Search

Introduction: This exploratory review aimed to provide empirical evidence on the definitions of labor, the statistical approaches and measures reported in randomized controlled trials (RCTs) and observational studies measuring the duration of labor. Methods: A systematic electronic literature search was conducted using different databases. An extraction form was designed and used to extract relevant data. English, French, and German studies published between 1999 and 2019 have been included. Only RCTs and observational studies analyzing labor duration (or a phase of labor duration) as a primary outcome have been included. Results: Ninety‐two RCTs and 126 observational studies were eligible. No definition of the onset of labor was provided in 21.7% (n = 20) of the RCTs and 23.8% (n = 30) of the observational studies. Mean was the most frequently applied measure of labor duration in the RCTs (89.1%, n = 82), and median in the observational studies (54.8%, n = 69). Most RCTs (83%, n = 76) and observational studies (70.6%, n = 89) analyzed labor duration using a bivariate method, with the t‐test being the most frequently applied (45.7% and 27%, respectively). Only 10.8% (n = 10) of the RCTs and 52.4% (n = 66) of the observational studies conducted a multivariable regression: 3 (30%; out of 10) RCTs and 37 (56%; out of 66) observational studies used a time‐to‐event adapted model. Conclusion: This survey reports a lack of agreement with respect to how the onset of labor and phases of labor duration are presented. Concerning the statistical approaches, few studies used survival analysis, which is the appropriate statistical framework to analyze time‐to‐event data. [ABSTRACT FROM AUTHOR]

Length of labor is one of the factors contributing to maternal and neonatal childbirth outcomes. Auriculotherapy is a potential therapeutic intervention for reducing labor duration. This systematic review aims to evaluate the efficacy of auriculotherapy in shortening labor time.This systematic review and meta-analysis included randomized controlled trials published from inception until July 2024. Scopus, Cochrane Library, Web of Science, Embase, and PubMed were searched for eligible studies. Article screening was performed using Endnote X8. Data analysis and assessment of the risk of bias were performed by Review Manager 5.3. Analysis of pooled data was performed using fixed and random effect models. Five studies (n = 433 participants) were included in the meta-analysis from an initial pool of 150 articles. The participants' mean age was 25.07 ± 4.52. Auriculotherapy reduced the length of the active and second phases of labor by approximately sixty (MD = -63.54; 95 percent CI: −84.47, −42.62; p <.00001) and seven minutes (MD = −7.67; 95 percent CI: −13.46, −1.89, p =.009), respectively. Auriculotherapy was found to significantly decrease the duration of the active and second phases of labor. However, it is not possible to generalize the results and further high-quality studies involving more individuals from various socioeconomic backgrounds are needed to provide support for these findings. [ABSTRACT FROM AUTHOR]

• Nonpharmacological applications are frequently used to reduce labor pain and fear. However, the effect of Neurolinguistic Programming (NLP) intervention on labor pain and fear is a matter of curiosity. • This study shows that NLP practice in primiparous and multiparous women significantly reduces labor pain and fear, shortens the duration of labor and increases mothers' labor satisfaction. • NLP can empower women during childbirth by supporting them with positive expressions, thoughts and emotions, and enable them to have a positive birth experience. Labor pain is one of the most severe pains experienced by women. In the literature, there is no research examining the effect of Neurolinguistic Programming (NLP) on birth pain and fear. It was aimed to determine the effect of NLP on labor pain, fear, duration, and maternal satisfaction in both nulliparous, and multiparous pregnant women. This study consists of each with two arms, parallel-group randomized controlled trials, on two different samples for both nulliparous and multiparous women. Data were collected between 3 October 2023–21 January 2024. A total of 124 women (62 nulliparous and 62 multiparous women) who gave birth vaginally constituted the sample of the study. Both nulliparous and multiparous women were randomly assigned to groups. The primary outcomes were labor pain, fear, duration, and satisfaction. When the cervical span was 3–4, 5–6, and 7–8 cm, NLP was applied to the experimental group for 20 min each, the control group rested for 20 min each. According to the measurement times, the mean pain score of the experimental group was lower than the control group. The mean VAS pain score measured over time decreased by 90.3 % in the NLP group compared to the control group for primiparous and 64.5 % compared to the control group for multiparous. In both nulliparous and multiparous, the fear of labor of the NLP group was lower, the duration of labor was shorter, and the satisfaction with labor was higher compared to the control group (p < 0.05). NLP reduces labor pain and fear, shortens the duration of labor, and increases maternal satisfaction in labor. [ABSTRACT FROM AUTHOR]

Background: Magnesium sulfate is used topically to reduce the duration of labor in some regions of the country. However, there is insufficient evidence about its effectiveness. This study aimed to determine whether topical magnesium sulfate reduces labor duration and improves childbirth experience (primary outcomes). Methods: In this randomized controlled trial, the participants were 98 women with low-risk, singleton, and full-term pregnancies admitted to a teaching hospital in Iran. They were randomly assigned to the intervention group (receiving 50% magnesium sulfate) or the control group (receiving distilled water) stratified by parity and onset of labor. The participants, interventionists, and data collectors were blinded. During the vaginal examination at the beginning of the active phase of labor, 10 mL of magnesium sulfate or distilled water was poured on the cervix of the uterus. Data collection was performed by the researcher with continuous monitoring up to two hours post-delivery and follow-up at 4–5 weeks postpartum. The Childbirth Experience Questionnaire 2.0 was used to examine childbirth experience. We performed a modified intention-to-treat analysis, excluding those whose outcome of interest could not be assessed. Independent-samples t-tests were used to compare the groups in terms of the mean of the primary outcomes. Results: Participant recruitment took place between December 2021 and December 2022. Thirty-three percent were primiparous and 37% had induced labor. Three women in the intervention group and seven in the control group underwent emergency cesarean sections. All 49 women assigned to each group were included in the analysis of labor duration outcome, while one and two women were excluded from the analysis of childbirth experience score due to loss to follow-up. In the intervention group, compared to the control group, the mean duration of the intervention until delivery was significantly shorter (1.59 vs. 2.93 h; MD -1.34, 95% CI [-1.88 to -0.79]) and the childbirth experience score was higher (3.1 vs. 2.3, MD 0.84; 95% CI [0.59 to 1.08]). Conclusions: According to the results of this trial, pouring 10 mL of 50% magnesium sulfate on the cervix at the beginning of the active phase of labor probably reduces labor duration and improves the childbirth experience. Trial registration: Ethics Committee of Tabriz University of Medical Sciences: IR.TBZMED.REC. 1400.726. Iranian Registry of Clinical Trials: IRCT20100414003706N40 Registration date: 21/11/2021 (https://en.irct.ir/trial/58323). [ABSTRACT FROM AUTHOR]

Abstract Background Magnesium sulfate is used topically to reduce the duration of labor in some regions of the country. However, there is insufficient evidence about its effectiveness. This study aimed to determine whether topical magnesium sulfate reduces labor duration and improves childbirth experience (primary outcomes). Methods In this randomized controlled trial, the participants were 98 women with low-risk, singleton, and full-term pregnancies admitted to a teaching hospital in Iran. They were randomly assigned to the intervention group (receiving 50% magnesium sulfate) or the control group (receiving distilled water) stratified by parity and onset of labor. The participants, interventionists, and data collectors were blinded. During the vaginal examination at the beginning of the active phase of labor, 10 mL of magnesium sulfate or distilled water was poured on the cervix of the uterus. Data collection was performed by the researcher with continuous monitoring up to two hours post-delivery and follow-up at 4–5 weeks postpartum. The Childbirth Experience Questionnaire 2.0 was used to examine childbirth experience. We performed a modified intention-to-treat analysis, excluding those whose outcome of interest could not be assessed. Independent-samples t-tests were used to compare the groups in terms of the mean of the primary outcomes. Results Participant recruitment took place between December 2021 and December 2022. Thirty-three percent were primiparous and 37% had induced labor. Three women in the intervention group and seven in the control group underwent emergency cesarean sections. All 49 women assigned to each group were included in the analysis of labor duration outcome, while one and two women were excluded from the analysis of childbirth experience score due to loss to follow-up. In the intervention group, compared to the control group, the mean duration of the intervention until delivery was significantly shorter (1.59 vs. 2.93 h; MD -1.34, 95% CI [-1.88 to -0.79]) and the childbirth experience score was higher (3.1 vs. 2.3, MD 0.84; 95% CI [0.59 to 1.08]). Conclusions According to the results of this trial, pouring 10 mL of 50% magnesium sulfate on the cervix at the beginning of the active phase of labor probably reduces labor duration and improves the childbirth experience. Trial registration Ethics Committee of Tabriz University of Medical Sciences: IR.TBZMED.REC. 1400.726. Iranian Registry of Clinical Trials: IRCT20100414003706N40 Registration date: 21/11/2021 ( https://en.irct.ir/trial/58323 ).

Abstract Background Cesarean section (C-section) rates are increasing globally, and repeated C-sections are associated with increased maternal morbidity. Trial of labor after C-section (TOLAC) is an approach to reduce the recurrence of C-sections. However, limited research exists on the impact of cesarean scars on labor duration in TOLAC, considering the termination of labor through C-section and selection bias. This study aimed to investigate the impact of cesarean scars on labor duration in TOLAC participants, accounting for potential confounding factors and biases. Methods This retrospective cohort study included 2,964 women who attempted vaginal birth at a single center in Japan from 2012 to 2021. The study categorized participants into TOLAC (n = 187) and non-TOLAC (n = 2,777) groups. Propensity scores were calculated based on 14 factors that could influence labor duration, and inverse probability of treatment weighting (IPTW) was applied. Cox proportional hazards regression analysis estimated hazard ratios (HRs) for labor duration, with and without IPTW adjustment. Sensitivity analyses used propensity score matching, bootstrapping, and interval censoring to address potential biases, including recall bias in the reported onset of labor. Results The unadjusted HR for labor duration in the TOLAC group compared to the non-TOLAC group was 0.83 (95% CI: 0.70–0.98, P = 0.027), indicating a longer labor duration in the TOLAC group. After adjusting for confounding factors using IPTW, the HR was 0.98 (95% CI: 0.74–1.30, P = 0.91), suggesting no significant difference in labor duration between the groups. Sensitivity analyses using propensity score matching, bootstrapping, and interval censoring yielded consistent results. These findings suggested that the apparent association between TOLAC and longer labor duration was because of confounding factors rather than TOLAC itself. Conclusions After adjusting for confounding factors and addressing potential biases, cesarean scars had a limited impact on labor duration in TOLAC participants. Maternal and fetal characteristics may have a more substantial influence on labor duration.

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. [ABSTRACT FROM AUTHOR]

Background: Cesarean section (C-section) rates are increasing globally, and repeated C-sections are associated with increased maternal morbidity. Trial of labor after C-section (TOLAC) is an approach to reduce the recurrence of C-sections. However, limited research exists on the impact of cesarean scars on labor duration in TOLAC, considering the termination of labor through C-section and selection bias. This study aimed to investigate the impact of cesarean scars on labor duration in TOLAC participants, accounting for potential confounding factors and biases. Methods: This retrospective cohort study included 2,964 women who attempted vaginal birth at a single center in Japan from 2012 to 2021. The study categorized participants into TOLAC (n = 187) and non-TOLAC (n = 2,777) groups. Propensity scores were calculated based on 14 factors that could influence labor duration, and inverse probability of treatment weighting (IPTW) was applied. Cox proportional hazards regression analysis estimated hazard ratios (HRs) for labor duration, with and without IPTW adjustment. Sensitivity analyses used propensity score matching, bootstrapping, and interval censoring to address potential biases, including recall bias in the reported onset of labor. Results: The unadjusted HR for labor duration in the TOLAC group compared to the non-TOLAC group was 0.83 (95% CI: 0.70–0.98, P = 0.027), indicating a longer labor duration in the TOLAC group. After adjusting for confounding factors using IPTW, the HR was 0.98 (95% CI: 0.74–1.30, P = 0.91), suggesting no significant difference in labor duration between the groups. Sensitivity analyses using propensity score matching, bootstrapping, and interval censoring yielded consistent results. These findings suggested that the apparent association between TOLAC and longer labor duration was because of confounding factors rather than TOLAC itself. Conclusions: After adjusting for confounding factors and addressing potential biases, cesarean scars had a limited impact on labor duration in TOLAC participants. Maternal and fetal characteristics may have a more substantial influence on labor duration. [ABSTRACT FROM AUTHOR]

Background: Labor pain is one of the most severe pain types known and it is especially more intense in primiparous women. For this reason, this experimental study was conducted on the rebozo technique applied during labor in primiparous pregnant women to determine its effect on the perception of labor pain and labor duration. Methods: This study was conducted between 1 July 2021 and 31 January 2022 in a private institution with two groups, 30 patients got treated with rebozo, rebozo group, 30 people in the control group, with a total of 60 patients. Data collection tools included patient information form, partograph form, Visual Analog Scale (VAS). Data was analysed with SPSS. Physical characteristics were similar (p>0.05). Results: Application of Rebozo technique shortened the duration of the active phase of labor, the duration of the total active phase and the duration between the active phase and delivery. VAS score was found to be significantly lower with Rebozo technique application (p

Background & Aims: There are different types of drugs to shorten prolonged labor. Spasmolytic drugs are used frequently in the delivery section to overcome cervical spasms and reduce the duration of labor. The study's objective was to evaluate the therapeutic efficacy of hyoscine N-butyl bromide (HBB) and Promethazine on the duration of the active phase of labor. Materials & Methods: We searched the Science Direct, PubMed Scopus, Google Scholar, MEDLINE, Web of Science, Cochrane Library, PsycINFO, and ProQuest databases, and reviewed the literature and reference lists of retrieved articles. We included reports of quantitative studies published in all Persian and English articles from 2000 to 2021 that focused on Promethazine or Hyoscine during. Two authors independently screened titles and abstracts and assessed articles in full text against the inclusion criteria. These criteria included vertex presentation, no previous uterine surgery, intact membranes, and spontaneous labor, with mothers having no contraindications for normal vaginal delivery. Results: Out of a total of 170 records initially screened, we included 44 articles in our review, and other studies were excluded. The results showed that 10, 20, 40 mg of HBB decreased the first stage of labor duration by 147.02 min, 58.95 min, and 71.60 min, respectively. Additionally, HBB decreased the first stage of labor duration by 100.61 min in multiparous women and 66.04 min in primipara women. To evaluate the Promethazine effect on labor duration, the results showed that the combined MD was not significant (p=0.67, 0.85, and 0.44 in the first, second, and third stages, respectively). Conclusion: HBB is more effective in multiparous women compared to primiparous women. On the other hand, Promethazine has no effect on reducing total labor duration and any stages of labor, so its use is not recommended.

Purpose: This study aimed to examine the effect of birth ball exercise on labor pain, delivery duration, birth comfort, and birth satisfaction. Methods: The study used a randomized controlled trial design. All 120 primiparous pregnant women were randomly assigned to the intervention (IG) and control groups (CG). After the cervical dilatation reached 4 cm, the pregnant women in the IG performed birth ball exercises, adhering to the birth ball guide created by the researcher. No intervention was made in the control group other than standard midwifery care practices. Results: The labor pain level between the groups (VAS 1-when cervical dilatation was 4 cm) was similar to each other. The labor pain level (VAS 2- when cervical dilatation was 9 cm) scores of the women in the IG were significantly lower than those in the CG (p < 0.05). The time between the active phase of labor until dilatation is complete and the time until the baby's head comes out after full dilatation was found to be statistically significantly shorter in the IG compared to the CG (p < 0.05). Childbirth comfort and satisfaction mean scores between the groups were found to be statistically insignificant (p > 0.05). Conclusion: As a result of the study, it was determined that the birth ball exercise significantly reduced labor pain and labor time. We recommend that the birth ball exercise be applied to all low-risk pregnant women because it helps fetal descent and cervical dilatation, and shortens labor pain and delivery time. [ABSTRACT FROM AUTHOR]

Objective: In our part of the world poverty and illiteracy has adversely affected our core objective of pregnancy i.e. healthy mother and healthy child. Exploring the role of a routinely used drug in reducing the duration of labor could be a breakthrough. Present study was planned accordingly to evaluate the effect of phloroglucinol (PHL). Materials and Methods: It was a Randomized controlled trial conducted at Department of Obstetrics & Gynecology, Combined Military Hospital, Bahawalpur from January 2019 to June 2019. This study included 60 cases of age 18 to 40 years, having singleton pregnancy and in active first stage of uncomplicated labor. Patients with history of multiple pregnancies, obstetrical and surgical complications and cardiorespiratory diseases were excluded. The cases were placed randomly into Group A & Group B and given intravenous PHL and a placebo respectively. After this, duration of the first stage of labor was recorded in minutes from when there was 3-4 cm cervical dilatation with regular uterine contractions to complete cervical dilation i.e. 10 cm and descent of the presenting fetal part. Results: Mean duration of active first stage of labor in experimental group A (230.20 ± 52.96 minutes) was significantly higher than that of control group B (345.30 ± 50.57 minutes). Conclusion: This study concluded that intravenous PHL has efficiently reduced the duration of active first stage of labor in these randomly selected nulliparous and multiparous women. PHL is a useful drug serving the purpose of a spasmolytic, analgesic and labor augmentation at the same time.

Background and Objectives: Long and ineffective labor causes hardships for mothers and doctors and increases the rate of cesarean sections and medical comorbidities. Several factors contribute to effective and less painful labor, including maternal age, parity, fetal characteristics, and the medications or procedures that obstetricians use for labor. We aimed to study the factors that affect labor duration and identify those that make labor more effective. Materials and Methods: This retrospective study included 141 patients who underwent normal vaginal deliveries at the Daegu Catholic University Medical Center between April 2013 and April 2022. Among the 141 patients, 44 received pethidine intravenously, 88 received oxytocin intravenously, and 64 received epidural anesthesia. The duration of the active phase and second stage of labor were recorded according to the findings of a manual examination of the cervix and continuous external electronic monitoring. We analyzed maternal and neonatal medical records and performed binomial logistic regression to identify the factors associated with a shorter active phase of labor. The clinical outcomes in mothers and neonates were also evaluated. Results: Among the various clinical factors, multiparity (odds ratio of parity 0.325) and the use of pethidine (odds ratio 2.906) were significantly associated with shortening the active phase of labor to less than 60 min. The use of epidural anesthesia or oxytocin was not significantly associated with reducing the active phase of labor. When patients were divided into two groups based on whether a pethidine injection had been used during labor, the duration of the active phase was shorter in the pethidine injection group than in the control group for both nulliparas and multiparas. No significant differences in the duration of the second stage of labor were observed between the pethidine injection and control groups. There were no significant differences in pregnancy outcomes, including the need for mechanical ventilation of neonates, Apgar scores, neonatal intensive care unit admissions, number of precipitous deliveries, maternal adverse side effects of drugs, or duration of maternal hospitalization between the two groups. Conclusions: Pethidine can be safely administered to women during labor to help reduce the duration of the active phase by promoting dilatation of the cervix and preventing complications that may result from prolonged labor. Pethidine may be helpful, especially for those who cannot receive epidural anesthesia or who cannot afford it. However, large-scale randomized controlled studies are required to evaluate the efficacy and safety of this drug during labor. Furthermore, it would be helpful if various studies were conducted depending on the timing of administration and indications for delivery. [ABSTRACT FROM AUTHOR]

Abstract Background Previous animal model studies have highlighted a role for cholesterol and its oxidized derivatives (oxysterols) in uterine contractile activity, however, a lipotoxic state associated with hypercholesterolemia may contribute to labor dystocia. Therefore, we investigated if maternal mid-pregnancy cholesterol and oxysterol concentrations were associated with labor duration in a human pregnancy cohort. Methods We conducted a secondary analysis of serum samples and birth outcome data from healthy pregnant women (N = 25) with mid-pregnancy fasting serum samples collected at 22–28 weeks of gestation. Serum was analyzed for total-C, HDL-C, and LDL-C by direct automated enzymatic assay and oxysterol profile including 7α-hydroxycholesterol (7αOHC), 7β-hydroxycholesterol (7βOHC), 24-hydroxycholesterol (24OHC), 25-hydroxycholesterol (25OHC), 27-hydroxycholesterol (27OHC), and 7-ketocholesterol (7KC) by liquid chromatography-selected ion monitoring-stable isotope dilution-atmospheric pressure chemical ionization-mass spectroscopy. Associations between maternal second trimester lipids and labor duration (minutes) were assessed using multivariable linear regression adjusting for maternal nulliparity and age. Results An increase in labor duration was observed for every 1-unit increment in serum 24OHC (0.96 min [0.36,1.56], p

Synopsis: Labor duration in spontaneous deliveries was associated with offspring neurodevelopmental delays at the age of 3 years depending on maternal parity and offspring sex. [ABSTRACT FROM AUTHOR]

The past 20 years witnessed an invigoration of research on labor progression and a change of thinking regarding normal labor. New evidence is emerging, and more advanced statistical methods are applied to labor progression analyses. Given the wide variations in the onset of active labor and the pattern of labor progression, there is an emerging consensus that the definition of abnormal labor may not be related to an idealized or average labor curve. Alternative approaches to guide labor management have been proposed; for example, using an upper limit of a distribution of labor duration to define abnormally slow labor. Nonetheless, the methods of labor assessment are still primitive and subject to error; more objective measures and more advanced instruments are needed to identify the onset of active labor, monitor labor progression, and define when labor duration is associated with maternal/child risk. Cervical dilation alone may be insufficient to define active labor, and incorporating more physical and biochemical measures may improve accuracy of diagnosing active labor onset and progression. Because the association between duration of labor and perinatal outcomes is rather complex and influenced by various underlying and iatrogenic conditions, future research must carefully explore how to integrate statistical cut-points with clinical outcomes to reach a practical definition of labor abnormalities. Finally, research regarding the complex labor process may benefit from new approaches, such as machine learning technologies and artificial intelligence to improve the predictability of successful vaginal delivery with normal perinatal outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To compare the effects of epidural analgesia (EA) and combined spinal epidural analgesia (SEA) on labor and maternal–fetal outcomes. Methods: We retrospectively identified and included 1499 patients with a single cephalic fetus who delivered at the study center from January 2015 to December 2018 and received neuraxial analgesia at the beginning of the active phase of labor (presence of regular painful contractions and cervical dilatation between 4 and 6 cm). Data including analgesia, labor characteristics, and maternal–fetal outcomes were retrieved from the prospectively collected delivery room database and medical records. Results: SEA was associated with a shorter first stage of labor than EA, with a median difference of 60 min. On multivariable ordinal logistic regression analysis, neuraxial analgesia, gestational age, fetal weight, labor induction, and parity were independently associated with the first stage length: patients in the EA group were 1.32 times more likely to have a longer first stage of labor (95% CI 1.06–1.64, p = 0.012) than those in the SEA group. Additionally, a significantly lower incidence of fundal pressure was performed among patients who underwent SEA (OR 0.55, 95% CI 0.34–0.9, p = 0.017). No associations were observed between the used neuraxial analgesia technique and other outcomes. Conclusions: SEA was associated with a shorter length of the first stage of labor and a lower rate of fundal pressure use than EA. Further studies confirming the effects of SEA on labor management and clarifying differences in maternal–fetal outcomes will allow concluding about the superiority of one technique upon the other. [ABSTRACT FROM AUTHOR]

Background and Objectives: Long and ineffective labor causes hardships for mothers and doctors and increases the rate of cesarean sections and medical comorbidities. Several factors contribute to effective and less painful labor, including maternal age, parity, fetal characteristics, and the medications or procedures that obstetricians use for labor. We aimed to study the factors that affect labor duration and identify those that make labor more effective. Materials and Methods: This retrospective study included 141 patients who underwent normal vaginal deliveries at the Daegu Catholic University Medical Center between April 2013 and April 2022. Among the 141 patients, 44 received pethidine intravenously, 88 received oxytocin intravenously, and 64 received epidural anesthesia. The duration of the active phase and second stage of labor were recorded according to the findings of a manual examination of the cervix and continuous external electronic monitoring. We analyzed maternal and neonatal medical records and performed binomial logistic regression to identify the factors associated with a shorter active phase of labor. The clinical outcomes in mothers and neonates were also evaluated. Results: Among the various clinical factors, multiparity (odds ratio of parity 0.325) and the use of pethidine (odds ratio 2.906) were significantly associated with shortening the active phase of labor to less than 60 min. The use of epidural anesthesia or oxytocin was not significantly associated with reducing the active phase of labor. When patients were divided into two groups based on whether a pethidine injection had been used during labor, the duration of the active phase was shorter in the pethidine injection group than in the control group for both nulliparas and multiparas. No significant differences in the duration of the second stage of labor were observed between the pethidine injection and control groups. There were no significant differences in pregnancy outcomes, including the need for mechanical ventilation of neonates, Apgar scores, neonatal intensive care unit admissions, number of precipitous deliveries, maternal adverse side effects of drugs, or duration of maternal hospitalization between the two groups. Conclusions: Pethidine can be safely administered to women during labor to help reduce the duration of the active phase by promoting dilatation of the cervix and preventing complications that may result from prolonged labor. Pethidine may be helpful, especially for those who cannot receive epidural anesthesia or who cannot afford it. However, large-scale randomized controlled studies are required to evaluate the efficacy and safety of this drug during labor. Furthermore, it would be helpful if various studies were conducted depending on the timing of administration and indications for delivery.

Background: Previous animal model studies have highlighted a role for cholesterol and its oxidized derivatives (oxysterols) in uterine contractile activity, however, a lipotoxic state associated with hypercholesterolemia may contribute to labor dystocia. Therefore, we investigated if maternal mid-pregnancy cholesterol and oxysterol concentrations were associated with labor duration in a human pregnancy cohort. Methods: We conducted a secondary analysis of serum samples and birth outcome data from healthy pregnant women (N = 25) with mid-pregnancy fasting serum samples collected at 22–28 weeks of gestation. Serum was analyzed for total-C, HDL-C, and LDL-C by direct automated enzymatic assay and oxysterol profile including 7α-hydroxycholesterol (7αOHC), 7β-hydroxycholesterol (7βOHC), 24-hydroxycholesterol (24OHC), 25-hydroxycholesterol (25OHC), 27-hydroxycholesterol (27OHC), and 7-ketocholesterol (7KC) by liquid chromatography-selected ion monitoring-stable isotope dilution-atmospheric pressure chemical ionization-mass spectroscopy. Associations between maternal second trimester lipids and labor duration (minutes) were assessed using multivariable linear regression adjusting for maternal nulliparity and age. Results: An increase in labor duration was observed for every 1-unit increment in serum 24OHC (0.96 min [0.36,1.56], p < 0.01), 25OHC (7.02 min [1.92,12.24], p = 0.01), 27OHC (0.54 min [0.06, 1.08], p < 0.05), 7KC (8.04 min [2.7,13.5], p < 0.01), and total oxysterols (0.42 min [0.18,0.06], p < 0.01]. No significant associations between labor duration and serum total-C, LDL-C, or HDL-C were observed. Conclusions: In this cohort, mid-pregnancy concentrations of maternal oxysterols (24OHC, 25OHC, 27OHC, and 7KC) were positively associated with labor duration. Given the small population and use of self-reported labor duration, subsequent studies are required for confirmation. [ABSTRACT FROM AUTHOR]

Objective Gene expression in placenta differs between vaginal and cesarean deliveries, but the influence of the duration of labor on placental gene expression is incompletely known. Our aim was to investigate associations between duration of labor and expression of some genes involved in growth or inflammation in human placental tissue. Methods Placenta samples (n = 126) were collected after an uncomplicated, singleton pregnancy and term vaginal delivery at Örebro University Hospital, Sweden. Duration of labor was recorded by the midwife in the delivery room. The expression of the following genes was analyzed by RT-qPCR: tumor necrosis factor (TNF), interleukin-6 (IL6), C-X-C motif chemokine ligand 8, toll-like receptor (TLR) 2, TLR4, insulin receptor, insulin-like growth factor (IGF) 1, IGF2, leptin, hepatocyte growth factor (HGF) and HGF receptor (MET). Multivariable linear regression models were used for the evaluation of associations with labor duration adjusting for potential confounding factors. The Benjamini-Hoschberg method was used to correct for multiple testing. Results The expression of TNF, IL6, IGF1 and IGF2 was inversely associated with the duration of the pushing phase of labor (B coefficients (95% confidence interval) = −0.150 (−0.277 to −0.023), −0.159 (−0.289 to −0.029), −0.099 (−0.176 to −0.021), and −0.081 (−0.145 to −0.017), respectively). Conclusions Longer duration of pushing is associated with downregulation of the expression of genes in placenta from vaginal deliveries. Future research on gene expression in labored placenta should take into account associations with labor duration and especially the pushing phase. Potential impact of these associations on the mother, the fetus and the new-born infant should also be explored. [ABSTRACT FROM AUTHOR]

Background: Obesity was related with high risks for maternal morbidity and mortality, Pregravid obesity is distinct potentially modifiable risk factors with differing associated adverse complications. Objectives: This study aimed to evaluate the effect of BMI on labor duration and determine the obesity effect on delivery mode in primigravida at term whether C/S rates are increased in overweight and obese women. Patients & Methods: This case control study was done in Gynecology department, Faculty of Medicine, Zagazig University Hospitals during the period from January to June 2019. It included 100 women (50 laboring primpgravidae Overweight and obese pregnant women, with (BMI=25 kg/m2) at = 37 weeks in the Obstetrics and 50 Healthy, primigravidae women (BMI 18.5-24.9 kg/m2) with a singleton vertex cephalic pregnancy of a gestational age 37-42 weeks as a control group). Results: The results of the study revealed that the duration of 1st stage of labor are differing significantly among obese, overweight, and normal weight primigravidae. There is directly proportional association between maternal BMI and the length of the 2nd stage in primigravidae. The C/S rate was significantly different between obese and normal-weight women, it was (54%) in overweight and obese group and (18%) in normal-weight group, there was no statistical significant difference between the bo th groups regarding postpartum complications. Conclusion: Labor progress in obese is more slowly with significantly longer labor duration especially first and second stages in comparison to average weight concerning BMI. Obese primigravida has more chance for induction failure and risk for C/S and its complication. [ABSTRACT FROM AUTHOR]

Management of labor in women with diabetes is challenging due to the high risk of peri- and postpartum complications. To avoid cesarean section and assist with labor progression, Pitocin, a synthetic oxytocin, is frequently used to induce and augment labor. However, the efficacy of Pitocin is often compromised in diabetic pregnancies, leading to increased cesarian delivery. As diabetes deregulates the body's circadian timekeeping system and the time-of-day of the first Pitocin administration contributes to labor duration, our objective was to determine how the time of day and the circadian clock gene, Bmal1 , gates oxytocin efficacy. Our studies in mice show that, compared to the rest phase of the day (lights on), the uterotonic efficacy of oxytocin is significantly increased during the active phase (lights off). Using in vitro studies, a myometrium-specific Bmal1 conditional knockout mouse model, and a mouse model of food-induced gestational diabetes, we find that Bmal1 is crucial for maintaining oxytocin receptor expression and response in the myometrium in mice. These findings also translate to humans, where oxytocin-induced human myometrial cell contraction is time-of-day dependent, and retrospective clinical data suggest that administration of Pitocin in the morning should be considered for pregnant women with gestational diabetes., Competing Interests: Conflict of interest The authors have declared that no conflict of interest exists.

Aim: To reassess the normal duration of each stage of labor in a contemporary Japanese cohort, and to determine whether prolongation of each stage of labor increases the rate of postpartum hemorrhage (PPH) in vaginal deliveries. Methods: Clinical data of women who delivered at term at 12 facilities between 2012 and 2018 were retrospectively collected. A total of 31 758 women were subdivided into three or four subgroups according to the duration of each stage of labor and parity. Univariate and multivariate logistic regression analyses were performed to estimate crude and adjusted odds ratios (ORs) of PPH (blood loss ≥ 1000 mL) in each subgroup, with women with the shortest durations in each subgroup used as the reference group. Results: The reference range of each stage of labor was found to be shorter than that previously reported. Women with prolonged second (primiparity, adjusted OR: 1.15–1.78; multiparity, adjusted OR: 1.14–1.74) and third (primiparity, adjusted OR: 1.39–4.95; multiparity, adjusted OR: 1.46–3.80) stages of labor showed an increased risk of PPH, whereas those with prolonged first stage did not. A significantly increased risk of PPH was found both in primiparous and multiparous women with third stages of labor ≥ 5 min. Conclusions: The normal duration of each stage of labor in the Japanese population needs to be revised and well‐recognized by obstetric care providers. A prolonged third stage of labor was a more important contributing factor to PPH than prolonged first or second stages. [ABSTRACT FROM AUTHOR]

Abstract Background Labor epidural analgesia (LEA) effectively relieves the labor pain, but it is still not available consistently for multiparous women in many institutions because of their obviously shortened labor length. Methods A total of 811 multiprous women were retrospective enrolled and firstly divided into two groups: LEA group or non-LEA group. And then they were divided into seven subgroups and analyzed according to the use of LEA and cervical dilation. The primary outcomes (time intervals, blood loss and Apgar scores) and secondary outcomes (maternal demographic characteristics and birth weight) were collected by checking electronic medical records. Results The prevalence of using LEA in multiprous women was 54.5 %. Using LEA significantly lengthened the duration of labor stage by 56 min (P

The maintenance of coordinated powerful episodic contractions of the uterus is the crucial factor for normal labor. The uterine contractility is gradually enhanced with the progression of labor, which is related to the gene expression of the myometrium. Competing endogenous RNA (ceRNA) can also regulate the gene expression. To better understand the role of ceRNA network in labor, transcriptome sequencing was performed on the myometrium of 17 parturients at different labor durations (0–24 h). From this, expression levels of mRNA, long non-coding RNA (lncRNA), circular RNA (circRNA), and microRNA (miRNA) were correlated with labor duration. Then, targeting relationships between mRNAs, lncRNAs, circRNAs, and miRNAs were predicted, and the ceRNA regulatory network was established. The mRNA expression patterns associated with cervical dilation and postpartum bleeding were further investigated. This analysis identified 932 RNAs positively correlated with labor duration (859 mRNAs, 28 lncRNAs, and 45 circRNAs) and 153 RNAs negatively correlated with labor duration (122 mRNAs, 28 lncRNAs, and 3 miRNAs). These mRNAs were involved in protein metabolism, transport, and cytoskeleton functions. According to the targeting relationship among these ceRNAs and mRNAs, a ceRNA network consisting of 3 miRNAs, 72 mRNAs, 2 circRNAs, and 1 lncRNA was established. In addition, two mRNA expression patterns were established using time-series analysis of mRNA expression in different phases of cervical dilation. A ceRNA network analysis for blood loss was performed; postpartum bleeding was closely related to inflammatory response, angiogenesis, and hemostasis. This study identified human myometrial transcriptome and established the ceRNA regulatory network depending on labor duration and highlighted the dynamic changes that occur at ceRNAs during parturition, which need to be considered more in the future to better understand how changes in gene expression are relevant to functional changes in human myometrium at labor. [ABSTRACT FROM AUTHOR]

Background: A standard obstetric analgesic should have a good analgesic effect without reducing the intensity of uterine contraction. The present study aimed to evaluate and compare the efficacy of intramuscular tramadol and pethidine on labor pain and duration. Material and Methods: A total of 170 multigravida women in active labor were randomly assigned to two identical groups, so that 85 pregnant women received pethidine (50mg/2ml) and 85 pregnant women received tramadol (100mg/2ml) intramuscularly. Results: The labor duration in the tramadol group was shorter than in the pethidine group. In 1st stage of labor, 64.7% of the participants in the tramadol group received the drug for 120±30 minutes, while 67.1% in the pethidine group received the drug for 180±30 minutes. In the 2nd stage, 44.7% of the participants in the tramadol group received the drug for 15±5 minutes, while 51.8% in the pethidine group received the drug for 25±5 minutes. The Visual Analog Scale (VAS) was used before, and 1 and 3 hours after drug administration. The pethidine group obtained a lower VAS mean score compared to those in the tramadol group at 1 hour after drug administration (4 vs 6; P≤.001). Moreover, there was a significant higher level of vomiting and dizziness among women in the pethidine group (29.4% vs 1.2%; P≤.001). Conclusion: Tramadol appears to lead to a shorter labor duration and cause lower maternal side-effects, although its analgesic efficacy was not as much as pethidine.

Abstract Background Labor pain during childbirth can have devastating effects on the progress of labor, mother, and fetus. Consequently, the management of labor pain is crucial for the well-being of the mother and fetus. Transcutaneous electrical nerve stimulation (TENS) is a non -pharmacological analgesic technique. It uses a low-voltage electrical current to activate descending inhibitory systems in the central nervous system to relieve pain. This study aimed to determine the effects of TENS therapy in the first stage of labor. Methods In this single-blind randomized controlled trial, we screened low-risk pregnant women who anticipated spontaneous vaginal delivery. Women were assigned (1:1) to either the experimental group (received TENS therapy in the first stage of labor) or the control group (received routine obstetric care). The women, midwives, and researchers working in the gynecology and obstetric department were aware of the treatment group, but statisticians analysis the data were blinded. The primary outcome was labor pain intensity, assessed by visual analog scale (VAS) immediately after the randomization, at 30, 60, and 120 min after TENS therapy, and 2–24 h post-delivery. We used SPSS 21.0 software in data analysis. An independent sample t-test compared the mean VAS scores and labor duration between groups. A Chi-square test was employed to compare categorical variables between the groups. A significant level of ≤0.05 was statistically significant. Results A total of 326 pregnant women were eligible: experimental group (n = 161) and control group (n = 165). The experimental group had statistically significantly lower mean VAS scores at a different time (30, 60, and 120 min post-intervention and 2–24 h post-delivery) than the control group (p

The maintenance of coordinated powerful episodic contractions of the uterus is the crucial factor for normal labor. The uterine contractility is gradually enhanced with the progression of labor, which is related to the gene expression of the myometrium. Competing endogenous RNA (ceRNA) can also regulate the gene expression. To better understand the role of ceRNA network in labor, transcriptome sequencing was performed on the myometrium of 17 parturients at different labor durations (0–24 h). From this, expression levels of mRNA, long non-coding RNA (lncRNA), circular RNA (circRNA), and microRNA (miRNA) were correlated with labor duration. Then, targeting relationships between mRNAs, lncRNAs, circRNAs, and miRNAs were predicted, and the ceRNA regulatory network was established. The mRNA expression patterns associated with cervical dilation and postpartum bleeding were further investigated. This analysis identified 932 RNAs positively correlated with labor duration (859 mRNAs, 28 lncRNAs, and 45 circRNAs) and 153 RNAs negatively correlated with labor duration (122 mRNAs, 28 lncRNAs, and 3 miRNAs). These mRNAs were involved in protein metabolism, transport, and cytoskeleton functions. According to the targeting relationship among these ceRNAs and mRNAs, a ceRNA network consisting of 3 miRNAs, 72 mRNAs, 2 circRNAs, and 1 lncRNA was established. In addition, two mRNA expression patterns were established using time-series analysis of mRNA expression in different phases of cervical dilation. A ceRNA network analysis for blood loss was performed; postpartum bleeding was closely related to inflammatory response, angiogenesis, and hemostasis. This study identified human myometrial transcriptome and established the ceRNA regulatory network depending on labor duration and highlighted the dynamic changes that occur at ceRNAs during parturition, which need to be considered more in the future to better understand how changes in gene expression are relevant to functional changes in human myometrium at labor.

Epidural analgesia (EA) is one of the best pain relief for many pregnant women in labor. This study was conducted to evaluate the effect of epidural analgesia provided by a combination of bupivacaine plus meperidine or fentanyl on the mother, fetus, and labor process in term nulliparous women. A total of 558 nulliparous women were randomized into two groups of 279 subjects. The BF (Bupivacaine-Fentanyl) group received 16 ml bupivacaine 0.125% plus 50 mg fentanyl as a loading dose; then, an intermittent bolus of the same solution was administered once the patient requested analgesia. The BM (Bupivacaine-Meperidine) group received a loading dose of 16 ml bupivacaine 0.125% plus 20 mg meperidine followed by an intermittent bolus of the same solution if the patient requested analgesia. The time of labor phases 1 and 2 and the incidence of side effects were recorded. After the intervention, the pain score was significantly lower in the meperidine group compared to the fentanyl group during labor (P=0.006). The duration of the active phase of labor (P=0.04) and the rate of cesarean section (P=0.01) were significantly higher in the fentanyl group compared to the meperidine group. The duration of the second stage of labor was not significantly different between the two groups (P=0.24). Apgar score was significantly higher in the meperidine group. This study found that epidural meperidine could be a suitable alternative to fentanyl for improving pain relief and shortening the active phase of delivery without increasing the risk of the neonatal low Apgar score. [ABSTRACT FROM AUTHOR]

Abstract Background Oxytocin is effective in reducing labor duration, but can be associated with fetal and maternal complications such as neonatal acidosis and post-partum hemorrhage. When comparing discontinuing oxytocin in the active phase with continuing oxytocin infusion, previous studies were underpowered to show a reduction in neonatal morbidity. Thus, we aim at evaluating the impact of discontinuing oxytocin during the active phase of the first stage of labor on the neonatal morbidity rate. Methods STOPOXY is a multicenter, randomized, open-label, controlled trial conducted in 20 maternity units in France. The first participant was recruited January 17th 2020. The trial includes women with a live term (≥37 weeks) singleton, in cephalic presentation, receiving oxytocin before 4 cm, after an induced or spontaneous labor. Women aged 10 mmol/L and/or umbilical arterial lactates> 7 mmol/L and/or a 5 min Apgar score

Epidural analgesia (EA) is one of the best pain relief for many pregnant women in labor. This study was conducted to evaluate the effect of epidural analgesia provided by a combination of bupivacaine plus meperidine or fentanyl on the mother, fetus, and labor process in term nulliparous women. A total of 558 nulliparous women were randomized into two groups of 279 subjects. The BF (Bupivacaine-Fentanyl) group received 16 ml bupivacaine 0.125% plus 50 mg fentanyl as a loading dose; then, an intermittent bolus of the same solution was administered once the patient requested analgesia. The BM (Bupivacaine-Meperidine) group received a loading dose of 16 ml bupivacaine 0.125% plus 20 mg meperidine followed by an intermittent bolus of the same solution if the patient requested analgesia. The time of labor phases 1 and 2 and the incidence of side effects were recorded. After the intervention, the pain score was significantly lower in the meperidine group compared to the fentanyl group during labor (P=0.006). The duration of the active phase of labor (P=0.04) and the rate of cesarean section (P=0.01) were significantly higher in the fentanyl group compared to the meperidine group. The duration of the second stage of labor was not significantly different between the two groups (P=0.24). Apgar score was significantly higher in the meperidine group. This study found that epidural meperidine could be a suitable alternative to fentanyl for improving pain relief and shortening the active phase of delivery without increasing the risk of the neonatal low Apgar score.

Introduction: Perinatal asphyxia remains a frequent cause of neonatal mortality and long-term neurodevelopmental sequelae, despite the introduction of therapeutic hypothermia. Specific maternal characteristics may predispose asphyxiated newborns treated with hypothermia to worse outcome.Objective: To investigate the possible association between specific maternal factors and adverse outcome in asphyxiated newborns treated with hypothermia.Methods: We conducted a retrospective review of our database of 215 asphyxiated newborns treated with hypothermia from 2008 to 2015. We collected maternal characteristics including parity and labor duration, and we defined adverse outcome as death and/or brain injury. We compared the maternal characteristics between the asphyxiated newborns who developed adverse outcome and those who did not.Results: Asphyxiated newborns born to nulliparous mothers had a significantly higher risk of adverse outcome (61%), compared to asphyxiated newborns born from primiparous (19%) and multiparous (20%) mothers (p = .002). Labor duration was longer in nulliparous mothers (p = .04). Among mothers who delivered vaginally, labor duration was significantly longer in newborns developing adverse outcome (p = .04). In multivariable analysis, parity was confirmed as an independent predictor of adverse outcome in all newborns, but labor duration showed a borderline non-significant association with adverse outcome (p = .051) only in newborns born vaginally. Labor duration beyond 12 h of life was associated with maximal sensitivity and specificity in detecting asphyxiated newborns at an increased risk of adverse outcome despite hypothermia treatment (AUC 0.62, p = .044).Conclusions: Newborns with evidence of perinatal asphyxia, born to nulliparous mothers, and especially to those in whom the duration of labor has been prolonged, might be at higher risk of death or brain injury despite the use of therapeutic hypothermia. [ABSTRACT FROM AUTHOR]

Introduction: Uterine rupture is an obstetric emergency associated with maternal and neonatal morbidity. The main risk factor is a prior cesarean section, with rupture occurring in subsequent labor. The aim of this study was to assess the risk of uterine rupture by labor duration and labor management. Material and methods: This is a Swedish register‐based cohort study of women who underwent labor in 2013–2018 after a primary cesarean section (n = 20 046). Duration of labor was the main exposure, calculated from onset of regular labor contractions and birth; both timepoints were retrieved from electronic medical records for 12 583 labors, 63% of the study population. Uterine rupture was calculated as events per 1000 births at different timepoints during labor. Risk estimates for uterine rupture by labor duration, induction of labor, use of oxytocin and epidural analgesia were calculated using Poisson regression, adjusted for maternal and birth characteristics. Estimates were presented as adjusted rate ratios (ARR) with 95% confidence intervals (CI). Results: The prevalence of uterine rupture was 1.4% (282/20 046 deliveries). Labor duration was 9.88 hours (95% CI 8.93–10.83) for women with uterine rupture, 8.20 hours (95% CI 8.10–8.31) for women with vaginal delivery, and 10.71 hours (95% CI 10.46–10.97) for women with cesarean section without uterine rupture. Few women (1.0/1000) experienced uterine rupture during the first 3 hours of labor. Uterine rupture occurred in 15.6/1000 births with labor duration over 12 hours. The highest risk for uterine rupture per hour compared with vaginal delivery was observed at 6 hours (ARR 1.20, 95% CI 1.11–1.30). Induction of labor was associated with uterine rupture (ARR 1.54, 95% CI 1.19–1.99), with a particular high risk seen in those induced with prostaglandins and no risk observed with cervical catheter (ARR 1.19, 95% CI 0.83–1.71). Labor augmentation with oxytocin (ARR 1.60, 95% CI 1.25–2.05) and epidural analgesia (ARR 1.63, 95% CI 1.27–2.10) were also associated with uterine rupture. Conclusions: Labor duration is an independent factor for uterine rupture among women attempting vaginal delivery after cesarean section. Medical induction and augmentation of labor increase the risk, regardless of maternal and birth characteristics. [ABSTRACT FROM AUTHOR]

Fear and anxiety due to severe labor pains could also lead to prolonged labor. The efforts made to accelerate the second stage labor process are by providing emotional support with the support of a labor camera. The mother is allowed to observe the development state of her baby's head through video on a tablet or laptop screen. Furthermore, the mother's emotional level becomes more provoked and motivated to strain the labor process faster. This study aims to determine the effect of the labor cameras on the second state duration in primiparous. The design of this study was a posttest-only control group design experiment with a total sample of 30 primiparous of the second stage at independent midwife practice in Bengkulu city in November–December 2020. Each group consisted of 15 for treatment (with labor cameras) and 15 for control (without labor cameras)—the assessment of the labor duration by counting the labor time in seconds during the second state. The statistical results using the t test and chi-square test analysis showed that the intervention group's labor duration (1,393.3 seconds) was shorter than the control group's (2,340.6 seconds). The mean difference in the delivery time was 947.3 seconds or 15.7 minutes faster in the intervention group than in the control group. In conclusion, using a labor camera on the labor duration of the second stage in primiparous mothers is an effect of using a labor camera. PENGARUH KAMERA PERSALINAN TERHADAP DURASI PERSALINAN KALA II PADA PRIMIPARA Rasa takut dan cemas akibat nyeri persalinan yang berat juga dapat menyebabkan partus lama. Salah satu upaya yang dilakukan untuk mempercepat proses kala II persalinan adalah memberikan dukungan emosional dengan bantuan kamera persalinan. Ibu diberi kesempatan untuk melihat perkembangan pengeluaran kepala bayinya melalui video pada layar tablet atau laptop sehingga tingkat emosional ibu menjadi lebih terbangun dan termotivasi untuk mempercepat proses persalinan. Penelitian ini bertujuan mengetahui pengaruh kamera persalinan terhadap durasi persalinan kala II pada primipara. Desain penelitian adalah eksperimen posttest-only control group design dengan jumlah sampel 30 primipara kala II di bidan praktik mandiri Kota Bengkulu pada November–Desember 2020. Tiap-tiap kelompok berjumlah 15 untuk kelompok perlakuan (menggunakan kamera persalinan) dan 15 untuk kontrol (tidak menggunakan kamera persalinan). Penilaian durasi persalinan dengan menghitung detik selama kala II berlangsung. Pengujian statistik menggunakan analisis uji t dan uji chi-square menunjukkan bahwa durasi persalinan kelompok perlakuan (1.393,3 detik) lebih singkat daripada kelompok kontrol (2.340,6 detik). Selisih perbedaan waktu persalinan rerata selama 947,3 detik atau 15,7 menit lebih cepat pada kelompok intervensi dibanding dengan kelompok kontrol. Simpulan, terdapat pengaruh penggunaan kamera persalinan terhadap durasi persalinan kala II pada ibu primipara.

This randomized controlled experimental study was conducted with an intervention group (n = 61) and a control group (n = 63) consisting of primipara pregnant women. The pregnant women in the intervention group were asked to focus their attention on Maryam's flower opening its leaf buds and imagine the labor's progress during the course of their labor. The VAS was administered to each group at specific times (at 4–5 cm, 6–7 cm, 8–9 cm cervical dilatation) to determine their level of labor pain. A statistically significant difference was found between the groups' mean pain scores at 4–5 cm, 6–7 cm, and 8–9 cm cervical dilatation (p <.05). The labor duration of the pregnant women in the intervention group was significantly shorter than that of the pregnant women in the control group (p =.017). The physical comfort level of the intervention group was significantly higher than that of the control group at 8–9 cm cervical dilatation (p =.039). [ABSTRACT FROM AUTHOR]

Introduction: Despite widespread belief that anxiety causes longer labor, evidence of association is inconsistent. Data gathered as part of a prospective epidemiological longitudinal study were used to investigate associations between antenatal anxiety and pregnancy‐specific stress, and labor progression was assessed by duration and use of augmentation. Material and methods: Pregnant primiparous women completed measures for anxiety and pregnancy‐specific stress at 20 weeks' gestation (n = 1145). Birth outcome data were extracted from medical records. Regression analyses and a path analysis assessed associations between antenatal anxiety and pregnancy‐specific stress, and indices of labor progression (labor duration and augmentation). Results: Anxiety/pregnancy‐specific stress were not directly associated with duration of stage 1 labor (HIGH/LOW anxiety: mean difference = 13.94 minutes, SD = 20.66, 95% CI −26.60 to 54.49, P <.50)/(HIGH/LOW pregnancy‐specific stress: mean difference = 12.05 minutes, SD = 16.09, 95% CI −19.52 to 43.63, P <.45). However, anxiety/pregnancy‐specific stress were associated with epidural use (HIGH/LOW anxiety: 39% vs 31%, P <.042; HIGH/LOW pregnancy‐specific stress: 38% vs 29%, P <.001), which was itself associated with longer labor (mean difference: 158.79 minutes, SD = 16.76, 95% CI 125.89‐191.68, P <.001). Anxiety and pregnancy‐specific stress were associated with increased likelihood of augmentation but these associations were nonsignificant after accounting for epidural, which was itself highly associated with augmentation. However, path analysis indicated an indirect effect linking pregnancy‐specific stress, but not general anxiety, to labor duration and augmentation: elevated pregnancy‐specific stress led to greater use of epidural, which was linked to both increased rates of augmentation, and increased labor duration. Conclusions: Contrary to general belief, general anxiety and specific pregnancy stress were not directly linked to longer duration of stage one labor. However specific pregnancy stress was associated with epidural use, which in turn was significantly associated with risk of augmentation, and longer stage one labor. Identification of pregnancy‐specific stress could help to identify women for whom psychological interventions could improve birth experience. [ABSTRACT FROM AUTHOR]

Abstract Background Labor pain is one of the leading causes of fear of childbirth. Acupressure is a non-pharmacological pain relief method that has shown promising results in relieving this pain. The present study is designed to compare the effects of body acupressure at multiple points and auricular acupressure on the pain and duration of labor. Methods/design In a randomized controlled trial, 90 primigravida women who attend for childbirth will be randomly assigned to one of three groups (intervention groups of either body acupressure or auricular acupressure; control, consisting of routine care). Computer-generated six-block randomization techniques will be used to determine the allocation sequence with a 1:1:1 ratio. To hide the allocation, the type of intervention will be written according to the generated sequence and put in opaque envelopes; these as well as questionnaires will be encoded. The pain score for all participants will be measured at the peak uterine contraction at 4-cm cervical dilation and at 10-cm dilation based on a visual analog scale (VAS). The duration of the active phase of labor in these groups will be recorded too. Data will be imported into SPSS-16 software. First, normality of the data distribution will be investigated. To compare labor duration among the research groups, ANOVA will be used, which will be followed, in case of significance, by the Scheffe post hoc test. Furthermore, Chi-squared test will be used to compare the categorized demographic variables and ANOVA or Kruskal–Wallis tests will be used to compare the quantitative variables in the studied groups. A significance level of 0.05 is considered significant. Discussion In this study the effect of auricular acupressure and body acupressure on pain and duration of first stage of labor will be compared. Trial registration Iranian Registry of Clinical Trials, IRCT20180218038789N1. Registered 2018-03-04; pre result.

Introduction: Effacement and dilatation are important factors affecting the progress and duration of labor. Impairment in their progression can disrupt the normal progress of labor and lead to maternal and neonatal complications. For many years, topical magnesium sulfate has been used experimentally for labor progression in Iran. Therefore, this study was performed with aim to determine the effects of topical magnesium sulfate on progression of effacement, dilatation and duration of labor in nulliparous women. Methods: This double-blind randomized clinical trial was conducted on 72 nulliparous women with term pregnancy that had referred to Tehran Mahdieh hospital for delivery from March 2016 to September 2017. The participants were randomly divided into two groups of magnesium sulfate and placebo (n=36 in each group). In the magnesium sulfate group (intervention), 10 cc of magnesium sulfate 50%, and in the control group, 10 cc of distilled water was poured on the cervix in the beginning of the active phase, and the labor progress was assessed in two groups. Data were analyzed by SPSS software (version 17) and using independent t-test, Mann-Whitney, Chi-square and Fisher's exact tests. P0.05). Conclusion: The use of topical magnesium sulfate on the cervix in the active phase improves effacement and dilatation and shortens the duration of labor. Since there are very few studies on this subject, performing further studies are recommended.

Background: Normal vaginal delivery is considered a painful process and it is difficult to tolerate the pain. The goal of this study was to compare the effect of injection of sterile distilled water and normal saline on pain intensity in nulliparous women. Materials and Methods: This triple-blind clinical trial was conducted on 164 nulliparous women randomly selected from among those who were hospitalized in Motahari Hospital of Jahrom, Iran, from 1 May 2012 to 1 October 2013. Women with a gestational age of 37–42 weeks, dilatation of 4–6 cm, and delivery 180 min after the intervention were selected. The subjects were randomly allocated to four groups of intracutaneous and subcutaneous sterile water and normal saline injections. Pain severity was measured 5 min before the injection and every 30 min up to 3 h after the injection using a visual analog scale. The data were analyzed using Chi-square, Scheffe, and Spearman's correlation tests in SPSS software. Results: There was no significant difference among the four studied groups concerning gestational age and other demographic characteristics. Chi-square test showed lower pain intensity 120 min after the injection in group 4 (subcutaneous injection of normal saline) (F3= 14.75, p < 0.001) and 150 min after the injection in group 3 (intracutaneous injection of normal saline) (F3= 14.75, p < 0.001). Chi-square test showed that the duration of the second stage of labor was shorter in group 4 participants (subcutaneous injection of normal saline) (F3= −'12.23, p < 0.001). Conclusions: The study showed that subcutaneous and intracutaneous injection of normal saline reduced the intensity of pain during childbirth.

Background: Labor epidural analgesia (LEA) effectively relieves the labor pain, but it is still not available consistently for multiparous women in many institutions because of their obviously shortened labor length. Methods: A total of 811 multiprous women were retrospective enrolled and firstly divided into two groups: LEA group or non-LEA group. And then they were divided into seven subgroups and analyzed according to the use of LEA and cervical dilation. The primary outcomes (time intervals, blood loss and Apgar scores) and secondary outcomes (maternal demographic characteristics and birth weight) were collected by checking electronic medical records. Results: The prevalence of using LEA in multiprous women was 54.5 %. Using LEA significantly lengthened the duration of labor stage by 56 min (P < 0.001), increased the blood loss (P < 0.001) and lowered Apgar scores (P = 0.001). In the comparison of sub-group analysis, using LEA can obviously prolong the duration of first-second stage in women with 2 cm cervical dilation (P < 0.001) and 3 cm cervical dilation (P = 0.014), while there was no significant difference with 4 cm or more cervical dilation (P = 0.69). Using LEA can significantly increased the blood loss when the initiation of LEA in the women with 2 cm cervical dilation (P < 0.001) and 3 cm cervical dilation (P = 0.035), meanwhile there were no significantly differences in the women with 4 cm or more cervical dilation (P = 0.524). Using LEA can significantly lower the Apgar scores when the initiation of LEA in the women with 2 cm cervical dilation (P = 0.001) and 4 cm or more cervical dilation (P = 0.025), while there were no significantly differences in the women with 3 cm cervical dilation (P = 0.839). Conclusions: Labor epidural analgesia for the multiparous woman may alter progress of labor, increase postpartum blood loss and lower Apgar scores. Early or late initiation of LEA should be defined as with cervical dilatation of less or more than 3 cm and the different effect should be understand. Trial registration: ChiCTR2100042746. Registered 27 January 2021-Prospectively registered, http://www.chictr.org.cn. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to describe labor duration of women managed with current obstetric practices in a French national population‐based cohort and to assess the association of age and BMI on this duration. Methods: All women in the French perinatal survey of 2016 with a singleton cephalic fetus, delivering at term after a spontaneous labor were included. Duration of labor was defined as time between admission to the labor ward and birth. Duration of total labor and first and second stage of labor were described. Then, duration of labor was estimated according to maternal age and BMI, using Kaplan‐Meier's method and compared with the log‐rank test after stratification on parity. Intrapartum cesarean birth was considered as a censoring event. Multivariable modeling was performed using Cox's proportional hazard's method. Results: Data of 3120 nulliparous and 4385 multiparous women were analyzed. Median labor duration was 6.1 hours ([5th; 95th percentile]) [1.4; 12.6] and 3.1 hours [0.3; 8.5] in nulliparous and multiparous women. Multivariable Cox analysis showed no independent association of maternal age and duration of labor. Nulliparous obese women had significantly lower odds of having a shorter labor than women with a BMI < 25 kg/m2, HR: 0.75; 95% CI [0.64‐0.88], but BMI was not associated with labor duration in multiparous women. Conclusions: Our study provides important information for both women and care practitioners on what to expect when entering the labor ward. There appears to be little association between maternal characteristics and labor duration, with the exception of BMI in nulliparous women. [ABSTRACT FROM AUTHOR]

Background: Labor pain during childbirth can have devastating effects on the progress of labor, mother, and fetus. Consequently, the management of labor pain is crucial for the well-being of the mother and fetus. Transcutaneous electrical nerve stimulation (TENS) is a non -pharmacological analgesic technique. It uses a low-voltage electrical current to activate descending inhibitory systems in the central nervous system to relieve pain. This study aimed to determine the effects of TENS therapy in the first stage of labor.Methods: In this single-blind randomized controlled trial, we screened low-risk pregnant women who anticipated spontaneous vaginal delivery. Women were assigned (1:1) to either the experimental group (received TENS therapy in the first stage of labor) or the control group (received routine obstetric care). The women, midwives, and researchers working in the gynecology and obstetric department were aware of the treatment group, but statisticians analysis the data were blinded. The primary outcome was labor pain intensity, assessed by visual analog scale (VAS) immediately after the randomization, at 30, 60, and 120 min after TENS therapy, and 2-24 h post-delivery. We used SPSS 21.0 software in data analysis. An independent sample t-test compared the mean VAS scores and labor duration between groups. A Chi-square test was employed to compare categorical variables between the groups. A significant level of ≤0.05 was statistically significant.Results: A total of 326 pregnant women were eligible: experimental group (n = 161) and control group (n = 165). The experimental group had statistically significantly lower mean VAS scores at a different time (30, 60, and 120 min post-intervention and 2-24 h post-delivery) than the control group (p < 0.001). The experimental group demonstrated a statistically significant shorter duration of the active labor phase than the control group (p < 0.001).Conclusion: This study indicates that TENS can be used as a non-pharmacological therapy to reduce pain and shorten the active labor phase.Trial Registration: ISRCTN registry, ISRCTN23857995 . Registered on 11/12/2020, 'retrospectively registered. [ABSTRACT FROM AUTHOR]

Abstract Background The use of synthetic oxytocin for augmentation of labor is rapidly increasing worldwide. Hyper-stimulation is the most significant side effect, which may cause fetal distress and operative delivery. We performed an intervention consisting of an educational program and modified guidelines to achieve a more appropriate use of oxytocin. Methods This prospective intervention study included 431 first-time mothers at term with spontaneous onset of labor before (October 2012 to May 2013), and 664 after the intervention (April 2014 to April 2015). Our outcomes were prevalence and duration of oxytocin treatment, mode of delivery, indication for operative delivery, episiotomy, anal sphincter tears, bleeding, labor duration, pain relief and the effect of oxytocin on mode of delivery. Results After the intervention, 52.9% were diagnosed with dystocia, compared with 68.9% before (p

Background/Objective: To evaluate the association between the duration of the latent phase of labor and subsequent processes and outcomes. Methods: Secondary analysis of prospectively collected data among 1,189 women with low‐risk pregnancies and spontaneous labor. Results: Longer latent phase duration was associated with labor dystocia (eg, nulliparous ≥ mean [compared with < mean] aOR 3.95 [2.70‐5.79]; multiparous ≥ mean [compared with < mean] aOR 5.45 [3.43‐8.65]), interventions to ameliorate dystocia, and epidurals to cope or rest (eg, oxytocin augmentation: nulliparous > 80th% [compared with < 80th%] aOR 6.39 [4.04‐10.12]; multiparous ≥ 80th% [compared with < 80th%] aOR 6.35 [3.79‐10.64]). Longer latent phase duration was also associated with longer active phase and second stage. There were no associations between latent phase duration and risk for cesarean delivery or postpartum hemorrhage in a practice setting with relatively low rates of primary cesarean. Newborns born to multiparous women with latent phase of labor durations at and beyond the 80th% were more frequently admitted to the NICU (≥80th% [compared with < 80th%] aOR 2.7 [1.22‐5.84]); however, two‐thirds of these NICU admissions were likely for observation only. Conclusions: Longer duration of the spontaneous latent phase of labor among women with low‐risk pregnancies may signal longer total labor processes, leading to an increase in diagnosis of dystocia, interventions to manage dystocia, and epidural use. Apart from multiparous neonatal NICU admission, no other maternal or child morbidity outcomes were elevated with longer duration of the latent phase of labor. [ABSTRACT FROM AUTHOR]

Background: Oxytocin is effective in reducing labor duration, but can be associated with fetal and maternal complications such as neonatal acidosis and post-partum hemorrhage. When comparing discontinuing oxytocin in the active phase with continuing oxytocin infusion, previous studies were underpowered to show a reduction in neonatal morbidity. Thus, we aim at evaluating the impact of discontinuing oxytocin during the active phase of the first stage of labor on the neonatal morbidity rate.Methods: STOPOXY is a multicenter, randomized, open-label, controlled trial conducted in 20 maternity units in France. The first participant was recruited January 17th 2020. The trial includes women with a live term (≥37 weeks) singleton, in cephalic presentation, receiving oxytocin before 4 cm, after an induced or spontaneous labor. Women aged < 18 years, with a lack of social security coverage, a scarred uterus, a multiple pregnancy, a fetal congenital malformation, a growth retardation <3rd percentile or an abnormal fetal heart rate at randomization are excluded. Women are randomized before 6 cm when oxytocin is either continued or discontinued. Randomization is stratified by center and parity. The primary outcome, neonatal morbidity is assessed using a composite variable defined by an umbilical arterial pH at birth < 7.10 and/or a base excess > 10 mmol/L and/or umbilical arterial lactates> 7 mmol/L and/or a 5 min Apgar score < 7 and/or admission in neonatal intensive care unit. The primary outcome will be compared between the two groups using a chi-square test with a p-value of 0.05. Secondary outcomes include neonatal complications, duration of active phase, mode of delivery, fetal and maternal complications during labor and delivery, including cesarean delivery rate and postpartum hemorrhage, and birth experience. We aim at including 2475 women based on a reduction in neonatal morbidity from 8% in the control group to 5% in the experimental group, with a power of 80% and an alpha risk of 5%.Discussion: Discontinuing oxytocin during the active phase of labor could improve both child health, by reducing moderate to severe neonatal morbidity, and maternal health by reducing cesarean delivery and postpartum hemorrhage rates.Trial Registration: Clinical trials NCT03991091 , registered June 19th, 2019. [ABSTRACT FROM AUTHOR]

Objective: Preeclampsia is a severe obstetric complication affecting 2-8% of pregnancies. There is a common belief that women with preeclampsia experience a shorter duration of labor, where it is thought that increased inflammation that occurs with the disease facilitates labor. However, little evidence exists to support or refute this. Thus, we undertook a register-based cohort study investigating the association between hypertensive disorders of pregnancy and labor duration.Study Design: This was a Swedish register-based cohort study of nulliparous women with spontaneous or induced onset of labor at >34 weeks of gestation with a singleton fetus in cephalic presentation. Information of duration of labor was retrieved from electronic birth records and compared between women with hypertensive disorders and normotensives pregnancies. Data was represented as mean adjusted difference in hours (adjusted for pre-gestational disorders, maternal characteristics and mode of delivery) and adjusted hazard ratios (aHR), with an event defined as vaginal birth and women with intrapartum caesarean section censored. An aHR >1 indicated shorter duration of labor.Results: Among 101,531 women, 5548 (5.5%) developed a hypertensive disorder of pregnancy. The overall mean duration of labor was 9.43 (SD 5.32) hours. Women with hypertensive disorders experienced a shorter duration of labor compared to normotensive women, with an adjusted mean difference of -0.68 h (95% CI -0.90, -0.47) for gestational hypertension and -1.53 h (95% CI -1.72, -1.35) for preeclampsia. This corresponded to an aHR of 1.05 (95% CI 1.01, 1.10) and 1.12 (95% CI 1.08, 1.17), respectively. However, when we confined the analysis to those who labored spontaneously, the presence of hypertensive disorders did not alter duration of labor (aHR 0.98, 95% CI 0.95,1.01). Only women who were induced and also had hypertensive disorders experienced a shorter duration of labor (aHR 1.07, 95% CI 1.04,1.09).Conclusions: Hypertensive disorders did not alter labor duration among women with spontaneous onset of labor, however an association was observed among women who were induced. [ABSTRACT FROM AUTHOR]

Objective: Hyoscine butyl bromide (HBB) is known for its antispasmodic action and has been in use for over five decades, there is however no consensus on its effectiveness in the labor process. The aim of this study was to determine the effect of HBB on the duration of the active phase of labor. Materials and methods: A randomized double-blind placebo-controlled clinical trial involving 160 parturient who received either intravenous Hyoscine butyl-bromide (20 mg in 1 ml; n = 80) or intravenous normal saline (1 ml, n = 80). The mean duration of active phase of labor was compared between the two groups. Results: The observed mean duration of the active phase of labor was significantly shorter (P = 0.001) in the Hyoscine butyl-bromide group (365.11 ± 37.32 min, range = 280–490) than in the Placebo group (388.46 ± 51.65 min, range = 280–525). There was no significant difference between the two groups in the mean duration of the second and third stages of labor (20.46 ± 10.46 vs. 23.38 ± 18.95 min, P = 0.43 and 8.96 ± 4.34 vs. 9.23 ± 5.92 min, P = 0.75, respectively). The mean 1-min APGAR scores were also comparable (8.08 ± 1.54 vs. 7.64 ± 1.60, P = 0.08). The mean postpartum blood loss was significantly less in the Hyoscine butyl-bromide group (303 ± 96.52 vs. 368 ± 264.19 ml, P = 0.04). Conclusion: Hyoscine butyl-bromide was effective in shortening the duration of the active phase of labor. It was also associated with significantly less postpartum blood loss.

Background: Labor pain is one of the leading causes of fear of childbirth. Acupressure is a non-pharmacological pain relief method that has shown promising results in relieving this pain. The present study is designed to compare the effects of body acupressure at multiple points and auricular acupressure on the pain and duration of labor.Methods/design: In a randomized controlled trial, 90 primigravida women who attend for childbirth will be randomly assigned to one of three groups (intervention groups of either body acupressure or auricular acupressure; control, consisting of routine care). Computer-generated six-block randomization techniques will be used to determine the allocation sequence with a 1:1:1 ratio. To hide the allocation, the type of intervention will be written according to the generated sequence and put in opaque envelopes; these as well as questionnaires will be encoded. The pain score for all participants will be measured at the peak uterine contraction at 4-cm cervical dilation and at 10-cm dilation based on a visual analog scale (VAS). The duration of the active phase of labor in these groups will be recorded too. Data will be imported into SPSS-16 software. First, normality of the data distribution will be investigated. To compare labor duration among the research groups, ANOVA will be used, which will be followed, in case of significance, by the Scheffe post hoc test. Furthermore, Chi-squared test will be used to compare the categorized demographic variables and ANOVA or Kruskal-Wallis tests will be used to compare the quantitative variables in the studied groups. A significance level of 0.05 is considered significant.Discussion: In this study the effect of auricular acupressure and body acupressure on pain and duration of first stage of labor will be compared.Trial Registration: Iranian Registry of Clinical Trials, IRCT20180218038789N1. Registered 2018-03-04; pre result. [ABSTRACT FROM AUTHOR]

Background: Neuraxial anesthesia is considered as the gold standard in the control labor of pain. Its variants are epidural analgesia and combined spinal-epidural analgesia. Few studies, as yet, have investigated the duration of labor as a primary outcome. Some authors have suggested that combined spinal-epidural analgesia may reduce labor duration but at the moment the benefit of shortening labor is uncertain. The main aim of this study was to compare combined spinal-epidural with epidural analgesia in terms of their effect on duration of stage I labor, maternal, and neonatal outcomes. Methods: A prospective cohort study was conducted. Parturients who requested analgesia at cervical dilatation <6 cm were included. Analgesia was either epidural with low concentration levobupivacaine or combined spinal epidural with subarachnoid sufentanil. The primary outcome was the length of stage I labor. Onset and quality of analgesia, mode of delivery, effects on uterine activity and use of oxytocin, fetal heart rate abnormalities and uterine hyperkinesia, maternal, and neonatal complications were also considered. Results: We enrolled 400 patients: 176 in the combined spinal-epidural group and 224 in the epidural group. Patients in the two treatment groups were similar with regard to demographic characteristics, parity, and incidence of obstetric comorbidities, labor induction, oxytocin infusion, Bishop score, and Visual Analogue Score (VAS) at analgesia request. Duration of stage I labor did not differ, at 195 (120-300) minutes for both the groups (p = .7). Combined spinal-epidural was associated with less reduction in uterine contractility after initial administration: 15.34 versus 39.73%, (p < .001) and with delayed need for oxytocin, at dilations of 7 ± 2.5 cm versus 6. ± 2.7, (p = .002). Onset of analgesia was quicker for combined spinal-epidural analgesia: 31 versus 20%, with VAS <4 after 5 minutes, (p < .001); and lower VAS scores after initial analgesia administration. No differences were found in the other outcomes. Conclusions: Combined spinal-epidural with subarachnoid sufentanil may not reduce the duration of stage I labor, but in our study it appeared to affect uterine contractility less. It also had a more rapid onset and was more effective, without any concomitant increase in maternal or neonatal complications. [ABSTRACT FROM AUTHOR]