Amniotomy versus expectant management during the active phase of labor defined by the new WHO definition on the duration of labor: A randomized controlled trial.

OBJECTIVE: To compare the labor duration and other maternal and neonatal outcomes between hospitalized women with uncomplicated pregnancies receiving amniotomy at 5 cm cervical dilatation and those not receiving amniotomy. METHODS: This prospective, randomized controlled trial was conducted at a tertiary hospital between June 2020 and October 2021. The study included low-risk pregnant women with spontaneous onset of labor at term, carrying a single fetus in cephalic presentation and with intact amniotic membranes. When the cervical dilatation reached 5 cm, participants were randomly assigned to receive or not receive amniotomy. Maternal demographics, labor and delivery data, and neonatal outcomes were compared between the two groups. RESULTS: The amniotomy group had a significantly shorter duration of labor compared with the control group (mean difference 49.4 min, 95% confidence interval [CI] 16.8-81.9, P = 0.003). The following outcomes were not significantly different between the two groups: (1) the need for oxytocin to augment labor; (2) cesarean section rates; (3) the incidence rates of suspected fetal distress and instrumental delivery; and (4) neonatal outcomes. CONCLUSIONS: Compared with expectant management, amniotomy during the active phase of labor (as newly defined by WHO) can shorten the labor duration without an increased risk of cesarean delivery or other negative consequences. THAI CLINICAL TRIALS REGISTRY (TCTR) (TCTR20200522001): https://www.thaiclinicaltrials.org/show/TCTR20200522001.

Non-clinical interventions for reducing unnecessary caesarean section.

BACKGROUND: Caesarean section rates are increasing globally. The factors contributing to this increase are complex, and identifying interventions to address them is challenging. Non-clinical interventions are applied independently of a clinical encounter between a health provider and a patient. Such interventions may target women, health professionals or organisations. They address the determinants of caesarean births and could have a role in reducing unnecessary caesarean sections. This review was first published in 2011. This review update will inform a new WHO guideline, and the scope of the update was informed by WHO's Guideline Development Group for this guideline. OBJECTIVES: To evaluate the effectiveness and safety of non-clinical interventions intended to reduce unnecessary caesarean section. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers in March 2018. We also searched websites of relevant organisations and reference lists of related reviews. SELECTION CRITERIA: Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series studies and repeated measures studies were eligible for inclusion. The primary outcome measures were: caesarean section, spontaneous vaginal birth and instrumental birth. DATA COLLECTION AND ANALYSIS: We followed standard methodological procedures recommended by Cochrane. We narratively described results of individual studies (drawing summarised evidence from single studies assessing distinct interventions). MAIN RESULTS: We included 29 studies in this review (19 randomised trials, 1 controlled before-after study and 9 interrupted time series studies). Most of the studies (20 studies) were conducted in high-income countries and none took place in low-income countries. The studies enrolled a mixed population of pregnant women, including nulliparous women, multiparous women, women with a fear of childbirth, women with high levels of anxiety and women having undergone a previous caesarean section.Overall, we found low-, moderate- or high-certainty evidence that the following interventions have a beneficial effect on at least one primary outcome measure and no moderate- or high-certainty evidence of adverse effects.Interventions targeted at women or familiesChildbirth training workshops for mothers alone may reduce caesarean section (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.33 to 0.89) and may increase spontaneous vaginal birth (RR 2.25, 95% CI 1.16 to 4.36). Childbirth training workshops for couples may reduce caesarean section (RR 0.59, 95% CI 0.37 to 0.94) and may increase spontaneous vaginal birth (RR 2.13, 95% CI 1.09 to 4.16). We judged this one study with 60 participants to have low-certainty evidence for the outcomes above.Nurse-led applied relaxation training programmes (RR 0.22, 95% CI 0.11 to 0.43; 104 participants, low-certainty evidence) and psychosocial couple-based prevention programmes (RR 0.53, 95% CI 0.32 to 0.90; 147 participants, low-certainty evidence) may reduce caesarean section. Psychoeducation may increase spontaneous vaginal birth (RR 1.33, 95% CI 1.11 to 1.61; 371 participants, low-certainty evidence). The control group received routine maternity care in all studies.There were insufficient data on the effect of the four interventions on maternal and neonatal mortality or morbidity.Interventions targeted at healthcare professionalsImplementation of clinical practice guidelines combined with mandatory second opinion for caesarean section indication slightly reduces the risk of overall caesarean section (mean difference in rate change -1.9%, 95% CI -3.8 to -0.1; 149,223 participants). Implementation of clinical practice guidelines combined with audit and feedback also slightly reduces the risk of caesarean section (risk difference (RD) -1.8%, 95% CI -3.8 to -0.2; 105,351 participants). Physician education by local opinion leader (obstetrician-gynaecologist) reduced the risk of elective caesarean section to 53.7% from 66.8% (opinion leader education: 53.7%, 95% CI 46.5 to 61.0%; control: 66.8%, 95% CI 61.7 to 72.0%; 2496 participants). Healthcare professionals in the control groups received routine care in the studies. There was little or no difference in maternal and neonatal mortality or morbidity between study groups. We judged the certainty of evidence to be high.Interventions targeted at healthcare organisations or facilitiesCollaborative midwifery-labourist care (in which the obstetrician provides in-house labour and delivery coverage, 24 hours a day, without competing clinical duties), versus a private practice model of care, may reduce the primary caesarean section rate. In one interrupted time series study, the caesarean section rate decreased by 7% in the year after the intervention, and by 1.7% per year thereafter (1722 participants); the vaginal birth rate after caesarean section increased from 13.3% before to 22.4% after the intervention (684 participants). Maternal and neonatal mortality were not reported. We judged the certainty of evidence to be low.We studied the following interventions, and they either made little or no difference to caesarean section rates or had uncertain effects.Moderate-certainty evidence suggests little or no difference in caesarean section rates between usual care and: antenatal education programmes for physiologic childbirth; antenatal education on natural childbirth preparation with training in breathing and relaxation techniques; computer-based decision aids; individualised prenatal education and support programmes (versus written information in pamphlet).Low-certainty evidence suggests little or no difference in caesarean section rates between usual care and: psychoeducation; pelvic floor muscle training exercises with telephone follow-up (versus pelvic floor muscle training without telephone follow-up); intensive group therapy (cognitive behavioural therapy and childbirth psychotherapy); education of public health nurses on childbirth classes; role play (versus standard education using lectures); interactive decision aids (versus educational brochures); labourist model of obstetric care (versus traditional model of obstetric care).We are very uncertain as to the effect of other interventions identified on caesarean section rates as the certainty of the evidence is very low. AUTHORS' CONCLUSIONS: We evaluated a wide range of non-clinical interventions to reduce unnecessary caesarean section, mostly in high-income settings. Few interventions with moderate- or high-certainty evidence, mainly targeting healthcare professionals (implementation of guidelines combined with mandatory second opinion, implementation of guidelines combined with audit and feedback, physician education by local opinion leader) have been shown to safely reduce caesarean section rates. There are uncertainties in existing evidence related to very-low or low-certainty evidence, applicability of interventions and lack of studies, particularly around interventions targeted at women or families and healthcare organisations or facilities.

Fundal height growth curve patterns of pregnant women with term low birth weight infants.

PURPOSE: To investigate the patterns of fundal height (FH) growth curve in pregnant women with term low birth weight (LBW) infants compared with the standard FH growth curve for Thai women. SUBJECTS AND METHODS: A retrospective study was conducted at the four governmental general hospitals in the northern part of Thailand between 2009 and 2011. All data were obtained from antenatal records and labor registry. Serial FH measurements in centimeters of 75 pregnant women with term LBW infants were plotted against the standard FH growth curve for Thai women throughout pregnancy. RESULTS: SIX PATTERNS OF THE FH GROWTH CURVE WERE SUMMARIZED: pattern I: FH below or around the tenth percentile throughout pregnancy (n=17, 22.7%); pattern II: FH below normal in early pregnancy, caught up with normal, then decelerated or stagnant (n=19, 25.3%); pattern III: FH normal in early pregnancy, then decelerated or stagnant (n=17, 22.7%); pattern IV: FH normal in early pregnancy, decelerated or stagnant, then caught up to normal (n=6, 8.0%); pattern V: FH normal throughout pregnancy except for the last visit (n=6, 8.0%); and pattern VI: FH normal throughout pregnancy (n=10, 13.3%). CONCLUSION: Patterns I-V may be used to recognize women who are likely to deliver term LBW infants from early pregnancy, during pregnancy, and on the day of admission for labor. Ultrasound evaluation is still recommended in cases with known risk factors that might be undetectable by FH, or in cases where FH measurement may be inaccurate.

Non-clinical interventions for reducing unnecessary caesarean section.

BACKGROUND: Caesarean section rates are steadily increasing globally. The factors contributing to these observed increases are complex. Non-clinical interventions, those applied independent of patient care in a clinical encounter, may have a role in reducing unnecessary caesarean sections. OBJECTIVES: To evaluate the effectiveness and safety of non-clinical interventions for reducing unnecessary caesarean sections. SEARCH STRATEGY: We searched the following electronic databases: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (29 March 2010), the Cochrane Pregnancy and Childbirth Group Specialised Register (29 March 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 2); MEDLINE (1950 to March 2010); EMBASE (1947 to March 2010) and CINAHL (1982 to March 2010). SELECTION CRITERIA: We included randomised controlled trials (RCTs), quasi-experimental studies, controlled clinical trials (CCTs), controlled before and after studies (CBAs) with at least two intervention and control sites, and interrupted time series analyses (ITS) where the intervention time was clearly defined and there were at least three data points before and three after the intervention. Studies evaluated non-clinical interventions to reduce unnecessary caesarean section rates. Participants included pregnant women and their families, healthcare providers who work with expectant mothers, communities and advocacy groups. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed the quality and abstracted data of all eligible studies using a standardised data extraction form, modified from the Cochrane EPOC checklists. We contacted study authors for additional information. MAIN RESULTS: We included 16 studies in this review.Six studies specifically targeted pregnant women. Two RCTs were shown to be effective in reducing caesarean section rates: a nurse-led relaxation training programme for women with a fear or anxiety of childbirth and birth preparation sessions. However, both RCTs were small in size and targeted younger mothers with their first pregnancies. There is insufficient evidence that prenatal education and support programmes, computer patient decision-aids, decision-aid booklets and intensive group therapy are effective.Ten studies targeted health professionals. Three of these studies were effective in reducing caesarean section rates. A cluster-RCT of guideline implementation with mandatory second opinion resulted in a small, statistically significant reduction in total caesarean section rates (adjusted risk difference (RD) -1.9; 95% confidence interval (CI) -3.8 to -0.1); this reduction was predominately in intrapartum sections. An ITS study of mandatory second opinion and peer review feedback at department meetings found statistically significant results at 48 months for reducing repeat caesarean section rates (change in level was -6.4%; 95% CI -9.7% to -3.1% and change in slope -1.14%; 95% CI -1.9% to -0.3%) but not for total caesarean section rates. A cluster-RCT of guideline implementation with support from local opinion leaders increased the proportion of women with a previous caesarean section being offered a trial of labour (absolute difference 16.8%) and the number who had a vaginal birth (VBAC rates) (absolute difference 13.5%). The P values are, however, not reported due to unit of analysis errors. There was insufficient evidence that audit and feedback, training of public health nurses, insurance reform, external peer review and legislative changes are effective. AUTHORS' CONCLUSIONS: Implementation of guidelines with mandatory second opinion can lead to a small reduction in caesarean section rates, predominately in intrapartum sections. Peer review, including pre-caesarean consultation, mandatory secondary opinion and postcaesarean surveillance can lead to a reduction in repeat caesarean section rates. Guidelines disseminated with endorsement and support from local opinion leaders may increase the proportion of women with previous caesarean sections being offered a trial of labour in certain settings. Nurse-led relaxation classes and birth preparation classes may reduce caesarean section rates in low-risk pregnancies.

Admission tests other than cardiotocography for fetal assessment during labour.

BACKGROUND: Evidence on the benefits of admission tests other than cardiotocography in preventing adverse perinatal outcomes has not been established. OBJECTIVES: To assess the effectiveness of admission tests other than cardiotocography in preventing adverse perinatal outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011). SELECTION CRITERIA: Randomised (individual and cluster) controlled trials, comparing labour admission tests other than CTG for the prevention of adverse perinatal outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed eligibility, quality and extracted data. MAIN RESULTS: We included one study involving 883 women.Comparison of sonographic assessment of amniotic fluid index (AFI) on admission versus no sonographic assessment of AFI on admission. The incidence of cesarean section for fetal distress in the intervention group (29 of 447) was significantly higher than those of controls (14 of 436) (risk ratio (RR) 2.02; 95% confidence interval (CI) 1.08 to 3.77).The incidence of Apgar score less than seven at five minutes in the intervention group (10 of 447) was not significantly different from controls (seven of 436) (RR 1.39, 95% CI 0.54 to 3.63).The incidence of artificial oxytocin for augmentation of labour in the intervention group (213 of 447) was significantly higher than controls (132 of 436) (RR 1.57; 95% CI 1.32 to 1.87).The incidence of neonatal NICU admission in the intervention group (35 of 447) was not significantly different from the controls (33 of 436) (RR 1.03; 95% CI 0.66 to 1.63) AUTHORS' CONCLUSIONS: There is not enough evidence to support the use of admission tests other than cardiotocography for fetal assessment during labour. Appropriate randomised controlled trials with adequate sample size of admission tests other than cardiotocography for fetal assessment during labour are required.

Infant male sex as a risk factor for shoulder dystocia but not for cephalopelvic disproportion: an independent or confounded effect?

BACKGROUND: Shoulder dystocia (ShD) and cephalopelvic disproportion (CPD) share some common risk factors. Whether infant male sex is an independent risk factor for ShD, or if the risk is confounded by other known factors, is uncertain. OBJECTIVE: The aim of this study was to explore the unconfounded effect of infant male sex on the risk for ShD and its interaction with other risk factors compared with CPD. METHODS: A retrospective data analysis was conducted of deliveries in Lamphun Hospital, Lamphun, Thailand. All vaginal deliveries complicated by ShD were collected as ShD cases. All labors terminated by cesarean delivery (CD) due to CPD were collected as CD/CPD cases. Vaginal deliveries that took place immediately before or after the index ShD cases were collected as controls. Multivariable adjusted odds ratios (AORs) for infant male sex and its 95% CI in cases of ShD and CD/CPD were computed by multichotomous logistic regression controlling for other obstetric risks. The effects of maternal height, gestational age, and birth weight on the risk for ShD or CD/CPD among male or female infants was also explored. Stability of the effect of the risk between male and female infants was tested with Chow tests. RESULTS: Thirty-five ShD cases and 199 CD/CPD cases were collected, as were 586 controls. Infant male sex was a significant independent risk factor for ShD (AOR = 5.00; 95% CI, 1.83-13.61; P = 0.002), but not for CD/CPD (AOR = 1.09; 95% CI, 0.75-1.59; P = NS). For CD/CPD, the effects of maternal height, gestational age, and birth weight were similar for male and female infants, but the corresponding effect on ShD was more pronounced in male than in female infants (P < 0.001 for all comparisons). CONCLUSIONS: Infant male sex is a risk factor for ShD independent of other known risks. Male sex also amplified the existing effects of short maternal height, extended gestational age, and greater birth weight. If infant sex is known to be male before delivery, the obstetrician may consider avoiding vaginal delivery in mothers who have other strong risks for ShD.

Development of risk scoring scheme for prediction of cesarean delivery due to cephalopelvic disproportion in Lamphun Hospital, Thailand.

AIM: To develop a simple risk scoring scheme for the prediction of cesarean delivery due to cephalopelvic disproportion (CPD) in Lamphun Hospital, Thailand. METHODS: A case-control study was conducted including 116 pregnant women with cesarean delivery due to CPD and 307 pregnant women delivering by normal labor. Obstetric information was retrieved from medical records. Risk indicators measurable at the time of admission were analyzed by a stepwise logistic regression to obtain a set of statistically significant predictors. Regression coefficients were transformed into item scores and added up to a total score. Risk of cesarean delivery due to CPD was analyzed using total scores as the only predictor. RESULTS: A risk scoring scheme was developed from five obstetric predictors: maternal age, height, parity, pregnancy weight gain and symphysis-fundal height. Item scores ranged from 0 up to 3.5 and the total score from 0-14.5. The scheme explained, by the area under the receiver operating characteristic curve, 88% of cesarean delivery due to CPD. The likelihood of cesarean delivery due to CPD in pregnant women with low risk (scores below 5), moderate risk (scores 5-9.5) and high risk (scores 10 and over) were 0.09, 0.86 and 10.11, respectively. CONCLUSIONS: The risk of cesarean delivery due to CPD may be forecasted by a simple scoring scheme using five predictors that correctly identified women with low, moderate and high risk. This scheme may be applicable to physicians and midwives for identifying high-risk pregnant women in order to take appropriate action.

Validation of risk scoring scheme for cesarean delivery due to cephalopelvic disproportion in Lamphun Hospital.

OBJECTIVE: To validate the risk scoring scheme for cesarean delivery due to cephalopelvic disproportion in Lamphun Hospital. MATERIAL AND METHOD: A case-control study was conducted between January 1st, 2005 and April 30th, 2006, including, prospectively collected, 132 women who had cesarean delivery due to cephalopelvic disproportion (CPD) as cases and 394 women who delivered by normal labor as controls. Cases and controls were evaluated for risk scores, the scoring scheme of which had previously been developed. The prediction by the risk score was tested with an area under the receiver operating characteristic (ROC) curve of a logistic regression. Another independent set of obstetric cases referred form community hospitals in Lamphun were also evaluated for the risk scores. RESULTS: The risk scores explained 84.5% of the probability of CPD as demonstrated by the area under the ROC curve. The scores of pregnant women referred from rural hospital underwent cesarean delivery were higher than those with vacuum extraction and with normal delivery (mean = 9.2 +/- 2.4, 7.5 +/- 3.2 and 6.4 +/- 2.3 respectively). The score of cesarean delivery was significantly higher than normal delivery (p < 0.001) while the score of vacuum extraction was in between and only slightly higher (p = 0.116). CONCLUSION: Risk scores obtained form this scoring scheme predicted cesarean delivery with high precision. The scores also discriminated cesarean deliveries from normal deliveries among cases referred from community hospitals. Community hospitals may gain benefit by adopting this simple scoring scheme into their practices.

Risk indicators for cesarean section due to cephalopelvic disproportion in Lamphun hospital.

OBJECTIVE: To investigate risk indicators for cesarean section due to cephalopelvic disproportion. SETTING: Department of Obstetrics & Gynecology, Lamphun Hospital. DESIGN: Case-control study. MATERIAL AND METHOD: Cases were 87 pregnant women delivered by cesarean section due to cephalopelvic disproportion at Lamphun Hospital between October 1st, 2003 and June 30th, 2004. Controls were 113 pregnant women delivered by normal labour during the same period. Maternal age, gravidity, parity, maternal height, pre-pregnancy weight, gestational age, weight before delivery, weight gain, symphysis-fundal height, birthweight and newborn gender were mainly focused. Information were obtained from medical records. Groups were compared by t-test and exact probability test as appropriate. Risk indicators were analyzed by odds ratio from univariable and multiviariable logistic regression. RESULTS: Risk indicators significantly associated with cesarean section due to cephalopelvic disproportion included symphysis-fundal height greater than 35 cm. (OR = 9.38, 95% CI = 3.42-25.73); nulliparity (OR = 5.36, 95%CI = 2.24-12.82); maternal height less than 152 cm. (OR = 3.65, 95%CI = 1.63-8.17) and weight gain more than 15 kg. (OR = 2.67, 95%C1 = 1.32-5.39). CONCLUSION: Risk factors for cesarean section due to cephalopelvic disproportion included symphysis-fundal height greater than 35 cm, nulliparity, maternal height less than 152 cm. and weight gain more than 15 kg. Early detection of these risk indicators before delivery helps obstetricians and nurses to recognize potential obstructed labor and prepare for safe delivery in advance.