Inter-institutional variations in oxytocin augmentation during labour in German university hospitals: a national survey.

BACKGROUND: There are several international guidelines on oxytocin regimens for induction and augmentation of labour, but no agreement on a standardised regimen in Germany. This study collated and reviewed the oxytocin regimens used for labour augmentation in university hospitals, with the long-term aim of contributing to the development of a national clinical guideline. METHODS: Germany has 34 university hospital compounds, representing 39 maternity units. In this observational study we asked units to provide standard operational procedures on oxytocin augmentation during labour or provide the details in a structured survey. Data were collected on the dosage of oxytocin, type and volume of solutions used, indications and contraindications for use and discontinuation, case-specific administration, and on who developed the procedures. Findings were analysed descriptively. RESULTS: A total of 35 (90%) units participated in this study. Standard operating procedures were available in 24 units (69%), seven units (20%) did not have procedures and information was missing from four units (11%). Midwives participated in the development of standard operating procedures in 15 units (43%). Infusions were most commonly prepared using six units of oxytocin in 500 ml 0.9% normal saline solution (12 mU/ml). The infusions were started at 120 mU/hour and increased by 120 mU/hour at 20-min intervals up to a maximum dosage of 1200 mU/hour. The most common indication for use was delayed progress in labour. Infusions were stopped when uterine contractions became hypertonic and/or the fetal heart rate showed signs of distress. Most of the practices described aligned with international guidance. All units used reduced oxytocin dosages for women with a history of previous caesareans section, as recommended in the international guidelines, and restrictive use was advised in multiparous women. The main difference between units related to combined use of amniotomy and oxytocin, recommended by three guidelines but used in only four maternity units (11%). CONCLUSIONS: While there was considerable variation in the oxytocin augmentation procedures, most but not all practices used in these 35 German maternity units were comparable. Establishing a national guideline on the criteria for and administration of oxytocin for augmentation of labour would eliminate the observed differences and minimise risk of administration and medication error.

Standardised electronic algorithms for monitoring prophylaxis of postoperative nausea and vomiting.

INTRODUCTION: Despite comprehensive guidelines with high-grade evidence, postoperative nausea and vomiting (PONV) remains a frequent problem in anaesthesia care. Anaesthesia information management systems (AIMS) may aid clinicians in PONV prevention, but their benefit is critically dependent on the details of implementation into practice. This study aimed to examine strengths and weaknesses of the local AIMS-based algorithm in prevention of PONV. MATERIAL AND METHODS: This retrospective study was conducted in the post-anaesthesia care unit (PACU) of a university hospital and included 10 604 patients aged 18 or older who were followed up in the PACU (intracranial, obstetrical or cardiothoracic surgery excluded) from March 2013 until March 2014. The PONV incidence in PACU and AIMS data validity were analysed. RESULTS: Adherence to PONV guideline recommendations was considerably low, with only 5749 (54%) of the patients receiving correct PONV prophylaxis. Two thousand seven hundred sixty-six (26%) of the patients received an insufficient PONV prophylaxis, which was associated with an excess PONV incidence (11% vs. 4% with correct prophylaxis, p < 0.001) in the PACU. Two thousand four hundred forty-nine (23%) of all patients were discharged from the PACU with an insufficient PONV prophylaxis despite perioperative digital PONV prevention algorithms. CONCLUSIONS: Adherence to PONV prophylaxis guidelines in the era of AIMS software and decision support is still remarkably low. The AIMS data usefulness depends on the user, the type of data input and the configuration of the software. Adherence to correct PONV prophylaxis should be re-evaluated systematically before discharge from PACU.

[Outcomes of Planned Out-of-Hospital and Low-Risk Hospital Births in Lower Saxony]. / Outcomes geplanter außerklinischer und klinischer Low-Risk Geburten in Niedersachsen.

Introduction Internationally, there is debate on the safety of different birth settings inside and outside of hospitals. Low-risk women in Germany can choose where they give birth, and out-of-hospital births are especially necessary in regions lacking infrastructure. To date, national studies are required. Materials and Methods We investigated planned out-of-hospital (OH) and hospital births in Lower Saxony, Germany, in 2005. Women with a singleton fetus in the vertex position were included once they reached 34+0 gestational weeks. 1 273 out of 4 424 births were included via risk assessment. Outcomes were compared using Pearson's chi-squared test, the Mann-Whitney test, and logistic regression. Results 152 (36.6%) nulliparae (NP) and 263 (63.4%) multiparae (MP) gave birth out of hospital, 439 (51.2%) nulliparae and 419 (48.8%) multiparae in a hospital. 10.1% of women whose care started outside of the hospital needed a transfer to the hospital. Women who planned OH were older and had a higher level of education. Women without a migration background displayed an increased rate of out-of-hospital birth. A higher proportion received their antenatal care from midwives rather than medical doctors. Induction of labor was less likely for women with planned out-of-hospital births, as were other intrapartum interventions. In hospital births, fetal monitoring was more likely performed via cardiotocograph instead of intermittent auscultation. Duration of labor was significantly longer in OH births (median: NP: 9.01 h vs. 7.38 h; MP: 4.53 h vs. 4.25 h). Nulliparae had more spontaneous births out-of-hospital (94.7%) than in hospital (73.6%). There was no difference in adverse fetal outcomes, blood loss, and severe perineal lacerations. The perineum was less frequently intact in hospital births. Retained placenta was more often documented in out-of-hospital births. Conclusions In an out-of-hospital setting, fewer interventions were performed, spontaneous births occurred more often, and there was no difference in neonatal outcomes. OH birth appears reasonably safe with thorough pre-labor risk assessment and good transfer management. Some beneficial aspects of OH birth care (like continuity of care and restriction of routine interventions) could be adopted by hospital labor wards, leading to a higher rate of vaginal births and improved care.

Early versus Late Admission to Labor Affects Labor Progression and Risk of Cesarean Section in Nulliparous Women.

BACKGROUND: Rates of cesarean section increase worldwide, and the components of this increase are partially unknown. A strong role is prescribed to dystocia, and at the same time, the diagnosis of dystocia is highly subjective. Previous studies indicated that risk of cesarean is higher when women are admitted to the hospital early in the labor. METHODS: We examined data on 1,202 nulliparous women with singleton, vertex pregnancies and spontaneous labor onset. We selected three groups based on cervical dilatation at admission: early (0.5-1.5 cm, N = 178), intermediate (2.5-3.5 cm, N = 320), and late (4.5-5.5 cm, N = 175). The Kaplan-Meier estimator was used to analyze the risk of delivery by cesarean section at a given dilatation, and thin-plate spline regression with a binary outcome (R library gam) to assess the form of the associations between the cesarean section in either the first or second stage versus vaginal delivery and dilatation at admission. RESULTS: Women who were admitted to labor early had a higher risk of delivery by cesarean section (18 versus 4% in the late admission group), while the risk of instrumental delivery did not differ (24 versus 24%). Before 4 cm dilatation, the earlier a woman was admitted to labor, the higher was her risk of delivery by cesarean section. After 4 cm dilatation, however, the relationship disappeared. These patterns were true for both first and second stage cesarean deliveries. Oxytocin use was associated with a higher risk of cesarean section only in the middle group (2.5-3.5 cm dilatation at admission). CONCLUSION: Early admission to labor was associated with a significantly higher risk of delivery by cesarean section during the first and second stages. Differential effects of oxytocin augmentation depending on dilation at admission may suggest that admission at the early stage of labor is an indicator rather than a risk factor itself, but admission at the intermediate stage (2.5-3.5 cm) becomes a risk factor itself. Further research is needed to study this hypothesis.

The dynamics of epidural and opioid analgesia during labour.

PURPOSE: To investigate the association of analgesia, opioids or epidural, or the combination of both with labour duration and spontaneous birth in nulliparous women. METHODS: A secondary data analysis of an existing cohort study was performed and included nulliparous women (n = 2074). Durations of total labour and first and second labour stage were calculated with Kaplan-Meier estimation for the four different study groups: no analgesia (n = 620), opioid analgesia (n = 743), epidural analgesia (n = 482), and combined application (n = 229). Labour duration was compared by Cox regression while adjusting for confounders and censoring for operative births. Logistic regression was used to investigate the association between the administration of different types of analgesia and mode of birth. RESULTS: Most women in the combined application group were first to receive opioid analgesia. Women with no analgesia had the shortest duration of labour (log rank p < 0.001) and highest chance of a spontaneous birth (p < 0.001). If analgesia was administered, women with opioids had a shorter first stage (p = 0.018), compared to women with epidural (p < 0.001) or women with combined application (p < 0.001). Women with opioids had an increased chance to reach full cervical dilatation (p = 0.006). Women with epidural analgesia (p < 0.001) and women with combined application (p < 0.001) had a prolonged second stage and decreased chance of spontaneous birth compared to women without analgesia. CONCLUSIONS: Women with opioids had a prolonged first stage, but increased chance to reach full cervical dilatation. Women with epidural analgesia and women with both opioid and epidural analgesia had a prolonged first and second stage and a decreased chance of a spontaneous birth.

Labour duration and timing of interventions in women planning vaginal birth after caesarean section.

OBJECTIVE: understanding the labour characteristics of women attempting vaginal birth after caesarean (VBAC) may suggest how to improve intrapartum management and may enhance success rates. Promoting VBAC is a relevant factor in decreasing overall caesarean section (c-section) rates. However, the labour processes of women attempting VBAC are not well investigated. The aim of this paper is to compare multiparae planning a first VBAC (pVBAC) with primiparae and with multiparae planning a second vaginal birth, all starting to give birth vaginally, with regard to (a) perinatal characteristics, (b) the timing of intrapartal spontaneous rupture of membranes (SROM) and of interventions, and (c) labour duration, with respect to the first and second stages. SETTING: cohort study of women planning vaginal birth in 47 obstetric units in Lower Saxony, Germany. PARTICIPANTS: 1897 primiparae, 211 multiparae with one previous c-section and 1149 multiparae with one previous vaginal birth. MEASUREMENTS: secondary analysis of data from an existing cohort study. Kaplan-Meier estimates, log rank test, Wilcoxon test and shared frailty Cox regression models including time-varying covariates were used to compare the timing of interventions and labour duration between the subsamples. Analyses were done with the statistics programme Stata 13. FINDINGS: perinatal and labour characteristics of multiparae with pVBAC mainly resembled those of primiparae and differed from those of multiparae planning a second vaginal birth. However, compared to primiparae, multiparae with pVBAC received oxytocin less often (48.82 versus 56.95%, p=0.024) and gave birth vaginally significantly less often (69.19 versus 83.40%, p<0.001). The timing of intrapartal SROM (2.67 versus 3.42 hours, p=0.112) and of interventions (amniotomy: 5.50 versus 5.83 hours, p=0.198; oxytocin: 5.75 versus 6.00 hours, p=0.596; epidural: 4.00 versus 4.67 hours, p=0.416; opioids: 3.83 versus 3.78, p=0.851) was similar to that in primiparae although timings of all interventions but not of SROM differed significantly from that in multiparae with second vaginal birth (SROM: 2.67 versus 2.67 hours, p=0.481; amniotomy: 5.50 versus 3.93 hours, p<0.001; oxytocin: 5.75 versus 4.25 hours, p<0.001; epidural: 4.00 versus 3.50 hours, p=0.009; 3.83 versus. 2.75 hours, p=0.026). Overall and first-stage labour duration were comparable to primiparae (overall labour duration: 8.83 versus 8.57 hours, HR=0.998, 95% CI=0.830-1.201, p=0.987; first stage: 7.42 versus 7.00 hours, HR=0.916, 95% CI=0.774-1.083, p=0.303) but significantly longer than in other multiparae (overall labour duration: 8.83 versus 4.63 hours, HR=0.319, 95% CI=0.265-0.385, p<0.001; first stage: 7.42 versus 4.25 hours, HR=0.402, 95% CI=0.339-0.478, p<0.001). However, the second stage of labour was significantly shorter in multiparae with pVBAC than in primiparae (0.55 versus 0.77 hours, HR=1.341, 95% CI=1.049-1.714, p=0.019), but longer than in multiparae with second vaginal birth (0.55 versus 0.22 hours, HR=0.334, 95% CI=0.262-0.426, p<0.001). KEY CONCLUSION: labour patterns of multiparous women planning a VBAC differ from those of primiparae and other multiparous women. Multiparae with pVBAC should be considered as a distinct group of parturients. IMPLICATION FOR PRACTICE: expectations regarding labour progression for multiparae with first pVBAC should be similar to those for primiparae. However, the chance that the second stage of labour might be shorter than in primiparae is relevant and motivating information for pregnant women with a previous c-section in deciding the planned mode of birth.

The sequence of intrapartum interventions: a descriptive approach to the cascade of interventions.

PURPOSE: To model the timing and sequence of intrapartum interventions and to estimate the association with labor length and delivery mode. METHODS: A longitudinal multi-center cohort study included data from 3,955 low-risk women who gave birth in hospitals in Lower Saxony, Germany. We analyzed three intrapartum interventions: amniotomy, oxytocin augmentation and epidural analgesia. We divided births into time intervals delineated by these interventions and noted cervical dilation at interval onset. We analyzed the duration of intervals from onset of labor until the first intervention and between intrapartum interventions with Kaplan-Meier's estimate, regarding the three interventions as competing risks. Further, we analyzed the cervical dilation before an intervention by Kaplan-Meier's estimate without censoring. RESULTS: 73.2 % of the included 2,082 nulliparae (n = 1,525) and 59.6 % of the included 1,873 multiparae (n = 1,117) received at least one intervention, while 1,313 women (33.2 %) experienced a normal labor without any of these interventions. The intervals from onset of labor until the first intervention and from the first until the second intervention were significantly shorter in multiparae than in nulliparae. The intervention cascade in nulliparae most often started with epidural analgesia in early labor (n = 579, 27.8 %). Oxytocin augmentation most often followed after a short interval (n = 343, 59.2 %, median 1.57 h). In multiparae, amniotomy was most often the first intervention (n = 629, 33.6 %), and spontaneous birth most often followed (n = 503, 80.0 %). Labor duration and operative deliveries increased as interventions increased. CONCLUSIONS: The temporal sequence of intrapartum interventions varied in association with parity, cervical dilation, labor duration and mode of birth.

Women's perception of the onset of labour and epidural analgesia: a prospective study.

OBJECTIVE: childbearing women and their midwives differ in their diagnoses of the onset of labour. The symptoms women use to describe the onset of labour are associated with the process of labour. Perinatal factors and women's attitudes may be associated with the administration of epidural analgesia. Our study aimed to assess the correlation between women's perception of the onset of labour and the frequency and timing of epidural analgesia during labour. DESIGN: prospective cohort study. SETTING: 41 maternity units in Lower Saxony, Germany. PARTICIPANTS: 549 nulliparae (as defined in the "Methods" section) and 490 multiparae giving birth between April and October 2005. Women were included after 34 completed weeks of gestation with a singleton in vertex presentation and planned vaginal birth. MEASUREMENTS: the association between women's symptoms at the onset of labour and the administration of epidural analgesia - frequency, timing in relation to onset of labour and cervical dilatation - was assessed. The analysis was performed by Kaplan-Meiers estimation, logistic regression and Cox regression. FINDINGS: a total of 174 nulliparae and 49 multiparae received epidural analgesia during labour. Nulliparae received it at a median time of 5.47hrs (range: 0.25-51.17hrs) after onset of labour, at a median cervical dilatation of 3.3cm (range: 1.0-10.0cm). In multiparae, epidural analgesia was applied at a median time of 3.79hrs (range: 0.42-28.55hrs) after onset of labour; the median cervical dilatation was 3.0cm (range: 1.0-8.0cm). Women who were admitted with advanced cervical dilatation received epidural analgesia less often. Women who defined their onset of labour earlier than it was diagnosed by their midwives received epidural analgesia earlier. Gastrointestinal symptoms and irregular pain at the onset of labour were associated with later administration of epidural analgesia. Induction of labour was associated with a reduced interval from the onset of labour to epidural analgesia. KEY CONCLUSIONS: women's self-diagnosis of the onset of labour and their perception of their labour duration when meeting their midwives has some impact on their admission to the labour ward and the timing of epidural analgesia. IMPLICATIONS FOR PRACTICE: consideration of women's own perceptions and expectations regarding the onset and process of labour is necessary for individual care during labour.

The timing of interventions during labour: descriptive results of a longitudinal study.

OBJECTIVE: To describe the timing and frequency of interventions during labour, and in addition to compare the timings of the interventions against the partogram action lines. DESIGN: Longitudinal prospective and retrospective cohort study. SETTING: 47 Hospitals in Lower Saxony, Germany. PARTICIPANTS: 3963 Births of nulliparae and multiparae with singletons in vertex presentation giving birth between April and October 2005. The participation rate for the prospectively recruited sample (n = 1169) was 4.7%. MEASUREMENTS: Time intervals until intrapartal interventions were calculated by Kaplan-Meiers estimation. Outcome variables were duration of labour and mode of birth. FINDINGS: Multiparae had slightly longer median time intervals between the onset of labour and the beginning of care by the midwife than nulliparae. With regard to the intervals between the onset of labour and the occurrence of interventions, multiparae had shorter median durations than nulliparae in respect of amniotomy, oxytocin augmentation and neuraxial analgesia. By three hours after onset of labour 8.4% of nulliparae had received oxytocin augmentation, 10.7% neuraxial analgesia and 8.9% an amniotomy. Of multiparae, 9.1% had received oxytocin augmentation but only 5.6% neuraxial analgesia; 20.0% had had an amniotomy. The median time interval before the initiation of water immersion and massage was between three and four hours; that before the initiation of vertical positioning was 1.8 hours. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Current German practice without the use of partogram action lines reveals that early interventions were performed before the partogram action lines were met. Interventions applying midwifery care techniques such as vertical positioning preceded more invasive medical interventions during the process of childbirth.

Association between women's self-diagnosis of labor and labor duration after admission.

AIMS: To examine the association between women's perception of onset and the duration of labor after hospital admission. METHODS: Women whose labor started spontaneously at term, delivering at the Hannover Medical School Hospital, Germany, between 2001 and 2004 were asked when and how labor had started. Answers were analyzed using structured content analysis. Women's symptoms were grouped in eight predefined categories; inter-rater agreement was assessed (kappa=0.93). Associations between women's symptoms and labor duration after admission were also analyzed. RESULTS: Duration of labor after admission was longer in nulliparas (n=347) than in multiparas (n=304, P<0.001). Nulliparas experienced shorter labor in association with recurrent pain, advanced cervical dilatation at admission and spontaneous rupture of membranes. Oxytocin augmentation and epidural analgesia were associated with a longer duration. In multiparas, advanced cervical dilatation at admission, spontaneously ruptured membranes, blood-tinged mucus or emotional upheaval perceived by women were associated with a shorter interval from admission until birth. CONCLUSIONS: How women diagnose their onset of labor relates to some extent with labor duration after admission. Recognized symptoms and their association with labor duration differed between nulliparas and multiparas.