-
The New England Journal of Medicine Apr 2021
Review
Topics: Antifibrinolytic Agents; Blood Transfusion; Female; Fluid Therapy; Humans; Oxytocics; Postpartum Hemorrhage; Pregnancy; Risk Factors; Tampons, Surgical; Tranexamic Acid; Uterine Inertia; Uterus
PubMed: 33913640
DOI: 10.1056/NEJMra1513247 -
American Family Physician Jan 2021Dystocia (abnormally slow or protracted labor) accounts for 25% to 55% of primary cesarean deliveries. The latent phase of labor begins with onset of regular, painful... (Review)
Review
Dystocia (abnormally slow or protracted labor) accounts for 25% to 55% of primary cesarean deliveries. The latent phase of labor begins with onset of regular, painful contractions and continues until 6 cm of cervical dilation. Current recommendations are to avoid admission to labor and delivery during the latent phase, assuming maternal/fetal status is reassuring. The active phase begins at 6 cm. An arrested active phase is defined as more than four hours without cervical change despite rupture of membranes and adequate contractions and more than six hours of no cervical change without adequate contractions. Managing a protracted active phase includes oxytocin augmentation with or without amniotomy. The second stage of labor begins at complete cervical dilation and continues to delivery. This stage is considered protracted if it lasts three hours or more in nulliparous patients without an epidural or four hours or more in nulliparous patients with an epidural. Primary interventions for a protracted second stage include use of oxytocin and manual rotation if the fetus is in the occiput posterior position. When contractions or pushing is inadequate, vacuum or forceps delivery may be needed. Effective measures for preventing dystocia and subsequent cesarean delivery include avoiding admission during latent labor, providing cervical ripening agents for induction in patients with an unfavorable cervix, encouraging the use of continuous labor support (e.g., a doula), walking or upright positioning in the first stage, and not diagnosing failed induction during the latent phase until oxytocin has been given for 12 to 18 hours after membrane rupture. Elective induction at 39 weeks' gestation in low-risk nulliparous patients may reduce the risk of cesarean delivery.
Topics: Delivery, Obstetric; Dystocia; Female; Humans; Labor Stage, First; Labor Stage, Second; Labor, Induced; Oxytocics; Oxytocin; Parity; Pregnancy; Time Factors
PubMed: 33448772
DOI: No ID Found -
Current Opinion in Obstetrics &... Apr 2022Postpartum hemorrhage (PPH) is the leading preventable cause of maternal morbidity and mortality worldwide. Uterine atony is identified as the underlying etiology in up... (Review)
Review
PURPOSE OF REVIEW
Postpartum hemorrhage (PPH) is the leading preventable cause of maternal morbidity and mortality worldwide. Uterine atony is identified as the underlying etiology in up to 80% of PPH. This serves as a contemporary review of the epidemiology, risk factors, pathophysiology, and treatment of uterine atony.
RECENT FINDINGS
Rates of postpartum hemorrhage continue to rise worldwide with the largest fraction attributed to uterine atony. A simple 0-10 numerical rating score for uterine tone was recently validated for use during cesarean delivery and may allow for more standardized assessment in clinical and research settings. The optimal prophylactic dose of oxytocin differs depending on the patient population, but less than 5 units and as low as a fraction of one unit is needed for PPH prevention, with an increased requirements within that range for cesarean birth, those on magnesium, and advanced maternal age. Carbetocin is an appropriate alternative to oxytocin. Misoprostol shows limited to no efficacy for uterine atony in recent studies. Several uncontrolled case studies demonstrate novel mechanical and surgical interventions for treating uterine atony.
SUMMARY
There is a critical, unmet need for contemporary, controlled studies to address the increasing threat of atonic PPH.
Topics: Female; Humans; Misoprostol; Oxytocics; Oxytocin; Postpartum Hemorrhage; Pregnancy; Uterine Inertia
PubMed: 35102109
DOI: 10.1097/GCO.0000000000000776 -
The Veterinary Clinics of North... Sep 2023Canine Cesarean Section (CS) is primarily performed to increase survival of newborns and less commonly to save the life or reproductive future of the dam. Conducting... (Review)
Review
Canine Cesarean Section (CS) is primarily performed to increase survival of newborns and less commonly to save the life or reproductive future of the dam. Conducting proper ovulation timing to accurately predict the due date will allow a planned, elective CS as an excellent alternative to a high-risk natural whelping, and possible dystocia, for certain breeds and situations. Techniques for ovulation timing, anesthesia, and surgery tips are provided.
Topics: Pregnancy; Animals; Dogs; Female; Cesarean Section; Reproduction; Dystocia; Dog Diseases
PubMed: 37246012
DOI: 10.1016/j.cvsm.2023.04.007 -
Obstetrics and Gynecology Clinics of... Jun 2021Macrosomia results from abnormal fetal growth and can lead to serious consequences for the mother and fetus. In cases of suspected macrosomia, patients must be counseled... (Review)
Review
Macrosomia results from abnormal fetal growth and can lead to serious consequences for the mother and fetus. In cases of suspected macrosomia, patients must be counseled carefully regarding a delivery plan, and Cesarean section should be considered when indicated. Techniques to assess for suspected macrosomia include clinical measurements, ultrasound, and MRI.
Topics: Birth Injuries; Cesarean Section; Clavicle; Delivery, Obstetric; Female; Fetal Development; Fetal Macrosomia; Humans; Infant, Newborn; Infant, Newborn, Diseases; Magnetic Resonance Imaging; Male; Neonatal Brachial Plexus Palsy; Pregnancy; Pregnancy Complications; Risk Factors; Shoulder Dystocia; Ultrasonography, Prenatal
PubMed: 33972073
DOI: 10.1016/j.ogc.2021.02.008 -
Reproductive Sciences (Thousand Oaks,... Mar 2023Abnormally prolonged labor, or labor dystocia, is a common complication of parturition. It is the indication for about half of unplanned cesarean deliveries in low-risk... (Review)
Review
Abnormally prolonged labor, or labor dystocia, is a common complication of parturition. It is the indication for about half of unplanned cesarean deliveries in low-risk nulliparous women. Reducing the rate of unplanned cesarean birth in the USA has been a public health priority over the last two decades with limited success. Labor dystocia is a complex disorder due to multiple causes with a common clinical outcome of slow cervical dilation and fetal descent. A better understanding of the pathophysiologic mechanisms of labor dystocia could lead to new clinical opportunities to increase the rate of normal vaginal delivery, reduce cesarean birth rates, and improve maternal and neonatal health. We conducted a literature review of the causes and pathophysiologic mechanisms of labor dystocia. We summarize known mechanisms supported by clinical and experimental data and newer hypotheses with less supporting evidence. We review recent data on uterine preparation for labor, uterine contractility, cervical preparation for labor, maternal obesity, cephalopelvic disproportion, fetal malposition, intrauterine infection, and maternal stress. We also describe current clinical approaches to preventing and managing labor dystocia. The variation in pathophysiologic causes of labor dystocia probably limits the utility of current general treatment options. However, treatments targeting specific underlying etiologies could be more effective. We found that the pathophysiologic basis of labor dystocia is under-researched, offering wide opportunities for translational investigation of individualized labor management, particularly regarding uterine metabolism and fetal position. More precise diagnostic tools and individualized therapies for labor dystocia might lead to better outcomes. We conclude that additional knowledge of parturition physiology coupled with rigorous clinical evaluation of novel biologically directed treatments could improve obstetric quality of care.
Topics: Infant, Newborn; Pregnancy; Female; Humans; Dystocia; Labor, Obstetric; Parturition; Delivery, Obstetric; Cesarean Section
PubMed: 35817950
DOI: 10.1007/s43032-022-01018-6 -
Obstetrics and Gynecology Feb 2021To identify and quantify risk factors for atonic postpartum hemorrhage. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To identify and quantify risk factors for atonic postpartum hemorrhage.
DATA SOURCES
PubMed, CINAHL, EMBASE, Web of Science, and and ClinicalTrials.gov databases were searched for English language studies with no restrictions on date or location. Studies included randomized trials, prospective or retrospective cohort studies, and case-control studies of pregnant patients who developed atonic postpartum hemorrhage and reported at least one risk factor.
METHODS OF STUDY SELECTION
Title, abstract, and full-text screening were performed using the Raayan web application. Of 1,239 records screened, 27 studies were included in this review. Adjusted or unadjusted odds ratios (ORs), relative risks, or rate ratios were recorded or calculated. For each risk factor, a qualitative synthesis of low and moderate risk of bias studies classifies the risk factor as definite, likely, unclear, or not a risk factor. For risk factors with sufficiently homogeneous definitions and reference ranges, a quantitative meta-analysis of low and moderate risk of bias studies was implemented to estimate a combined OR.
TABULATION, INTEGRATION, AND RESULTS
Forty-seven potential risk factors for atonic postpartum hemorrhage were identified in this review, of which 15 were judged definite or likely risk factors. The remaining 32 assessed risk factors showed no association with atonic postpartum hemorrhage or had conflicting or unclear evidence.
CONCLUSION
A substantial proportion of postpartum hemorrhage occurs in the absence of recognized risk factors. Many risk factors for atonic hemorrhage included in current risk-assessment tools were confirmed, with the greatest risk conferred by prior postpartum hemorrhage of any etiology, placenta previa, placental abruption, uterine rupture, and multiple gestation. Novel risk factors not currently included in risk-assessment tools included hypertension, diabetes, and ethnicity. Obesity and magnesium were not associated with atonic postpartum hemorrhage in this review.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO, CRD42020157521.
Topics: Female; Humans; Postpartum Hemorrhage; Pregnancy; Risk Factors; Uterine Inertia
PubMed: 33417319
DOI: 10.1097/AOG.0000000000004228 -
Obstetrics and Gynecology Jan 2024The purpose of this document is to define labor and labor arrest and provide recommendations for the management of dystocia in the first and second stage of labor and...
PURPOSE
The purpose of this document is to define labor and labor arrest and provide recommendations for the management of dystocia in the first and second stage of labor and labor arrest.
TARGET POPULATION
Pregnant individuals in the first or second stage of labor.
METHODS
This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one maternal-fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.
RECOMMENDATIONS
This Clinical Practice Guideline includes definitions of labor and labor arrest, along with recommendations for the management of dystocia in the first and second stages of labor and labor arrest. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.
Topics: Female; Humans; Pregnancy; Dystocia; Labor Stage, Second; Obstetrics; Perinatology
PubMed: 38096556
DOI: 10.1097/AOG.0000000000005447 -
American Family Physician Jul 2020Shoulder dystocia is an obstetric emergency in which normal traction on the fetal head does not lead to delivery of the shoulders. This can cause neonatal brachial...
Shoulder dystocia is an obstetric emergency in which normal traction on the fetal head does not lead to delivery of the shoulders. This can cause neonatal brachial plexus injuries, hypoxia, and maternal trauma, including damage to the bladder, anal sphincter, and rectum, and postpartum hemorrhage. Although fetal macrosomia, prior shoulder dystocia, and preexisting or gestational diabetes mellitus increases the risk of shoulder dystocia, most cases occur without warning. Labor and delivery teams should always be prepared to recognize and treat this emergency. Training and simulation exercises improve physician and team performance when shoulder dystocia occurs. Unequivocally announcing that dystocia is happening, summoning extra assistance, keeping track of the time from delivery of the head to full delivery of the neonate, and communicating with the patient and health care team are helpful. Calm and thoughtful use of release maneuvers such as knee to chest (McRoberts maneuver), suprapubic pressure, posterior arm or shoulder delivery, and internal rotational maneuvers will almost always result in successful delivery. When these are unsuccessful, additional maneuvers, including intentional clavicular fracture or cephalic replacement, may lead to delivery. Each institution should consider the length of time it will take to prepare the operating room for general inhalational anesthesia and abdominal rescue and practice this during simulation exercises.
Topics: Female; Humans; Infant, Newborn; Pregnancy; Curriculum; Delivery, Obstetric; Education, Medical, Continuing; Emergency Medical Services; Fractures, Bone; Health Personnel; Practice Guidelines as Topic; Shoulder Dystocia
PubMed: 32667171
DOI: No ID Found