Intrapartum pyrexia, cardiotocography traces and histologic chorioamnionitis: a case-control study

OBJECTIVES

To compare characteristics of labor, cardiotocography traces, and maternal and neonatal outcomes, in a cohort of pregnancies at term complicated by maternal intrapartum pyrexia, with or without a histologic diagnosis of chorioamnionitis.

METHODS

This is a retrospective case-control study including pregnancies at term with detection of maternal intrapartum pyrexia, delivered between January 2020 and June 2021. Cardiotocography traces were entirely evaluated, since admission till delivery, and classified according to the International Federation of Obstetrics and Gynecology (FIGO) guideline. Maternal and neonatal outcomes were also recorded as secondary outcomes. Placentas have been studied according to the Amniotic Fluid Infection Nosology Committee.

RESULTS

Forty four patients met the inclusion criteria and were included in the study cohort. There was a significant association between the use of oxytocin augmentation in labor and the histologic diagnosis of chorioamnionitis. A significative recurrence of loss and/or absence of accelerations at the point of pyrexia was also documented in women with histological chorioamnionitis compared to the others.

CONCLUSIONS

Chorioamnionitis appears to be associated with myometrial disfunction, as suggested by the increased use of oxytocin augmentation during active labor of women at term with intrapartum pyrexia and histologic diagnosis of chorioamnionitis.

Oxytocin is not associated with postpartum hemorrhage in labor augmentation in a retrospective cohort study in the United States

BACKGROUND

Previous studies reported conflicting results on the relationship between oxytocin use for labor augmentation and the risk of postpartum hemorrhage, probably because it is rather challenging to disentangle oxytocin use from labor dystocia.

OBJECTIVE

This study aimed to investigate the independent association between oxytocin use for augmentation and the risk of postpartum hemorrhage by using advanced statistical modeling to control for labor patterns and other covariates.

STUDY DESIGN

We used data from 20,899 term, cephalic, singleton pregnancies of patients with spontaneous onset of labor and no previous cesarean delivery from Intermountain Healthcare in Utah in the Consortium on Safe Labor. Presence of postpartum hemorrhage was identified on the basis of a clinical diagnosis. Propensity scores were calculated using a generalized linear mixed model for oxytocin use for augmentation, and covariate balancing generalized propensity score was applied to obtain propensity scores for the duration and total dosage of oxytocin augmentation. A weighted generalized additive mixed model was used to depict dose-response curves between the duration and total dosage of oxytocin augmentation and the outcomes. The average treatment effects of oxytocin use for augmentation on postpartum hemorrhage and estimated blood loss (mL) were assessed by inverse probability weighting of propensity scores.

RESULTS

The odds of both postpartum hemorrhage and estimated blood loss increased modestly when the duration and/or total dosage of oxytocin used for augmentation increased. However, in comparison with women for whom oxytocin was not used, oxytocin augmentation was not clinically or statistically significantly associated with estimated blood loss (6.5 mL; 95% confidence interval, 2.5-10.3) or postpartum hemorrhage (adjusted odds ratio, 1.02; 95% confidence interval, 0.82-1.24) when rigorously controlling for labor pattern and potential confounders. The results remained consistent regardless of inclusion of women with an intrapartum cesarean delivery.

CONCLUSION

The odds of postpartum hemorrhage and estimated blood loss increased modestly with increasing duration and total dosage of oxytocin augmentation. However, in comparison with women for whom oxytocin was not used and after controlling for potential confounders, there was no clinically significant association between oxytocin use for augmentation and estimated blood loss or the risk of postpartum hemorrhage.

Randomized controlled trial comparing efficacy of a combination regime containing two cervical sensitizers (mifepristone + Foley's catheter) versus single agent mifepristone or Foley's catheter for labor induction in women attempting TOLAC at late third trimester with a dead fetus in utero

Randomized controlled trial comparing efficacy of a combination regime containing two cervical sensitizers (mifepristone + Foley's catheter) versus single agent mifepristone or Foley's catheter for labor induction in women attempting TOLAC at late third trimester with a dead fetus in utero.

AIM

To compare efficacy and safety of a new combination regime comprising of two cervical sensitizers used simultaneously with single agents, for labor induction in women attempting TOLAC at ≥34 weeks' gestation with a dead fetus.

METHOD

This was a multiarm randomized controlled trial (RCT) where participants received one of the three regimes-single agent oral Mifepristone 200 mg, intracervical Foley's catheter (16 Fr size, filled with 40 mL normal saline after intracervical instillation), and combination regime consisting of both used simultaneously. Number of women undergoing vaginal birth within 48 h of induction (VB48 ) was the primary outcome compared between groups.

RESULTS

VB48 was higher in participants on combination regime in comparison to participants on Foley's catheter (54 vs. 42). Total vaginal births were higher in participants on combination regime compared to both single agents (58 vs. 48 and 44). Duration and dose of oxytocin augmentation was lower in participants on combination regime compared to both single agents. Induction birth interval was short in participants on combination regime compared to those on Foley's catheter. Maternal complications between groups were similar.

CONCLUSION

Combination of cervical sensitizers for labor induction in late third trimester among women with dead fetus attempting TOLAC resulted in higher proportion of vaginal births and might reduce risk of scar dehiscence due to requirement of a lower dose of oxytocin for augmentation.

Dosage of oxytocin for augmentation of labor and women's childbirth experiences: A randomized controlled trial

Introduction

The aim of this study was to compare childbirth experiences and experience of labor pain in primiparous women who had received high‐ vs low‐dose oxytocin for augmentation of delayed labor.

Material and methods

A multicenter, parallel, double‐blind randomized controlled trial took place in six Swedish labor wards. Inclusion criteria were healthy primiparous women at term with uncomplicated singleton pregnancies, cephalic fetal presentation, spontaneous onset of labor, confirmed delayed labor progress and ruptured membranes. The randomized controlled trial compared high‐ vs low‐dose oxytocin used for augmentation of a delayed labor progress. The Childbirth Experience Questionnaire version 2 (CEQ2) was sent to the women 1 month after birth. The CEQ2 consists of 22 items in four domains: Own capacity, Perceived safety, Professional support and Participation. In addition, labor pain was reported with a visual analog scale (VAS) 2 hours postpartum and 1 month after birth. The main outcome was the childbirth experience measured with the four domains of the CEQ2. The clinical trial number is NCT01587625.

Results

The CEQ2 was sent to 1203 women, and a total of 1008 women (83.8%) answered the questionnaire. The four domains of childbirth experience were scored similarly in the high‐ and low‐dose oxytocin groups of women: Own capacity (P = .36), Perceived safety (P = .44), Professional support (P = .84), Participation (P = .49). VAS scores of labor pain were reported as similar in both oxytocin dosage groups. Labor pain was scored higher 1 month after birth compared with 2 hours postpartum. There was an association between childbirth experiences and mode of birth in both the high‐ and low‐dose oxytocin groups.

Conclusions

Different dosage of oxytocin for augmentation of delayed labor did not affect women’s childbirth experiences assessed through CEQ2 1 month after birth, or pain assessment 2 hours or 1 month after birth.

The Labor Progression Study: The use of oxytocin augmentation during labor following Zhang's guideline and the WHO partograph in a cluster randomized trial

INTRODUCTION

This study aims to investigate the use of oxytocin augmentation during labor in nulliparous women following Zhang's guideline or the WHO partograph.

MATERIAL AND METHODS

This is a secondary analysis of a cluster randomized controlled trial in 14 birth-care units in Norway, randomly assigned to either the intervention group, which followed Zhang's guideline, or to the control group, which followed the WHO partograph, for labor progression. The participants were nulliparous women who had a singleton full-term fetus in a cephalic presentation and spontaneous onset of labor, denoted as group 1 in the Ten Group Classification System.

RESULTS

Between December 2014 and January 2017, 7277 participants were included. A total of 3219 women (44%) received augmentation with oxytocin during labor. Oxytocin was used in 1658 (42%) women in the Zhang group compared with 1561 (47%) women in the WHO group. The adjusted relative risk for augmentation with oxytocin was 0.98 (95% CI 0.84-1.15; P = .8) in the Zhang vs WHO group, with an adjusted risk difference of -0.8% (95% CI -7.8 to 6.1). The participants in the Zhang group were less likely to be augmented with oxytocin before reaching 6 cm of cervical dilatation (24%) compared with participants in the WHO group (28%), with an adjusted relative risk of 0.84 (95% CI 0.75-0.94; P = .003). Oxytocin was administered for almost 20 min longer in the Zhang group than in the WHO group, with an adjusted mean difference of 17.9 min (95% CI 2.7-33.1; P = .021). In addition, 19% of the women in the Zhang group and 23% in the WHO group received augmentation with oxytocin without being diagnosed with labor dystocia.

CONCLUSIONS

Although no significant difference in the proportion of oxytocin augmentation was observed between the 2 study groups, there were differences in how oxytocin was used. Women in the Zhang group were less likely to receive oxytocin augmentation before 6 cm of cervical dilatation. The duration of augmentation with oxytocin was longer in the Zhang group than in the WHO group.

Association between provider type and cesarean birth in healthy nulliparous laboring women: A retrospective cohort study

BACKGROUND

Term nulliparous women have the greatest variation across hospitals and providers in cesarean rates and therefore present an opportunity to improve quality through optimal care. We evaluated associations between provider type and mode of birth, including examination of intrapartum management in healthy, laboring nulliparous women.

METHODS

Retrospective cohort study using prospectively collected perinatal data from a United States academic medical center (2005-2012). The sample included healthy nulliparous women with spontaneous labor onset and term, singleton, vertex fetus managed by either obstetricians or certified nurse-midwives. Univariate and multivariate logistic regression was used to compare labor interventions and mode of birth by provider type.

RESULTS

A total of 1339 women received care by an obstetrician (n = 749) or nurse-midwife (n = 590). The cesarean rate was 13.4% (179/1339). Adjusting for maternal and pregnancy characteristics, care by obstetricians was associated with an increased risk of unplanned cesarean birth (adjusted odds ratio [aOR] 1.48 [95% confidence interval {CI} 1.04-2.12]) compared with care by midwives. Obstetricians more frequently used oxytocin augmentation (aOR 1.41 [95% CI 1.10-1.80]), neuraxial anesthesia (aOR 1.69 [95% CI 1.29-2.23]), and operative vaginal delivery with forceps or vacuum (aOR 2.79 [95% CI 1.75-4.44]). Adverse maternal or neonatal outcomes were not different by provider type across all modes of birth, but were more frequent in women with cesarean than vaginal births.

DISCUSSION

In low-risk nulliparous laboring women, care by obstetricians compared with nurse-midwives was associated with increased risk of labor interventions and operative birth. Changes in labor management or increased use of nurse-midwives could decrease the rate of a first cesarean in low-risk laboring women.

Can oxytocin augmentation modify the risk of epidural analgesia by maternal age in cesarean sections?

INTRODUCTION

Maternal age is an established risk factor for cesarean section; epidural analgesia and oxytocin augmentation may modify this association. We investigated the effects and interactions of oxytocin augmentation, epidural analgesia and maternal age on the risk of cesarean section.

MATERIAL AND METHODS

In all, 416 386 nulliparous women with spontaneous onset of labor, ≥37 weeks of gestation and singleton infants with a cephalic presentation during 2000-2011 from Norway and Denmark were included [Ten-group classification system (Robson) group 1]. In this case-control study the main exposure was maternal age; epidural analgesia, oxytocin augmentation, birthweight and time period were explanatory variables. Chi-square test and logistic regression were used to estimate associations and interactions.

RESULTS

The cesarean section rate increased consistently with advancing maternal age, both overall and in strata of epidural analgesia and oxytocin augmentation. We observed strong interactions between maternal age, oxytocin augmentation and epidural analgesia for the risk of cesarean section. Women with epidural analgesia generally had a reduced adjusted odds ratio when oxytocin was used compared with when it was not used. In Norway, this applied to all maternal age groups but in Denmark only for women ≥30 years. Among women without epidural, oxytocin augmentation was associated with an increased odds ratio for cesarean section in Denmark, whereas no difference was observed in Norway.

CONCLUSIONS

Oxytocin augmentation in nulliparous women with epidural analgesia is associated with a reduced risk of cesarean section in labor with spontaneous onset.

Effect of early amniotomy on the outcome of spontaneous labour: a randomized controlled trial of pregnant women in Enugu, South-east Nigeria

BACKGROUND

Early amniotomy is common in obstetric practice but, its effectiveness has not been proven.

OBJECTIVES

To determine the effects of early amniotomy on the duration of labour, and other maternal / neonatal outcomes of uncomplicated pregnancies in Enugu, South-east Nigeria.

METHODS

A randomized controlled study of 214 consenting term pregnant women at the University of Nigeria Teaching Hospital Enugu, Nigeria. Intervention group received amniotomy early in active labour while the control group had their membranes conserved.

RESULTS

Mean duration of labour for the amniotomy group (279.4 ± 53.7 minutes) was significantly lower than that of control group (354.4 ± 67.5 minutes), (t = -8.988, p <0.001). Three (3.8%) women in amniotomy group needed oxytocin augmentation as against 21 (19.6%) women in the control group RR = 0.14, (CI 95%: 0.04 - 0.46), NNT = 16. The two groups did not vary with respect to cesarean section rate, newborn Apgar scores, and need for new born special care unit admission.

CONCLUSION

Early amniotomy when compared to fetal membrane conservation reduced the duration of labour and need for oxytocin augmentation among term singleton pregnant women in Enugu, Nigeria. Its routine use in well selected cases may reduce prolonged labour and its complications.