392 eligible pregnant women with labor induction attending to a teaching hospital affiliated with Iran University of Medical Sciences from April to October 2018 in Tehran, Iran. Women were randomly assigned to two groups; the trans-labial ultrasound plus vaginal examination (group A), and the vaginal examination only (group B). Women were included in the study if they satisfied the following criteria: singleton pregnancy, 37 to 42 weeks of gestational age, fetal head presentation, a living fetus with no abnormalities, uncomplicated pregnancy, and no previous cesarean section or any uterine surgery. We used a partograph for both groups to assess the fetal head position and the fetal head station. In group 1, the Angle of Progression (AoP) and Rotation Angle (RA) were also assessed. Finally, the success and progression of vaginal delivery in two groups were compared by predicting the duration of delivery and mode of delivery.

RESULTS

The findings showed that 8.68% of women in the trans-labial plus vaginal examination group delivered by cesarean section, while 6.13% in the vaginal examination only group delivered by cesarean section (P = 0.55). In women with cesarean section in positive fetal head stations, Angle of Progression (AoP) was significantly decreased ranging from 90 to 135 degrees compared to women who delivered vaginally (135-180 degrees; P <  0.001). In addition, the Rotation Angle (RA) was significantly decreased in women with cesarean section ranging from 0 to 30 degrees compared to women who delivered vaginally (60-90degrees; P <  0.001). Further analysis indicated that a higher risk of cesarean section was associated with vaginal examination only as compared to trans-labial ultrasound plus vaginal examination (HR: 8.65, P <  0.001).

CONCLUSION

Angle of Progression (AoP) and Rotation Angle (RA) indexes might be useful parameters to predict labor progression and successful vaginal delivery among women undergoing labor induction.

The influence of maternal psychological distress on the mode of birth and duration of labor: findings from the FinnBrain Birth Cohort Study

Antepartum depression, general anxiety symptoms, and pregnancy-related anxiety have been recognized to affect pregnancy outcomes. Systematic reviews on these associations lack consistent findings, which is why further research is required. We examined the associations between psychological distress, mode of birth, epidural analgesia, and duration of labor. Data from 3619 women with singleton pregnancies, from the population-based FinnBrain Birth Cohort Study were analyzed. Maternal psychological distress was measured during pregnancy at 24 and 34 weeks, using the Pregnancy-Related Anxiety Questionnaire-Revised 2 (PRAQ-R2) and its subscale "Fear of Giving Birth" (FOC), the anxiety subscale of the Symptom Checklist-90 (SCL-90) and the Edinburgh Postnatal Depression Scale (EPDS). Mode of birth, epidural analgesia, and labor duration were obtained from the Finnish Medical Birth Register. Maternal psychological distress, when captured with PRAQ-R2, FOC, and SCL-90, increased the likelihood of women having an elective cesarean section (OR: 1.04, 95% CI 1.01-1.06, p = .003; OR: 1.13, 95% CI 1.07-1.20, p < .001; OR: 1.06, 95% CI 1.03-1.10, p = .001), but no association was detected for instrumental delivery or emergency cesarean section. A rise in both the PRAQ-R2, and FOC measurements increased the likelihood of an epidural analgesia (OR: 1.02, 95% CI 1.01-1.03, p = .003; OR: 1.09, 95% CI 1.05-1.12, p < .001) and predicted longer second stage of labor (OR: 1.01, 95% CI 1.00-1.01, p = .023; OR: 1.03, 95% CI 1.02-1.05, p < .001). EPDS did not predict any of the analyzed outcomes. The results indicate that maternal anxiety symptoms (measured using PRAQ-R2, FOC, and SCL-90) are associated with elective cesarean section. Psychological distress increases the use of epidural analgesia, but is not associated with complicated vaginal birth.

A time-driven activity-based costing approach for identifying variability in costs of childbirth between and within types of delivery

Background

Recently, time-driven activity-based costing (TDABC) is put forward as an alternative, more accurate costing method to calculate the cost of a medical treatment because it allows the assignment of costs directly to patients. The objective of this paper is the application of a time-driven activity-based method in order to estimate the cost of childbirth at a maternal department. Moreover, this study shows how this costing method can be used to outline how childbirth costs vary according to considered patient and disease characteristics. Through the use of process mapping, TDABC allows to exactly identify which activities and corresponding resources are impacted by these characteristics, leading to a more detailed understanding of childbirth cost.

Methods

A prospective cohort study design is performed in a maternity department. Process maps were developed for two types of childbirth, vaginal delivery (VD) and caesarean section (CS). Costs were obtained from the financial department and capacity cost rates were calculated accordingly.

Results

Overall, the cost of childbirth equals €1894,12 and is mainly driven by personnel costs (89,0%). Monitoring after birth is the most expensive activity on the pathway, costing €1149,70. Significant cost variations between type of delivery were found, with VD costing €1808,66 compared to €2463,98 for a CS. Prolonged clinical visit (+ 33,3 min) and monitoring (+ 775,2 min) in CS were the main contributors to this cost difference. Within each delivery type, age, parity, number of gestation weeks and education attainment were found to drive cost variations. In particular, for VD an age >  25 years, nulliparous, gestation weeks > 40 weeks and higher education attainment were associated with higher costs. Similar results were found within CS for age, parity and number of gestation weeks.

Conclusions

TDABC is a valuable approach to measure and understand the variability in costs of childbirth and its associated drivers over the full care cycle. Accordingly, these findings can inform health care providers, managers and regulators on process improvements and cost containment initiatives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04134-4.

The degree of cervical length shortening as a predictor of successful or failed labor induction

OBJECTIVE

To evaluate whether the degree of cervical length change was associated with successful cervical dilatation during labor induction.

MATERIALS AND METHODS

We conducted a secondary analysis of a prospective observational study of term singleton pregnant women who underwent labor inductions. Cases of Cesarean section due to fetal distress or maternal request during the first stage of labor were excluded. The enrolled women were categorized into two groups according to achievement of full cervical dilatation. The cervical length near induction and cervical length shortening over the last four weeks of pregnancy were compared between the two groups. A receiver operating characteristics (ROC) analysis was performed to evaluate the screening performance for failed cervical dilatation during labor induction.

RESULTS

A total of 165 women were enrolled for the final analysis; of these, 145 (87.9%) women reached the second stage of labor and 20 (12.1%) women failed to achieve full cervical dilatation. Women who failed to achieve full cervical dilatation had a significantly longer cervical length near induction and less cervical length change over previous four weeks compared with women who achieved full cervical dilatation (P = 0.018 and 0.005, respectively). Multivariate analysis showed that cervical length >29 mm (odds ratios [OR], 4.15; 95% confidence interval [CI], 1.290-13.374, P = 0.017) and cervical length shortening ≦ 6 mm (OR, 5.87; 95% CI, 1.552-22.271, P = 0.009) were significantly associated with failed cervical dilatation after adjusting for birthweight and previous history of vaginal delivery. Cervical length shortening alone provided a better prediction of failed cervical dilatation than the combination of cervical length and shortening (sensitivity, 76.9%; specificity, 63.8%).

CONCLUSION

The probability of failed cervical dilatation during labor induction was significantly increased in cases when the cervical length was greater than 29 mm near induction or when the cervical length shortening was less than 6 mm over the last four weeks.

Intrauterine contraction parameters at baseline and following epidural and combined spinal-epidural analgesia: A repeated measures comparison

OBJECTIVE

The effects of epidural and combined spinal-epidural analgesia on uterine contraction parameters are unclear, although as many as 80% of laboring women use neuraxial analgesia. We explored the effects of epidural and combined spinal-epidural analgesia on all uterine contraction parameters using a retrospective analysis of selected parturients, who required Intrauterine Pressure Catheter (IUPC) instrumentation for clinical management. Additionally, we analyzed the effects of parity, Pitocin dose, and mode of neuraxial anesthesia, i.e. epidural verses combined spinal-epidural on uterine contractility.

DESIGN

Using a retrospective within and between repeated measure design we compared uterine contraction parameters at 4 time points (epochs): (1) baseline, (2) pre-epidural fluid bolus, (3) immediate and (4) secondary post-epidural/combined spinal-epidural analgesia to detect differences in contractility over time comparing two types of epidural interventions.

METHODS

Eighteen healthy parturients at term gestation were admitted to the labor unit for induction, augmentation, or spontaneous labor. Contraction parameters including frequency, duration, peak intensity, resting intensity and duration, and Montevideo Units (MVUs) were collected using fetal monitor strip data with intrauterine pressure catheter (IUPC) instrumentation.

FINDINGS

Parametric and non-parametric tests showed no significant differences within or between the two Epidural intervention groups for frequency, duration, peak intensity, resting intensity and duration, and MVUs at all epochs at the .05 alpha level. Compared with Nulliparous women, multiparous women had significantly lower contraction intensity and longer contraction duration. Based on multilevel modeling (MLM), neither Pitocin dose nor type of epidural intervention revealed significant differences on any contraction parameters.

CONCLUSIONS

When parity, other demographic variables and Pitocin dose were statistically controlled, no uterine contraction parameter changed from baseline through 90 min following either epidural or combined spinal-epidural analgesia. Obstetrical care providers should consider the preciseness their contraction monitoring instrumentation and their clinical management preferences as well parity as before prescribing Pitocin after neuraxial analgesia intervention.

Factors associated with delayed onset of active labor following vaginal misoprostol administration among women at Mbarara Regional Referral Hospital, Uganda

OBJECTIVE

To determine the factors associated with delayed onset of active labor following labor induction with vaginal misoprostol.

METHODS

We conducted a prospective cohort study over 6 months at a tertiary hospital in Uganda. We enrolled mothers with pregnancies of at least 28 weeks, who were undergoing labor induction with 50 µg of vaginal misoprostol, administered every 6 hours with a maximum of four doses, and followed them up until onset of active labor. Labor onset was considered delayed if it occurred later than 12 hours after the first dose. Bivariate and multivariate analysis was performed to determine factors associated with delayed onset of active labor.

RESULTS

Of the 88 mothers enrolled, 22.7% (n=20) had delayed onset of active labor. Nulliparity (adjusted relative risk [aRR] 2.34, 95% confidence interval [CI] 1.17-4.68) and gestational age less than 37 weeks (aRR 3.79, 95% CI 1.40-10.23) were associated with delayed onset of active labor following vaginal misoprostol administration whereas higher body mass index (aRR 0.38, 95% CI 0.18-0.79) decreased the risk.

CONCLUSION

Delayed onset of active labor following labor induction remains an important obstetric care challenge. Mothers undergoing labor induction should have their body mass index documented, and nulliparous women and mothers at less than 37 weeks of gestation should have their labor monitored for a longer duration following labor induction.

Comparison of different methods of measuring angle of progression in prediction of labor outcome

OBJECTIVES

First, to compare the manual sagittal and parasagittal and automated parasagittal methods of measuring the angle of progression (AoP) by transperineal ultrasound during labor, and, second, to develop models for the prediction of time to delivery and need for Cesarean section (CS) for failure to progress (FTP) in a population of patients undergoing induction of labor.

METHODS

This was a prospective observational study of transperineal ultrasound in a cohort of 512 women with a singleton pregnancy undergoing induction of labor. A random selection of 50 stored images was assessed for inter- and intraobserver reliability of AoP measurements using the manual sagittal and parasagittal and automated parasagittal methods. In cases of vaginal delivery, univariate linear, multiple linear and quantile regression analyses were performed to predict time to delivery. Univariate and multivariate binomial logistic regression analyses were performed to predict CS for FTP in the first stage of labor.

RESULTS

The intraclass correlation coefficient (ICC) for the manual parasagittal method for a single observer was 0.97 (95% CI, 0.95-0.98) and for two observers it was 0.96 (95% CI, 0.93-0.98), indicating good reliability. The ICC for the sagittal method for a single observer was 0.93 (95% CI, 0.88-0.96) and for two observers it was 0.74 (95% CI, 0.58-0.84), indicating moderate reliability for a single observer and poor reliability between two observers. Bland-Altman analysis demonstrated narrower limits of agreement for the manual parasagittal approach than for the sagittal approach for both a single and two observers. The automated parasagittal method failed to capture an image in 19% of cases. The mean difference in AoP measurements between the sagittal and manual parasagittal methods was 11°. In pregnancies resulting in vaginal delivery, 54% of the variation in time to delivery was explained in a model combining parity, epidural and syntocinon use during labor and the sonographic findings of fetal head position and AoP. In the prediction of CS for FTP in the first stage of labor, a model which combined maternal factors with the sonographic measurements of AoP and estimated fetal weight was superior to one utilizing maternal factors alone (area under the receiver-operating-characteristics curve, 0.80 vs 0.76).

CONCLUSIONS

First, the method of measuring AoP with the greatest reliability is the manual parasagittal technique and future research should focus on this technique. Second, over half of the variation in time to vaginal delivery can be explained by a model that combines maternal factors, pregnancy characteristics and ultrasound findings. Third, the ability of AoP to provide clinically useful prediction of CS for FTP in the first stage of labor is limited. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Babies born in the pre-hospital setting attended by ambulance clinicians in the north east of England

Introduction:

The majority of births in the United Kingdom happen in hospital or at stand-alone midwife led centres, or with the support of midwives in a planned fashion outside of hospital. The unplanned birth of a baby in the pre-hospital setting is a rare event which may result in an ambulance being called, so attendance at a birth is a rare event for ambulance clinicians. A service evaluation was conducted to report which clinical observations were recorded on babies born in the pre-hospital setting who were attended by ambulance clinicians from the North East Ambulance Service (NEAS) over a one-year period.

Methods:

A retrospective service evaluation was conducted using routinely collected data. All electronic patient care records covering a one-year period between 1 October 2017 and 30 September 2018 with a primary impression of ‘childbirth’ were examined.

Results:

This evaluation identified 168 individual pre-hospital childbirth cases attended by NEAS clinicians during the evaluation timeframe. The majority (85%) of babies were born to multiparous mothers with a median gestation of 39 weeks. Very few clinical observations were recorded on the babies (respiratory rate 23%, heart rate 21%, temperature 10%, APGAR 8%, blood sugar 1%) and no babies had all five of these observations documented. Only 5% of babies had any complications documented.

Conclusion:

This study showed that NEAS ambulance clinicians rarely attend babies born in the pre-hospital setting and that complications were infrequently recorded. There was a lack of observations recorded on the babies, which is an issue due to the clear link between easily measurable characteristics such as temperature and mortality and morbidity.