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Cesarean birth has increased substantially in many parts of the world over recent decades and concerns have been raised about the propriety of this change in obstetric practice. Sometimes, a cesarean is necessary to preserve fetal and maternal health. But in balancing the risks of surgical intervention the implicit assumption has been that cesarean birth is an equivalent alternative to vaginal birth from the standpoint of the immediate and long-term health of the fetus and neonate. Increasingly, we realize this is not necessarily so. Delivery mode per se may influence short-term and abiding problems with homeostasis in offspring, quite independent of the indications for the delivery and other potentially confounding factors. The probability of developing various disorders, including respiratory compromise, obesity, immune dysfunction, and neurobehavioral disorders has been shown in some studies to be higher among individuals born by cesarean. Moreover, many of these adverse effects are not confined to the neonatal period and may develop over many years. Although the associations between delivery mode and long-term health are persuasive, their pathogenesis and causality remain uncertain. Full exploration and a clear understanding of these relationships is of great importance to the health of offspring., (© 2022 Walter de Gruyter GmbH, Berlin/Boston.)

During labor mother and fetus are evaluated at intervals to assess their well-being and determine how the labor is progressing. These assessments require skillful physical diagnosis and the ability to translate the acquired information into meaningful prognostic decision-making. We describe a coordinated approach to the assessment of labor. Graphing of serial measurements of cervical dilatation and fetal station creates "labor curves," which provide diagnostic and prognostic information. Based on these curves we recognize nine discrete labor abnormalities. Many may be related to insufficient or disordered contractile mechanisms. Several factors are strongly associated with development of labor disorders, including cephalopelvic disproportion, excess analgesia, fetal malpositions, intrauterine infection, and maternal obesity. Clinical cephalopelvimetry involves assessing pelvic traits and predicting their effects on labor. These observations must be integrated with information derived from the labor curves. Exogenous oxytocin is widely used. It has a high therapeutic index, but is easily misused. Oxytocin treatment should be restricted to situations in which its potential benefits clearly outweigh its risks. This requires there be a documented labor dysfunction or a legitimate medical reason to shorten the labor. Normal labor and delivery pose little risk to a healthy fetus; but dysfunctional labors, especially if stimulated excessively by oxytocin or terminated by complex operative vaginal delivery, have the potential for considerable harm. Conscientiously implemented, the approach to the evaluation of labor outlined in this review will result in a reasonable cesarean rate and minimize risks that may accrue from the labor and delivery process., (© 2020 Walter de Gruyter GmbH, Berlin/Boston.)

In the 1930s, investigators in the US, Germany and Switzerland made the first attempts to quantify the course of labor in a clinically meaningful way. They emphasized the rupture of membranes as a pivotal event governing labor progress. Attention was also placed on the total number of contractions as a guide to normality. Beginning in the 1950s, Friedman determined that changes in cervical dilatation and fetal station over time were the most useful parameters for the assessment of labor progress. He showed all normal labors had similar patterns of dilatation and descent, differing only in the durations and slopes of their component parts. These observations led to the formulation of criteria that elevated the assessment of labor from a rather arbitrary exercise to one guided by scientific objectivity. Researchers worldwide confirmed the basic nature of labor curves and validated their functionality. This system allows us to quantify the effects of parity, analgesia, maternal obesity, prior cesarean, maternal age, and fetal presentation and position on labor. It permits analysis of outcomes associated with labor aberrations, quantifies the effectiveness of treatments and assesses the need for cesarean delivery. Also, dysfunctional labor patterns serve as indicators of short- and long-term risks to offspring. We still lack the necessary translational research to link the physiologic manifestations of uterine contractility with changes in dilatation and descent. Recent efforts to interpret electrohysterographic patterns hold promise in this regard, as does preliminary exploration into the molecular basis of dysfunctional labor. For now, the clinician is best served by a system of labor assessment proposed more than 60 years ago and embellished upon in considerable detail since.

To determine if oxytocin dosage used for labor induction differed in obese and lean women, we analyzed records of patients who underwent term labor induction and delivered vaginally. Each of a cohort of 27 patients with a body mass index (BMI) >40 kg/m2 was matched with a patient with a BMI <28 kg/m2 for gestational age, for birth weight, and for cervical dilatation and fetal station at admission. The oxytocin dose administered during first stage labor was calculated for each patient. In addition to the matched characteristics, there was no difference between groups in parity, frequency of diabetes, epidural anesthesia use, or pharmacologic cervical ripening. Oxytocin utilization was significantly greater in obese women than in lean women. The maximum administration rate was 17.7±4.7 and 13.1±5.0 mU/min, respectively (P=0.001). Oxytocin administered per minute during the first stage of labor was greater in the obese group (11.6±4.8 vs. 8.6±4.1 mU/min; P=0.020). Neither active phase duration nor the maximum rate of dilatation differed significantly between the groups. That obese parturients required more oxytocin than lean women during the first stage of successful labor induction could not be explained by group differences in parity, birth weight, dysfunctional labor, pre-induction dilatation and station, or epidural use.

Objective: We hypothesized that predictive value of traditional Ebola virus disease (EVD) screening in West African pregnant women is low because febrile and hemorrhagic complications of pregnancy that can mimic EVD are common., Methods: Proportions of various categories of pregnancy loss from a hypothetical cohort of West African gravidas were used to construct a Kaplan-Meier curve. The incidence rate of each category was determined by multiplying its proportion by the overall incidence rate, calculated from the inverse of the area under the curve. Incidence rates of Ebola-like illnesses during pregnancy were obtained by multiplying their percentages by the incidence rates of categories of loss with which they coincide., Results: During pregnancy about 1.5% of suspected EVD cases would prove to have EVD. Most of the remaining 98.5% would have hemorrhagic and febrile complications of pregnancy., Conclusion: Current guidelines consider obstetrical interventions inappropriate in suspected EVD during pregnancy. However, because the overwhelming majority of cases suspected by screening do not have EVD and might benefit from obstetrical intervention, policy makers must consider whether the small risk to properly protected health care workers from the 1.5% with true EVD justifies withholding potentially life-saving care from the 98.5% who ultimately test negative for EVD.

To determine whether the effectiveness of oxytocin treatment of arrest of dilatation differed in obese compared to lean women, we did a retrospective analysis of 118 subjects in spontaneous labor whose arrest of dilatation was treated with oxytocin. Cases were stratified by maternal body mass index (BMI): Group A, <25 kg/m2; Group B, 25.0-29.9 kg/m2; Group C, 30.0-34.9 kg/m2; and Group D, ≥ 35 kg/m². Groups were comparable in maternal age, parity, gestational age, birth weight, and the frequency of infection. Full dilatation was reached in about 90% of Group A and B, 72% of Group C, and 39% of Group D, the most obese women (P<0.001). The cesarean rate was directly related to maternal BMI, 11.4%, 22.9%, 34.3%, and 69.6% in Groups A through D, respectively (P<0.001). Significantly more oxytocin was used in group D than in the other groups during the first 3h of infusion in attempting to overcome the arrest (P=0.003). We conclude that oxytocin treatment of arrest of dilatation was less effective in obese than in lean women. This effect was most prominent in women with a BMI >35 kg/m2, who were, despite having received more oxytocin than those in the leaner groups, less than half as likely to attain full dilatation and more than twice as likely to deliver by cesarean.

We studied changes in the width of the symphysis pubis in 32 women examined serially by ultrasound during labor. Measurements were made at the superior border of the symphysis and at its narrowest breadth in the latent phase, the active phase, and the second stage of labor. There was a significant increase in the width of the symphysis between the first and second stages of labor at both measured levels. Widening was observed in 94% at the superior symphyseal breadth and in 59% at the narrowest. Of those cases in which the width of the symphysis increased, there was a large spectrum of change, ranging from 9 to 98% of the original width at the narrowest measurement site and from 2 to 139% at the superior breadth. There was a strong inverse correlation between maternal age and the degree of symphyseal widening in nulliparas, but not in multiparas. We conclude that labor is associated with a substantial widening of the symphysis pubis in most, but not all women.

Aim: To determine whether maternal obesity is associated with dysfunctional labor patterns., Methods: In a case-control design we compared the graphic labor patterns of a group of 105 very obese subjects [body mass index (BMI) >35 kg/m(2)] with those of 113 lean controls (BMI<26 kg/m(2)). All entered spontaneous labor at term. Cases with birth weights >4 kg, diabetes mellitus, hypertension and prior cesarean delivery were excluded., Results: The obese group had a significantly higher frequency of arrest of dilatation (17.6 vs. 5.2%; P=0.005)., Conclusions: Maternal obesity is associated with active phase labor dysfunction, specifically arrest of dilatation.

We devised a method to predict risk of neonatal Erb palsy using variables ascertainable before delivery. Multiple logistic regression modeling was used to construct an Erb palsy risk score from a case-control study of 45 consecutive Erb palsy cases and 90 controls. Receiver-operator characteristics identified a range of scores for which likelihood ratios were determined for calculation of predictive values across a range of prior probabilities. In the final model, large estimated fetal weight, gestational diabetes, large maternal body mass index, large weight gain, and black race were associated with 2.3-4.8 times greater odds of Erb palsy. A long second stage had a modest effect on the odds (OR=2.7, P=0.13), unless preceded by a long deceleration phase, which combination increased the odds of Erb palsy to 20.1 (P=0.001). A risk score of 0.72 had a sensitivity of 36% and a specificity of 99%. In a theoretical population with a birth prevalence of brachial plexus palsy of 2.5/1000, application of the risk score would prevent 36% of cases and result in about 14 cesareans for every nerve injury prevented. We conclude that risk scoring using multiple logistic regression coefficients of variables that can be known in time to affect decision-making about mode of delivery has the potential to guide intervention to prevent some Erb palsies.

Acute postpartum hemorrhage is the leading worldwide cause of maternal mortality, such deaths being usually related to the development of hemorrhagic shock and its consequences, especially the multiple organ dysfunction syndrome. Obstetricians should be aware of the clinical manifestations and principles of management of hemorrhagic shock. Initial assessment of the bleeding patient requires monitoring blood pressure, pulse, capillary refill, mental status and urinary output. This allows estimation of the amount and the rate of blood loss and helps direct treatment. Hemorrhagic shock is a condition in which inadequate perfusion of organs results in insufficient availability of oxygen to satisfy the metabolic needs of the tissues. A catabolic state develops. The consequences of these changes are inflammation, endothelial dysfunction, and disruption of normal metabolic processes in vital organs. Once these events become established, the process of shock is often irreversible, even if volume and red cell deficits are corrected. The principal goals of management are controlling the source of the blood loss; restoring adequate oxygen carrying capacity; and maintaining adequate tissue perfusion. Patients with severe postpartum hemorrhage are at risk of developing hypothermia, an insidious complication that contributes substantially to morbidity and mortality. It must be prevented or treated promptly. Successful treatment of exsanguinating postpartum hemorrhage depends on efficient collaboration among all members of the patient care team, and a management plan based on an understanding of the pathophysiology of shock and tailored to the individual patient's situation.