Search

To investigate the impact of severe obesity (body mass index [BMI] ≥35 kg/mExploratory, blinded analysis of a randomised controlled trial cohort.Two labour wards, one in a university tertiary hospital and one in a central hospital.In all, 686 parturients with singleton pregnancies, gestational age ≥37 weeks, fetus in cephalic presentation, and intrauterine tocodynamometry during labour. [Correction added on 6 June 2022, after first online publication: the number of parturients has been corrected to 686.] METHODS: Uterine contractile activity was assessed as intrauterine pressure, frequency of contractions and basal tonus of uterine muscle. The use of oxytocin and cervical dilatation were recorded simultaneously.Primary outcome: uterine contractile activity.use of oxytocin, labour outcomes.Obese parturients reached intrauterine pressure ≥200 Montevideo units (MVU) during the first stage of labour more often than leaner parturients; 62% vs 49%; odds ratio [OR] 1.67 (95% CI 1.05-2.67) and had higher basal tone of uterine muscle. However, obese parturients without previous vaginal delivery were not able to reach the active stage of labour as often as leaner ones, and their vaginal delivery success rate was lower. If a parturient had had previous vaginal delivery, obesity did not influence uterine activity, nor was there a risk of caesarean section. Doses and total consumption of oxytocin did not differ between BMI groups.Obese nulliparas have stronger uterine contractile activity than leaner ones, but they more often fail to reach the active phase of labour and their vaginal delivery success rate is lower.Despite higher strength of uterine contractions among obese parturients, they reach the active stage of labour less often than leaner ones.

Introduction Twin trial of labor presents a challenge to obstetricians, as it is associated with a greater number of adverse birth outcomes compared with singleton deliveries. The risk of poor outcome has shown to be highest with unsuccessful vaginal twin delivery. The purpose of this study was to identify the clinical risk factors associated with intrapartum cesarean section in late preterm and term twin births. Material and methods All live diamniotic twin deliveries of at least 35+0 weeks of gestation with planned vaginal delivery were included in this retrospective single-center cohort study. Maternal and newborn characteristics were compared between a vaginal delivery group and an intrapartum cesarean section group. Logistic regression analysis was carried out to determine independent risk factors of intrapartum cesarean section. Further, maternal and neonatal outcomes were compared between groups of vaginal delivery and cesarean section for both twins and also between groups of vaginal delivery and cesarean section for the second twin only (combined delivery). The impact of presentation of the second twin on the mode of twin delivery and on neonatal outcome was also examined. Results Among 821 twin pregnancies, 581 mothers (70.8%) attempted trial of labor and were eligible for the study. With a cephalic-presenting first twin, the trial of labor rate was 89.3% and vaginal delivery was successful in 82.8%. Nulliparity (odds ratio [OR] 3.2, 95% confidence interval [CI] 2.0-5.1) and non-cephalic presentation of the second twin (OR 3.0, 95% CI 1.9-4.8) were found to be independent risk factors of cesarean section. However, 76.1% of mothers with non-cephalic second twins achieved vaginal delivery and perinatal outcomes were comparable with cases of cephalic-presenting second twins. When comparing delivery modes, maternal outcomes were more favorable with vaginal delivery, whereas combined delivery increased the second twin's risk of adverse neonatal outcome. Conclusions This study, with high rates of trial of labor and successful vaginal twin delivery, found nulliparity and non-cephalic presentation of the second twin to be risk factors of intrapartum cesarean section in twin pregnancies.

Objective To investigate whether the use of intrauterine tocodynamometry versus external tocodynamometry (IT versus ET) during labour reduces operative deliveries and improves newborn outcome. As IT provides more accurate information on labour contractions, the hypothesis was that it may more appropriately guide oxytocin use than ET. Design Randomised controlled trial. Setting Two labour wards, in a university tertiary hospital and a central hospital. Population A total of 1504 parturients with singleton pregnancies, gestational age ≥37 weeks and fetus in cephalic position: 269 women with uterine scars, 889 nulliparas and 346 parous women with oxytocin augmentation. Methods Participants underwent IT (n = 736) or ET (n = 768) during the active first stage of labour. Main outcome measures Primary outcome: rate of operative deliveries. Secondary outcomes duration of labour, amount of oxytocin given, adverse neonatal outcomes. Results Operative delivery rates were 26.9% (IT) and 25.9% (ET) (odds ratio 1.05, 95% CI 0.84-1.32, P = 0.663). The ET to IT conversion rate was 31%. We found no differences in secondary outcomes (IT versus ET). IT reduced oxytocin use during labours with signs of fetal distress, and trial of labour after caesarean section. Conclusions IT did not reduce the rate of operative deliveries, use of oxytocin, or adverse neonatal outcomes, and it did not shorten labour duration. Tweetable abstract IT (versus ET) reduced oxytocin use in high-risk labours but did not influence operative delivery rate or adverse neonatal outcomes.

Twin birth is a special setting for women giving birth, and the experience of childbirth can be different from singleton birth. The objective of this study was to evaluate and compare the childbirth experiences of twin mothers and singleton mothers. We also aimed to identify the risk factors of a negative childbirth experience in the whole study population.All live diamniotic twin deliveries in the study hospital of at least 35The twin mothers' overall childbirth experience was positive. They reported a significantly lower opportunity to choose the birthing position (p 0.001). Otherwise, there were no differences in the CEQ mean total scores between the study groups. Intrapartum cesarean section raised the risk of a negative childbirth experience and there was a high level of satisfaction with midwifery care among the whole study population.The overall maternal experience in planned vaginal twin birth was positive. Twin mothers felt less often able to choose their birthing position, otherwise the childbirth experience did not differ from that of singleton mothers.

Purpose The optimal postoperative analgesia after cesarean section (CS) remains to be determined. The primary objective of this study was to assess whether oral oxycodone provides the same or better pain control and satisfaction with pain relief as oxycodone given intravenously using a patient-controlled analgesia (PCA) infusion device. The secondary objectives were to compare the gastrointestinal symptoms and postsurgical recovery of the two groups. Methods This prospective randomized trial was conducted at a University Hospital between February 2015 and June 2017. Altogether 270 CS patients were randomly assigned to receive postoperative oxycodone pain relief by IV PCA (n = 133) or orally (n = 137). Pain control and satisfaction with pain treatment were assessed by a numeric rating scale (NRS) at 2, 4, 8, and 24 h postoperatively. Results No differences were found in NRS pain scores or satisfaction between the groups except at 24 h pain when coughing; there was a statistically significant difference favoring the IV PCA group (p = 0.006). In the IV PCA group, the patients experienced more nausea at 4 h (p = 0.001) and more vomiting at 8 h (p = 0.010). Otherwise, postoperative recovery was similar in both groups. The equianalgesic dose of oxycodone was significantly smaller in the oral group (p = 0.003). Conclusions This study indicates that oral oxycodone provides pain control and satisfaction with pain relief equal to IV oxycodone PCA for postoperative analgesia after cesarean section. Satisfaction with pain treatment was high in both groups, and both methods were well tolerated. Early nausea was less common with oral medication.

BackgroundChildbirth Experience Questionnaire (CEQ) was developed in Sweden to assess the childbirth experience in multiple dimensions. It has been translated and validated in English, Spanish, Chinese and Persian with the aim to evaluate childbirth experience reliably. This study aimed to validate the Finnish version of the questionnaire, CEQ-FI.MethodsPrimiparous women who had given birth in Tampere University Hospital between January and May 2019 were included in the study. Women planning a cesarean delivery, delivering preterm, or women whose children were transferred to neonatal care were excluded. Eligible 450 women were mailed the questionnaire one month postpartum, and those who completed the questionnaire were mailed it again six weeks postpartum. Test-retest reliability was evaluated by computing kappa coefficients for the two responses. Background data was collected from patient records and used to perform known-groups validation. Internal consistency was assessed by calculating Cronbach’s alpha.ResultsOne hundred seventy-five women returned the questionnaire. Internal consistency and test-retest reliability were good. Women with known risk factors for a negative childbirth experience scored lower in the questionnaire, as expected.ConclusionCEQ-FI is a valid and reliable instrument in measuring childbirth experience also among Finnish-speaking women.

Objective To examine the impact of the mode of delivery on neonatal and maternal outcomes in moderately and late preterm twin birth. Methods This single-center cohort study included 275 live diamniotic moderately and late preterm twin deliveries at 32+0 -36+6 weeks of gestation. These twin deliveries were divided into two groups according to the planned mode of delivery: trial of labor (TOL) (N=199, 72.4%) and planned cesarean section (CS) (N=76, 27.6%). The primary outcome was neonatal morbidity. Maternal outcome and the effects of gestational age and chorionicity on neonatal outcome were also studied. Results Of the women in the TOL group, 170 (85.4%) delivered vaginally. Both for the first and second twin, and for dichorionic or monochorionic deliveries, there were no differences between the TOL and CS groups in composite neonatal morbidity or in other neonatal outcomes. No significant differences were found between the TOL and CS groups when the moderately and late preterm gestational age cohorts were studied separately. Mothers in the planned CS group more often had puerperal infection and surgical complications in comparison with mothers in the TOL group. Conclusion Among 275 moderately and late preterm twin deliveries, planned mode of delivery did not affect neonatal outcome.

Objective To compare neonatal and maternal outcomes in spontaneously onset preterm breech deliveries after trial of labor (BTOL) and intended cesarean section (BCS), and between BTOL and vertex control deliveries, in singleton fetuses at 32+0–36+6 weeks of gestation. Study design Retrospective single center cohort study in a Finnish University Hospital including all spontaneous-onset preterm breech deliveries with 32 completed gestational weeks in 2003–2015. The study population comprised a total of 176 preterm breech and 103 vertex control deliveries, matched by gestational age and whether the mother had given birth vaginally before or not. Infants with severe malformations and antepartum fetal distress were excluded. Subgroup analyses were made in two cohorts according to gestational age. Main outcome measures were maternal and neonatal mortality and morbidity, low cord pH and Apgar score. Results No mortality was observed, and severe morbidity was rare. No difference in incidence of low cord pH or five-minute Apgar score was observed between the groups. Apgar scores at the age of one minute were comparable in the breech groups but more often low in the BTOL group compared to the vertex control group. 16.5% of neonates in the BTOL group, 23.3% in the BCS group and 7.8% in the vertex group needed intensive care. In logistic regression analysis, lower gestational age and being small for gestational age were associated with the need for neonatal intensive care. Being allowed a trial of labor was not associated with the need for neonatal intensive care. Maternal morbidity was similar across the groups, but median blood loss was more pronounced in the BCS group compared to the BTOL group. Conclusion In breech deliveries at 32+0–36+6 gestational weeks, trial of labor did not increase neonatal morbidity compared to intended cesarean delivery. Infants born after a trial of labor in breech presentation display low one-minute Apgar score and need intensive care more often compared to vertex controls.

Introduction Gestational diabetes mellitus (GDM) is an indicator of future cardiovascular disease. We investigated whether sensitive biomarkers of increased cardiovascular risk differ between women with and without a history of GDM few years after pregnancy, and whether obesity affects the results. Material and methods We studied two cohorts – 120 women with a history of GDM and 120 controls, on average 3.7 years after delivery. Circulating concentrations of oxidized low-density lipoprotein (oxLDL) were determined by ELISA. The homeostasis model assessment of insulin resistance (HOMA-IR) index was used to estimate insulin resistance. Central blood pressure (cBP) was measured noninvasively from a radial artery pulse wave. The primary outcomes were possible differences in oxLDL, HOMA-IR or cBP between the groups. Secondly, we investigated the influence of obesity on the results, also using adjusted multiple linear regression analyses. Results OxLDL concentrations or cBP did not differ between the two cohorts, but HOMA-IR was significantly higher in women with previous GDM than in controls, 1.3 ± 0.9 (SD) and 1.1 ± 0.9, respectively (p = 0.022). In subgroup analyses, HOMA-IR (p

Introduction Neonatal outcomes after the maternal obstetric near-miss complications of uterine rupture, abnormally invasive placenta, and emergency peripartum hysterectomy were assessed. Material and methods This case-control study was conducted as part of the Nordic Obstetric Surveillance Study (NOSS). Data on 211 newborns from 197 deliveries in which an obstetric near-miss complication was involved, were collected prospectively from April 2009 to August 2011 from all Finnish delivery units via questionnaires. Missing cases were obtained from national health registers and confirmed by the clinics. Control populations consisted of all other children born during the same period of time in the Finnish Medical Birth Register (n = 147 551). Results The number of stillbirths in this cohort was high [n = 8, 3.8% vs. 0.3% among controls, odds ratio (OR) 12.5, 95% confidence interval (CI) 6.32–24.9]. In addition, there were two neonatal deaths. The majority of cases (n = 8, 80%) were connected to uterine rupture. The risk of severe birth asphyxia diagnosis was increased compared with controls (n = 17, 8.1% vs. 0.1%, OR 137, 95% CI 82.7–226). A low umbilical artery pH (

To compare neonatal and maternal outcomes in spontaneously onset preterm breech deliveries after trial of labor (BTOL) and intended cesarean section (BCS), and between BTOL and vertex control deliveries, in singleton fetuses at 32Retrospective single center cohort study in a Finnish University Hospital including all spontaneous-onset preterm breech deliveries with 32 completed gestational weeks in 2003-2015. The study population comprised a total of 176 preterm breech and 103 vertex control deliveries, matched by gestational age and whether the mother had given birth vaginally before or not. Infants with severe malformations and antepartum fetal distress were excluded. Subgroup analyses were made in two cohorts according to gestational age. Main outcome measures were maternal and neonatal mortality and morbidity, low cord pH and Apgar score.No mortality was observed, and severe morbidity was rare. No difference in incidence of low cord pH or five-minute Apgar score was observed between the groups. Apgar scores at the age of one minute were comparable in the breech groups but more often low in the BTOL group compared to the vertex control group. 16.5% of neonates in the BTOL group, 23.3% in the BCS group and 7.8% in the vertex group needed intensive care. In logistic regression analysis, lower gestational age and being small for gestational age were associated with the need for neonatal intensive care. Being allowed a trial of labor was not associated with the need for neonatal intensive care. Maternal morbidity was similar across the groups, but median blood loss was more pronounced in the BCS group compared to the BTOL group.In breech deliveries at 32

Background Purpose of this study was to investigate differences between primiparous term pregnancies, one leading to vaginal delivery (VD) and the other to acute cesarean section (CS) due to labor dystocia in the first stage of labor. We particularly wanted to assess the influence of body mass index (BMI) on CS risk. Methods A retrospective case-control study in a tertiary delivery unit with 5200 deliveries annually. Cases were 296 term primiparous women whose intended vaginal labor ended in acute CS because of dystocia. Controls were primiparas with successful vaginal delivery VD (n = 302). The data were retrieved from medical records. Multiple logistic regression analyses were used to assess the associations between BMI and covariates on labor dystocia. Results In the cases ending with acute CS, women were older (OR 1.06 [1.03–1.10]), shorter (OR 0.94 [0.91–0.96]) and more often had a chronic disease (OR 1.60 [1.1–2.29]). In this group fetal malposition (OR 42.0 [19.2–91.9]) and chorioamnionitis (OR 10.9 [5.01–23.6]) were more common, labor was less often in an active phase (OR 3.37 [2.38–4.76]) and the cervix was not as well ripened (1.5 vs. 2.5 cm, OR 0.57 [0.48–0.67] on arrival at the birth unit. BMI was higher in the dystocia group (24.1 vs. 22.6 kg/m2, p < 0.001), and rising maternal pre-pregnancy BMI had a strong association with dystocia risk. If BMI increased by 1 kg/m2, the risk of CS was 10% elevated. Among obese primiparas, premature rupture of membranes, chorioamnionitis and induction of labor were more common. Their labors were less often in an active phase at hospital admission. Severely obese primiparas (BMI ≥ 35 kg/m2) had 4 hours longer labor than normal-weight parturients. Conclusions Labor dystocia is a multifactorial phenomenon in which the possibility to ameliorate the condition via medical treatment is limited. Hospital admission at an advanced stage of labor is recommended. Pre-pregnancy weight control in the population at reproductive age is essential, as a high BMI is strongly associated with labor dystocia.

Although metabolic syndrome (MetS) is evidently associated with the risk of cardiovascular disease (CVD), recently its use has been questioned. We studied the utility of MetS diagnosis when estimating individual CVD risk.We compared 27 fertile women with MetS and 27 counterparts without the syndrome, matched pairwise according to well-known risk factors of CVD. Pulse wave velocity (PWV) and central blood pressure (cBP) were determined noninvasively via a SphygmoCor device. Arterial compliance was measured noninvasively with an HDI/PulseWavePWV (7.1 ± 2.5 versus 6.5 ± 1.1 m/s, p = .037), and both systolic (120.9 ± 12.2 versus 111.5 ± 16.0 mmHg, p = .031) and diastolic cBP (81.3 ± 8.5 versus 74.1 ± 11.2 mmHg, p = .035) were higher in the MetS group. Systemic arterial compliance values were lower in both large (15.1 ± 8.0 versus 16.1 ± 4.4 mL/mmHg × 10, p = .034) and small arteries (7.1 ± 2.5 versus 9.3 ± 3.2 mL/mmHg ×100, p = .010) in women with MetS.Fertile women with MetS had increased arterial stiffness, as measured by three different methods. Our results highlight the utility of MetS when revealing increased individual CVD risks in fertile-aged women. Key messages Women with MetS have increased arterial stiffness when measured by different methods. MetS is a useful clinical tool to assess increased cardiovascular risk, particularly among fertile-aged women.

Aim To study the opinions of paediatric and obstetric personnel on the perinatal treatment and delivery outcome of infants from 22+0 to 27+6 weeks' gestation. Methods An email questionnaire was sent to 2963 professionals in 32 maternity hospitals in Finland. Results The questionnaire survey was completed by 856 (28%) professionals in 30 hospitals. Opinions on outcome were most pessimistic if the infant was very premature. More than a third (37%) assumed no survival at the earliest gestational age, but none dismissed the possibility at 26 weeks' gestation. Paediatric professionals took a more active approach to the treatment of a premature birth and baby than obstetric personnel. Opinions on treatment activity were based firstly on what was best for the baby and secondly on experience. Gynaecologists reported discussing matters regarding premature birth with the parents more often than paediatricians and were much more likely to be influenced by these discussions. Conclusion Paediatric personnel showed a more positive attitude and a more active approach to extremely premature deliveries and babies than obstetric personnel. There would appear to be some inconsistency between prenatal counselling and treatment activity after birth at the limit of viability.

Introduction The main aims of this study were to compare maternal and neonatal outcomes in term twin birth according to the planned mode of delivery and to study the effects of chorionicity and inter-twin delivery time on neonatal outcome. Material and methods A single-center cohort study of 495 women with twin deliveries at ≥37+0 weeks of gestation. Term twin deliveries were divided into a trial of labor group (TOL, 69.3%) and a planned cesarean section (CS) group (30.7%). The primary outcomes were maternal and neonatal morbidity. Results 80.8% of women attempting TOL achieved vaginal birth. In the TOL group, mothers had less bleeding [median 500 mL (range 150–2700 mL) vs. 950 mL (range 150–3500 mL), p < 0.001) and fewer surgical complications (3.2% vs. 8.6%, p = 0.011), whereas second twins more often had five-minute Apgar scores of

BACKGROUND: The safety of vaginal breech delivery has been debated for decades. Although it has been shown to predispose infants to immediate depression, several observational studies have also shown that attempting vaginal breech delivery does not increase perinatal morbidity or low Apgar score at the age of five minutes. Cardiotocography monitoring is recommended during vaginal breech delivery, but comparative data describing differences between cardiotocography tracings in breech and vertex deliveries is scarce. This study aims to evaluate differences in intrapartum cardiotocography tracings between breech and vertex deliveries in the final 60 min of delivery. A secondary goal is to identify risk factors for suboptimal neonatal outcome in the study population. METHODS: One hundred eight breech and 108 vertex singleton, intended vaginal deliveries at term from a tertiary hospital with 5000 annual deliveries were included. Two experienced obstetricians, blinded to fetal presentation, neonatal outcome and actual mode of delivery, evaluated traces recorded 60 min before delivery. They provided a three-tier classification and evaluated different trace features according to FIGO (1987) guidelines. Factors associated with acidemia and low Apgar scores were identified by univariate and multivariable analyses performed with binary logistic regression. Student's T-test and chi-square test were used, as appropriate. RESULTS: Late decelerations were seen in 13.9 % of breech and 2.8 % of vertex deliveries (p = 0.003) and decreased variability in 26.9 % of breech and 8.3 % of vertex deliveries (p

Although neuraxial analgesia is available to the majority of parturients in developed countries, alternative neural blocks for labour analgesia are needed for medical, individual, and institutional reasons. Paracervical and pudendal blocks are usually administered transvaginally by an obstetrician. An injection of 0.25% bupivacaine using a superficial technique into the lateral fornixes gives rapid pain relief and has been found to have no negative effect on either fetal oxygenation, or maternal and neonatal outcomes. Low rates of post-analgesic bradycardia and high rates of spontaneous vaginal delivery have been described in low-risk populations. The analgesic effect of a paracervical block is moderate and is limited to the first stage of labour. A pudendal block, administered transvaginally, can be used for pain relief in the late first stage, the second stage, in cases of vacuum extraction, or for episiotomy repair. In clinical use, 1% lidocaine gives rapid pain relief but the success rate is variable. The complications of pudendal block are rare and localized. The sympathetic and paravertebral blocks are currently mainly of historic interest. However, they may benefit parturients in exceptional conditions if the anaesthesiologist is experienced in the techniques. Lumbar sympathetic block provides fast pain relief during the first stage of labour when a combination of 0.5% bupivacaine with fentanyl and epinephrine is employed. With the currently available data, no conclusion on the analgesic effects of thoracic paravertebral block can be drawn when it is used for labour pain relief. Potential maternal risks limit the use of these methods in modern obstetrics.

Objective. To compare the neonatal outcome between planned vaginal or planned cesarean section (CS) breech delivery and planned vaginal vertex delivery at term with singleton fetuses. Design. A cohort study. Setting. Delivery Unit, Tampere University Hospital, Finland, with 5200 annual deliveries. Population. The term breech deliveries over a period of five years (January 2004 to January 2009), a total of 751 breech deliveries, and 257 vertex controls. Methods. The data were collected from the mother's medical records, including a summary of the newborn. In the case of neonatal health problems, the pediatric records were also examined. Main outcome measures. Maternal and neonatal mortality and morbidity as defined in the Term Breech Trial. Low Apgar scores or umbilical cord pH as secondary end-points. Results. There was no neonatal mortality. Severe morbidity was rare in all groups, with no differences between groups. The Apgar scores at one minute were lower in the planned vaginal delivery group compared with the other groups, but there was no difference at the age of five minutes. Significantly more infants in the vaginal delivery group had a cord pH < 7.05. There was one maternal death due to a complicated CS in the planned CS group and none in the other groups. Mothers in the planned CS group suffered significantly more often from massive bleeding and needed transfusions. Conclusions. Vaginal delivery remains an acceptable option for breech delivery in selected cases.

Two cases of post-partum uterine artery pseudoaneurysm are described, 1 after normal vaginal delivery and the other after Caesarean section. Both cases were complicated by heavy bleeding and treated with catheter embolization. A turbulent arterial-type velocity waveform with high peak velocity and forward end-diastolic flow was registered in the feeding vessel. The peak blood flow velocity was high in both cases. The resistance index in the uterine artery was lower in the affected side of the uterus. Three-dimensional angiosonography was used to calculate the volume of the lesion, demonstrate its shape, and identify the feeding vessel.

Background. The objective of the study was to evaluate and compare the safety of levobupivacaine and racemic bupivacaine for paracervical block (PCB) in the first stage of labor after uncomplicated pregnancy. Methods. Forty women in an open pilot study and 397 women in a double-blind randomized study received PCB for pain relief in the first stage of labor, either with 25 mg of levobupivacaine or with 25 mg of racemic bupivacaine. The incidence of cardiotocographic pathology was compared between the groups using Fisher's exact test. The 95% confidence intervals for the between-group difference were calculated by Newcombe's method. Results. In the randomized double-blind study, the incidence of any pathological result in cardiotocography (CTG) was 10.4% in the levobupivacaine group and 12.8% in the racemic bupivacaine group. The incidence of fetal bradycardia in the groups was 2.6 and 3.8%, respectively. All the cardiotocographic changes were transient, and no operative intervention was indicated because o...

Background. The objective of the study was to evaluate the analgesic effect of paracervical block (PCB) in labor pain relief and to discover the determinants associated with good analgesia. Methods. In a prospective trial, 341 women received PCB for pain relief in the first stage of labor, with 10 ml of 0.25% levobupivacaine or racemic bupivacaine. All these pregnancies were uncomplicated and the progress of labor was normal. The analgesic effect of PCB was measured by using a visual analog scale (VAS). The factors associated with good pain relief (>50% decrease in the VAS score within 30 min) were analyzed statistically by Student's t -test or the Mann-Whitney test (continuous variables), Fisher's exact test (categorial variables) and after univariate analysis by logistic regression analysis. For pairwise comparisons, Wilcoxon's signed ranks test was used. Results. Good pain relief was achieved in 47.2% of the cases. 12.3% of the parturients needed subsequent epidural or spinal analgesia. In logistic reg...

The objective of the study was to evaluate the analgesic effect of paracervical block (PCB) in labor pain relief and to discover the determinants associated with good analgesia.In a prospective trial, 341 women received PCB for pain relief in the first stage of labor, with 10 ml of 0.25% levobupivacaine or racemic bupivacaine. All these pregnancies were uncomplicated and the progress of labor was normal. The analgesic effect of PCB was measured by using a visual analog scale (VAS). The factors associated with good pain relief (50% decrease in the VAS score within 30 min) were analyzed statistically by Student's t-test or the Mann-Whitney test (continuous variables), Fisher's exact test (categorial variables) and after univariate analysis by logistic regression analysis. For pairwise comparisons, Wilcoxon's signed ranks test was used.Good pain relief was achieved in 47.2% of the cases. 12.3% of the parturients needed subsequent epidural or spinal analgesia. In logistic regression analysis, primiparity, a high pain score before PCB, and PCB given by a specialized obstetrician were found to affect the level of pain relief 30 min after PCB.The best pain relief after PCB was achieved among primiparas. Good pain relief was connected with a high pain score before PCB and an experienced obstetrician.

The purpose of this study was to evaluate the effect of acute tocolysis on severely pathological cardiotocographic (CTG) readings during the first stage of labor. Seventy-three consecutive parturients with full-term pregnancy were treated by acute tocolysis with a beta-mimetic agent after recognition of severe CTG abnormality in the first stage of labor. The main outcome measures were normalization or persistence of the CTG pattern after tocolysis. Risk factors with regard to CTG effect of tocolysis were also evaluated. In 67% of cases the CTG pattern normalized at a mean of 4 minutes after the beginning of intravenous tocolysis. No characteristic feature of the parturient, labor course, CTG abnormality, or the parameters of uterine contractive activity was found to be a predictive factor with regard to the CTG effect of tocolysis. No adverse effects of tocolytic therapy were found. Tocolysis with a beta-mimetic agent is an effective method to normalize the CTG pattern during the first stage of labor, even in cases without uterine hypertonicity.

Objective. To compare the neonatal outcome between planned vaginal or planned cesarean section (CS) breech delivery and planned vaginal vertex delivery at term with singleton fetuses. Design. A cohort study. Setting. Delivery Unit, Tampere University Hospital, Finland, with 5200 annual deliveries. Population. The term breech deliveries over a period of five years (January 2004 to January 2009), a total of 751 breech deliveries, and 257 vertex controls. Methods. The data were collected from the mother's medical records, including a summary of the newborn. In the case of neonatal health problems, the pediatric records were also examined. Main outcome measures. Maternal and neonatal mortality and morbidity as defined in the Term Breech Trial. Low Apgar scores or umbilical cord pH as secondary end-points. Results. There was no neonatal mortality. Severe morbidity was rare in all groups, with no differences between groups. The Apgar scores at one minute were lower in the planned vaginal delivery group compared with the other groups, but there was no difference at the age of five minutes. Significantly more infants in the vaginal delivery group had a cord pH < 7.05. There was one maternal death due to a complicated CS in the planned CS group and none in the other groups. Mothers in the planned CS group suffered significantly more often from massive bleeding and needed transfusions. Conclusions. Vaginal delivery remains an acceptable option for breech delivery in selected cases.

Background Women with gestational diabetes mellitus (GDM) are at an increased risk of developing metabolic syndrome (MetS) after delivery. Recently, the prevalence of both GDM and MetS has increased worldwide, in parallel with obesity. We investigated whether the presentation of MetS and its clinical features among women with previous GDM differs from that among those with normal glucose tolerance during pregnancy, and whether excess body weight affects the results. Methods This hospital-based study of two cohorts was performed in Kanta-Häme Central Hospital, Finland. 120 women with a history of GDM and 120 women with a history of normal glucose metabolism during pregnancy, all aged between 25 and 46 were enrolled. They all underwent physical examination and had baseline blood samples taken. All 240 women were also included in subgroup analyses to study the effect of excess body weight on the results. Results Although the groups did not differ in body mass index (BMI; p = 0.069), the risk of developing MetS after pregnancy complicated by GDM was significantly higher than after normal pregnancy, 19 vs. 8 cases (p = 0.039). Fasting glucose (p

Background The optimal mode of breech birth remains controversial. In Finland, a trial of vaginal delivery is possible if strict selection criteria are met. As clinical practice in managing vaginal breech birth differs from that in normal delivery, the birth experience may also be different. This cohort study compares the childbirth experience between term breech and vertex deliveries. Methods Intended vaginal term breech births from 2008 to October 2012 were included, and for every breech delivery, a vertex control was selected. The proportions of deliveries ending in a cesarean section and of mothers who had given birth vaginally before were equal in both groups. Three hundred eight mothers were sent the childbirth experience questionnaire and 170 returned it. Results The birth experience does not differ between breech and vertex births, except for aspects with respect to the choice of birthing position. Indications of an even more positive experience were observed in the breech group, with the exception of the choice of analgesia, but these were not statistically significant. Primiparity, emergency cesarean section, infant birth trauma and prolonged hospital stay were identified as risk factors for a negative birth experience. Conclusion The birth experience of vaginal breech birth seems to be at least as positive as the vaginal vertex birth experience.

Objectives To examine the clinical risk factors and complications of shoulder dystocia today and to evaluate ultrasound methods predicting it. Study design Retrospective, matched case-control study at a University Hospital with 5000 annual deliveries. The study population consisted of 152 deliveries complicated by shoulder dystocia over a period of 8.5 years (January 2004–June 2012) and 152 controls matched for gestational age and parity. The data was collected from the medical records of mothers and children and analyzed by conditional logistic regression. Incidences and odds ratios were calculated for risk factors and complications. Antenatal ultrasound data was analyzed when available by conditional logistic regression to test for significant differences between study groups. Results Birthweight (OR 12.1 for ≥4000 g; 95% CI 4.18–35.0) and vacuum extraction (OR 3.98; 95% CI 1.25–12.7) remained the most significant clinical risk factors. Only a trend of an association of pregestational or gestational diabetes was noticed (OR 1.87; 95% CI 0.997–3.495, probability of type II error 51%). Of the complications of shoulder dystocia the incidence of brachial plexus palsies was high (40%). Antenatal ultrasound method based on the difference between abdominal and biparietal diameters had a significant difference between cases and controls. Conclusions The impact of diabetes as a risk factor has diminished, which may reflect improved screening and treatment. Antenatal ultrasound methods are showing some promise, but the predictive value of ultrasound alone is probably low.

To compare the neonatal outcome between planned vaginal or planned cesarean section (CS) breech delivery and planned vaginal vertex delivery at term with singleton fetuses.A cohort study.Delivery Unit, Tampere University Hospital, Finland, with 5200 annual deliveries.The term breech deliveries over a period of five years (January 2004 to January 2009), a total of 751 breech deliveries, and 257 vertex controls.The data were collected from the mother's medical records, including a summary of the newborn. In the case of neonatal health problems, the pediatric records were also examined.Maternal and neonatal mortality and morbidity as defined in the Term Breech Trial. Low Apgar scores or umbilical cord pH as secondary end-points.There was no neonatal mortality. Severe morbidity was rare in all groups, with no differences between groups. The Apgar scores at one minute were lower in the planned vaginal delivery group compared with the other groups, but there was no difference at the age of five minutes. Significantly more infants in the vaginal delivery group had a cord pH7.05. There was one maternal death due to a complicated CS in the planned CS group and none in the other groups. Mothers in the planned CS group suffered significantly more often from massive bleeding and needed transfusions.Vaginal delivery remains an acceptable option for breech delivery in selected cases.

Although millions of parturients profit from neuraxial analgesia for labor, there are far more of those who do not have this choice for one reason or another. They need alternative ways to relieve labor pain.Paracervical block gives less efficient analgesia compared with single-shot spinal in a sample of multiparae at active labor but is associated with better umbilical artery pH. Use of a neurostimulator may increase success in pudendal block. It is possible to reduce nitrous oxide occupational exposure by a developed scavenging system. Intravenous remifentanil gives less efficient pain relief than epidural analgesia. The maternal satisfaction, however, may be comparable.Paracervical block with modern technique is a viable option for selected cases. It is rapid and does not affect the course of labor, but its efficacy is only modest. Pudendal block can be used in the second stage of labor or for episiotomy tear repair and pain. Intravenous remifentanil is currently becoming an established method, although its safety is still an issue. Nitrous oxide is a useful method to be used alone or together with the other methods.

Objective: This prospective observational study evaluated maternal symptoms and characteristics that predict successful labor induction with oral misoprostol. Methods: A total of 244 consecutive women undergoing labor induction voluntarily completed a questionnaire about subjective sensations and pain scores during the induction protocol. Maternal and neonatal characteristics were collected retrospectively from patient files. On the first day of induction, oral misoprostol (50 μg) every 4 h up to three doses was used. Results: A total of 46% of the parturients delivered or reached the active phase of labor 24 h after the initial dose of misoprostol (ID). In the whole study, 87% of the women delivered vaginally. In multivariable analysis, rupture of membranes, cervical dilatation before the initial dose, maternal sensation of painful contractions at 8 h after the initial dose, and gestational age, were found to be associated with successful labor induction. Conclusions: Maternal sensation of painful contractions 8 h after an ID is an independent predictive factor of successful labor induction (defined as delivery or active phase of labor 24 h after beginning of induction). Other independent predictive factors are rupture of membranes, cervical dilatation before the initial dose, and gestational age.

Objective: To evaluate and compare interobserver variation in interpretation of intrapartum cardiotocograms. Subjects: Fifteen senior (experience >4 years) and 16 junior (experience

The objective of the study was to evaluate and compare the safety of levobupivacaine and racemic bupivacaine for paracervical block (PCB) in the first stage of labor after uncomplicated pregnancy.Forty women in an open pilot study and 397 women in a double-blind randomized study received PCB for pain relief in the first stage of labor, either with 25 mg of levobupivacaine or with 25 mg of racemic bupivacaine. The incidence of cardiotocographic pathology was compared between the groups using Fisher's exact test. The 95% confidence intervals for the between-group difference were calculated by Newcombe's method.In the randomized double-blind study, the incidence of any pathological result in cardiotocography (CTG) was 10.4% in the levobupivacaine group and 12.8% in the racemic bupivacaine group. The incidence of fetal bradycardia in the groups was 2.6 and 3.8%, respectively. All the cardiotocographic changes were transient, and no operative intervention was indicated because of CTG. No difference in the analgesic effect between the drugs was found. Most of the parturients in the levobupivacaine group (97%) and in the racemic bupivacaine group (96%) had spontaneous vaginal delivery. Neonatal outcome was good in both groups.No difference in cardiotocographic pathology was found between PCB with levobupivacaine compared with PCB with racemic bupivacaine. The incidence of bradycardia was low. PCB was found to be a safe pain-relief method for low-risk parturients.

Objective To compare the combination of intravenous propranolol and oxytocin with oxytocin only in augmentation of labour. Study design A prospective randomized double-blind study in an obstetric department of a large university hospital in Finland. A total of 107 parturients with arrested first stage of labour owing to inadequate uterine contractility were randomized to receive intravenously once or twice a 2 mg dose of propranolol or placebo combined with oxytocin infusion. The main outcome measure was the effect of intravenous propranolol on the frequency of Caesarean section among parturients with arrested labour. The secondary outcome measures were the duration of labour, the required dosage of oxytocin, CTG readings, neonatal outcome and maternal and cord plasma levels of β-adrenoceptor-binding component of propranolol. Categorial variables between the groups were compared using Chi square and Fisher's exact tests. Continuous variables were compared using the Mann–Whitney U-test and Student's t-test. Results No reduction in Caesarean section rate was found in the propranolol group. Seventy-three percent of the parturients in the propranolol group and 85% in the placebo group had spontaneous vaginal delivery, RR = 0.86 (95% CI 0.70–1.05). The percentage proportion of the augmented part of labour was significantly shorter in the propranolol group than in the placebo group. No differences in the required oxytocin dosage or CTG pathology were found between the groups. Propranolol was found to be safe for the neonates. The concentrations of its β-adrenoceptor-binding component after a 2 mg intravenous dose were quite similar in parturients and neonates at the time of delivery. The active drug component crossed placental barriers with an average neonate umbilical artery/parturient venous plasma ratio of 0.7. After a 4 mg dose the active drug concentrations in parturients were rather similar to those measured after 2 mg dose, whereas in neonates there were signs of drug accumulation. No picture could be obtained from the kinetics of the β-adrenoceptor-binding component of propranolol from the data. Conclusions Propranolol (2 or 4 mg i.v.) combined with oxytocin, as treatment for arrested labour did not affect the Caesarean section rate compared with placebo plus oxytocin. The percentage proportion of the augmented part of labour was significantly shorter after propranolol. Propranolol was safe for the neonates and can be used as an additional medication among parturients with arrested labour.

Arrested labor secondary to dystocia remains a major indication for acute cesarean section (CS) in many parts of the world. Apart from anatomic problems and malpresentation, the major culprit is uterine dysfunction in the form of weak contractions. Although amniotomy and augmentation with oxytocin are frequently used to augment labor, they have not lessened the frequency of CS. The beta-blocker propranolol, given intravenously, reportedly increases uterine activity, and it has safely augmented labor in a small series of primiparous women. The present study evaluated a combination of intravenous propranolol and oxytocin, compared with oxytocin alone, in women arrested in the first stage of labor. The study, a prospective, randomized, double-blind trial undertaken at a large university hospital, enrolled 107 women whose first-stage arrest of labor was ascribed to inadequate uterine contractions. All of them received oxytocin infusion and, in addition, were randomized to received either 2 mg propranolol intravenously or placebo in a 10-minute period. A second dose was given after 60 minutes if the cervix remained unchanged. Specialists lacking knowledge of the assigned treatment monitored the fetus by cardiotocography (CTG). Women given propranolol had no reduction in rates of CS or vacuum extraction. Rates of spontaneous vaginal delivery were 73% and 85%, respectively, in the propranolol and placebo groups, for a relative risk of 0.86 (95% confidence interval, 0.70-1.05). Excluding women having CS, augmented labor constituted 21% of the entire course of labor in the propranolol group and 29% in placebo recipients. The augmented part of labor was 38 minutes shorter in the propranolol group, a difference that was not statistically significant. Before augmentation, the state of the cervix was the same in the 2 groups. Peak oxytocin infusion rates did not differ significantly. Contractions became stronger over time in both groups, but at no time was there a significant group difference. CTG monitoring disclosed 2 cases of transient bradycardia in each group. In addition, 2 infants in the placebo group had decreased variability and 2 others had missing accelerations. There were no significant group differences in heart rate or blood pressure 1 hour after augmentation. Markers of fetal well-being were comparable in the 2 groups. There was no indication of drug accumulation in women given 2 doses of propranolol.

publishedVersion