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.

Outpatient labor induction-Exploring future potential by assessing eligibility in a historical cohort.

INTRODUCTION: Labor induction rates have increased over the last decades, and in many high-income countries, more than one in four labors are induced. Outpatient management of labor induction has been suggested in low-risk pregnancies to improve women's birth experiences while also promoting a more efficient use of healthcare resources. The primary aim of this paper was to assess the proportion of women in a historical cohort that would have been eligible for outpatient labor induction with oral misoprostol. Second, we wanted to report safety outcomes and assess efficacy outcomes for mothers and infants in pregnancies that met the criteria for outpatient care. MATERIAL AND METHODS: Criteria for outpatient labor induction with oral misoprostol were applied to a historical cohort of women with induction of labor at two Norwegian tertiary hospitals in the period January 1, through July 31, 2021. The criteria included low-risk women with an unscarred uterus expecting a healthy, singleton baby in cephalic position at term. The primary outcome was the proportion of women eligible for outpatient labor induction. Secondary outcomes included reasons for ineligibility and, for eligible women, safety and efficacy outcomes. RESULTS: Overall, 29.7% of the 1320 women who underwent labor induction in a singleton term pregnancy met the criteria for outpatient labor induction. We identified two serious adverse events that potentially could have occurred outside the hospital if the women had received outpatient care. The mean duration from initiation of labor induction to administration of the last misoprostol was 22.4 h. One in 14 multiparous women gave birth within 3 h after the last misoprostol dose. CONCLUSIONS: In this historical cohort, three in ten women met the criteria for outpatient management of labor induction with oral misoprostol. Serious adverse events were rare. The average time span from the initiation of labor induction to the last misoprostol was nearly 24 h. This suggests a potential for low-risk women with an induced labor to spend a substantial period of time at home before labor onset. However, larger studies testing or evaluating labor induction with oral misoprostol as an outpatient procedure are needed to draw conclusions.

New insights on labor progression: a systematic review.

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.

The effect of Zhang's guideline vs the WHO partograph on childbirth experience measured by the Childbirth Experience Questionnaire in the Labor Progression Study (LaPS): A cluster randomized trial.

INTRODUCTION: Childbirth experience is an increasingly recognized and important measure of quality of obstetric care. Previous research has shown that it can be affected by intrapartum care and how labor is followed. A partograph is recommended to follow labor progression by recording cervical dilation over time. There are currently different guidelines in use worldwide to follow labor progression. The two main ones are the partograph recommended by the World Health Organization (WHO) based on the work of Friedman and Philpott and a guideline based on Zhang's research. In our study we assessed the effect of adhering to Zhang's guideline or the WHO partograph on childbirth experience. Zhang's guideline describes expected normal labor progression based on data from contemporary obstetric populations, resulting in an exponential progression curve, compared with the linear WHO partograph. The choice of labor curve affects the intrapartum follow-up of women and this could potentially affect childbirth experience. MATERIAL AND METHODS: The Labor Progression Study (LaPS) study was a prospective, cluster randomized controlled trial conducted at 14 birth centers in Norway. Birth centers were randomized to either follow Zhang's guideline or the WHO partograph. Nulliparous women in active labor, with one fetus in cephalic presentation at term and spontaneous labor onset were included. At 4 weeks postpartum, included women received an online login to complete the Childbirth Experience Questionnaire (CEQ). Total score on the CEQ, the four domain scores on the CEQ, and scores on the individual items on the CEQ were compared between the two groups. RESULTS: There were 1855 women in the Zhang group and 1749 women in the WHO partograph group. There was no difference in the total or domain CEQ scores between the two groups. We found statistically significant differences for two individual items; women in the Zhang group scored lower on positive memories and feeling of control. CONCLUSIONS: Based on our findings on childbirth experience there is no reason to prefer Zhang's guideline over the WHO partograph.

Maternal body mass index and risk of obstetric, maternal and neonatal outcomes: A cohort study of nulliparous women with spontaneous onset of labor.

INTRODUCTION: This study investigates associations between maternal body mass index (BMI) early in pregnancy and obstetric interventions, maternal and neonatal outcomes. MATERIAL AND METHODS: This is a cohort study of nulliparous women originally included in a cluster randomized controlled trial carried out at 14 Norwegian obstetric units between 2014 and 2017. The sample included 7189 nulliparous women with a singleton fetus, cephalic presentation and spontaneous onset of labor at term, denoted as group 1 in the Ten-Group Classification System. The women were grouped according to the World Health Organization BMI classifications: underweight (BMI <18.5), normal weight (BMI 18.5-24.9), pre-obesity (BMI 25.0-29.9), obesity class I (BMI 30.0-34.9), and obesity classes II and III (BMI ≥35.0). We used binary logistic regression to estimate crude and adjusted odds ratios (ORs) of the interventions and outcomes, with associated 95% confidence intervals (CIs), comparing women in different BMI groups with women of normal weight. RESULTS: We found an increased risk of intrapartum cesarean section in women of obesity class I and obesity classes II and III, with adjusted OR of 1.70 (95% CI 1.21-2.38) and 2.31 (95% CI 1.41-3.77), respectively. Women in obesity groups had a gradient of risk of epidural analgesia and use of continuous CTG (including STAN), with adjusted OR of 2.39 (95% CI 1.69-3.38) and 3.28 (95% CI 1.97-5.48), respectively. Women in obesity classes II and III had higher risk of amniotomy (adjusted OR = 1.42, 95% CI 1.02-1.96), oxytocin augmentation (adjusted OR = 1.54, 95% CI 1.11-2.15), obstetric anal sphincter injuries (adjusted OR = 2.21, 95% CI 1.01-4.85) and postpartum hemorrhage ≥1000 mL (adjusted OR = 2.20, 95% CI 1.29-3.78). We found a reduced likelihood of spontaneous vaginal delivery for pre-obese women (adjusted OR = 0.85, 95% CI 0.74-0.97) and no associations between maternal BMI and neonatal outcomes. CONCLUSIONS: Obese women in Ten-Group Classification System group 1 had increased risks of obstetric interventions and maternal complications. There was a gradient of risk for intrapartum cesarean section, with the highest risk for women in obesity classes II and III. No associations between maternal BMI and neonatal outcomes were observed.

The frequency of intrapartum caesarean section use with the WHO partograph versus Zhang's guideline in the Labour Progression Study (LaPS): a multicentre, cluster-randomised controlled trial.

BACKGROUND: There is an ongoing debate concerning which guidelines and monitoring tools are most beneficial for assessing labour progression, to help prevent use of intrapartum caesarean section (ICS). The WHO partograph has been used for decades with the assumption of a linear labour progression; however, in 2010, Zhang introduced a new guideline suggesting a more dynamic labour progression. We aimed to investigate whether the frequency of ICS use differed when adhering to the WHO partograph versus Zhang's guideline for labour progression. METHODS: We did a multicentre, cluster-randomised controlled trial at obstetric units in Norway, and each site was required to deliver more than 500 fetuses per year to be eligible for inclusion. The participants were nulliparous women who had a singleton, full-term fetus with cephalic presentation, and who entered spontaneous active labour. The obstetric units were treated as clusters, and women treated within these clusters were all given the same treatment. We stratified these clusters by size and number of previous caesarean sections. The clusters containing the obstetric units were then randomly assigned (1:1) to the control group, which adhered to the WHO partograph, or to the intervention group, which adhered to Zhang's guideline. The randomisation was computer-generated and was done in the Unit of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway, and investigators in this unit had no further involvement in the trial. Our study design did not enable masking of participants or health-care providers, but the investigators who were analysing the data were masked to group allocation. The primary outcome was use of ICS during active labour (cervical dilatation of 4-10 cm) in all participating women. The Labour Progression Study (LaPS) is registered with ClinicalTrials.gov, number NCT02221427. FINDINGS: Between Aug 1, 2014, and Sept 1, 2014, 14 clusters were enrolled in the LaPS trial, and on Sept 11, 2014, seven obstetric units were randomly assigned to the control group (adhering to the WHO partograph) and seven obstetric units were randomly assigned to the intervention group (adhering to Zhang's guideline). Between Dec 1, 2014, and Jan 31, 2017, 11 615 women were judged to be eligible for recruitment in the trial, which comprised 5421 (46·7%) women in the control group units and 6194 (53·3%) women in the intervention group units. In the control group, 2100 (38·7%) of 5421 women did not give signed consent to participate and 16 (0·3%) women abstained from participation. In the intervention group, 2181 (35·2%) of 6194 women did not give signed consent to participate and 41 (0·7%) women abstained from participation. 7277 (62·7%) of 11 615 eligible women were therefore included in the analysis of the primary endpoint. Of these women, 3305 (45·4%) participants were in an obstetric unit that was randomly assigned to the control group (adhering to the WHO partograph) and 3972 (54·6%) participants were in an obstetric unit that was randomly assigned to the intervention group (adhering to Zhang's guideline). No women dropped out during the trial. Before the start of the trial, ICS was used in 9·5% of deliveries in the control group obstetric units and in 9·3% of intervention group obstetric units. During our trial, there were 196 (5·9%) ICS deliveries in women in the control group (WHO partograph) and 271 (6·8%) ICS deliveries in women in the intervention group (Zhang's guideline), and the frequency of ICS use did not differ between the groups (adjusted relative risk 1·17, 95% CI 0·98-1·40; p=0·08; adjusted risk difference 1·00%, 95% CI -0·1 to 2·1). We identified no maternal or neonatal deaths during our study. INTERPRETATION: We did not find any significant difference in the frequency of ICS use between the obstetric units assigned to adhere to the WHO partograph and those assigned to adhere to Zhang's guideline. The overall decrease in ICS use that we observed relative to the previous frequency of ICS use noted in these obstetric units might be explained by the close focus on assessing labour progression more than use of the guidelines. Our results represent an important contribution to the discussion on implementation of the new guideline. FUNDING: Østfold Hospital Trust.

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.

Study protocol: the Labor Progression Study, LAPS - does the use of a dynamic progression guideline in labor reduce the rate of intrapartum cesarean sections in nulliparous women? A multicenter, cluster randomized trial in Norway.

BACKGROUND: The increasing rate of intrapartum cesarean sections is subject of attention and concern as it is associated with adverse outcomes. Labor dystocia is one of the most frequent indications for cesarean sections even though there is no consensus on criteria for labor dystocia. Traditionally the progression of labor follows guidelines based on Friedman's curve from the mid 1950s. In 2010 Zhang presented a new labor curve and a dynamic guideline for labor progression based on contemporary research. The main aim of this trial is to evaluate whether adhering to Zhang's guideline for labor progression, changes the intrapartum cesarean section rate in nulliparous women without jeopardising maternal and neonatal outcomes compared to a traditional guide line called the 4-h action line based on Friedman's curve. METHODS/DESIGN: A multicenter cluster randomized trial including 14 birth care units in Norway is conducted. Seven units are randomized to use the 4-h action line guideline for labor progression and seven units are randomized to use Zhang's new dynamic guideline for labor progression, for all nulliparous women with a singleton fetus in a cephalic presentation and spontaneous onset of labor at term. Clinical outcomes are compared between the groups. The determination of the sample size (number of clusters and individuals) is based on a power calculation of intrapartum cesarean section, which is 9.2% in the study population (p1). Further, we expect that the intrapartum cesarean section rate will be 6.7% (p2) which is a 25% reduction, when using the new guideline. With a chosen significance level of 0.05, a power of 80% and p1 = 9.2% and p2 = 6.9%, we should include at least 14 clusters and 6582 individuals. DISCUSSION: Clinical consequences when using the guideline by Zhang have, to the best of our knowledge, not been investigated earlier. The results will provide a strong basis to make a qualified decision on whether it is beneficial to introduce a dynamic labor progression curve in contemporary obstetrics both nationally and internationally. TRIAL REGISTRATION: Clinicaltrials, NCT02221427.

Evaluation of satisfaction with care in a midwifery unit and an obstetric unit: a randomized controlled trial of low-risk women.

BACKGROUND: Satisfaction with birth care is part of quality assessment of care. The aim of this study was to investigate possible differences in satisfaction with intrapartum care among low-risk women, randomized to a midwifery unit or to an obstetric unit within the same hospital. METHODS: Randomized controlled trial conducted at the Department of Obstetrics and Gynecology, Østfold Hospital Trust, Norway. A total of 485 women with no expressed preference for level of birth care, assessed to be at low-risk at onset of spontaneous labor were included. To assess the overall satisfaction with intrapartum care, the Labour and Delivery Satisfaction Index (LADSI) questionnaire, was sent to the participants 6 months after birth. To assess women's experience with intrapartum transfer, four additional items were added. In addition, we tested the effects of the following aspects on satisfaction; obstetrician involved, intrapartum transfer from the midwifery unit to the obstetric unit during labor, mode of delivery and epidural analgesia. RESULTS: Women randomized to the midwifery unit were significantly more satisfied with intrapartum care than those randomized to the obstetric unit (183 versus 176 of maximum 204 scoring points, mean difference 7.2, p = 0.002). No difference was found between the units for women who had an obstetrician involved during labor or delivery and who answered four additional questions on this aspect (mean item score 4.0 at the midwifery unit vs 4.3 at the obstetric unit, p = 0.3). Intrapartum transfer from the midwifery unit to an obstetric unit, operative delivery and epidurals influenced the level of overall satisfaction in a negative direction regardless of allocated unit (p < 0.001). CONCLUSION: Low-risk women with no expressed preference for level of birth care were more satisfied if allocated to the midwifery unit compared to the obstetric unit. TRIAL REGISTRATION: The trial is registered at www.clinicaltrials.gov NCT00857129 . Initially released 03/05/2009.

Labor curves based on cervical dilatation over time and their accuracy and effectiveness: A systematic scoping review.

OBJECTIVES: This systematic scoping review was conducted to 1) identify and describe labor curves that illustrate cervical dilatation over time; 2) map any evidence for, as well as outcomes used to evaluate the accuracy and effectiveness of the curves; and 3) identify areas in research that require further investigation. METHODS: A three-step systematic literature search was conducted for publications up to May 2023. We searched the Medline, Maternity & Infant Care, Embase, Cochrane Library, Epistemonikos, CINAHL, Scopus, and African Index Medicus databases for studies describing labor curves, assessing their effectiveness in improving birth outcomes, or assessing their accuracy as screening or diagnostic tools. Original research articles and systematic reviews were included. We excluded studies investigating adverse birth outcomes retrospectively, and those investigating the effect of analgesia-related interventions on labor progression. Study eligibility was assessed, and data were extracted from included studies using a piloted charting form. The findings are presented according to descriptive summaries created for the included studies. RESULTS AND IMPLICATIONS FOR RESEARCH: Of 26,073 potentially eligible studies, 108 studies were included. Seventy-three studies described labor curves, of which ten of the thirteen largest were based mainly on the United States Consortium on Safe Labor cohort. Labor curve endpoints were 10 cm cervical dilatation in 69 studies and vaginal birth in 4 studies. Labor curve accuracy was assessed in 26 studies, of which all 15 published after 1986 were from low- and middle-income countries. Recent studies of labor curve accuracy in high-income countries are lacking. The effectiveness of labor curves was assessed in 13 studies, which failed to prove the superiority of any curve. Patient-reported health and well-being is an underrepresented outcome in evaluations of labor curves. The usefulness of labor curves is still a matter of debate, as studies have failed to prove their accuracy or effectiveness.

Association of oxytocin augmentation and duration of labour with postpartum haemorrhage: A cohort study of nulliparous women.

OBJECTIVE: Both duration of labour and use of oxytocin for augmentation are known risk factors for postpartum haemorrhage but distinguishing between the significance of these factors is complex. In this study, we aimed to investigate the association between both labour duration and oxytocin augmentation, for postpartum haemorrhage. DESIGN: A cohort study based on a secondary analysis of a cluster-randomised trial. PARTICIPANTS AND SETTING: Term nulliparous women with a single foetus in cephalic presentation, spontaneous onset of active labour and a vaginal birth. The participants were originally included in cluster-randomised trial conducted in Norway from December 1, 2014, to January 31, 2017, that aimed to compare the frequency of intrapartum caesarean sections when adhering to the WHO partograph versus Zhang's guideline. MEASUREMENTS: The data were analysed through four statistical models. Model 1 investigated the effect of oxytocin augmentation as a dichotomous variable (yes/no); Model 2 investigated the effect of the duration of oxytocin augmentation; Model 3 investigated the effect of the maximum dose of oxytocin; and Model 4 investigated the effect of both the duration of augmentation and the maximum dose of oxytocin. All four models included duration of labour divided into five time-intervals. We used binary logistic regression to estimate the odds ratios of postpartum haemorrhage, defined as blood loss of ≥ 1000 ml, including a random intercept for hospital and mutually adjusting for oxytocin augmentation and labour duration in addition to maternal age, maternal marital status, maternal higher education level, maternal smoking habits in the first trimester, maternal body mass index and birth weight. FINDINGS: Model 1 found a significant association between the use of oxytocin and postpartum haemorrhage. In Model 2, oxytocin augmentation of ≥ 4.5 h was associated with postpartum haemorrhage. In Model 3, we found an association between a maximum dose of oxytocin of ≥ 20 mU/min and postpartum haemorrhage. Model 4 showed that a maximum dose of oxytocin ≥ 20 mU/min was associated with postpartum haemorrhage both for those augmented < 4.5 h and for those augmented ≥ 4.5 h. Duration of labour was associated with postpartum haemorrhage in all models if lasting ≥ 16 h. KEY CONCLUSIONS: We found both oxytocin augmentation and labour duration to be associated with postpartum haemorrhage. Oxytocin doses of ≥ 20 mU/min and a labour duration of ≥ 16 h showed an independent association. IMPLICATION FOR PRACTICE: The potent drug oxytocin should be carefully administered, as doses of ≥ 20 mU/min were associated with an increased risk of PPH, regardless of the duration of oxytocin augmentation.

Association between one-to-one midwifery care in the active phase of labour and use of pain relief and birth outcomes: A cohort of nulliparous women.

OBJECTIVE: To investigate the association between one-to-one midwifery care and birth outcomes with pain relief as the primary outcome. Secondary outcomes include obstetric and neonatal outcomes, such as mode of birth and Apgar score. DESIGN: A cohort study of women originally included in a cluster randomised trial. SETTING AND PARTICIPANTS: The analysis is based on data from The Labour Progression Study (LaPS), a cluster randomised controlled trial (RCT) including 7,277 women, conducted in fourteen obstetric units in Norway, between 2014 and 2017. The participants were nulliparous with a singleton full-term foetus in a cephalic presentation and spontaneous onset of labour. In this cohort, 7,103 women with information about on one-to-one midwifery care were included. MEASUREMENTS AND FINDINGS: Logistic regression analysis show that nulliparous women receiving one-to-one midwifery care in the active phase of labour are less likely to have an epidural analgesia, adjusted OR of 0.81 (95% CI 0.72,0.91), less likely to be given nitrous oxide, adjusted OR of 0.77 (95% CI 0.69,0.85), and they more often received massages, adjusted OR of 1.76 (95% CI 1.47,2.11), compared with women not receiving one-to-one midwifery care. Descriptive analyses show that women receiving one-to-one midwifery care in the active phase of labour are less likely to have a caesarean section (5.8% vs. 7.2%) and they are less likely to have an operative vaginal birth (16.5% vs. 23.7%). No significant differences were observed between the groups in terms of low Apgar scores at five minutes. KEY CONCLUSIONS: We found that one-to-one midwifery care in the active phase of labour may be associated with birth outcomes, including decreased use of epidural analgesia and a decreased rate of caesarean sections and operative vaginal birth. IMPLICATIONS FOR PRACTICE: The results of this study could encourage midwives to be present during the active phase of labour to promote physiological birth.

Associations between cervical dilatation on admission and mode of delivery, a cohort study of Norwegian nulliparous women.

OBJECTIVE: To investigate associations between cervical dilatation at hospital admission and mode of delivery. METHODS: A cohort study with data from a cluster-randomised controlled trial, the Labour Progression Study. The study population of 6511 nulliparous women with a singleton fetus in cephalic presentation with spontaneous onset of labour at term, was divided into two groups: <4 cm and ≥ 4 cm cervical dilatation on admission. Binary logistic regression comparing mode of delivery was used to estimate crude and adjusted OR with associated 95% CI. RESULTS: Of the total study population, 56.7% were admitted with < 4 cm cervical dilatation and 43.3% with ≥ 4 cm. Women admitted with ≥ 4 cm had a significantly higher chance of spontaneous delivery, with adjusted OR of 1.28 (95% CI: 1.14-1.44), and a significantly lower risk of caesarean sections, with an adjusted OR of 0.51 (95% CI: 0.41-0.64). For operative vaginal delivery, there were no significant difference between the study groups. Intrapartum interventions as epidural analgesia and augmentation with oxytocin were lower among women admitted with ≥ 4 cm cervical dilatation. CONCLUSION: The study found a significantly higher chance of spontaneous delivery among women admitted with ≥ 4 cm. More research is needed to investigate why so many women are admitted early in labour, and how these women can be better cared for to increase their chances of a spontaneous delivery.

Associations between duration of active second stage of labour and adverse maternal and neonatal outcomes: A cohort study of nulliparous women with spontaneous onset of labour.

OBJECTIVE: To investigate associations between the duration of the active second stage of labour and adverse maternal and neonatal outcomes. METHOD: This cohort study is based on data from a cluster randomised controlled trial (RCT) undertaken at 14 Norwegian birth clinics in Norway from 2014 to 2017. The final sample involved 6804 nulliparous women with a singleton fetus, cephalic presentation, spontaneous onset of labour at term, vaginal delivered and with an active second stage of labour. The women were grouped to active second stage of labour ≤ 60 min and active second stage of labour > 60 min. Binary logistic regression was used to estimate crude and adjusted odds ratios (ORs) of the maternal and neonatal outcomes with an associated 95% confidence intervals (CIs), comparing women in the two groups. RESULTS: There was an increased risk of postpartum haemorrhage > 1000 ml with an adjusted OR 1.31 (95% CI: 1.01-1.69) when the active second stage of labour exceeded 60 min. There was no significant difference in the risk of obstetric anal sphincter injuries (adjusted OR 0.93 [95% CI: 0.65-1.39]), Apgar scores < 7 at 5 min age (adjusted OR 1.13 [95% CI: 0.65-1.97]) or admission to the neonatal intensive care unit (adjusted OR 1.46 [95% CI: 0.61-3.51]) between the study groups. CONCLUSION: Women with an active second stage of labour that exceeds 60 min had an increased risk of postpartum haemorrhage > 1000 ml. We found no association between duration of active stage of labour and obstetric anal sphincter injuries or adverse neonatal outcomes.

Implementation of the Moyo fetal heart rate monitor in district hospitals in Bihar, India: a feasibility study.

OBJECTIVES: Globally, half of all stillbirths occur during birth. Detection of fetal distress with fetal heart rate monitoring (FHRM), followed by appropriate and timely management, might reduce fresh stillbirths and neonatal morbidity. This study aimed to investigate the barriers and facilitators for the implementation of Moyo FHRM use in Bihar state, and secondarily, the feasibility of collecting reliable obstetrical and neonatal outcome data to assess the effect of implementation. SETTING: CARE Bihar and the hospital management at four district hospitals (DHs) in Bihar state, each with 6500 to 15 000 deliveries a year, agreed to testing the implementation of Moyo FHRM through a process of meetings, training sessions and collecting data. At each hospital, a clinical training expert was trained to train others, while a clinical assessment facilitator collected data. METHODOLOGY: Observational notes were taken at all training sessions and meetings. Individual interviews (n=4) were conducted with clinical training experts (CTEs) on training experiences and barriers and facilitators for Moyo FHRM implementation. The CTEs recoded field notes in diaries. Descriptive analyses performed on pre-implementation and post-implementation data (n=521) assessed quality and completeness. RESULTS: Main barriers to implementation of Moyo FHRM were health system and cultural challenges involving (1) existing practices, (2) insufficient human resources, (3) action delays and (4) cultural and local challenges. Another barrier was insufficient involvement of doctors. Facilitators for implementation were easy use of the Moyo FHRM device and adequate training for staff.Electronic collection of obstetrical data worked well but had substantial missing data. CONCLUSION: Health system and cultural challenges are a major constraint to Moyo FHRM implementation in low-resource settings. Improvements at all levels of infrastructure, practices and skills will be critical in busy DHs in Bihar. Full-scale implementation needs doctor-led leadership and ownership. Obstetrical data collection for the purpose of scientific analysis needs to be improved.

Use of the partograph - Current thinking.

The partograph (sometimes called partogram) is a labour monitoring tool that is used in countries worldwide to enable early detection of complications, so that referral, action or closer observations can ensue. While the partograph has received global support, from health professionals, there are concerns that it has not reached its full potential in improving clinical outcomes. This has resulted in several variations of the tool and a plethora of studies aimed at exploring the barriers and facilitators to its use. In this chapter, we will discuss the history of the partograph, outlining how it has evolved over time. We will also suggest reasons why the tool may not be meeting the needs of all practitioners. In particular, we will explore partograph use as a complex intervention, suggesting that its success is likely to be dependent on multiple contextual factors.

The Labour Progression Study (LaPS): Duration of labour following Zhang's guideline and the WHO partograph - A cluster randomised trial.

OBJECTIVE: To investigate labour duration in different phases of labour when adhering to Zhang's guideline for labour progression compared with the WHO partograph. DESIGN: A secondary analysis of a cluster randomised controlled trial. SETTING: Fourteen Norwegian birth care units, each with more than 500 deliveries per year constituted the clusters. PARTICIPANTS: A total of 7277 nulliparous women with singleton foetus in a cephalic presentation and spontaneous onset of labour at term were included. INTERVENTION: Seven clusters were randomised to the intervention group that adhered to Zhang's guideline (n = 3972) and seven to the control group that adhered to the WHO partograph (n = 3305) for labour progression. MEASUREMENTS: The duration of labour from the first registration of cervical dilatation (≥ 4 cm) to the delivery of the baby and the duration of the first and second stages of labour; the time-to-event analysis was used to compare the duration of labour between the two groups after adjusting for baseline covariates. FINDINGS: The adjusted median duration of labour was 7.0 h in the Zhang group, compared with 6.2 h in the WHO group; the median difference was 0.84 h with 95% confidence interval [CI] (0.2-1.5). The adjusted median duration of the first stage was 5.6 h in the Zhang group compared with 4.9 h in the WHO group; the median difference was 0.66 h with 95% CI (0.1-1.2). The corresponding adjusted median duration of the second stage was 88 and 77 min; the median difference was 0.18 h with 95% CI (0.1-0.3). KEY CONCLUSIONS: The women who adhered to Zhang's guideline had longer overall duration and duration of the first and second stages of labour than women who adhered to the WHO partograph. IMPLICATIONS FOR PRACTICE: Understanding the variations in the duration of labour is of great importance, and the results offer useful insights into the different labour progression guidelines, which can inform clinical practice.

Oxytocin and dystocia as risk factors for adverse birth outcomes: a cohort of low-risk nulliparous women.

OBJECTIVES: augmented and not augmented women without dystocia were compared to investigate associations between oxytocin and adverse birth outcomes. Augmented women with and without dystocia were compared, to investigate associations between dystocia and adverse birth outcomes. DESIGN: a cohort of low-risk nulliparous women originally included in a randomised controlled trial. SETTING: the Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Norway. PARTICIPANTS: the study population consists of 747 well defined low-risk women. MEASUREMENTS: incidence of oxytocin augmentation, and associations between dystocia and augmentation, and mode of delivery, transfer of newborns to the intensive care unit, episiotomy and postpartum haemorrhage. FINDINGS: of all participants 327 (43.8%) were augmented with oxytocin of which 139 (42.5%) did not fulfil the criteria for dystocia. Analyses adjusted for possible confounders found that women without dystocia had an increased risk of instrumental vaginal birth (OR 3.73, CI 1.93-7.21) and episiotomy (OR 2.47, CI 1.38-4.39) if augmented with oxytocin. Augmented women had longer active phase if vaginally delivered and longer labours if delivered by caesarean section if having dystocia. Among women without dystocia, those augmented had higher body mass index, gave birth to heavier babies, had longer labours if vaginally delivered and had epidural analgesia more often compared to women not augmented. KEY CONCLUSION: in low-risk nulliparous without dystocia, we found an association between the use of oxytocin and an increased risk of instrumental vaginal birth and episiotomy. IMPLICATIONS FOR PRACTICE: careful attention should be paid to criteria for labour progression and guidelines for oxytocin augmentation to avoid unnecessary use.

Economic evaluation of birth care in low-risk women. A comparison between a midwife-led birth unit and a standard obstetric unit within the same hospital in Norway. A randomised controlled trial.

OBJECTIVE: to investigate the cost-effectiveness in birth care for low-risk women, in an alongside midwife-led unit (MU) compared to a standard obstetric unit (SCU) within the same hospital. DESIGN: economic evaluation based on the findings of a randomised trial, randomising participants either into the MU or SCU. The hospital's activity-based costing system CPP was used to estimate costs, as no data on complete resource use exists. SETTING: the Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Norway. PARTICIPANTS: the study population consists of 1,110 consenting healthy women, assessed to be at low-risk at spontaneous onset of labour. MEASUREMENTS: effect measures; avoided caesarean sections, instrumental vaginal deliveries, complications requiring treatment in the operating room, epidural analgesia and oxytocin augmentation. Costs (€) were calculated by costs per day multiplied with length of stay, added costs for procedures performed outside the units. The results are expressed in incremental cost-effectiveness ratios (ICER) with SCU as comparator. FINDINGS: total costs per stay were significantly lower for women at the MU (€1,672) compared to the SCU (€1,950, p<0.001). The ICER showed that MU was a dominant strategy (lower costs and reduction in clinical procedures) for all effect measures. Based on the sensitivity analysis, allocating low-risk women to MU significantly reduced costs, but was not a dominant strategy for all outcomes. KEY CONCLUSIONS: the MU is more cost-effective than the SCU for low-risk women without prelabour preference for level of birth care provided equal capacity at the units. IMPLICATIONS FOR PRACTICE: it is cost-effective to organise birth care for low-risk women in a separate midwife-led unit.