A multisite study to develop and validate first trimester, circulating microparticle biomarkers for tiered risk stratification of spontaneous preterm birth in nulliparas.

BACKGROUND: Despite much research, advances in early prediction of spontaneous preterm birth (sPTB) has been slow. The evolving field of circulating microparticle (CMP) biology may identify novel blood-based, and clinically useful, biomarkers. OBJECTIVE: To test the ability of a previously identified, 7-marker set of CMP-derived proteins from the first trimester of pregnancy, in the form of an in vitro diagnostic multivariate index assay (IVDMIA), to stratify pregnant patients according to their risk for sPTB. STUDY DESIGN: We employed a previously validated set of CMP protein biomarkers, utilizing mass spectrometry assays and a nested case-control design in a subset of participants from the Nulliparous Pregnancy Outcomes Study: monitoring mothers-to-be (nuMoM2b). We evaluated these biomarkers in the form of an IVDMIA to predict risk for sPTB at different gestational ages. Plasma samples collected at 9- to 13-weeks' gestation were analyzed. The IVDMIA assigned subjects to 1 of 3 sPTB risk categories: low risk (LR), moderate risk (MR), or high risk (HR). Independent validation on a set-aside set confirmed the IVDMIA's performance in risk stratification. RESULTS: Samples from 400 participants from the nuMoM2b cohort were used for the study; of these, 160 delivered<37 weeks and 240 delivered at term. Through Monte Carlo simulation in which the validation results were adjusted based on actual weekly sPTB incidence rates in the nuMoM2b cohort, the IVDMIA stratifications demonstrated statistically significant differences among the risk groups in time-to-event (birth) analysis (P<.0001). The incidence-rate adjusted cumulative risks of sPTB at ≤32 weeks' gestation were 0.4%, 1.6%, and 7.5%, respectively for the LR, MR, and HR groups, respectively. Compared to the LR group, the corresponding risk ratios of the IVDMIA assigned MR and HR group were 4.25 (95% confidence interval [CI] 2.2-7.9) and 19.92 (95% CI 10.4-37.4), respectively. CONCLUSION: A first trimester CMP protein biomarker panel can be used to stratify risk for sPTB at different gestational ages. Such a multitiered stratification tool could be used to assess risk early in pregnancy to enable timely clinical management and interventions, and, ultimately, to enable the development of tailored care pathways for sPTB prevention.

Menstrual cup use and intrauterine device expulsion in a copper intrauterine device randomized trial.

OBJECTIVE: To evaluate menstrual cup use and intrauterine device (IUD) expulsion. STUDY DESIGN: We performed a secondary analysis of a 3-year contraceptive efficacy trial comparing two copper 380 mm2 IUDs. Investigators randomized participants approximately 1:4 to the TCu380A or NTCu380-Mini IUD. Approximately 12 months after enrollment began, we advised participants against menstrual cup use due to observed IUD expulsions in cup users. We evaluated IUD expulsion (including spontaneous partial and complete expulsion and accidental self-removal) at 12 and 36 months. We used multivariable logistic regression to evaluate IUD expulsion by age, baseline menstrual volume, body mass index, IUD type, menstrual cup use, parity, and uterine length. RESULTS: This analysis included 1046 participants (203 TCu380A and 843 NTCu380-Mini), with 879 (84.0%) nulliparas. Through 12 and 36 months, expulsion occurred in 74 (7.1%, 95% CI 5.5-8.6%) and 133 (12.7%, 95% CI 10.7-14.7%) participants, respectively. Overall, 250 (23.9%) reported menstrual cup use. More menstrual cup users than non-users experienced expulsion through 12 months (32/203 [15.8%] vs. 42/843 [5.0%]) and 36 months (58/250 [23.2%] vs. 75/796 [9.4%]). Through 36 months, NTCu380-Mini menstrual cup users had higher expulsion odds, while TCu380A cup users did not. Menstrual cup users more frequently experienced accidental self-removal than non-users in participants using the TCu380A (3/53 [5.7%] vs. 0/150 [0.0%]) and the NTCu380-Mini (20/197 [10.2%] vs. 7/646 [1.1%]). In multivariable regression, we found increased odds of expulsion through 36 months in participants using menstrual cups with the NTCu380-Mini (aOR 3.13, 95% CI 1.16-8.46) and <25 years (aOR 1.59, 95% CI 1.07-2.34). CONCLUSIONS: We found higher odds of IUD expulsion with menstrual cup and concurrent NTCu380-Mini IUD use over 36 months of use, but not with concurrent TCu380A IUD use. Menstrual cup users experienced higher likelihood of accidental self-removal regardless of IUD type. IMPLICATIONS: Menstrual cup and NTCu380-Mini use may increase IUD expulsion risk and may increase accidental self-removal risk with TCu380A and NTCu380-Mini use. Clinicians should advise patients of these risks and consider warning patients using an IUD shaped like the NTCu380-Mini (Nova-T frames) of expulsion risk with menstrual cup use.

Electric massage chairs reduce labor pain in nulliparous patients: a randomized crossover trial.

BACKGROUND: Labor pain varies significantly among pregnant women, ranging from mild to extremely distressing. Nonpharmacologic pain relief methods during vaginal birth are increasingly popular, either as a complement to pharmacologic agents or, at times, as the primary method of pain relief. Multiple trials have reported that manual or by-hand massage reduces labor pain. The effectiveness of full-body mechanical massage using electric massage chairs on labor pain remains unexplored. OBJECTIVE: This study aimed to evaluate mechanical massage using an electric massage chair on labor pain in nulliparous women. STUDY DESIGN: A randomized counterbalanced crossover trial was conducted in a university hospital in Malaysia from August 2022 to February 2023. Eligible nulliparas in labor with a minimum labor pain score of 5 (0-10 numerical rating scale) were enrolled. Participants were randomized to 30 minutes on the massage chair with mechanical massage followed by 30 minutes on the massage chair without mechanical massage or the other way around in the massage sequence. The primary outcome was a change in pain score comparing pain with and without mechanical massage as a paired comparison for the entire trial participants. The secondary outcomes were across arms analyses of maternal and neonatal outcomes. The paired t test, t test, Mann-Whitney U test, chi-square test, and Fisher exact test were used as appropriate for the data. RESULTS: Overall, 208 women were randomized: 104 to each intervention. Data were available from 204 participants (103 randomized to massage first and 101 to no massage first). The primary outcomes of change in labor pain scores (0-10 numerical rating scale) after massage and no massage (all participants included after crossover, paired t test analysis) were 4.51±2.30 and 5.38±2.10, respectively (mean difference, -0.87; 95% confidence interval, -1.14 to -0.59; P<.001), a significant reduction in pain score after electric chair mechanical massage compared with no massage. On the across randomized arms secondary analyses, labor pain scores after their first massage chair session were 4.35±2.52 (randomized to massage first, received massage as initial intervention) and 5.66±1.73 (randomized to no massage first, received no massage as initial intervention) (mean difference, -1.31; 95% confidence interval, -1.91 to -0.748; P<.001), a significant reduction after mechanical massage. Other distal maternal outcomes (mode of delivery, labor analgesia, duration of labor, and maternal agreement that mechanical massage is effective for labor pain) and neonatal outcomes (Apgar scores at 1 and 5 minutes, cord artery blood pH and base excess, and neonatal admission) were not different across randomized arms. CONCLUSION: Mechanical massage using an electric massage chair significantly reduced labor pain, offering a potential nonpharmacologic pain management option during labor.

The effect of pelvic floor muscle training and perineal massage in late pregnancy on postpartum pelvic floor function in nulliparas: A randomised controlled clinical trial.

OBJECTIVE: To evaluate the effects of pelvic floor muscle training (PFMT) and perineal massage during late pregnancy on postpartum pelvic floor function in nulliparas. DESIGN: Randomised controlled trial. SETTING: The Peking University First Hospital, a teaching hospital in China. PARTICIPANTS: Two-hundred nulliparas were included. INTERVENTIONS: Nulliparas were randomised into four groups in a 1:1:1:1 ratio. Group A, control; group B, perineal massage; group C, pelvic floor muscle training (PFMT); group D, perineal massage and PFMT. The intervention group received the corresponding intervention from 34 weeks of gestation until delivery. MEASUREMENTS: Changes in pelvic floor function from 34 weeks of gestation to 6 weeks postpartum were assessed using pelvic floor electromyography (EMG), pelvic organ prolapse quantitation (POP-Q), and pelvic floor distress inventory-20 (PFDI-20). RESULTS: Those with PFMT (groups C and D) had a smaller decline in pelvic floor EMG of fibre II than those without PFMT (groups A and B) [- 0.2 (- 7.1, 11.3) µV vs 6.1 (- 0.2, 15.2) µV, P = 0.040]. The same scenario was observed in the pelvic floor EMG of fibre I. The Aa point measurement differences of those with PFMT (groups C and D) were smaller than those without PFMT (groups A and B) [0.0 (0.0, 2.0) cm vs 1.0 (0.0, 3.0) cm, P = 0.006]. The same result was observed for point Ba. No difference was observed in EMG and POP-Q in nulliparas with (groups B and D) or without perineal massage (groups A and C). No differences were observed in PFDI-20 scores. KEY CONCLUSIONS: PFMT during late pregnancy enhanced pelvic floor EMG, while perineal massage alone or PFMT combined with perineal massage did not. IMPLICATIONS FOR PRACTICE: PFMT in late pregnancy enhances pelvic floor function.

Meconium-stained amniotic fluid and neonatal morbidity in nulliparous patients with prolonged pregnancy.

INTRODUCTION: Our objective was to study the strength of the association between meconium-stained amniotic fluid and severe morbidity among neonates of nulliparas with prolonged pregnancies. MATERIAL AND METHODS: This was a secondary analysis of the NOCETER randomized trial that took place between 2009 and 2012 in which 11 French maternity units included 1373 nulliparas at 41+0 weeks of gestation onwards with a single live fetus in cephalic presentation. This analysis excluded patients with a cesarean delivery before labor and those with bloody amniotic fluid or of unreported consistency. The principal end point was a composite criterion of severe neonatal morbidity (neonatal death, 5-minute Apgar <7, convulsions in the first 24 h, meconium aspiration syndrome, mechanical ventilation ≥24 h, or neonatal intensive care unit admission for 5 days or more). The neonatal outcomes of pregnancies with thin or thick meconium-stained amniotic fluid were compared with those with normal amniotic fluid. The association between the consistency of the amniotic fluid and neonatal morbidity was tested by univariate and then multivariate analysis adjusted for gestational age at birth, duration of labor, and country of birth. RESULTS: This study included 1274 patients: 803 (63%) in the group with normal amniotic fluid, 196 (15.4%) in the thin amniotic fluid group, and 275 (21.6%) in the thick amniotic fluid group. The neonates of patients with thick amniotic fluid had higher rates of neonatal morbidity than those of patients with normal amniotic fluid (7.3% vs. 2.2%; p < 0.001; adjusted relative risk [aRR] 3.3, 95% confidence interval [CI] 1.7-6.3), but those of patients with thin amniotic fluid did not (3.1% vs. 2.2%; p = 0.50; aRR 1.0, 95% CI, 0.4-2.7). CONCLUSIONS: Among nulliparas at 41+0 weeks onwards, only thick meconium-stained amniotic fluid is associated with a higher rate of severe neonatal morbidity.

Micturition in the toilet compared with bedpan in laboring Nulliparas: a randomized controlled trial.

BACKGROUND: Bladder overdistension in labor may lead to prolonged postpartum urinary retention. We hypothesized that nulliparas mobilizing to toilet is more likely to achieve satisfactory micturition. METHODS: One hundred sixteen (58 in each arm) term nulliparas in labor with filled bladders were randomized to mobilizing to the toilet or using bedpan to micturate. Primary outcome was satisfactory micturition defined as ultrasound derived post-void bladder volume < 150 ml. Following unsatisfactory micturition, participants crossover to the opposed intervention. Participants were catheterized if after crossover, residual bladder volume was ≥250 ml. RESULTS: Satisfactory micturition rates were 55/58 (95%) vs. 43/58 (74%) RR 1.28 95%CI 1.08-1.51 NNTb 4.8 95%CI 3.0-12.4 P = 0.008, failure to micturate 1/58 (2%) vs. 8/58 (14%) RR 0.13 95%CI 0.02-0.97 NNTb 8.3 95%CI 4.6-38.7 P = 0.047. After cross over following unsatisfactory bladder voiding, satisfactory micturition rates were 0/3 (0%) vs 13/15 (87%) P = 0.024, bladder catheterization rates were 3/58 (5%) vs. 2/58 (4%) RR 95%CI 1.5 (0.26-8.65) P = 0.648, maternal satisfaction with allocated intervention 55/58 (95%) vs. 9/58 (16%) RR 95%CI 6.1 (3.3-11.2) NNTb 95%CI 1.3 (1.1-1.5) P <  0.0001 and preference for mobilizing to the toilet if micturition was needed again during labor 55/58 (95%) vs. 53/58 (92%) for mobilizing to the toilet compared to bedpan use arms respectively. Labor and neonatal outcomes were similar. CONCLUSION: Satisfactory micturition was more frequently achieved with mobilization to the toilet than bedpan use. Women in both arms overwhelmingly prefer to mobilize to the toilet to urinate. TRIAL REGISTRATION: This study was registered with ISRCTN on 17/07/2019 with trial identification number: ISRCTN17787339 . First participant was recruited on 31/07/2019. The last patient was recruited on 18/12/2019.

Combined perineal massage and warm compress compared to massage alone during active second stage of labour in nulliparas: A randomised trial.

OBJECTIVE: To evaluate the effect of combined perineal massage and warm compress to the perineum (MassComp) compared to perineal massage alone during pushing in the second stage of labour in reducing perineal trauma requiring suturing in nulliparas. STUDY DESIGN: A randomised trial was performed in a University hospital, Malaysia from June 2020 to May 2021. 281 term nulliparas who were about to start pushing in the second stage of labour were randomised to combined perineal massage and warm compress or perineal massage alone to the perineum. Primary outcome was suturing for perineal injury (episiotomy or tear). The Chi-square test was used to analyse categorical data, Student t test to compare means and distributions for normally distributed continuous data and Mann Whitney U test for appropriate ordinal data. RESULTS: Data from 277 participants (140 MassComp arm, 137 perineal massage alone arm) were analysed based on modified intention to treat basis. Perineal suturing rates were 133/140(95.0%) [MassComp] vs. 128/137(93.4%) [perineal massage alone] RR 1.02(95%CI 0.96-1.08), P = 0.615. Of the secondary outcomes, Likert scale response to recommend allocated treatment to a friend was 103/140(73.6%) vs. 84/137(61.3%) RR 1.20(95%CI 1.02-1.42)NNTb 9(95%CI 4.3-76.4) P = 0.029, participants' satisfaction with care (visual numerical rating scale 0-10) median [interquartile range] 6[6-8] vs. 6[5-8] P = 0.392, intervention to delivery intervals were 25[15-35] vs. 19[14-30] minutes P = 0.012, major perineal injury (episiotomy, second degree or higher tears) rates 116/140(82.9%) vs. 119/137(86.9%) RR 0.95(95%CI 0.86-1.05), P = 0.404, episiotomy rates 97/140(69.3%) vs. 97/140(70.8%) RR 0.98(95%CI 0.84-1.14), P = 0.795, and spontaneous vaginal delivery rates 103/140(73.6%) vs. 106/137(77.4%) RR 0.95(95%CI 0.83-1.09), P = 0.488 for MassComp vs. perineal massage alone respectively. Other maternal and neonatal outcomes were not significantly different. CONCLUSION: Massage and warm compress during pushing did not decrease the likelihood of perineal injury requiring suturing in nulliparas when compared to perineal massage alone. Women were more likely to recommend massage and warm compress during pushing to a friend.

Development of a scale for parent-to-baby emotions: Concepts, design, and factor structure.

Aim: Although infant crying is a prerequisite for a baby's survival, it often leads to negative consequences for the caregivers. We hypothesized that this would be mediated by a primary emotion that we feel directly in response to an internal or external event. Hence, this study aimed to develop a new scale to measure basic and self-conscious emotions as primary emotions towards an infant's cry. Methods: We conducted a cross-sectional web survey including the scale for parent-to-baby emotions (SPBE)-with 73 items elicited from a literature review-targeted at mothers at 1 month after childbirth (N = 879). A series of explanatory and confirmatory factor analyses were conducted using item parcels. Internal consistency of the scale was calculated by omega indices. We also examined measurement invariance of the scale. Results: The theory-driven six basic emotions bifactor model (comparative fit index [CFI] = 0.968, root mean square of error approximation [RMSEA] = 0.070) and four self-conscious emotions factor model (CFI = 0.973, RMSEA = 0.079) were judged as the best models. They were stable in terms of configural, measurement, and structural invariances across parity. Conclusion: The SPBE we created is a psychometrically robust measure to assess the primary emotions under the rubric of parent-to-baby emotions. It is a promising tool for measuring parent-to-baby emotions in clinical and research settings.

Chorioamnionitis after premature rupture of membranes in nulliparas undergoing labor induction: prostaglandin E2 vs. oxytocin.

OBJECTIVES: To assess the risk of chorioamnionitis in nulliparous, term, singleton, vertex (NTSV) pregnancies with premature rupture of membranes (PROM) and an unfavorable cervix undergoing labor induction with either prostaglandin E2 (PGE2) or oxytocin only. METHODS: Retrospective cohort of NTSV pregnancies presenting with PROM who underwent labor induction with either PGE2 (n=94) or oxytocin (n=181) between October 2015 and March 2019. The primary outcome of chorioamnionitis was compared between the two groups. Statistical analysis included Chi-squared and Wilcoxon rank-sum tests, as well as logistic regression. For time to delivery, a Cox proportional hazard regression was used to determine the hazard ratio (HR) and adjusted HR (aHR). RESULTS: Baseline characteristics were similar between the two groups. Cervical ripening with PGE2 was associated with an increased rate of chorioamnionitis (18.1 vs. 6.1%; aOR 4.14, p=0.001), increased neonatal intensive care unit admissions (20.2 vs. 9.9%; aOR 2.4, p=0.02), longer time interval from PROM to delivery (24.4 vs. 17.9 h; aHR 0.56, p=<0.0001), and lower incidence of meconium (7.4 vs. 14.4%; aOR 0.26, p=0.01), compared to the oxytocin group. CONCLUSIONS: Based on our data, the use of oxytocin appears both superior and safer compared to PGE2 in NTSV pregnancies with PROM undergoing labor induction.

Combined massage and warm compress to the perineum during active second stage of labor in nulliparas: A randomized trial.

OBJECTIVE: To evaluate the combined effect of massage and warm compress to the perineum (MassComp) compared with standard "hands-off" in the second stage of labor. METHODS: A randomized trial was conducted in a University hospital in Malaysia. Nulliparous women at term who were about to start pushing were randomized to massage during pushing and warm compress to the perineum in between pushes or to standard "hands-off" care. Primary outcome was suturing for perineal injury (episiotomy or tear). RESULTS: A total of 156 participants were analyzed based on intention to treat. Perineal repair rates were 53/79 (67%) for MassComp versus 70/77 (91%) for control (relative risk [RR] 0.72, 95% confidence interval [CI] 0.61-0.98, number needed to treat for an additional beneficial outcome [NNTb ] 5, 95% CI 2.83-8.62, P < 0.001). Of the secondary outcomes, participants' satisfaction with care (visual numerical rating scale 0-10; 8.3 ± 1.2 vs 7.8 ± 1.2, P = 0.014), major perineal injury (second degree or higher) rates 34/79 (43%) versus 51/77 (66%) (RR 0.72, 95% CI 0.58-0.97, NNTb 5, 95% CI 2.61-12.56, P = 0.004), episiotomy rates 28/79 (37%) versus 40/77 (53%) (RR 0.72, 95% CI 0.52-0.98, NNTb 8, 95% CI 3.63-36.46, P = 0.043), intervention to delivery intervals 29.5 ± 13.6 versus 27.9 ± 13.8 minutes (P = 0.472) and spontaneous vaginal delivery rates 63/79 (79.7%) versus 56/77 (72.7%) (RR 1.11, 95% CI 0.92-1.34, P = 0.306) for MassComp versus control, respectively. CONCLUSION: Massage and warm compress during pushing decreased the perineal suturing, major perineal injury, and episiotomy rates and improved maternal satisfaction. CLINICAL TRIAL REGISTRATION: https://doi.org/10.1186/ISRCTN42773879.

Speculum versus digital insertion of Foley catheter for induction of labor in Nulliparas with unripe cervix: a randomized controlled trial.

BACKGROUND: Induction of labor (IoL) is an increasingly common obstetric procedure. Foley catheter IoL is recommended by WHO. It is associated with the lowest rate of uterine hyperstimulation syndrome and similar duration to delivery and vaginal delivery rate compared to other methods. Insertion is typically via speculum but digital insertion has been reported to be faster, better tolerated and with similar universal insertion success compared to speculum insertion in a mixed population of nulliparas and multiparas. Transcervical procedure is more challenging in nulliparas and when the cervix is unripe. We evaluated the ease and tolerability of digital compared to speculum insertion of Foley catheter for induction of labor in nulliparas with unripe cervixes. METHODS: A randomized trial was performed in a university hospital in Malaysia. Participants were nulliparas at term with unripe cervixes (Bishop Score ≤ 5) admitted for IoL who were randomized to digital or speculum-aided transcervical Foley catheter insertion in lithotomy position. Primary outcomes were insertion duration, pain score [11-point Visual Numerical Rating Scale (VNRS)], and failure. All primary outcomes were recorded after the first insertion. RESULTS: Data from 86 participants were analysed. Insertion duration (with standard deviation) was 2.72 ± 1.85 vs. 2.25 ± 0.55 min p = 0.12, pain score (VNRS) median [interquartile range] 3.5 [2-5] vs. 3 [2-5] p = 0.72 and failure 2/42 (5%) vs. 0/44 (0%) p = 0.24 for digital vs speculum respectively. There was no significant difference found between the two groups for all three primary outcomes. Induction to delivery 30.7 ± 9.4 vs 29.6 ± 11.5 h p = 0.64, Cesarean section 25/60 (64%) vs 28/64 (60%) RR 0.9 95% CI p = 0.7 and maternal satisfaction VNRS score with the birth process 7 [IQR 6-8] vs 7 [7-8] p = 0.97 for digital vs. speculum arms respectively. Other labor, delivery and neonatal secondary outcomes were not significantly different. CONCLUSION: Digital and speculum insertion in nulliparas with unripe cervixes had similar insertion performance. As digital insertion required less equipment and consumables, it could be the preferred insertion method for the equally adept and the insertion technique to train towards. TRIAL REGISTRATION: This trial was registered with ISRCTN registration number 13804902 on 15 November 2017.

Lithuania's experience in reducing caesarean sections among nulliparas: the impact of the quality improvement course.

BACKGROUND: To evaluate the role of the quality improvement course (QIC) to reduce the caesarean section (CS) rate among nulliparas (Robson groups 1 and 2) and to find out which group of women have reduced the CS rate following attendance at the course. METHODS: The QIC was organized in 2015. For the evaluation of the CS rate after the OIC, deliveries from the selected hospitals in 2014 and 2016 were compared using MS EXCEL and SPSS 23.0. RESULTS: Nulliparas accounted for 44.6% (3585/8046) and 42.9% (3628/8460) of all the deliveries in 2014 and 2016 years, respectively. The CS rate among nulliparas decreased from 19.0% (665/3502) in 2014 to 16.8% (593/3526) in 2016 (p = 0.018). The greatest decrease in absolute contribution to the overall CS rate was recorded in group 1 (p = 0.08). Perinatal mortality was 3.1 in 2014 and 3.9 in 2016 per 1000 deliveries (p = 0.569). CONCLUSION: The QIC has helped to reduce the CS rate among nulliparas without a negative influence on perinatal mortality. The greatest decrease in the overall CS rate was recorded among nulliparous women who were treated with oxytocin and managed to reach a full cervical dilatation.

Contextual-relationship and stress-related factors of postpartum depression symptoms in nulliparas: a prospective study from Ljubljana, Slovenia.

BACKGROUND: For a significant proportion of women, postpartum depression (PPD) is the first mood episode in their lives, yet its aetiology still remains unclear. Insecure attachment in close adult relationships is considered to be a risk factor for depressive symptoms. This study aimed to gain further insight into the risk factors for postpartum depression symptoms (PPDS) of nulliparas in Slovenia and to examine vulnerability to developing depressive symptoms, with an emphasis on contextual and stress-related characteristics. METHODS: The sample consisted of 156 nulliparas in the third trimester of pregnancy enrolled in a childbirth preparation program. The following instruments were applied: Experiences in Close Relationships-Revised, the Edinburgh Postpartum Depression Scale (EPDS), the Zung Anxiety Scale and a question battery designed by the research team including questions about emotional support and work-related stress. Logistic regression was used to test the association between demographic, social, environmental, personality and attachment variables and PPD of nulliparas (EPDS ≥10), controlling for baseline (prepartum) depression score. A multivariable linear regression model was built with the postpartum EPDS continuous score as a dependent variable. RESULTS: 28/156 (17,9%) were evaluated as being at risk for depression (EPDS≥10) in the last trimester and 25/156 (16%) at six weeks postpartum. The results of the logistic regression model controlled for prepartum depression score showed that increased risk for developing PPDS was associated with anxiety level postpartum, intimate-partner-attachment anxiety postpartum, and elevated stress due to loss of employment or an unsuccessful search for employment in the previous year. The results of the multivariable regression model, however, showed the association with education and postpartum anxiety with PPDS continuous score; EPDS after giving birth was higher for more educated and more anxious primiparas. CONCLUSIONS: Our findings demonstrate the importance of anxiety symptoms and higher education level in assessments of nulliparas' mental health. The results of our study show and confirm the results of previous research that anxiety symptoms in the immediate postpartum period are likely to be associated with depressive symptoms in nulliparas. The results also suggest that higher level of education of first-time mothers might not be a protective factor, especially for nulliparas with the university level of education. Further studies on larger samples should be considered.

Individual and Contextual Factors of Nulliparas' Levels of Depression, Anxiety and Fear of Childbirth in the Last Trimester of Pregnancy: Intimate Partner Attachment a Key Factor?

BACKGROUND: Depression, anxiety and fear of childbirth have numerous consequences for women and their developing offspring. Insecure attachment in close adult relationships is considered to be a risk factor for depressive symptoms. This study aims to gain further insight into the risk factors for depressive and anxiety symptoms in nulliparous women during the third trimester of pregnancy regarding the main contextual relations, with an emphasis on partner attachment. METHODS: A group of 325 nulliparas in the third trimester of pregnancy was enrolled in a childbirth preparation program. The following instruments were applied: Experiences in Close Relationships-Revised, the Edinburgh Depression Scale, the Zung Anxiety Scale, and a questionnaire regarding fear of childbirth. Three separate multiple linear regression models were built to explore the associations between demographic, social and attachment variables and mental health functioning. RESULTS: Highly educated nulliparas and those with a higher level of co-workers' emotional support experienced a lower level of anxiety when other predictors in the model were held constant. Of all the predictors in the model, only attachment anxiety and co-workers' support were statistically significantly associated with the level of depression. Attachment anxiety was significantly associated with all three mental health indicators (level of depression, anxiety and fear of childbirth). CONCLUSIONS: The results suggest that intimate attachment anxiety could be a key contextual factor for mood and anxiety mental health functioning during the third trimester of pregnancy, accessible to change. Our results could facilitate the formulation of interventions for reducing antenatal depressive symptoms.

Vaginal assessment and expedited amniotomy in oral misoprostol labor induction in nulliparas: a randomized trial.

BACKGROUND: Labor is induced in 20-30% of maternities, with an increasing trend of use. Labor induction with oral misoprostol is associated with reduced risk of cesarean deliveries and has a safety and effectiveness profile comparable to those of mechanical methods such as Foley catheter use. Labor induction in nulliparous women continues to be challenging, with the process often quite protracted. The eventual cesarean delivery rate is high, particularly when the cervix is unfavorable and ripening is required. Vaginal examination can cause discomfort and emotional distress particularly to nulliparous women, and plausibly can affect patient satisfaction with the induction and birth process. OBJECTIVE: The aim of this study was to evaluate regular (4-hourly prior to each oral misoprostol dose with amniotomy when feasible) compared with restricted (only if indicated) vaginal assessments during labor induction with oral misoprostol in term nulliparous women MATERIALS AND METHODS: We performed a randomized trial between November 2016 and September 2017 in a university hospital in Malaysia. Our oral misoprostol labor induction regimen comprised 50 µg of misoprostol administered 4 hourly for up to 3 doses in the first 24 hours. Participants assigned to regular assessment had vaginal examinations before each 4-hourly misoprostol dose with a view to amniotomy as soon as it was feasible. Participants in the restricted arm had vaginal examinations only if indicated. Primary outcomes were patient satisfaction with the birth process (using an 11-point visual numerical rating scale), induction to vaginal delivery interval, and vaginal delivery rate at 24 hours. RESULTS: Data from 204 participants (101 regular, 103 restricted) were analyzed. The patient satisfaction score with the birth process was as follows (median [interquartile range]): 7 [6-9] vs 8 [6-10], P = .15. The interval of induction to vaginal delivery (mean ± standard deviation) was 24.3 ± 12.8 vs 31.1 ± 15.0 hours (P = .013). The vaginal delivery rate at 24 hours was 27.7% vs 20.4%; (relative risk [RR], 1.4; 95% confidence interval [CI], 0.8-2.3; P = .14) for the regular vs restricted arms, respectively. The cesarean delivery rate was 50% vs 43% (RR, 1.1; 95% CI, 0.9-1.5; P = .36). When assessed after delivery, participants' fidelity to their assigned vaginal examination schedule in a future labor induction was 45% vs 88% (RR, 0.5; 95% CI, 0.4-0.7; P < .001), and they would recommend their assigned schedule to a friend (47% vs 87%; RR, 0.6; 95% CI, 0.5-0.7; P < .001) in the regular compared with the restricted arms, respectively. CONCLUSION: Despite a shorter induction to vaginal delivery interval with regular vaginal examination and a similar vaginal delivery rate at 24 hours and birth process satisfaction score, women expressed a higher preference for the restricted examination schedule and were more likely to recommend such a schedule to a friend.

Lithuania's experience in reducing caesarean sections among nulliparas.

BACKGROUND: To evaluate the role of the TGCS to reduce the caesarean section (CS) rate among nulliparas (Robson groups 1 and 2) and to find out which group of women have reduced the CS rate by using this tool. METHODS: The Robson classification was introduced in Lithuanian hospitals prospectively classifying all the deliveries in 2012. The CS rate overall and in each Robson group was calculated and the results were discussed. The analysis was repeated in 2014 and the data from the selected hospitals were compared using MS EXCEL and SPSS 23.0. RESULTS: Nulliparas accounted for 43% (3746/8718) and 44.6% (3585/8046) of all the deliveries in 2012 and 2014 years, respectively. The CS rate among nulliparas decreased from 23.9% (866/3626) in 2012 to 19.0% (665/3502) in 2014 (p < 0.001).The greatest decrease in absolute contribution to the overall CS rate was recorded in groups 1 (p = 0.005) and 2B (p < 0.001). Perinatal mortality was 3.5 in 2012 and 3.1 in 2014 per 1000 deliveries (p = 0.764). CONCLUSION: The TGCS can work as an audit intervention that could help to reduce the CS rate without a negative impact on perinatal mortality.

Maternal body mass index and oxytocin exposure in nulliparous women: is there an interaction associated with maternal and neonatal morbidities?

OBJECTIVE: Increasing body mass index (BMI) and administered doses of oxytocin are related to maternal and neonatal morbidities. We evaluated the effect of oxytocin dosage, BMI, and their interaction on select perinatal outcomes. STUDY DESIGN: We retrospectively studied nulliparas with singletons ≥36 weeks' gestation who received oxytocin and reached the second stage of labor. Oxytocin dosage was defined by the oxytocin product ([maximum oxytocin dose] × [duration of oxytocin infusion]/100 (milliunits)). Outcomes included cesarean, postpartum hemorrhage, puerperal infection, and a composite of neonatal morbidities. Logistic regression produced odds ratios (OR) for BMI and oxytocin product. The final model included a BMI-oxytocin product interaction term. RESULTS: One thousand two hundred and four women met enrollment criteria. Increasing BMI was associated with longer duration from first exam to delivery and higher rates of cesarean. Oxytocin dosage increased linearly with BMI (p < .001). There were increasing odds of all four outcomes as both BMI and oxytocin dosage increased (except cesarean with oxytocin). However, there was no significant interaction between BMI and oxytocin for any outcome. CONCLUSIONS: BMI and oxytocin dosage are associated with select maternal and neonatal outcomes. However, the lack of interaction between BMI and oxytocin product suggests that the higher administered dose of oxytocin associated with increasing BMI does not synergistically potentiate maternal and neonatal morbidities.

La no-maternidad en México. El rol del género y la desigualdad socioeconómica

a no-maternidad en México se perfila como un complejo fenómeno distinto al de las sociedades industrializadas y altamente urbanizadas en las que ha sido fundamentalmente estudiada. Las desiguales condiciones en la que esta se lleva a cabo aluden a una diversidad de experiencias que requieren ser documentadas. Este estudio busca contribuir al conocimiento de la no-maternidad en México, explorando, a partir de fuentes secundarias y análisis descriptivos, sus aspectos sociales y económicos más relevantes. Los resultados ratifican que la no-maternidad ocurre bajo diferentes contextos socioeconómicos, que llegan a ser incluso antagónicos. La no unión conyugal se presenta como un aspecto importante de la nomaternidad que, al no haberse asociado con índices migratorios, muestra que en México las mujeres que no son madres tampoco son esposas, sugiriendo con ello, una doble transgresión al modelo hegemónico del ser mujer, al tiempo que revela una realidad hasta ahora poco visible de las mujeres no madres y no esposas: la de las mujeres con limitaciones físicas.

he non-maternity in Mexico is emerging as a complex phenomenon different from the highly urbanized and industrialized societies in which primarily has been studied. The unequal conditions in which it takes place refer to a variety of experiences that need to be documented. This study seeks to contribute to the knowledge of non-maternity in Mexico, exploring, from secondary sources and descriptive analysis, its most important social and economic aspects. The results confirm that non-maternity occurs under different socioeconomic contexts, that become even antagonistic. Non-marital union was presented as an important aspect of non-maternity that, not having been associated with migration rates, shows that in Mexico women who are not mothers neither are wives, thereby suggesting a double transgression of the hegemonic model of womanhood, while it is revealing a reality hitherto little visible of women who are neither mothers nor wives: the women with physical limitations to work.

Parâmetros clínicos, hematológicos e bioquímicos de novilhas com hipocalcemia subclínica pré-parto suplementadas com dieta aniônica / Anionic diet on clinical, haematological and biochemical parameters of heifers with subclinical hypocalcemia prepartum

A hipótese do presente estudo consiste em que uma dieta aniônica prolongada acarretaria uma mobilização mais rápida do cálcio sanguíneo. O objetivo proposto foi avaliar parâmetros clínicos, hematológicos e bioquímicos de novilhas, com hipocalcemia subclínica, submetidas a diferentes períodos de fornecimento de dieta aniônica no pré-parto. Foram utilizadas nove novilhas da raça Holandês induzidas à hipocalcemia subclínica no pré-parto, divididas em três grupos: G0 = sem dieta aniônica antes da indução; G11 = 11 dias de dieta aniônica pré-indução; e G15 = 15 dias de dieta aniônica pré-indução. Foi realizado exame clínico antes e depois da indução, e avaliaram-se cálcio total e ionizado, magnésio e albumina nos dias -2, 0, 1, 2 e 3 (dia 0 = momento da indução) e parâmetros hematológicos nos dias 0, 1, 2 e 3. O G11 apresentou maiores concentrações de cálcio total e ionizado que o G0 e maiores níveis de cálcio total que o G15 (P<0,01). O magnésio teve maiores valores no G15 quando comparado aos outros grupos (P<0,01). O G0 apresentou os maiores valores de monócitos e neutrófilos bastonetes (P<0,01). A dieta aniônica por 11 dias é suficiente para manter a homeostase do cálcio e a resposta leucocitária em novilhas desafiadas a uma diminuição do cálcio sanguíneo.(AU)

This study's hypothesis is that cows receiving anionic diet for a longer period respond more quickly to decreased blood calcium. The aim was to evaluate the heifers' clinical, hematological, and biochemical parameters, with subclinical hypocalcemia, subjected to different periods of anionic diet supply during antepartum. Nine heifers were induced to subclinical hypocalcemia during antepartum, sorted in 3 groups: G0 = no anionic diet before induction; G11= eleven days of anionic diet before induction; and G15 = fifteen days of anionic diet before induction. Examinations were held before and after induction and total and ionized calcium, magnesium and albumin were evaluated from days -2, 0, 1, 2 and 3, day 0 being the moment of induction; hematologic parameters were evaluated at days 0, 1, 2 and 3. G11 presented a higher total and ionized calcium concentration than G0 and higher total calcium concentration than G15 (P < 0.01). Magnesium had its highest values at G15 when compared to the other two groups (P < 0.01). G0 presented its highest values of monocytes and neutrophils rods (P<0.01). The eleven days of anionic diet supply were enough to maintain calcium homeostasis and leukocyte response in heifers challenged to reduction in blood calcium.(AU)

Clinical and sonographic parameters at mid-trimester and the risk of cesarean delivery in low-risk nulliparas.

BACKGROUND: To examine the potential clinical and sonographic parameters at mid-trimester that predict the risk of intrapartum cesarean delivery at term among low-risk nulliparas. METHODS: This prospective study recruited nulliparas with singleton low-risk pregnancies at 20.0-24.0 weeks. Sonographic measurement of the cervical length and fetal biometry was performed. The data collected at enrollment included maternal age, measured weight at first prenatal visit to the hospital, current weight, height, fetal biometric parameters, and cervical length. A multivariate analysis was conducted, with control for known intra- and postpartum confounding factors associated with cesarean delivery, including sex of the fetus. RESULTS: Based on multivariate analyses of 652 women, of all variables at mid-trimester, only maternal height was significantly associated with increased risk of cesarean delivery (61, 9.4%), whereas for intra- or postpartum variables, induction of labor, epidural analgesia, male gender, and nightshift delivery showed statistically significant association with the risk of cesarean delivery. CONCLUSIONS: Maternal height and fetal gender, as measured at mid-trimester, are potential independent predictors for the risk of intrapartum cesarean delivery at term in low-risk nulliparas; however, sonographic measurements of the cervical length, fetal biometric ratio, maternal age, and current weight at mid-trimester were not predictive of cesarean delivery at term. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43:235-242, 2015.