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The Cochrane Database of Systematic... Mar 2023Women with a suspected large-for-dates fetus or a fetus with suspected macrosomia (birthweight greater than 4000 g) are at risk of operative birth or caesarean section.... (Review)
Review
BACKGROUND
Women with a suspected large-for-dates fetus or a fetus with suspected macrosomia (birthweight greater than 4000 g) are at risk of operative birth or caesarean section. The baby is also at increased risk of shoulder dystocia and trauma, in particular fractures and brachial plexus injury. Induction of labour may reduce these risks by decreasing the birthweight, but may also lead to longer labours and an increased risk of caesarean section.
OBJECTIVES
To assess the effects of a policy of labour induction at or shortly before term (37 to 40 weeks) for suspected fetal macrosomia on the way of giving birth and maternal or perinatal morbidity.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), contacted trial authors and searched reference lists of retrieved studies.
SELECTION CRITERIA
Randomised trials of induction of labour for suspected fetal macrosomia.
DATA COLLECTION AND ANALYSIS
Review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We contacted study authors for additional information. For key outcomes the quality of the evidence was assessed using the GRADE approach.
MAIN RESULTS
We included four trials, involving 1190 women. It was not possible to blind women and staff to the intervention, but for other 'Risk of bias' domains these studies were assessed as being at low or unclear risk of bias. Compared to expectant management, there was no clear effect of induction of labour for suspected macrosomia on the risk of caesarean section (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.76 to 1.09; 1190 women; four trials, moderate-quality evidence) or instrumental delivery (RR 0.86, 95% CI 0.65 to 1.13; 1190 women; four trials, low-quality evidence). Shoulder dystocia (RR 0.60, 95% CI 0.37 to 0.98; 1190 women; four trials, moderate-quality evidence), and fracture (any) (RR 0.20, 95% CI 0.05 to 0.79; 1190 women; four studies, high-quality evidence) were reduced in the induction of labour group. There were no clear differences between groups for brachial plexus injury (two events were reported in the control group in one trial, low-quality evidence). There was no strong evidence of any difference between groups for measures of neonatal asphyxia; low five-minute infant Apgar scores (less than seven) or low arterial cord blood pH (RR 1.51, 95% CI 0.25 to 9.02; 858 infants; two trials, low-quality evidence; and, RR 1.01, 95% CI 0.46 to 2.22; 818 infants; one trial, moderate-quality evidence, respectively). Mean birthweight was lower in the induction group, but there was considerable heterogeneity between studies for this outcome (mean difference (MD) -178.03 g, 95% CI -315.26 to -40.81; 1190 infants; four studies; I = 89%). For outcomes assessed using GRADE, we based our downgrading decisions on high risk of bias from lack of blinding and imprecision of effect estimates.
AUTHORS' CONCLUSIONS
Induction of labour for suspected fetal macrosomia has not been shown to alter the risk of brachial plexus injury, but the power of the included studies to show a difference for such a rare event is limited. Also antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed. Nevertheless, induction of labour for suspected fetal macrosomia results in a lower mean birthweight, and fewer birth fractures and shoulder dystocia. The observation of increased use of phototherapy in the largest trial, should also be kept in mind. Findings from trials included in the review suggest that to prevent one fracture it would be necessary to induce labour in 60 women. Since induction of labour does not appear to alter the rate of caesarean delivery or instrumental delivery, it is likely to be popular with many women. In settings where obstetricians can be reasonably confident about their scan assessment of fetal weight, the advantages and disadvantages of induction at or near term for fetuses suspected of being macrosomic should be discussed with parents. Although some parents and doctors may feel the evidence already justifies induction, others may justifiably disagree. Further trials of induction shortly before term for suspected fetal macrosomia are needed. Such trials should concentrate on refining the optimum gestation of induction, and improving the accuracy of the diagnosis of macrosomia.
Topics: Infant; Infant, Newborn; Pregnancy; Female; Humans; Cesarean Section; Fetal Macrosomia; Birth Weight; Shoulder Dystocia; Fetal Weight; Labor, Induced
PubMed: 36884238
DOI: 10.1002/14651858.CD000938.pub3 -
American Journal of Obstetrics and... Mar 2024This tutorial of the intrapartum management of shoulder dystocia uses drawings and videos of simulated and actual deliveries to illustrate the biomechanical principles... (Review)
Review
This tutorial of the intrapartum management of shoulder dystocia uses drawings and videos of simulated and actual deliveries to illustrate the biomechanical principles of specialized delivery maneuvers and examine missteps associated with brachial plexus injury. It is intended to complement haptic, mannequin-based simulation training. Demonstrative explication of each maneuver is accompanied by specific examples of what not to do. Positive (prescriptive) instruction prioritizes early use of direct fetal manipulation and stresses the importance of determining the alignment of the fetal shoulders by direct palpation, and that the biacromial width should be manually adjusted to an oblique orientation within the pelvis-before application of traction to the fetal head, the biacromial width is manually adjusted to an oblique orientation within the pelvis. Negative (proscriptive) instructions includes the following: to avoid more than usual and/or laterally directed traction, to use episiotomy only as a means to gain access to the posterior shoulder and arm, and to use a 2-step procedure in which a 60-second hands-off period ("do not do anything") is inserted between the emergence of the head and any initial attempts at downward traction to allow for spontaneous rotation of the fetal shoulders. The tutorial presents a stepwise approach focused on the delivering clinician's tasks while including the role of assistive techniques, including McRoberts, Gaskin, and Sims positioning, suprapubic pressure, and episiotomy. Video footage of actual deliveries involving shoulder dystocia and permanent brachial plexus injury demonstrates ambiguities in making the diagnosis of shoulder dystocia, risks of improper traction and torsion of the head, and overreliance on repeating maneuvers that prove initially unsuccessful.
Topics: Pregnancy; Female; Humans; Dystocia; Shoulder Dystocia; Shoulder; Episiotomy; Prenatal Care; Delivery, Obstetric
PubMed: 38462247
DOI: 10.1016/j.ajog.2022.03.016 -
Tierarztliche Praxis. Ausgabe G,... Oct 2019
Topics: Animals; Dystocia; Female; Pregnancy
PubMed: 31634944
DOI: 10.1055/a-1004-9774 -
International Journal of Obstetric... Nov 2021Postpartum hemorrhage is a leading cause of maternal morbidity and mortality, and uterine atony is the leading cause of postpartum hemorrhage. Risk factors for uterine... (Review)
Review
Postpartum hemorrhage is a leading cause of maternal morbidity and mortality, and uterine atony is the leading cause of postpartum hemorrhage. Risk factors for uterine atony include induced or augmented labor, preeclampsia, chorio-amnionitis, obesity, multiple gestation, polyhydramnios, and prolonged second stage of labor. Although a risk assessment is recommended for all parturients, many women with uterine atony do not have risk factors, making uterine atony difficult to predict. Oxytocin is the first-line drug for prevention and treatment of uterine atony. It is a routine component of the active management of the third stage of labor. An oxytocin bolus dose as low as 1 IU is sufficient to produce satisfactory uterine tone in almost all women undergoing elective cesarean delivery. However, a higher bolus dose (3 IU) or infusion rate is recommended for women undergoing intrapartum cesarean delivery. Carbetocin, available in many countries, is a synthetic oxytocin analog with a longer duration than oxytocin that allows bolus administration without an infusion. Second line uterotonic agents include ergot alkaloids (ergometrine and methylergonovine) and the prostaglandins, carboprost and misoprostol. These drugs work by a different mechanism to oxytocin and should be administered early for uterine atony refractory to oxytocin. Rigorous studies are lacking, but methylergonovine and carboprost are likely superior to misoprostol. Currently, the choice of second-line agent should be based on their adverse effect profile and patient comorbidities. Surgical and radiologic management of uterine atony includes uterine tamponade using balloon catheters and compression sutures, and percutaneous transcatheter arterial embolization.
Topics: Carboprost; Female; Humans; Misoprostol; Oxytocics; Oxytocin; Postpartum Hemorrhage; Pregnancy; Uterine Inertia
PubMed: 34391025
DOI: 10.1016/j.ijoa.2021.103207 -
Wiadomosci Lekarskie (Warsaw, Poland :... 2020The aim: to study the possible role of psychosocial stressors in the emergence of anomalies of childbirth, as well as to examine their nature using the example of...
OBJECTIVE
The aim: to study the possible role of psychosocial stressors in the emergence of anomalies of childbirth, as well as to examine their nature using the example of pregnant women who have been forcefully displaced from Donetsk and Luhansk regions of Ukraine.
PATIENTS AND METHODS
Materials and methods: 115 internally displaced pregnant women from Donetsk and Luhansk regions, were surveyed. All women underwent a comprehensive neuropsychological examination of their psycho-emotional status via interviews, questioning, and psychological testing (Spielberg-Haning's Situational and Personal Anxiety Scale). The following analysis of the childbirth process' nature was conducted.
RESULTS
Results: The prevalence of high level of situational and personal anxiety by the Spielberg-Haning's test were determined in the internally displaced women. This indicates a high level of social anxiety (stress) in these pregnant women. Labours in women in this group can be characterized by 3 main features: rapid (precipitated) labour with high levels of obstetric traumatism (tear of perineum) and labour medicalization (EDA). The characteristics described above are due to such labour activity anomalies as hypertensive uterine dysfunction - the cases when the speed and strength of uterine contractions significantly exceed the normative parameters. The reasons for the high level of pain in labour in displaced women could be objecttive and subjective factors: excessive nociceptor irritation due to cervical-uterine dysfunction and impaired individual perception of pain.
CONCLUSION
Conclusions: Chronic psychosocial stress has an impact on labour activity in displaced women. A mandatory standard for managing such pregnancy is psychological counselling and correction of the identified disorders.
Topics: Dystocia; Female; Humans; Labor, Obstetric; Pregnancy; Stress, Psychological; Ukraine
PubMed: 32759415
DOI: No ID Found -
Journal of Personalized Medicine May 2024The term dystocia refers to labor characterized by a slow progression with delayed rates or even pauses in the dilation of the cervix or the descent of the fetus.... (Review)
Review
The term dystocia refers to labor characterized by a slow progression with delayed rates or even pauses in the dilation of the cervix or the descent of the fetus. Dystocia describes the deviation from the limits that define a normal birth and is often used as a synonym for the term pathological birth. Shoulder dystocia, also known as the manual exit of the shoulders during vaginal delivery on cephalic presentation, is defined as the "failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head". This means that obstetric interventions are necessary to deliver the fetus's body after the head has been delivered, as gentle traction has failed. Abnormal labor (dystocia) is expressed and represented in partograms or by the prolongation of the latent phase or by slowing and pausing in the phases of cervical dilatation and fetal descent. While partograms are helpful in visualizing the progress of labor, regular use of them has not been shown to enhance obstetric outcomes considerably, and no partogram has been shown to be superior to others in comparative trials. Dystocia can, therefore, appear in any phase of the evolution of childbirth, so it is necessary to simultaneously assess all the factors that may contribute to its abnormal evolution, that is, the forces exerted, the weight, the shape, the presentation and position of the fetus, the integrity and morphology of the pelvis, and its relation to the fetus. When this complication occurs, it can result in an increased incidence of maternal morbidity, as well as an increased incidence of neonatal morbidity and mortality. Although several risk factors are associated with shoulder dystocia, it has proven impossible to recognize individual cases of shoulder dystocia in practice before they occur during labor. Various guidelines have been published for the management of shoulder dystocia, with the primary goal of educating the obstetrician and midwife on the importance of a preplanned sequence of maneuvers, thereby reducing maternal and neonatal morbidity and mortality.
PubMed: 38929807
DOI: 10.3390/jpm14060586 -
PloS One 2022A caesarean section is a major obstetric procedure that can save the life of mother and child. Its purpose is to protect the mother's health from the complications of...
INTRODUCTION
A caesarean section is a major obstetric procedure that can save the life of mother and child. Its purpose is to protect the mother's health from the complications of childbirth and to protect the baby's health. In sub-Saharan Africa (SSA), there are major inequalities in access to caesarean sections and significant variations in practices to determine the indications for the procedure. Periodic analyses of maternal deaths have shown that more than half of maternal and new born deaths are due to suboptimal care and are therefore potentially preventable. The objective of our study is to assess the impact of health staff training under the PADISS project (to support the health system's integrated development) on the quality of CS procedures in North Kivu, by comparing two periods.
MATERIAL AND METHODS
The populations compared were recruited from the referral hospitals in North Kivu, DRC (Democratic Republic of Congo). The first (group 1) was made up of patient files studied retrospectively for the period from 01/11/2013 to 01/01/2016. The second group (group 2), studied prospectively, comprised patient files from June 2019 to January 2020. Obstetric, maternal and foetal data were compared. Statistical analyses were performed using STATA/IC 15.0 for Windows. Univariate and multiple logistic regression was performed to determine which characteristics are associated with maternal and perinatal morbidity and mortality. A p value < 0.05 was considered statistically significant.
RESULTS
CS frequency was approximately 17% in both study periods. We observed a CS frequency of about 34% at North Kivu provincial hospital for the two populations studied. The main indications for CS were dystocia, foetal distress and scarred uterus for both populations. In the population studied prospectively, after the implementation of health staff training, there were fewer incidence rate of dystocia, foetal distress and neonatal death, a more complete patient record, shorter hospital stay, and fewer blood transfusions but more incidence rate of scarred uterus, post-operative complications and low birth weight. Intervention had no statistically significant impact on low birth weight (OR = 1.9, p = 0.13), on neonatal mortality (OR = 0.69, p = 0.21).
CONCLUSION
Our study shows a decrease in neonatal deaths, dystocia and foetal distress, but an increase in post-operative complications, maternal deaths and cases of scarred uterus and low birth weight. However, multiple logistic regression did no support the conclusion.
Topics: Caregivers; Cesarean Section; Cicatrix; Dystocia; Female; Fetal Distress; Humans; Infant, Newborn; Maternal Death; Pregnancy; Retrospective Studies
PubMed: 35617343
DOI: 10.1371/journal.pone.0264251 -
BMC Pregnancy and Childbirth Mar 2021Intrauterine inflammation affects short- and long-term neonatal outcomes. Histological chorioamnionitis and funisitis are acute inflammatory responses in the fetal...
BACKGROUND
Intrauterine inflammation affects short- and long-term neonatal outcomes. Histological chorioamnionitis and funisitis are acute inflammatory responses in the fetal membranes and umbilical cord, respectively. Although labor dystocia includes a potential risk of intrauterine inflammation, the risk of histological chorioamnionitis and funisitis of labor dystocia has not been evaluated yet. This study aimed to examine the association between labor dystocia and risk of histological chorioamnionitis and funisitis.
METHODS
In this retrospective cohort study, the cases who underwent histopathological examinations of the placenta and umbilical cord at Fukushima Medical University Hospital, Japan, between 2015 and 2020, were included. From the dataset, the pathological findings of the patients with labor dystocia and spontaneous preterm birth were reviewed. Based on the location of leukocytes, the inflammation in the placenta (histological chorioamnionitis) and umbilical cord (funisitis) was staged as 0-3. Multiple logistic regression analysis was performed to evaluate the risk of histological chorioamnionitis, histological chorioamnionitis stage ≥2, funisitis, and funisitis stage ≥2.
RESULT
Of 317 women who met the study criteria, 83 and 144 women had labor dystocia and spontaneous preterm birth, respectively, and 90 women were included as controls. Labor dystocia was a risk factor for histological chorioamnionitis (adjusted odds ratio, 6.3; 95% confidential interval, 1.9-20.5), histological chorioamnionitis stage ≥2 (adjusted odds ratio, 6.0; 95% confidence interval, 1.7-21.8), funisitis (adjusted odds ratio, 15.4; 95% confidence interval, 2.3-101.3), and funisitis stage ≥2 (adjusted odds ratio, 18.5; 95% confidence interval, 2.5-134.0). Spontaneous preterm birth was also a risk factor for histological chorioamnionitis (adjusted odds ratio, 3.7; 95% confidence interval, 1.7-7.8), histological chorioamnionitis stage ≥2 (adjusted odds ratio, 3.0; 95% confidence interval, 1.2-7.9), and funisitis (adjusted odds ratio, 6.6; 95% confidence interval, 1.4-30.6). However, the adjusted odds ratio was smaller in spontaneous preterm births than in labor dystocia.
CONCLUSION
Labor dystocia is a risk factor for severe histological chorioamnionitis and funisitis. Further studies are required to evaluate the effects of histological chorioamnionitis and funisitis on long-term neonatal outcomes.
Topics: Adult; Chorioamnionitis; Datasets as Topic; Dystocia; Female; Humans; Infant, Newborn; Japan; Placenta; Pregnancy; Premature Birth; Retrospective Studies; Risk Factors; Severity of Illness Index; Tertiary Care Centers; Umbilical Cord
PubMed: 33784970
DOI: 10.1186/s12884-021-03719-3 -
American Journal of Obstetrics and... May 2023The past 20 years witnessed an invigoration of research on labor progression and a change of thinking regarding normal labor. New evidence is emerging, and more advanced...
The past 20 years witnessed an invigoration of research on labor progression and a change of thinking regarding normal labor. New evidence is emerging, and more advanced statistical methods are applied to labor progression analyses. Given the wide variations in the onset of active labor and the pattern of labor progression, there is an emerging consensus that the definition of abnormal labor may not be related to an idealized or average labor curve. Alternative approaches to guide labor management have been proposed; for example, using an upper limit of a distribution of labor duration to define abnormally slow labor. Nonetheless, the methods of labor assessment are still primitive and subject to error; more objective measures and more advanced instruments are needed to identify the onset of active labor, monitor labor progression, and define when labor duration is associated with maternal/child risk. Cervical dilation alone may be insufficient to define active labor, and incorporating more physical and biochemical measures may improve accuracy of diagnosing active labor onset and progression. Because the association between duration of labor and perinatal outcomes is rather complex and influenced by various underlying and iatrogenic conditions, future research must carefully explore how to integrate statistical cut-points with clinical outcomes to reach a practical definition of labor abnormalities. Finally, research regarding the complex labor process may benefit from new approaches, such as machine learning technologies and artificial intelligence to improve the predictability of successful vaginal delivery with normal perinatal outcomes.
Topics: Child; Female; Humans; Pregnancy; Artificial Intelligence; Delivery, Obstetric; Dystocia; Labor Stage, First; Labor, Obstetric
PubMed: 37164489
DOI: 10.1016/j.ajog.2022.11.1299 -
Journal of Midwifery & Women's Health May 2020Labor dystocia is the most common cause of cesarean birth in the United States, yet how dystocia develops during labor remains elusive. Uterine activity monitoring has... (Review)
Review
INTRODUCTION
Labor dystocia is the most common cause of cesarean birth in the United States, yet how dystocia develops during labor remains elusive. Uterine activity monitoring has significant potential for advancing our understanding of labor dystocia. While evaluating contraction frequency and amplitude is a common component of labor dystocia management, the literature describing the relationship between measures of uterine activity and labor dystocia is heterogeneous and has not been synthesized to identify the best methods for use in clinical investigation.
METHODS
We conducted a literature search for original research exploring the relationship between uterine activity and labor dystocia published between 2000 and 2019. Included articles were critically reviewed and synthesized.
RESULTS
Across 11 identified studies, investigators employed 3 different techniques for monitoring uterine activity and 9 different measures were employed. Uterine activity measures, including Montevideo units, uterine electromyography power density spectrum and sample entropy, and the fall-to-rise ratio of contraction shape, detected patterns associated with labor dystocia or cesarean birth.
DISCUSSION
The use of multiple regression with clinical covariates and a uterine activity measure increased the accuracy of predicting cesarean delivery. Uterine electromyography may be especially useful to evaluate labor dystocia phenotypes to differentiate uterine muscle fatigue from understimulation and lead to algorithms for increased precision in the diagnosis of labor dystocia and innovative approaches to treatment.
Topics: Adult; Cesarean Section; Dystocia; Electromyography; Female; Humans; Labor, Obstetric; Obstetric Labor Complications; Pregnancy; Uterus
PubMed: 32478978
DOI: 10.1111/jmwh.13119