Associations between fetal position at delivery and duration of active phase of labor: A historical cohort study.

INTRODUCTION: In clinical experience, occiput posterior (OP) position is associated with longer labor duration than occiput anterior (OA) position, but few studies have investigated the association between labor duration and fetal position. We aimed to compare duration of the active phase of labor in OP deliveries with OA deliveries in a contemporary population using survival methods. Secondary aims were to compare the frequencies of operative interventions, obstetric anal sphincter injuries (OASIS), postpartum hemorrhage, and newborn outcomes in OP with OA deliveries. MATERIAL AND METHODS: We did a historical cohort study in three university hospitals in Norway from 2012 to 2022. Women with a single fetus in cephalic presentation, no previous cesarean section and gestational age ≥37 weeks were eligible and stratified into the first four groups of the Robson ten-group classification system (TGCS). We estimated the mean duration and calculated the hazard ratio (HR) for delivery using survival analyses. Cesarean sections and instrumental vaginal deliveries were censored. RESULTS: The study population comprised 112 019 women, 105 571 (94.2%) were delivered in OA and 6448 (5.8%) in OP position. The estimated mean duration of the active phase of labor was longer in women with the fetus in OP position in all four TGCS groups. The estimated duration was longer in the OP groups in analyses stratified with respect to epidural analgesia and oxytocin augmentation. The graphical abstract illustrates the probability of delivery in OP compared with OA position in merged TGCS groups 1 and 2a, as a function of time. The unadjusted HR was 0.33 (95% CI 0.31-0.36) for fetuses delivered in OP position compared with OA position in TGCS group 1, 0.25 (95% CI 0.21-0.27) in group 2a, 0.70 (95% CI 0.67-0.73) in group 3, and 0.61 (95% CI 0.55-0.67) in group 4a, respectively. Neither maternal age, gestational age, BMI nor birthweight had confounding effect. Operative delivery rates and OASIS rates were higher in OP position in all four groups. CONCLUSIONS: We found longer duration of the active phase of labor in women with the fetus delivered in OP position in all four TGCS groups.

Impact of additional theoretical training program in the diagnosis of the fetal head position during labor: a prospective observational study.

BACKGROUND: The accuracy of transvaginal digital examination in determining foetal head position is not high enough. This study aimed to evaluate whether an additional training on our new theory could improve the diagnostic accuracy of the foetal head position. METHODS: This was a prospective study conducted at a 3a grade hospital. The study included 2 residents in their first year of training in obstetrics without prior experience in transvaginal digital examination. In the observational study, 600 pregnant women without contraindications to vaginal delivery were included. Two residents were simultaneously trained in the theory of traditional vaginal examination, but resident B received an additional theoretical training program. The pregnant women were randomly assigned to have the foetal head position examined by resident A and resident B. The foetal head position was then confirmed by ultrasound, which was performed by the main investigator. After 300 examinations were independently performed by each resident, the accuracy of foetal head position and perinatal outcomes were compared between the two groups. RESULTS: During the 3-month period, 300 post training transvaginal digital examinations were performed by each resident in our hospital. The two groups were found to be homogeneous for age at delivery, BMI before delivery, parity, gestational weeks at delivery, the rate of epidural analgesia, foetal head position, presence of caput succedaneum, presence of moulding and foetal head station(p > 0.05). The diagnostic accuracy of head position by digital examination was higher for resident B, who was subjected to an additional theoretical training program, than for resident A (75.00% vs. 60.67%, p < 0.001). There were no significant differences in maternal and neonatal outcomes between the two groups (p > 0.05). CONCLUSION: An additional theoretical training program for residents increased the accuracy of vaginal assessment of foetal head position. TRIAL REGISTRATION: Registered at Chinese Clinical Trial Registry Platform (ChiCTR2200064783), October 17, 2022. https://www.chictr.org.cn/edit.aspx?pid=182857&htm=4.

Knowledge and experience of midwives and gynecologists about manual rotation of persistent occiput posterior position.

BACKGROUND: management of persistent occiput posterior position has always been controversial. Manual rotation by a delivery operator can reduce instrumental delivery and cesarean section. AIM: This study aims to determine the knowledge and experience of midwives and gynecologists about manual rotation of persistent occiput posterior position. METHODS: This descriptive cross-sectional study was performed in 2022. The questionnaire link was sent to 300 participating midwives and gynecologists via WhatsApp Messenger. Two hundred sixty-two participants completed the questionnaire. Data analysis was performed using SPSS22 statistical software and descriptive statistics. RESULTS: 189 people (73.3%) had limited information about this technique, and 240 (93%) had never performed it. If this technique is recognized as a safe intervention and is included in the national protocol, 239 people (92.6%) want to learn, and 212 (82.2%) are willing to do it. CONCLUSION: According to the results, the knowledge and skills of midwives and gynecologists need to be trained and improved for manual rotation of persistent occiput posterior position.

Predicting cesarean delivery for failure to progress as an outcome of labor induction in term singleton pregnancy.

BACKGROUND: Induction of labor is one of the most common interventions in modern obstetrics, and its frequency is expected to continue to increase. There is inconsistency as to how failed induction of labor is defined; however, the majority of studies define success as the achievement of vaginal delivery. Induction of labor in nulliparous women poses an additional challenge with a 15% to 20% incidence of failure, ending in emergency operative deliveries. The Bishop score has been traditionally used before decisions for induction of labor. Nonetheless, it is subjective and prone to marked interobserver variation. Several studies have been conducted to find alternative predictors, yet a reliable, objective method still remains to be introduced and validated. Hence, there is still a need for the development of new predictive tools to facilitate informed decision making, optimization of resources, and minimization of potential risks of failure. Furthermore, a peripartum transperineal ultrasound scan has been proven to provide objective, noninvasive assessment of labor. OBJECTIVE: This study aimed to assess the feasibility of developing and validating an objective and reproducible model for the prediction of cesarean delivery for failure to progress as an outcome of labor induction in term singleton pregnancies. STUDY DESIGN: This was a prospective observational cohort study conducted in Cairo University Hospitals and University of Bologna Hospitals between November 2018 and November 2019. We recruited 382 primigravidae with singleton term pregnancies in cephalic presentation. All patients had baseline Bishop scoring together with various transabdominal and transperineal ultrasound assessments of the fetus, maternal cervix, and pelvic floor. The managing obstetricians were blinded to the ultrasound scan findings. The method and indication of induction of labor, the total duration of stages of labor, mode of birth, and neonatal outcomes were all recorded. Women who had operative delivery for fetal distress or indications other than failure to progress in labor were excluded from the final analysis, leaving a total of 344 participants who were randomly divided into 243 and 101 pregnancies that constituted the model development and cross-validation groups, respectively. RESULTS: It was possible to perform transabdominal and transperineal scans and assess all the required parameters on all study participants. Univariate and multivariate analyses were used for selection of potential predictors and model fitting. The independent predictive variables for cesarean delivery included maternal age (odds ratio, 1.12; P=.003), cervical length (odds ratio, 1.08; P=.04), angle of progression at rest (odds ratio, 0.9; P=.001), and occiput posterior position (odds ratio, 5.7; P=.006). We tested the performance of the prediction model on our cross-validation group. The calculated areas under the curve for the ability of the model to predict cesarean delivery were 0.7969 (95% confidence interval, 0.71-0.87) and 0.88 (95% confidence interval, 0.79-0.97) for the developed and validated models, respectively. CONCLUSION: Maternal age and sonographic fetal occiput position, angle of progression at rest, and cervical length before labor induction are very good predictors of induction outcome in nulliparous women at term.

Persistent occiput posterior position and stress distribution in levator ani muscle during vaginal delivery computed by a finite element model.

INTRODUCTION AND HYPOTHESIS: Objective of this study was to develop an MRI-based finite element model and simulate a childbirth considering the fetal head position in a persistent occiput posterior position. METHODS: The model involves the pelvis, fetal head and soft tissues including the levator ani and obturator muscles simulated by the hyperelastic nonlinear Ogden material model. The uniaxial test was measured using pig samples of the levator to determine the material constants. Vaginal deliveries considering two positions of the fetal head were simulated: persistent occiput posterior position and uncomplicated occiput anterior position. The von Mises stress distribution was analyzed. RESULTS: The material constants of the hyperelastic Ogden model were measured for the samples of pig levator ani. The mean values of Ogden parameters were calculated as: µ1 = 8.2 ± 8.9 GPa; µ2 = 21.6 ± 17.3 GPa; α1 = 0.1803 ± 0.1299; α2 = 15.112 ± 3.1704. The results show the significant increase of the von Mises stress in the levator muscle for the case of a persistent occiput posterior position. For the optimal head position, the maximum stress was found in the anteromedial levator portion at station +8 (mean: 44.53 MPa). For the persistent occiput posterior position, the maximum was detected in the distal posteromedial levator portion at station +6 (mean: 120.28 MPa). CONCLUSIONS: The fetal head position during vaginal delivery significantly affects the stress distribution in the levator muscle. Considering the persistent occiput posterior position, the stress increases evenly 3.6 times compared with the optimal head position.

A model for predicting unscheduled caesarean section in nulliparae.

OBJECTIVE: The objective of the study is to analyze the predictors of unplanned cesarean section in nulliparae. DESIGN: Prospective cohort study. SETTING: Institute for the Care of Mother and Child in Prague. METHODS: This study consisted of nulliparae giving birth between the 37th and 42nd weeks of singleton low-risk pregnancy, with the fetus in vertex position and without primary indication for CS. Selected prenatal and intranatal factors were analyzed in relation to acute CS due to a failure to progress in labor and/or fetal distress. Using logistic regression analysis (LR1-3) and the classification tree method (chi-square automatic interaction detector 1-2), five prediction models were tested. RESULTS: Of 3,728 nulliparae, 908 (24.4%) had an acute CS. All logistic regression models were comparable (receiver operating characteristic (ROC) 0.837-0.0881) and identified the occiput posterior position (OPP) of the fetus, maternal age, and epidural analgesia as the most influential risk factors. Spontaneous onset of labor, oxytocin administration, and maternal body height decreased are likely indicated for acute CS. The ability to predict a vaginal delivery was 95.7-96.3% and CS was 58.5-61.8%. The classification tree method (ROC 0.860-0.861) identified similar risk factors such as the OPP, peridural analgesia, and spontaneous onset of labor. The prediction abilities were similar at 94.5-96.4% for vaginal delivery and 64.6-59.0% for CS. CONCLUSION: OPP of the fetus was the strongest risk factor for the unsuccessful trial of vaginal labor.

Efficiency of the modified Sims maternal position in the rotation of persistent occiput posterior position during labor: A randomized clinical trial.

BACKGROUND: Fetal occiput posterior position in labor is associated with more painful and prolonged labor, and an increase in both maternal and fetal morbidity. The aim of this study is to assess whether the modified Sims position on the side of the fetal spine increases the rotation to occiput anterior position in women with epidural analgesia and a fetus in persistent occiput posterior (POP) position. METHODS: This is an open, randomized controlled, clinical trial. One hundred and twenty women in labor with fetuses in POP position were included. The diagnosis was performed through digital vaginal examination and confirmed with an ultrasound scan. Women were randomized into the free position group or the modified Sims on the side of the fetal spine. The primary outcome was rotation to occiput anterior, and secondary outcomes were type of delivery, postpartum perineal condition, perinatal results, and maternal satisfaction. RESULTS: In pregnant women undergoing labor in the Sims position, fetuses in POP rotated to occiput anterior in 50.8% of cases, whilst in the free position group, the rotation occurred in 21.7% (P = .001). The rate of vaginal deliveries was higher in the Sims group compared with the free position group (84.7% vs 68.3%, P = .035). DISCUSSION: The modified Sims position is a maternal posture intervention efficient in POP rotation, which decreases cesarean delivery rate. It is a simple and noninvasive intervention, reproducible, and well tolerated by pregnant women.

Operative vaginal delivery in case of persistent occiput posterior position after manual rotation failure: a 6-month follow-up on pelvic floor function.

PURPOSE: To compare the short- and long-term perineal consequences (at 6 months postpartum) and short-term neonatal consequences of instrumental rotation (IR) to those induced by assisted delivery (AD) in the occiput posterior (OP) position, in case of manual rotation failure. METHODS: A prospective observational cohort study; tertiary referral hospital including all women presenting with persistent OP position who delivered vaginally after manual rotation failure with attempted IR or AD in OP position from September 2015 to October 2016. Maternal and neonatal outcomes of all attempted IR deliveries were compared with OP operative vaginal deliveries. Main outcomes measured were pelvic floor function at 6 months postpartum including Wexner score for anal incontinence and ICIQ-FLUTS for urinary symptoms. Perineal morbidity comprised severe perineal tears, corresponding to third and fourth degree lacerations. Fetal morbidity parameters comprised low neonatal Apgar scores, acidaemia, major and minor fetal injuries and neonatal intensive care unit admissions. RESULTS: Among 5265 women, 495 presented with persistent OP positions (9.4%) and 111 delivered after manual rotation failure followed by AD delivery: 58 in the IR group and 53 in the AD in OP group. The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.7% vs. 24.5%; p < 0.001) without increasing neonatal morbidity. At 6 months postpartum, AD in OP position was associated with higher rate of anal incontinence (30% vs. 5.5%, p = 0.001) and with more urinary symptoms, dyspareunia and perineal pain. CONCLUSIONS: OP operative deliveries are associated with significant perineal morbidity and pelvic floor dysfunction at 6 months postpartum.

Higher Rates of Operative Delivery and Maternal and Neonatal Complications in Persistent Occiput Posterior Position with a Large Head Circumference: A Retrospective Cohort Study.

INTRODUCTION: We investigated whether large head circumference (HC) combined with persistent occiput posterior (OP) position is associated with higher rates of operative delivery and obstetric and neonatal complications than OP deliveries without large HC or in occiput anterior (OA) position. MATERIALS AND METHODS: Term singleton deliveries in our centers from January 2010 to December 2014, delivered in cephalic OA (n = 41,038) or OP position (n = 1,740), were assessed. We compared delivery modes, maternal and neonatal complications in OA versus OP deliveries, and HC ≥90th centile versus HC <90th centile in persistent OP position. RESULTS: Persistent OP position combined with HC ≥90th centile was associated with higher rates of vacuum extraction and unplanned cesarean delivery than HC <90th centile in OP position (20.1 vs. 17.2%, OR 1.53 [95% CI 0.99-2.36], and 23.4 vs. 9.2%, OR 3.326 [95% CI 2.17-5.11], respectively). Rates of prolonged second stage of labor and neonatal intensive care unit admission were also increased compared to those in either OA position with HC ≥90th centile or OP position with HC <90th centile. DISCUSSION: Large HC combined with OP position is associated with higher rates of operative delivery and prolonged second stage of labor compared to OP delivery with HC <90th centile. HC might be included with other measures to assess women in labor, as it is associated with fetal outcomes in OP deliveries.

Duration of second stage of labor and instrumental delivery as risk factors for severe perineal lacerations: population-based study.

BACKGROUND: We sought to investigate the impact of the duration of second stage of labor on risk of severe perineal lacerations (third and fourth degree). METHODS: This population based cohort study was conducted in the Stockholm/Gotland region, Sweden, 2008-2014. Study population included 52 211 primiparous women undergoing vaginal delivery with cephalic presentation at term. Unconditional logistic regression analysis was used to calculate crude and adjusted odds ratios (OR), using 95% confidence intervals (CI). Main exposure was duration of second stage of labor, and main outcome was risks of severe perineal lacerations (third and fourth degree). RESULTS: Risk of severe perineal lacerations increased with duration of second stage of labor. Compared with a second stage of labor of 1 h or less, women with a second stage of more than 2 h had an increased risk (aOR 1.42; 95% CI 1.28-1.58). Compared with non-instrumental vaginal deliveries, the risk was elevated among instrumental vaginal deliveries (aOR 2.24; 95% CI 2.07-2.42). The risk of perineal laceration increased with duration of second stage of labor until less than 3 h in both instrumental and non-instrumental vaginal deliveries, but after 3 h, the ORs did not further increase. After adjustments for potential confounders, macrosomia (birth weight > 4 500 g) and occiput posterior fetal position were risk factors of severe perineal lacerations. CONCLUSIONS: The risk of severe perineal laceration increases with duration until the third hour of second stage of labor. Instrumental delivery is the most significant risk factor for severe lacerations, followed by duration of second stage of labor, fetal size and occiput posterior fetal position.

Neonatal outcomes of deliveries in occiput posterior position when delayed pushing is practiced: a cohort study.

BACKGROUND: To examine the impact of occiput posterior position, compared to occiput anterior position, on neonatal outcomes in a setting where delayed pushing is practiced. The specific aim was to estimate the risk of acidaemia. METHODS: Cohort study from a university hospital in Sweden between 2004 and 2012. Information was collected from a local database of 35,546 births. Umbilical artery sampling was routine. Outcomes were: umbilical artery pH < 7.00 and <7.10 and short-term neonatal morbidity. The association between occiput posterior position and neonatal outcomes was examined using logistic regression analysis, presented as adjusted odds ratio (AOR) with 95% confidence interval (CI). RESULTS: Of 27,648 attempted vaginal births, 1292 (4.7%) had occiput posterior position. Compared with occiput anterior, there was no difference in pH < 7.00 (0.4% vs. 0.5%) but a higher rate of pH < 7.10 in occiput posterior births (3.8 vs. 5.5%). Logistic regression analysis showed no increased risk of pH < 7.10 (AOR 1.28 95% CI 0.93-1.74) when occiput posterior was compared with occiput anterior births but, an increased risk of Apgar score < 7 at 5 min (AOR 1.84, 95% CI 1.11-3.05); neonatal care admission (AOR 1.68, 95% CI 1.17-2.42) and composite morbidity (AOR 1.66, 95% CI 1.19-2.31). CONCLUSIONS: With delayed pushing, birth in occiput posterior compared with anterior position is not associated with acidaemia. The higher risk of neonatal morbidity is of concern and any long-term consequences need to be investigated in future studies.

Intrapartum Ultrasound to Differentiate Flexion and Deflexion in Occipitoposterior Rotation.

OBJECTIVE: To evaluate the ability of intrapartum ultrasound to differentiate occipitoposterior (OP) rotation with normal flexion of the head from deflexion, to compare the accuracy of ultrasound with the digital examination, and to assess the outcome of labor according to the type of presentation. PATIENTS AND METHODS: A retrospective study of patients with abnormal labor because of either prolongation and/or abnormal cardiotocography and OP rotation who underwent intrapartum sonography. RESULTS: Normal flexion was inferred in 36/42 cases by a longitudinal sonographic view of the fetal face demonstrating the chin approaching the chest. In the remaining 6, deflexion was diagnosed by visualizing the chin separate and distant from the chest. In 3 of these cases, the orbits were at the same level of the pubis suggesting brow presentation. In the remaining 3 cases, the orbits were above the pubis, and sinciput presentation was inferred. Head deflexion was diagnosed more accurately with ultrasound than clinically and always required a cesarean section versus 36% of cases with OP flexed presentation (p = 0.0052). CONCLUSIONS: Fetuses with abnormal labor and OP rotation had deflexed presentations in 14% of cases and were never delivered vaginally. Sonography was far more accurate than the digital examination.

Sonographic evaluation of the fetal spine position and success rate of manual rotation of the fetus in occiput posterior position: A randomized controlled trial.

BACKGROUND: To evaluate whether sonographic (US) diagnosis of the fetal spine position could increase the success rate of manual rotation of the fetal occiput (MRFO) in second-stage arrest in persistent occiput posterior position (OPP). METHODS: In this randomized controlled parallel single-center trial, 58 nulliparous in second-stage arrest of labor with fetus in cephalic presentation and OPP diagnosed by US were randomly assigned to group A where the fetal spine position was not known by the operator or to group B where the operator knew it. The main outcome was the success of MRFO in the two groups. Secondary outcomes were perineal injuries, blood loss, duration of expulsive period, and neonatal APGAR at 5 minutes. RESULTS: A priori knowledge of the spine position improves the success of the MRFO (41.4% group A versus 82.8% group B, p value < 0.001), the percentage of spontaneous deliveries (27.6% group A versus 69% group B, p value = 0.01), and maternal outcome (intact perineum and blood loss). No differences were detected on the neonatal side. CONCLUSIONS: MRFO is a safe and useful procedure that should be performed in second-stage arrest in OPP. A better performance was observed when supported by the US knowledge of the spine position. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:472-476, 2017.

Lateral asymmetric decubitus position for the rotation of occipito-posterior positions: multicenter randomized controlled trial EVADELA.

BACKGROUND: Fetal occiput posterior positions are associated with poorer maternal outcomes than occiput anterior positions. Although methods that include instrumental and manual rotation can be used at the end of labor to promote the rotation of the fetal head, various maternal postures may also be performed from the beginning of labor in occiput posterior position. Such postures might facilitate flexion of the fetal head and favor its rotation into an occiput anterior position. OBJECTIVE: The purpose of this study was to determine whether a lateral asymmetric decubitus posture facilitates the rotation of fetal occiput posterior into occiput anterior positions. STUDY DESIGN: Evaluation of Decubitus Lateral Asymmetric posture was a multicenter randomized controlled trial that included 322 women from May 2013 through December 2014. Study participants were women who labored with ruptured membranes and a term fetus that was confirmed by ultrasound imaging to be in cephalic posterior position. Women who were assigned to the intervention group were asked to lie in a lateral asymmetric decubitus posture on the side opposite that of the fetal spine during the first hour and encouraged to maintain this position for as long as possible during the first stage of labor. In the control group, women adopted a dorsal recumbent posture during the first hour after random assignment. The primary outcome was occiput anterior position at 1 hour after random assignment. Secondary outcomes were occiput anterior position at complete dilation, mode of delivery, speed of dilation during the active first stage, maternal pain, and women's satisfaction. RESULTS: One hundred sixty women were assigned to the intervention group, and 162 women were assigned to the control group. One hour after random assignment, the rates of occiput anterior position did not differ between the intervention and control groups (21.9% vs 21.6%, respectively; P=.887). Occiput anterior rates did not differ between groups at complete dilation (43.7% vs 43.2%, respectively; P=.565) or at birth (83.1% vs 86.4%, respectively; P=.436). Finally, the groups did not differ significantly for cesarean delivery rates (18.1% among women in lateral asymmetric decubitus and 14.2% among control subjects (P=0.608) or for speed of cervical dilation during the active first stage of labor (P=.684), pain assessment (P=.705), or women's satisfaction (P=.326). No maternal or neonatal adverse effect that was associated with either posture was observed. CONCLUSION: Lateral asymmetric decubitus position on the side opposite that of the fetal spine did not facilitate rotation of fetal head. Nevertheless, other maternal positions may be effective in promoting fetal head rotation. Further research is needed; posturing during labor, nonetheless, should remain a woman's active choice.

Sonographic prediction of vaginal delivery in prolonged labor: a two-center study.

OBJECTIVE: To investigate whether head-perineum distance (HPD) measured by transperineal ultrasound is predictive of vaginal delivery and time remaining in labor in nulliparous women with prolonged first stage of labor and to compare the predictive value with that of angle of progression (AoP). METHODS: This was a prospective observational study at Stavanger University Hospital, Norway and Addenbrooke's Hospital, Cambridge, UK from January 2012 to April 2013, of nulliparous women with singleton pregnancies with cephalic presentation at term with prolonged first stage of labor. We used transperineal ultrasound to measure HPD (shortest distance between the outer bony limit of the fetal skull and the perineum) and AoP (angle between a line through the long axis of the symphysis and the tangent to the fetal head) and transabdominal ultrasound to classify fetal head position. The main outcomes were vaginal delivery and time remaining in labor. RESULTS: Of 150 women enrolled, 39 underwent delivery by Cesarean section. The area under the receiver-operating characteristics curve for the prediction of vaginal delivery was 81% (95% CI, 73-89%) using HPD as the test variable and 72% (95% CI, 63-82%) using AoP. HPD was ≤ 40 mm in 84 (56%) women, of whom 77 (92%; 95% CI, 84-96%) delivered vaginally. HPD was > 40 mm in the other 66 (44%) women, of whom 34 (52%; 95% CI, 40-63%) delivered vaginally. AoP was ≥ 110° in 84 of the 145 (58%) in whom this was available and, of these, 74 (88%; 95% CI, 79-93%) delivered vaginally. AoP was < 110° in the other 61 (42%) women, of whom 35 (57%; 95% CI, 45-69%) delivered vaginally. Multivariable logistic regression analysis showed that HPD ≤ 40 mm (odds ratio (OR), 4.92; 95% CI, 1.54-15.80), AoP ≥ 110° (OR, 3.11; 95% CI, 1.01-9.56), non-occiput posterior position (OR, 3.36; 95% CI, 1.24-9.12) and spontaneous onset of labor (OR, 4.44; 95% CI, 1.42-13.89) were independent predictors for vaginal delivery. Both ultrasound methods were predictive for the time remaining in labor. CONCLUSION: Transperineal ultrasound measurement of HPD and AoP provide important information about the likelihood of vaginal delivery and the time remaining in labor in nulliparous women with prolonged labor.

Management of occiput posterior position in the second stage of labor: a survey of midwifery practice in Australia.

BACKGROUND: The management of the occiput posterior (OP) position has been controversial for many years. Manual rotation can be performed by midwives and could reduce cesarean sections and instrumental births. We aimed to determine current midwifery views, knowledge, and practice of manual rotation. METHOD: A de-identified, self-reported questionnaire was e-mailed to all Australian College of Midwives full members (n = 3,997). RESULTS: Of 3,182 surveyed, 57 percent (1,817) responded, of whom 51 percent (920) were currently practicing midwifery. Seventy-seven percent of midwives thought that manual rotation at full dilatation was a valid intervention. Sixty-four percent stated the procedure was acceptable before instrumental delivery, but 30 percent were unsure. Most practicing midwives (93%) had heard of manual rotation, but only 18 percent had performed one in the last year. Midwives would support the routine performance of manual rotation for OP position if it reduced operative births from 68 to 50 percent and would support manual rotation for occiput transverse (OT) position if it reduced operative births from 39 to 25 percent. CONCLUSION: This study indicates that manual rotation is considered acceptable by most midwives in Australia, yet is only performed by a minority. Midwives would be willing to perform prophylactic manual rotation if it was known to facilitate normal vaginal births suggesting a scope to introduce this procedure into widespread clinical practice.

Persistent occiput posterior: OUTcomes following digital rotation: a pilot randomised controlled trial.

AIM: To determine the feasibility of a multicentre randomised controlled trial (RCT) to investigate whether digital rotation of the fetal head from occiput posterior (OP) position in the second stage of labour reduces the risk of operative delivery (defined as caesarean section (CS) or instrumental delivery). METHODS: We conducted the study between December 2010 and December 2011 in a tertiary referral hospital in Australia. A transabdominal ultrasound was performed early in the second stage of labour on women with cephalic, singleton pregnancies to determine the fetal position. Those women with a fetus in the OP position were randomised to either a digital rotation or a sham procedure. In all other ways, participants received their usual intrapartum care. Data regarding demographics, mode of delivery, labour, post natal period and neonatal outcomes were collected. RESULTS: One thousand and four women were consented, 834 achieved full dilatation, and 30 were randomised. An additional portable ultrasound scan and a blinded 'sham' digital rotation were acceptable to women and staff. Operative delivery rates were 13/15 in the digital rotation (four CS and nine instrumental) and 12/15 in the sham (three CS and nine instrumental) groups, respectively. CONCLUSION: A large double-blinded multicentre RCT would be feasible and acceptable to women and staff. Strategies to improve recruitment such as consenting women with an effective epidural in active labour should be considered. This would be the first RCT to answer a clinically important question which could significantly affect the operative delivery rate in Australia and internationally.

Oxytocin augmentation and neurotransmitters in prolonged delivery: An experimental appraisal.

The uterus is a highly innervated organ, and during labor, this innervation is at its highest level. Oxytocinergic fibers play an important role in labor and delivery and, in particular, the Lower Uterine Segment, cervix, and fundus are all controlled by motor neurofibers. Oxytocin is a neurohormone that acts on receptors located on the membrane of the smooth cells of the myometrium. During the stages of labor and delivery, its binding causes myofibers to contract, which enables the fundus of the uterus to act as a mediator. The aim of this study was to investigate the presence of oxytocinergic fibers in prolonged and non-prolonged dystocic delivery in a cohort of 90 patients, evaluated during the first and second stages of labor. Myometrial tissue samples were collected and evaluated by electron microscopy, in order to quantify differences in neurofibers concentrations between the investigated and control cohorts of patients. The authors of this experiment showed that the concentration of oxytocinergic fibers differs between non-prolonged and prolonged dystocic delivery. In particular, in prolonged dystocic delivery, compared to non-prolonged dystocic delivery, there is a lower amount of oxytocin fiber. The increase in oxytocin appeared to be ineffective in patients who experienced prolonged dystocic delivery, since the dystocic labor ended as a result of the altered presence of oxytocinergic fibers detected in this group of patients.

Persistent occiput posterior position: predictive factors of spontaneous rotation of the fetal head.

OBJECTIVES: To assess factors associated with spontaneous rotation in the occiput anterior position for fetuses in persistent occiput posterior (OP) during the second stage of labor. To evaluate maternal and fetal outcomes after spontaneous rotation of persistent OP. METHODS: This is a prospective cohort of 495 women with fetuses in persistent OP position, confirmed with ultrasonography during the second stage of labor. We performed simple logistic regressions, followed by multiple logistic regressions. RESULTS: Among 495 women with fetuses in persistent OP position, 78 fetuses (16%) underwent a spontaneous rotation during the second stage of labor. The multivariate analysis found that a short duration of the first stage of labor (<7 h) was associated with a spontaneous rotation of the fetal head in the second stage of labor (OR 0.43 [0.23; 0.76. There were fewer episiotomies (25.6% vs 52.3%, p < .01), cesarean sections (0% v. 5.4%, p = .03), and instrumental deliveries (8.9% vs. 50%, p < .01) in the "spontaneous rotation" group, and the two groups were similar regarding post-partum hemorrhage.The newborns in the "spontaneous rotation" group had a higher Apgar score at 1 min (10 v. 9, p = .02). The two groups did not differ for other neonatal parameters, such as arterial pH value, Apgar score at 5 min, birth trauma, or transfer into the pediatric unit. CONCLUSION: A shorter duration of the first stage of labor (< 7 h) is a predictive factor of spontaneous rotation in the occiput anterior position for fetuses in persistent OP position. A spontaneous rotation in case of an OP position is associated with better maternal and fetal outcomes.