Foley catheter placement for induction of labor with or without stylette: a randomized clinical trial.

BACKGROUND: Foley catheters are used for cervical ripening during induction of labor. Previous studies suggest that use of a stylette (a thin, rigid wire) to guide catheter insertion decreases insertion failure. However, stylette effects on insertion outcomes have been sparsely studied. OBJECTIVE: The purpose of this study was to compare catheter insertion times, patient-assessed pain levels, and insertion failure rates between women who received a digitally placed Foley catheter for cervical ripening with the aid of a stylette and women who received the catheter without a stylette. STUDY DESIGN: We conducted a randomized clinical trial of women aged ≥ 18 years who presented for induction of labor. Inclusion criteria were singletons with intact membranes and cephalic presentation. Women received a computer-generated random assignment of a Foley catheter insertion with a stylette (treatment group, n = 62) or without a stylette (control group, n = 61). For all women, a standard insertion technique protocol was used. Three primary outcomes were of interest, including the following: (1) insertion time (total minutes to successful catheter placement), (2) patient-assessed pain level (0-10), and (3) failure rate of the randomly assigned insertion method. Treatment control differences were first examined using the Pearson's test of independence and the Student t test. Per outcome, we also constructed 4 regression models, each including the random effect of physician and fixed effects of stylette use with patient nulliparity, a history of vaginal delivery, cervical dilation at presentation, or postgraduate year of the performing resident physician. RESULTS: Women who received the Foley catheter with the stylette vs without the stylette did not differ by age, race/ethnicity, body mass index, or any of several other characteristics. Regression models revealed that insertion time, patient pain, and insertion failure were unrelated to stylette use, nulliparity, and history of vaginal delivery. However, overall insertion time and failure were significantly influenced by cervical dilation, with insertion time decreasing by 21% (95% confidence interval [CI], 5-34%) and odds of failure decreasing by 71% (odds ratio, 0.29; 95% CI, 0.10-0.86) per 1 cm dilation. Resident postgraduate year also significantly influenced insertion time, with greater time required of physicians with less experience. Mean insertion time was 51% (95% CI, 23-69%) shorter for fourth-year than second-year residents. Statistically nonsignificant but prominent patterns in outcomes were also observed, suggesting stylette use may lengthen the overall insertion procedure but minimize variability in pain levels and decrease insertion failure. CONCLUSIONS: The randomized trial suggests that, even after accounting for nulliparity, history of vaginal delivery, cervical dilation, and physician experience, Foley catheter insertions with and without a stylette are equivalent in insertion times, patient pain levels, and failure of catheter placement.

Family-centered cesarean delivery: a randomized controlled trial.

BACKGROUND: Women who undergo cesarean delivery report that they are less satisfied with their child birthing experience and have a later skin-to-skin contact. Because cesarean deliveries account for nearly one-fifth of all births globally, improving the child birthing experience is imperative. One delivery technique that may improve the child birthing experience, termed the family-centered cesarean, allows the mother to view the birth of her baby and to have the baby immediately placed on her chest following delivery. OBJECTIVE: Our primary outcome was to compare satisfaction with birthing experiences between women who underwent either a family-centered or traditional cesarean delivery. Our secondary outcomes compared timing of skin-to-skin contact, and maternal and neonatal outcomes between the 2 methods of cesarean delivery. STUDY DESIGN: Pregnant women aged ≥18 years who had been admitted to Labor and Delivery with a planned cesarean delivery at 1 of 2 delivery units were prospectively enrolled. Women were randomized 1:1, but not blinded, to either the family-centered cesarean (Method 1; N=68) or traditional cesarean (Method 2; N=61). Time to skin-to-skin interactions and newborn vitals were recorded by a nurse at time of delivery. A self-administered questionnaire was provided to participants in the hospital on postpartum to obtain satisfaction with the birthing experience using a modified Likert scale, ranging from 1 (lowest) to 5 (highest). Baseline characteristics and all other variables of interest were abstracted from the electronic medical record. Baseline characteristics, maternal satisfaction, and maternal or neonatal outcomes between methods of delivery were compared using t tests and Pearson chi-squared (or Fisher exact), as appropriate. RESULTS: Between June 2016 and July 2018, women who were randomized to either Method 1 or Method 2 did not significantly differ by baseline characteristics. This study was unable to detect a difference in satisfaction (4.6 Method 1 vs 4.4 Method 2; P=.27). However, mean time to skin-to-skin contact was significantly different. Patients in Method 1 established skin-to-skin contact on average 11.2 minutes earlier than those in Method 2 (5.1 vs 16.3; P<.01). No other differences in maternal and neonatal outcomes were identified. CONCLUSION: Although our study did not find statistical differences in maternal or newborn outcomes, including maternal satisfaction, the family-centered cesarean was significantly associated with earlier skin-to-skin contact. Given the known benefits of earlier skin-to-skin contact without associated harm, women should be allowed to choose either method of cesarean delivery based on their personal preference.

Dancing During Labor: Social Media Trend or Future Practice?

Over the past 30 years, medical interventions in pregnancy and childbirth have increased. Some pregnant women seek less invasive and nonpharmacological options to manage discomforts during labor. While exercise during pregnancy is recommended, less is known about exercise, specifically dancing, during labor. While anecdotal evidence is supportive, little is known about the implications of exercise and dance during the first stage of labor for pain reduction and labor progression. Some movements common in dance, such as expanding hip circles that loosen and relax muscles of the pelvic floor, may be beneficial to women during labor. Available evidence suggests that dancing during the first stage of labor may decrease duration and intensity of pain and increase patient satisfaction, but further study is warranted. Ultimately, before assessing the implications of dance during labor, a feasibility study should be conducted to determine pregnant women's willingness to participate in a prospective or randomized controlled trial.

Management of the third stage of labor in second-trimester deliveries: How long is too long?

BACKGROUND: Retained placenta is the most common second-trimester delivery complication. As the optimal third stage of labor duration remains undefined, complications associated with retained placentas are difficult to study. OBJECTIVE(S): To determine the optimal third stage of labor duration in second-trimester deliveries based on estimates of time-specific probabilities of placental delivery, placental intervention, and postpartum complication. STUDY DESIGN: We retrospectively studied adult women with singleton second-trimester vaginal deliveries. We identified third stage of labor duration, placental delivery method (spontaneous vs. manual/operative intervention), and indication for intervention. Postpartum complication was examined as a composite outcome. Differences among groups defined by delivery method and postpartum complication were tested using parametric and nonparametric tests. Probability curves describing the time-specific probabilities of placental delivery were derived using lifetable methods with group differences tested using the log-rank test. Probability of placental intervention and complication by time to placental delivery were examined using logistic regression with adjustment for confounders and other predictors. RESULTS: We identified 215 second-trimester placental deliveries (77% spontaneous, 23% intervention). Overall, 27% experienced postpartum complication, primarily hemorrhage (91%). Complication rates differed significantly between spontaneous placental deliveries (16%) and interventions (61%, P < 0.01). Both placental intervention and postpartum complication were strongly associated with longer time to placental delivery. Spontaneous placental deliveries occurred earlier than deliveries requiring intervention (P < 0.01). At 2 h, placental delivery rates were 93% in spontaneous deliveries and 39% in those requiring intervention. The overall postpartum complication rate for spontaneous placental deliveries (16%) was used as the threshold of tolerable risk and the criterion for placental intervention. Adjusted probability curves for deliveries of average gestational age (21.6 weeks) suggested that most patients (63.9%) may not require intervention until approximately 2 h following fetal delivery. Patients with PPROM would require intervention by 34 min, and those with intrapartum fever or delivery EBL ≥500 mL would already exceed the risk threshold at fetal delivery. CONCLUSIONS: Our study suggests that an optimal third stage of labor duration of approximately 2 h maximizes probability of spontaneous delivery and minimizes complication risk. Timing of intervention may be further individualized for patients based on maternal characteristics and intrapartum conditions.

Does current cefazolin dosing achieve adequate tissue and blood concentrations in obese women undergoing cesarean section?

BACKGROUND: Prophylactic administration of antibiotics preceding cesarean delivery is the most effective measure taken for preventing postpartum infection. While obese women are at greater risk for infection than non-obese women, evidence-based recommendations for modifying dosing in these women are limited. OBJECTIVES: The purpose of this study was to determine whether obese women undergoing cesarean delivery similarly reach adequate cefazolin concentrations within tissue and blood when weighing <120kg and dosed 2g versus weighing ≥120kg and dosed 3g. STUDY DESIGN: We prospectively studied women ≥18 years old with body mass index ≥30kg/m2 who underwent scheduled cesarean delivery with singleton pregnancy from August 2014 through March 2016. Women were dosed with 2g and 3g of cefazolin for body weights <120kg and ≥120kg, respectively. Samples of subcutaneous adipose tissue (following skin incision and before skin closure), myometrial tissue, fetal cord blood, and maternal blood were collected to assess whether cefazolin concentrations were adequate, i.e., at/above the minimum inhibitory concentration (MIC). Concentrations, based on inhibition zones for Streptococcus sanguinis, were calculated per gram of solid tissue and milliliter of blood. For all sample types, log-transformed concentrations were compared between dosage groups. Using a range of published MICs (1-8µg/mL or µg/g), odds ratios, describing differential odds of falling below the MIC between dosage groups, were also computed. RESULTS: Women who received 2g (n=65) versus 3g (n=19) of cefazolin did not significantly differ by maternal or gestational age, race/ethnicity, pre-operative hemoglobin, estimated blood loss, fluid administration, duration of surgery, or timing of sample collections relative to cefazolin administration (Ps>0.05). Dosage groups also did not differ in cefazolin concentration (median [interquartile range]) within adipose tissue following skin incision (5.30µg/g [3.00-9.60] vs. 6.35µg/g [3.90-8.40]; P=0.551), adipose tissue before skin closure (4.45µg/g [2.78-7.25] vs. 6.90µg/g [2.60-10.6]; P=0.342), myometrial tissue (13.1µg/g [8.60-19.6] vs. 15.7µg/g [10.8-21.7]; P=0.116), or maternal blood (41.6µg/mL [26.3-57.0] vs. 45.3µg/mL [36.7-68.3]; P=0.143). However, cord blood concentrations differed significantly (19.5µg/mL [13.7-28.5] vs. 27.9µg/mL [15.8-39.4]; P=0.032), and, in 3 of 5 sample types, group concentrations differed at the dosing cut-point of 120kg (Ps<0.02). Within the range of MICs considered, differences in the odds of concentration inadequacy were not detected between dosage groups for any sample type. Across all patients, inadequate concentrations in one or more solid tissue types were observed in 1.19%, 17.9%, 59.5%, and 86.9% of patients, given the MICs of 1µg/g, 2µg/g, 4µg/g and 8µg/g, respectively. In adipose tissues, specifically, and both dosage groups, mean concentrations were significantly lower than the MIC of 8µg/g (Ps<0.03). Concentrations in one or both blood sample types were inadequate for only 8.33% of patients, given the 8-µg/mL MIC. CONCLUSIONS: Adequate cefazolin concentrations were achieved in blood for the majority of our patients. However, concentration adequacy was not achieved in solid tissue for a nearly equally large proportion of patients. Larger scale studies for determining modified protocols for dosing and applying MICs are warranted.