DNA damage analysis in newborns and their mothers related to pregnancy and delivery characteristics.

INTRODUCTION: Increased DNA damage is associated with early events in carcinogenesis. The foetus may be more susceptible to effects of environment by transplacental exposure. We aimed to evaluate DNA damage in cells from umbilical cord (arteries and vein) and maternal blood from pregnant women. METHODS: Fifty eight pregnant women and their offspring were included in this study. They were submitted to an interview to obtain information about personal history, clinical history, and lifestyle habits. Other Information was obtained from medical records. The samples were prepared for Single Cell Gel/Comet assay and Cytokinesis-block Micronucleus Cytome (CBMN-Cyt) assay. RESULTS: Correlation between DNA damage frequency by Comet assay from newborns and their mothers was statistically significant and was significantly associated with nulliparity and more than 1 h of second stage of labour (umbilical vein and maternal blood). A positive MNi relationship was noticed for age (mother's blood) and inappropriate birth weight for gestational age (maternal blood). When multivariate statistical analyses were applied to measure the degree of association between variables that influenced DNA damage markers in the first evaluation, inadequate birth weight and pregnant weight gain were associated with MNi frequency in maternal and newborns blood, respectively. DISCUSSION: Significant associations between DNA damage in newborns and pregnant women, and birth and pregnancy events suggest molecular evidence of transplacental genotoxic effects. However, a potentially increased risk of degenerative diseases, such as cancers, in this population should be carefully investigated by further prospective cohort studies.

Mueller-Hillis maneuver and angle of progression: Are they correlated? / Manobra de Mueller-Hillis e ângulo de progressão: eles estão correlacionados?

Summary Objective: Mueller-Hillis maneuver (MHM) and angle of progression (AOP) measured by transperineal ultrasound have been used to assess fetal head descent during the second stage of labor. We aimed to assess whether AOP correlates with MHM in the second stage of labor. Method: A prospective observational study including women with singleton pregnancy in the second stage of labor was performed. The AOP was measured immediately after the Mueller-Hillis maneuver. A receiver-operating characteristics (ROC) curve analysis was performed to determine the best discriminatory AOP cut-off for the identification of a positive MHM. A p-value less than 0.05 was considered statistically significant. Results: One hundred and sixty-six (166) women were enrolled in the study and 81.3% (n=135) had a positive MHM. The median AOP was 143º (106º to 210º). The area under the curve for the prediction of a positive maneuver was 0.619 (p=0.040). Derived from the ROC curve, an AOP of 138.5º had the best diagnostic performance for the identification of a positive MHM (specificity of 65% and a sensitivity of 67%). Conclusion: An AOP of 138º seems to be associated with a positive MHM in the second stage of labor.

Resumo Objetivo: A manobra de Mueller-Hillis (MHM) e o ângulo de progressão da apresentação (AOP) medido através de ecografia transperineal têm sido utilizados para avaliar a descida do polo cefálico durante o segundo estágio do trabalho de parto. O objetivo do nosso trabalho foi avaliar se o AOP se correlaciona com a MHM no segundo estágio do trabalho de parto. Método: Conduzimos um estudo observacional e prospectivo. Incluímos mulheres com gravidez unifetal com feto em apresentação cefálica, no segundo estágio do trabalho de parto. O AOP foi medido imediatamente após a manobra de Mueller-Hillis. Foi construída uma curva ROC (receiver-operating characteristics) para determinar o melhor AOP para a identificação de uma manobra positiva. Um valor p inferior a 0,05 foi considerado estatisticamente significativo. Resultados: Cento e sessenta e seis mulheres (166) foram incluídas no estudo, e em 81,3% (n=135) a MHM foi positiva. A mediana do AOP foi de 143º (106º a 210º). A área abaixo da curva para a previsão de uma manobra positiva foi 0,619 (p=0,040). Derivado da curva ROC, um AOP de 138,5º teve o melhor desempenho diagnóstico para a identificação de uma MHM positiva (especificidade de 65% e sensibilidade de 67%). Conclusão: Um AOP de 138º parece estar associado com uma MHM positiva no segundo estágio de trabalho de parto.

To cut or not to cut, that is the question: A review of the anatomy, the technique, risks, and benefits of an episiotomy.

Childbirth can be a traumatic experience on the female body. Some techniques may be implemented to make the process smoother and decrease the potential lacerations that can occur. Episiotomies have been used by obstetricians and midwives to help make the fetal decent down the vaginal canal less turbulent. A physician must use his best judgment on when it is necessary to make this incision and what form of incision to make. Before making an incision one must understand the female external and internal anatomy and thoroughly comprehend the stages of birth to understand how and what complications can occur. Even though an episiotomy is a minor incision, it is still a surgical incision nonetheless and as with any form of surgery there are both risks and benefits that are to be considered. Nevertheless, episiotomies have proven to help ease births that are complicated by shoulder dystocia, prevent severe lacerations, and decrease the second stage of labor. The following comprehensive review provides a description of the female anatomy, as well as an extensive description of why, when, and how an episiotomy is done. Clin. Anat. 30:362-372, 2017. © 2017 Wiley Periodicals, Inc.

Prolonged second stage of labor is associated with low Apgar score.

There is no consensus on the effects of a prolonged second stage of labor on neonatal outcomes. In this large Swedish population-based cohort study, our objective was to investigate prolonged second stage and risk of low Apgar score at 5 min. All nulliparous women (n = 32,796) delivering a live born singleton infant in cephalic presentation at ≥37 completed weeks after spontaneous onset of labor between 2008 and 2012 in the counties of Stockholm and Gotland were included. Data were obtained from computerized records. Exposure was time from fully retracted cervix until delivery. Logistic regression analyses were used to estimate crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Adjustments were made for maternal age, height, BMI, smoking, sex, gestational age, sex-specific birth weight for gestational age and head circumference. Epidural analgesia was included in a second model. The primary outcome measure was Apgar score at 5 min <7 and <4. We found that the overall rates of 5 min Apgar score <7 and <4 were 7.0 and 1.3 per 1000 births, respectively. Compared to women with <1 h from retracted cervix to birth, adjusted ORs of Apgar score <7 at 5 min generally increased with length of second stage of labor: 1 to <2 h: OR 1.78 (95% CI 1.19-2.66); 2 to <3 h: OR 1.66 (1.05-2.62); 3 to <4 h: OR 2.08 (1.29-3.35); and ≥4 h: OR 2.71 (1.67-4.40). We conclude that prolonged second stage of labor is associated with an increased risk of low 5 min Apgar score.

Uterine electric activity during the third stage of labor; a look into the physiology of a deserted stage.

OBJECTIVE: To evaluate uterine activity during the third stage of labor and compare it to that observed in the second stage of labor. STUDY DESIGN: Uterine electric activity was prospectively measured using electrical uterine myography (EUM) in 44 women with singleton pregnancy at term during the final 30 min of the second stage and throughout the third stage of labor. Results are reported using a scoring index of 1-5 mWS (micro-Watt-Second). Patients were stratified into two groups based on the duration of the third stage (<15 min and >=15 min) RESULTS: The mean durations of the second and third stages were 51.9 ± 63.5 and 15.4 ± 7.5 minutes, respectively. During the third stage, uterine activity (contractions peaks) was similar to that observed during the second stage of labor (3.43 ± 0.64 mWS versus 3.42 ± 0.57 mWS, p = 0.8). No correlation was found between the duration of the third stage and EUM measurements during the third (p = 0.9) or the second (p = 0.2) stages of labor. No association was found between EUM measurements during the third stage and parity, maternal age, fetal weight, duration of labor, gestational age, gravity or BMI. The rate of oxytocin use during the second stage and EUM measurements during the second or third stage did not differ among women with short versus long duration of the third stage. CONCLUSION: Uterine activity during the third stage is comparable and as intense as that occurring during the second stage. Third stage length cannot be predicted by contraction intensity during the second or third stage of labor.

Abdominal muscle electrical activity during labor expulsive stage: a cross-sectional study / Atividade elétrica muscular abdominal durante os esforços expulsivos do parto: um estudo transversal

BACKGROUND: During the second stage of labor, the progression of the fetal expulsion depends on many factors related to maternal and fetal parameters, including the voluntary abdominal pushing. OBJECTIVES: This study aimed to correlate the maternal and fetal parameters that may influence the voluntary maternal pushes during the second stage of labor by using surface electromyography. METHODS: The electromyographic activity of the rectus abdominis and external oblique muscles were measured during the second stage of labor in 24 Brazilian pregnant women. The diastasis of the rectus abdominis, the body mass index and the uterine fundal height were analyzed as maternal parameters and the fetal weight, cephalic circumference, APGAR scores and arterial pH and CO2 were analyzed as fetal parameters. The oxytocin usage and the expulsive phase duration were considered. RESULTS: A negative correlation between the rectus abdominis diastasis and the rectus abdomini muscle electromyographic parameters was found (r=-0.407 p=0.04). No statistically significant correlations were found among the rectus abdominis and external oblique muscles electromyography and the other maternal or fetal parameters, as well as among expulsive phase duration and the oxytocin usage. CONCLUSIONS: This study suggests that the rectus abdominis diastasis may be an influential parameter in generating voluntary pushes during the second stage of labor, however it cannot be considered the only necessary parameter for a successful labor.

CONTEXTUALIZAÇÃO: Durante o segundo estágio do parto, a progressão da expulsão fetal depende de vários fatores ligados a parâmetros maternos e fetais, dentre eles, o esforço abdominal voluntário. OBJETIVOS: Correlacionar os parâmetros maternos e fetais que podem influenciar os esforços voluntários durante a fase do segundo estágio do parto por meio da eletromiografia de superfície. MÉTODOS: As atividades eletromiográficas dos músculos retoabdominal e oblíquo externo foram medidas durante o segundo estágio do parto em 24 gestantes. A diástase do músculo retoabdominal, o índice de massa corpórea e a altura de fundo de útero foram analisados como parâmetros maternos, e o peso fetal, o perímetro cefálico, os índices de Apgar e o pH e pCO2 arterial foram analisados como parâmetros fetais. O uso de ocitocina e o tempo do período expulsivo foram considerados. RESULTADOS: Encontrou-se uma correlação negativa entre a diástase umbilical e os parâmetros eletromiográficos do músculo retoabdominal (p=0,04; r=-0,407). Não se encontrou correlação significativa entre a eletromiografia dos músculos retoabdominal e oblíquo externo e os demais parâmetros maternos e fetais, bem como entre o tempo do período expulsivo e o uso da ocitocina. CONCLUSÕES: O presente estudo sugere que a diástase umbilical pode ser um parâmetro influente na geração de esforços voluntários durante o período expulsivo do parto, porém não deve ser considerada de forma isolada para o sucesso do andamento do trabalho de parto.

The potential of hormones and selective oestrogen receptor modulators in preventing voiding dysfunction in rats.

OBJECTIVE: To investigate whether oestrogen, selective oestrogen receptor modulators (SERMs), and growth hormone (GH) can prevent the development of voiding dysfunction in a postpartum postmenopausal rat model of voiding dysfunction. MATERIALS AND METHODS: Immediately after spontaneous delivery, nine primiparous Sprague-Dawley rats served as uninjured controls (sham group) and 54 underwent intravaginal balloon dilation. On day 7, the 54 subject rats underwent bilateral ovariectomy. A week later, six treatment groups of nine rats were randomized to receive: normal saline (injured control group), 17beta-oestradiol (E(2)), raloxifene, levormeloxifene, GH, or GH + E(2). The treatment groups received daily subcutaneous injections for 3 weeks. The effects of hormone treatment were examined by conscious cystometry at the end of the study. Voiding dysfunction was defined to include overactive bladder and sphincter deficiency. RESULTS: The sham rats had a mean (sd) voiding frequency of 3 (0.87) times in 10 min and a bladder capacity of 0.43 (0.13) mL with smooth cystometry curves. The number of rats in each treatment group (each group contained nine rats) that had voiding dysfunction was as follows: E(2), three; raloxifene, six; levormeloxifene, four; and controls, four (P > 0.05 among the groups). Only one rat in the GH-treated group and no rats in the GH + E(2)-treated group had voiding dysfunction, which was significantly less in the GH + E(2)-treated group than in the controls (P = 0.041). CONCLUSION: This functional data suggest that the development of voiding dysfunction can be prevented by short-term administration of GH and GH + E(2) in our rat model. SERMs and E(2) alone seem to have no therapeutic effect.

Monitoring pudendal nerve function during labor.

BACKGROUND: To determine methodology and feasibility of pudendal nerve monitoring during labor and delivery. METHODS: With Institutional Review Board approval, 13 low-risk, singleton pregnant women were recruited. The latency and amplitude of the perineal branch of the pudendal nerve compound muscle action potential were recorded during the second stage of labor and after delivery. With the first two patients, a wire electrode was used to stimulate the pudendal nerve continuously at the ischial spine. For the remaining 11 patients, a St. Mark's electrode was used to stimulate transvaginally. Aurethral ring electrode on a 14 French foley catheter monitored the response from the urethral sphincter. All patients received prophylactic antibiotics. EXPERIENCE: Twelve patients delivered vaginally, and one by cesarean. In two patients, continuous wire stimulation showed a gradual decrease in amplitude. Changes were minimal over 15-minute intervals. Wire electrode placement was technically difficult and dislodged easily. With the remaining 11 patients, all had data available for interpretation, and of the 85 potential perineal branch of the pudendal nerve compound muscle action potentials, 53 were obtained. No patients developed cystitis. CONCLUSION: Intrapartum assessment of pudendal nerve function is feasible. Continuous wire stimulation is technically more difficult and does not provide additional information beyond that available from intermittent stimulation.

The acute release of maternal prolactin by instrumental cervical dilatation simulates the second stage of labor.

OBJECTIVE: We hypothesize that artificial stimulation of the cervix causes an acute secretion of maternal prolactin (PRL) that mimics PRL secretion during the second stage of human labor. METHODS: Eighteen women scheduled for first-trimester therapeutic abortion had a blood sample drawn at the following times: before and after laminaria tent (LT) insertion for cervical ripening, 18-24 hours later upon entry in the procedure room, after LT removal, during instrumental cervical dilatation and uterine evacuation by suction curretage, soon after evacuation, and 1/2 hour and 1 hour after evacuation. Local cervical anesthesia, intravenous analgesics, and sedation were administered before the procedure. Blood serum was assayed for PRL, human chorionic gonadotropin (hCG), and estradiol. RESULTS: The initial PRL levels were 34 ng/mL +/- 4.2 standard error of the mean (SEM) and did not change after 18-24 hours of LT placement nor after LT removal. However, PRL increased significantly (t = 5.8; P = .00001) over basal levels by 204% +/- 15 at the time of instrumental dilatation and rose to 378% +/- 33 at 1/2 hour postevacuation. After 1 hour, PRL had declined to 173% +/- 10%. Serum levels of estradiol and hCG changed only after evacuation. CONCLUSION: Artificial stimulation of the cervix causes an immediate surge in PRL levels. We suggest that the acute increase in pituitary PRL secretion that occurs during the second stage of labor results from a neural signal from the cervix and not from endocrine changes associated with labor.

Pattern of cervical dilatation in previous lower segment caesarean section patients.

The pattern of cervical dilatation during labour in 100 patients with previous lower segment caesarean section (LSCS) was determined in a prospective partographic study. Eighty-four subjects delivered successfully by vaginal route. The mean initial dilatation rate (IDR) and average dilatation rate (ADR) were 0.884 cm/hour and 1.255 cm/hour respectively. The mean IDR and ADR of the patients who delivered vaginally were 0.96 cm/hour and 1.41 cm/hour respectively, while of those who required repeat LSCS mean IDR was 0.44 cm/hour and mean ADR was 0.42 cm/hour. Hence ADR in cases who required repeat LSCS was significantly slower as compared to those who delivered vaginally (p < 0.01). Most (87.5%) of the cases who required repeat LSCS crossed the alert line as compared to 34.5% of patients who delivered vaginally. The mean admission delivery interval (ADI) was 9.45 +/- 4.29 hours in patients with no previous vaginal delivery and 8.02 +/- 4.83 hours in patients with previous vaginal delivery. The mean durations of 1st and 2nd stages of labour were 11.8 +/- 5.35 hours and 29.4 +/- 27.3 minutes respectively. It is concluded that partographic evaluation is an important aspect in management of labour of such patients.

PIP: The feasibility of vaginal delivery after a previous lower-segment cesarean section (LSCS) delivery was investigated in a prospective partographic study of 100 women with a LSCS history. Cervical dilatation, effacement, and fetal head descent were evaluated every 2-4 hours by vaginal examination and the results were recorded on the labor partogram. 84 of these women were able to deliver vaginally; the remaining 16 required repeat LSCS. The main indications for repeat LSCS were fetal distress (6 cases) and right occipitoposterior presentation (4 cases). The mean duration of the first stage of labor was significantly prolonged in women with one previous LSCS only compared with those with intercurrent vaginal deliveries. The mean initial and average dilatation rates were 0.96 and 1.41 cm/hour, respectively, among women who delivered vaginally and 0.44 and 0.42 cm/hour, respectively, in those who had a repeat LSCS. All women with an initial dilatation rate of 1 cm or more per hour and 96% of those with an average dilatation rate of 0.5 cm or more per hour delivered vaginally. 87.5% of women who required LSCS crossed the partogram's alert line compared with 34.5% of those who delivered vaginally. These findings confirm that vaginal delivery after cesarean section is both safe and successful in properly selected women. Partographic evaluation is an important tool in the management of the labor and delivery of previous LSCS patients.

[Pre-pathologic-pathologic cardiotocographic pattern in second stage of labor. Analysis of the incidence of acidosis and recommendations for fetal blood gas analysis]. / Präpathologisch-pathologische kardiotokographische Muster in der Austreibungsperiode. Analyse der Azidosefrequenz und Empfehlungen zur Fetalblutanalyse.

Fetal heart rate (FHR) patterns from 746 consecutive, documented vaginal deliveries within a 1 year period were reported on using the Hammacher Score. Characteristic FHR patterns were described and the frequency of acidosis calculated. FHR score, the single FHR parameters, baseline (BL), floatingline (FL) and oscillation type (OT) and the acid-base balance of the neonate were submitted to a correlation analysis according to Spearman. FHR patterns reported as ominous (FHR score > or = 5) were observed in 25.9% and were associated with a frequency of acidosis (pHUA < or = 7.20) of 38.1% Suspicious fetal heart rate patterns (FHR score 3-4) were seen in 60%, here the frequency of acidosis was 8.5%. With the inclusion of decelerations by the parameter FL an increased frequency of acidosis of 29% was registered only when 4 points were allocated. Total FHR score and the score parameter baseline (BL) correlated closest with the pH changes at the end of birth. Tachycardic FHR patterns showed the highest frequency of acidosis (55%) and ominous tracings (83%). The commonest FHR pattern, normocardia with decelerations (48%) exhibited only a low frequency of acidosis (8%) and ominous tracings (15%) with an average pH value of 7.27 +/- 0.08. To prevent an unnecessary operative delivery in the presence of an ominous FHR finding, whether in the late first stage or early second stage when birth is not imminent, a fetal blood analysis should be carried out. With a suspiciously assessed fetal heart rate pattern the fetal blood analysis will only rarely reveal a severe acidosis (pHUA < or = 7.10).

A second look at the second stage of labor.

This article focuses on the primary clinical issues during the second stage of labor: diagnosis, duration, maternal bearing-down efforts, and fetal descent, and ways to help women with their expulsive efforts during this time. A pattern of progression for the second stage/expulsive phase of labor is presented, with an emphasis on the importance of delaying direction to or encouragement of the woman to push until the obstetric conditions are optimal for descent and the women has entered the active phase of the second stage. Ongoing assessment of fetal status and descent, the quality of uterine contractions, and maternal condition are emphasized, rather than arbitrary time limits for the second stage. The use of various care practices, including maternal position and alternative bearing-down techniques, which optimize maternal and fetal outcomes, is described. Finally, women's concerns about this major life experience are considered in the context of the care that they receive during the second stage of labor.

Partograma con curvas de alerta en pacientes del cono sur de Lima / Partograph with alert linen in pregnancy patients of Lima

Durante los años 1991 y 1992, en el "Hospital María Auxiliadora" se escogió 1500 parturientas, de las cuales 587 fueron nuliparas y 913 multiparas. A todas se les aplicó los siguientes criterios: cronologia del embarazo entre 37 y 41 semanas, ausencia de patología, parto de inicio y evolución espontanea, no medicación durante el parto, pelvis normal, presentación cefálica y recien nacido de 2500 a 4000 gramos con score de Apgar mayor de 6 al nacer. Despues de aplicar estos criterios, reunimos finalmente 317 nuliparas (209 con membranas integras y 108 con membranas rotas) y 306 multiparas (231 con membranas integras y 75 con membranas rotas). Todas las pacientes estuvieron en decubito durante el trabajo de parto y fueron controladas en el centro obstetrico utilizando el partograma diseñado por el CLAP y cuidando de hacer los registros gráficos a partir de los 4 a 5 cms de dilatación cervical en adelante. Los datos de dilatación del cuello uterino en relación al tiempo fueron procesados en computadoras y se calculo el percentil 10, o sea el tiempo máximo aceptable que demora la dilatación cervical de centimetro a centimetro hasta el periodo expulsivo, y con ellos se construyo las curvas de alerta para cada uno de los cuatros subgrupos. La pendiente seguida en el proceso de dilatación del cuello uterino es la misma en nuestras parturientas que las reportadas por el CLAP, pero los tiempos estan recostados un poco hacia la derecha, particularmente en el subgrupo de nuliparas con membranas integras