Reassessing the Duration of the Second Stage of Labor in Relation to Maternal and Neonatal Morbidity.

OBJECTIVE: To assess the morbidity associated with continuing the second-stage duration of labor, weighing the probability of spontaneous vaginal birth without morbidity compared with birth with serious maternal or neonatal complications. METHODS: In a retrospective cohort, we analyzed singleton, vertex births at 36 weeks of gestation or greater without prior cesarean delivery (n=43,810 nulliparous and 59,605 multiparous women). We calculated rates of spontaneous vaginal birth and composite serious maternal or neonatal complications. Results were stratified by parity (nulliparous or multiparous) and epidural status (yes or no). Competing risks models were created for 1) spontaneous vaginal birth with no morbidity, 2) birth with maternal or neonatal morbidity, and 3) no spontaneous vaginal birth and no morbidity, and our main interest was in comparing number 1 against number 2. RESULTS: Rates of spontaneous vaginal birth without morbidity were slightly higher after the first half hour (greater than 0.5-1.0 hours) for nulliparous women, after which rates decreased with increasing second-stage duration. For multiparous women, rates of spontaneous vaginal birth without morbidity decreased with increasing second-stage duration. For illustration, for a nulliparous woman with an epidural at 3.0 hours of the second stage of labor who extended by another 1.0 hour, her likelihood of delivering by spontaneous vaginal birth was 31.4% compared with her likelihood of birth with any serious complication in the subsequent hour, which was 7.6%. The percentage of cesarean deliveries for nonreassuring fetal heart rate tracing were higher for women without compared with women with an epidural. CONCLUSION: Rates of spontaneous vaginal birth without serious morbidity steadily decreased for increasing second-stage duration except for the first half hour for nulliparous women. We did not observe an inflection point at a particular hour mark for either spontaneous vaginal delivery without morbidity or births with morbidity. Our findings will assist in decision-making for extending second-stage duration

Improved timed-mating, non-invasive method using fewer unproven female rats with pregnancy validation via early body mass increases

For studies requiring accurate conception-timing, reliable, efficient methods of detecting oestrus reduce time and costs, whilst improving welfare. Standard methods use vaginal cytology to stage cycle, and breeders are paired–up using approximately five proven females with proven males to achieve at least one conception on a specific day. We describe an alternative, fast, consistent, non-invasive method of timed-mating using detection of lordosis behaviour in Wistar and Lister-Hooded rats that used unproven females with high success rates. Rats under reverse-lighting had body masses recorded pre-mating, day (d) 3-4, d8, d10 and d18 of pregnancy. Using only the presence of the oestrus dance to time-mate females for 24-hrs, 89% Wistar and 88% Lister-Hooded rats successfully conceived. We did not observe behavioural oestrus in Sprague-Dawleys without males present. Significant body mass increases following mating distinguished pregnant from non-pregnant rats, as early as d4 of pregnancy (10% ± 1.0 increase cf 3% ± 1.2). The pattern of increases throughout gestation was similar for all pregnant rats until late pregnancy, when there were smaller increases for primi- and multiparous rats (32% ± 2.5; 25% ± 2.4), whereas nulliparous rats had highest gains (38% ± 1.5). This method demonstrated a distinct refinement of the previous timed-mating common practice used, as disturbance of females was minimised. Only the number required of nulli-, primi- or multiparous rats were mated, and body mass increases validated pregnancy status. This new breeding-management method is now established practice for two strains of rat and resulted in a reduction in animal use

Differences in Inflammatory Markers between Nulliparous Women Admitted to Hospitals in Preactive vs Active Labor

Objective To determine whether labor-associated inflammatory markers differ between low-risk, nulliparous women in preactive vs active labor at hospital admission and over time. Study Design Prospective comparative study of low-risk, nulliparous women with spontaneous labor onset at term (n = 118) sampled from 2 large Midwestern hospitals. Circulating concentrations of inflammatory markers were measured at admission and again 2 and 4 hours later: namely, neutrophil, and monocyte counts; and serum inflammatory cytokines (interleukin -1β, interleukin-6, tumor necrosis factor-α, interleukin-10) and chemokines (interleukin-8). Biomarker concentrations and their patterns of change over time were compared between preactive (n = 63) and active (n = 55) labor admission groups using Mann-Whitney U tests. Results Concentrations of interleukin-6 and interleukin-10 in the active labor admission group were significantly higher than concentrations in the preactive labor admission group at all 3 time points. Neutrophil levels were significantly higher in the active group at 2 and 4 hours after admission. The rate of increase in neutrophils and interleukin-10 between admission and 2 hours later was faster in the active group (P \u3c .001 and P = .003, respectively). Conclusion Circulating concentrations of several inflammatory biomarkers are higher and their rate of change over time since admission is faster among low-risk, nulliparous women admitted to hospitals in active labor, as compared with those admitted in preactive labor. More research is needed to determine if progressive changes in inflammatory biomarkers might be a useful adjunct to improving the assessment of labor progression and determining the optimal timing of labor admission

Gabapentin for pain management after osmotic dilator insertion and prior to dilation and evacuation: A randomized controlled trial.

ObjectiveTo evaluate if gabapentin 600 mg reduces pain after osmotic dilator placement the day before a dilation and evacuation (D&E) procedure.Study designWe conducted a double-blind, placebo-controlled, randomized (stratified by vaginal parity) trial among women undergoing osmotic dilator placement before D&E at 15-23 5/7 weeks gestation. Subjects received gabapentin 600 mg or placebo 30 min before dilator placement, with re-dosing 8 h later. We assessed pain after dilator placement using a numeric rating scale (NRS; scale 0-10) at 5 min, 2, 4, and 8 h, and at presentation for D&E. The primary outcome was median NRS pain score change from baseline to 8 h after dilator placement. Secondary outcomes included gabapentin-related side effects and analgesic use.ResultsOf 121 randomized women, we excluded three subjects (allergic reaction [placebo], randomization error, no NRS data), leaving 60 gabapentin and 58 placebo subjects. Of 110 (93%) women who provided 8-hour data, median pain score changes from baseline did not differ between gabapentin and placebo groups overall (2 vs. 2.5, p = 0.52), in vaginally nulliparous women (2 vs. 4, p = 0.10) or in parous women (2 vs. 1.5, p = 0.37). We found no statistically significant differences in median pain score change from baseline to any timepoint overall or when stratified by parity. Beginning at 2 h after dilator placement, more gabapentin than placebo users experienced dizziness (29/53[55%] vs. 11/53[21%], p = 0.001) and tiredness (34/54[63%] vs. 17/54[31%], p = 0.002). The proportion of women using narcotics did not differ between gabapentin (35/60[58%]) or placebo (40/58[69%]) users (p = 0.26).ConclusionsGabapentin does not reduce pain with overnight osmotic dilator placement prior to D&E and causes drug-related side effects.Implications statementWomen experience pain, mostly mild to moderate, with overnight cervical dilator placement at 15-23 5/7 weeks gestation. About 2/3 of women will use a limited quantity of narcotics if provided. Gabapentin does not decrease the pain with or following dilator placement and does not decrease narcotic use

How do pregnancy and birth experiences influence planned place of birth in future pregnancies? Findings from a longitudinal, narrative study.

A perception that first birth is more risky than subsequent births has led to women planning births in Obstetric Units, and care providers supporting these choices. This study explored the influence of pregnancy and birth experiences on women’s intended place of birth in current and subsequent pregnancies. Methods: Prospective, longitudinal narrative interviews (n=122) with forty-one women in three English NHS sites. During postnatal interviews, women reflected on their recent births and discussed where they might plan to give birth in a future pregnancy. Longitudinal narrative analysis methods were used to explore these data. Results: Women’s experience of care in their eventual place of birth had more influence upon decisions about the (hypothetical) next pregnancy than planned place of birth during pregnancy did. Women with complex pregnancies usually planned hospital Obstetric Unit (OU) births, but healthy women with straightforward pregnancies also chose OU and would often plan the same for the future, particularly if they experienced OU during recent births. Discussion: The experience of giving birth in a hospital OU reinforced the notion that birth is risky and uncertain, and that hospital OU is the best or safest setting for birth. The assumption that women will opt for lower acuity settings for second or subsequent births was not supported by these data, which may mean that multiparous women who best fit criteria for non-OU births are reluctant to plan births in these settings. This highlights the importance of providing balanced information about risks and benefits of different birth settings to all women during pregnancy

The Gonotrophic-Age Structure of a Population of the \u3ci\u3eSimulium Venustum\u3c/i\u3e Complex (Diptera: Simuliidae) in Algonquin Park, Ontario

Eight techniques for the determination of parity and gonotrophic age were assessed for the obligatorily anautogenous blackfly-species complex, Simulium venustum Say. All females could be age-graded by the presence or absence of dilatations on the ovarioles. However, multiple dilatations on a single ovariole were not found and the Polovodova method could not be used to determine the number of completed gonotrophic cycles. Most females could be age-graded by the appearance of the Malpighian tubules, which undergo morphological changes, probably as a result of a bloodmeal. In some cases, the size of the fat body, the presence of retained (relict), mature ova and the presence of meconium in the gut could be used as accessory age-grading criteria. Insemination status, the volume of the esophageal diverticulum, and the stage of development of the terminal ovarian follicles could not be used to age-grade females. The literature of age-grading in blackflies is reviewed, with special reference to the interpretability of the Polovodova method. Seasonal changes in the gonotrophic-age structure of a population of the S. venustum complex in Algonquin Park, ON, Canada, were examined over two years. The maximal proportion of parous females in the population was 75 and 62% in the two years, respectively. There was weak evidence that parous females were more likely to host seek in the morning and nulliparous females in the afternoon. Parity declined in mid-season, due to the recruitment of newly emerged adults to the population

Predictive and Protective Factors for Partial Necrosis in DIEP Flap Breast Reconstruction. Does Nulliparity Bias Flap Viability?

Although success rate of deep inferior epigastric perforator (DIEP) flap breast reconstruction has greatly improved, complications still occasionally occur. Perfusion-related complications (PRCs) (ie, fat necrosis and partial flap necrosis) are the most frequent concern, affecting aesthetic final result of the reconstructed breast.The aim of our study was to retrospectively investigate 287 consecutive DIEP flap breast reconstructions to investigate predictive and protective factors for PRCs.From May 2004 to February 2012, 287 DIEP flap breast reconstructions were performed on 270 patients; 247 unilateral flaps, including Holm vascular zones I to III, were retrospectively selected and analyzed. Tobacco use, mean blood pressure over the first postoperative 48 hours, superficial epigastric vein drainage, medial/lateral row perforator, nulliparity, crystalloid versus combined crystalloid/colloid intravenous fluid infusion therapy, and learning curve were evaluated by univariate and multivariate logistic regression analyses.Perfusion-related complications occurred 32 (12.9%) times, 79 (31.9%) patients were smokers, 48 (19.4%) showed postoperative mean blood pressure less than 75 mm Hg, 29 (11.7%) were nulliparous, and 173 (70%) had superficial epigastric vein drainage. Selected perforators were 110 (44.5%) from lateral row, 137 (55.5%) from medial row; 91 (36.8%) received crystalloid fluid infusion, whereas 156 (63.2%) combined crystalloid/colloid fluid infusion. From univariate analysis emerged significance of nulliparity, perforator row and intravenous fluid infusion for PRC. Nevertheless, multivariate model confirmed only nulliparity as a significant risk factor (P = 0.029), although variable correlations to other predictors were found: both medial row perforator and combined crystalloid/colloid fluid infusion potentially decrease the PRC risk of 11.6% and 27.6%, respectively. Learning curve did not show significant decrease of PRC risk over time.Our study first proved nulliparity as a statistically significant predictor for PRCs in DIEP flap breast reconstruction, possibly due to different superficial abdominal perfusion between pluriparous and nulliparous women, with potential weaker pattern of perforators and smaller angiosomes in the latter. The choice of medial row perforators and combined crystalloid/colloid fluid infusion might reduce PRC risk