oxytocin and Lacerations

During the third stage of labor, oxytocin and tranexamic acid, oxytocin and misoprostol, oxytocin and methylergometrine, or carbetocin is recommended for the prevention of postpartum hemorrhage after vaginal delivery. Intravenous oxytocin (10 IU) immediately after delivery of the neonate (after either anterior shoulder or whole-body delivery) and before delivery of the placenta is recommended. If oxytocin and tranexamic acid combination is chosen, intravenous tranexamic acid (1 g) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate and before placental delivery is recommended. If oxytocin and misoprostol combination is chosen, sublingual misoprostol (400 µg) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate is recommended. If there is no intravenous access or if in low-resource settings, sublingual misoprostol (400 µg) and intramuscular oxytocin (10 IU) are recommended. If oxytocin and methylergometrine combination is chosen, intramuscular methylergometrine (0.2 mg) and intravenous oxytocin (10 IU) immediately after delivery of the neonate are recommended. Single-dose intravenous or intramuscular carbetocin (100 µg) immediately after delivery of the neonate is recommended. Controlled cord traction and delayed cord clamping for approximately 60 seconds is recommended. There is insufficient evidence to support or refute umbilical cord milking, uterine massage, or nipple stimulation for the prevention of postpartum hemorrhage. Repair of first- and second-degree lacerations with continuous synthetic suture technique is recommended. No repair of first-degree lacerations if hemostatic and normal cosmesis can be considered. Repair of third-degree lacerations with end-to-end or overlap continuous synthetic suture technique is recommended. Repair of fourth-degree lacerations with delayed absorbable 4-0 or 3-0 polyglactin or chromic suture in a running fashion is recommended. The use of single-dose second-generation cephalosporin at the time of third- or fourth-degree laceration repairs can be considered. Skin-to-skin contact after delivery is recommended. There is insufficient evidence to support or refute routine cord blood gas sampling after delivery. Public cord blood banking is recommended.

Topics: Female; Humans; Infant, Newborn; Lacerations; Methylergonovine; Misoprostol; Oxytocics; Oxytocin; Placenta; Postpartum Hemorrhage; Pregnancy; Tranexamic Acid

Over the past 20 years, several randomized studies have compared Valsalva and spontaneous pushing techniques during vaginal delivery. This review summarizes current medical knowledge concerning their maternal and fetal consequences, focusing on pelvic and perineal outcomes.. We selected nine randomized controlled trials comparing Valsalva and spontaneous pushing, and a secondary analysis of a randomized controlled trial comparing different methods of perineal protection. Two trials showed that spontaneous pushing reduces the risk of perineal tears, but no firm conclusions can be drawn given the heterogeneity and inconsistent results of these studies. Conflicting results have been reported regarding the duration of the second stage of labor. Pushing technique does not seem to affect episiotomy, instrumental delivery or cesarean rates. Maternal satisfaction seems to be better after spontaneous pushing. Spontaneous pushing appears to have no adverse effects on neonatal well being, and one study showed a significant improvement in prenatal fetal parameters during the expulsive phase.. Valsalva and spontaneous pushing techniques currently appear comparable in terms of duration, pelvic floor, perineal, and neonatal outcomes. In the absence of strong evidence in favor of either technique, the decision should be guided by patient preference and the clinical situation. Additional, well-designed randomized controlled trials are required.

Topics: Cesarean Section; Delivery, Obstetric; Episiotomy; Female; Heart Rate, Fetal; Humans; Labor Stage, Second; Labor, Obstetric; Lacerations; Oxytocin; Patient Satisfaction; Pelvic Floor; Perineum; Pregnancy; Pregnancy Outcome; Prenatal Care; Randomized Controlled Trials as Topic; Valsalva Maneuver

To investigate the perinatal outcome and risk factors of precipitate labor in term primipara.. A total of 6951 full-term singleton primiparas with cephalic vaginal delivery in Women's Hospital, Zhejiang University School of Medicine from January 2020 to December 2020 were enrolled, among whom 381 cases of precipitate labor were classified as the precipitate labor group and 762 cases of normal labor were randomly selected as the control group. The perinatal outcomes of the two groups were compared, and the risk factors of precipitate labor were analyzed by multivariate logistic regression.. The incidence of precipitate labor in full-term, singleton pregnancy and cephalic primiparas was 5.48% (381/6951). The durations of the first and second stages of labor in the precipitate labor group were significantly shorter than that in the control group (. The incidence of precipitate labor in full-term, singleton pregnancy was not low. Precipitate labor could lead to a significant increase in perineal laceration. Maternal height, history of late miscarriage, membrane rupture before labor and labor induction by transcervical balloon, labor induction by propess are risk factors, while labor induction by oxytocin and late gestational time of delivery are protective factors for precipitate labor in term primipara.

Topics: Abortion, Spontaneous; Female; Humans; Infant, Newborn; Labor, Induced; Lacerations; Oxytocin; Pregnancy; Retrospective Studies; Risk Factors

To assess both severe maternal and neonatal mortality and morbidity after attempted operative vaginal deliveries by residents under supervision and by attending obstetricians.. Secondary analysis of a 5-year prospective study with cross-sectional analysis including 2192 women with live singleton term fetuses in vertex presentation who underwent an attempted operative vaginal delivery in a tertiary care university hospital. Obstetricians who attempted or performed an operative vaginal delivery were classified into 2 groups according to their level of experience: attending obstetricians (who had 5 years or more of experience) and obstetric residents (who had less than 5 years of experience) under the supervision of an attending obstetrician. We used multivariate logistic regression and propensity score methods to compare outcomes associated with attending obstetricians and obstetric residents. Severe maternal morbidity was defined as third- or fourth-degree perineal laceration, perineal hematoma, cervical laceration, extended uterine incision for cesareans, postpartum hemorrhage >1500 mL, surgical hemostatic procedures, uterine artery embolization, blood transfusion, infection, thromboembolic events, admission to the intensive care unit, or maternal death; severe neonatal morbidity was defined as a 5-minute Apgar score <7, umbilical artery pH <7.00, need for resuscitation or intubation, neonatal trauma, intraventricular hemorrhage greater than grade 2, neonatal intensive care unit admission for more than 24 hours, convulsions, sepsis, or neonatal death.. High prepregnancy body mass index, high dose of oxytocin, manual rotation, persistent occiput posterior or transverse positions, operating room delivery, midpelvic delivery, forceps, and spatulas were significantly more frequent in deliveries managed by attending obstetricians than residents whereas a second-stage pushing phase longer than 30 minutes was significantly more frequent in deliveries managed by residents. The rate of severe maternal morbidity was 7.8% (115/1475) for residents vs 9.9% (48/484) for attending obstetricians; for severe neonatal morbidity, the rates were 8.3% (123/1475) vs 15.1% (73/484), respectively. In the univariate, multivariable, and sensitivity analyses, attempted operative vaginal delivery managed by a resident was significantly and inversely associated with severe neonatal but not maternal morbidity. After propensity score matching, delivery managed by a resident was not significantly associated with severe maternal morbidity (adjusted odds ratio, 0.74; 95% confidence interval, 0.39-1.38) and was no longer associated with neonatal morbidity (adjusted odds ratio, 0.51; 95% confidence interval, 0.25-1.04).. Management of attempted operative vaginal deliveries by residents under the supervision of attending obstetricians, compared with by the attending obstetricians themselves, does not appear to be associated with either maternal or neonatal morbidity. These reassuring results support the continued use of residency programs for training in operative vaginal deliveries under the supervision of attending obstetricians.

Topics: Adult; Apgar Score; Birth Injuries; Body Mass Index; Cesarean Section; Extraction, Obstetrical; Female; Hematoma; Humans; Hydrogen-Ion Concentration; Internship and Residency; Labor Stage, Second; Lacerations; Logistic Models; Medical Staff, Hospital; Obstetrics; Operating Rooms; Oxytocics; Oxytocin; Pregnancy; Propensity Score; Prospective Studies; Scalp; Umbilical Arteries; Vacuum Extraction, Obstetrical

To provide evidence-based guidelines for safe and effective assisted vaginal birth.. Prerequisites, indications, contraindications, along with maternal and neonatal morbidity associated with assisted vaginal birth.. Medline database was searched for articles published from January 1, 1985, to February 28, 2018 using the key words "assisted vaginal birth," "instrumental vaginal birth," "operative vaginal delivery," "forceps delivery," "vacuum delivery," "ventouse delivery." The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on Preventive Health Care.. These guidelines were approved by the Clinical Practice Obstetrics Committee and the Board of the Society of Obstetricians and Gynaecologists of Canada.

Topics: Analgesia, Epidural; Birth Injuries; Brachial Plexus; Canada; Cardiotocography; Clinical Competence; Episiotomy; Extraction, Obstetrical; Facial Injuries; Female; Humans; Labor Presentation; Labor Stage, Second; Lacerations; Obstetrical Forceps; Oxytocics; Oxytocin; Peripheral Nerve Injuries; Pregnancy; Puerperal Disorders; Scalp; Shoulder Dystocia; Soft Tissue Injuries; Stress Disorders, Post-Traumatic; Time Factors; Vacuum Extraction, Obstetrical; Version, Fetal

To evaluate the effectiveness and safety of an ultra-low-cost uterine balloon tamponade package (ESM-UBT™) for facility-based management of uncontrolled postpartum haemorrhage (PPH) in Kenya, Sierra Leone, Senegal, and Nepal.. Prospective multi-centre case series.. Facilities in resource-scarce areas of Kenya, Sierra Leone, Nepal, and Senegal.. Women with uncontrolled postpartum haemorrhage in 307 facilities across the four countries.. A standardised ESM-UBT package was implemented in 307 facilities over 29 months (1 September 2012 to 1 February 2015). Data were collected via a multi-pronged approach including data card completion, chart reviews, and provider interviews. Beginning in August 2014, women who had previously undergone UBT placement were sought and queried regarding potential complications associated with UBT use.. All-cause survival, survival from PPH, and post-UBT use complications (surgery, hospitalisation, antibiotics for pelvic infection) associated with UBT use.. 201 UBTs were placed for uncontrolled vaginal haemorrhage refractory to all other interventions. In all, 38% (71/188) of women were either unconscious or confused at the time of UBT insertion. All-cause survival was 95% (190/201). However, 98% (160/163) of women survived uncontrolled PPH if delivery occurred at an ESM-UBT online facility. One (1/151) potential UBT-associated complication (postpartum endometritis) was identified and two improvised UBTs were placed in women with a ruptured uterus.. These pilot data suggest that the ESM-UBT package is a clinically promising and safe method to arrest uncontrolled postpartum haemorrhage and save women's lives. The UBT was successfully placed by all levels of facility-based providers. Future studies are needed to further evaluate the effectiveness of ESM-UBT in low-resource settings.. Evidence for ESM-UBT as a clinically promising and safe method to arrest uncontrolled PPH and save women's lives.

Topics: Adolescent; Adult; Breast Feeding; Cervix Uteri; Checklist; Condoms; Female; Health Resources; Humans; Kenya; Lacerations; Massage; Middle Aged; Misoprostol; Nepal; Oxytocics; Oxytocin; Perineum; Pilot Projects; Postpartum Hemorrhage; Prospective Studies; Senegal; Sierra Leone; Survival Rate; Urinary Catheters; Uterine Balloon Tamponade; Young Adult

A protocol including judicious use of oxytocin augmentation was investigated to determine whether it would change how oxytocin was used and eventually influence labor and fetal outcomes.. The population of this cohort study comprised 20 227 delivering women with singleton pregnancies ≥37 weeks, cephalic presentation, spontaneous or induced onset of labor, without previous cesarean section. Women delivering from 2009 to 2013 at Stavanger University Hospital, Norway, were included. Data were collected prospectively. Before implementing the protocol in 2010, oxytocin augmentation was used if progression of labor was perceived as slow. After implementation, oxytocin could only be started when the cervical dilation had crossed the 4-h action line in the partograph.. The overall use of oxytocin augmentation was significantly reduced from 34.9% to 23.1% (p < 0.01). The overall frequency of emergency cesarean sections decreased from 6.9% to 5.3% (p < 0.05) and the frequency of emergency cesarean sections performed due to fetal distress was reduced from 3.2% to 2.0% (p = 0.01). The rate of women with duration of labor over 12 h increased from 4.4% to 8.5% (p < 0.01) and more women experienced severe estimated postpartum hemorrhage (2.6% vs. 3.7%; p = 0.01). The frequency of children with pH <7.1 in the umbilical artery was reduced from 4.7% to 3.2% (p < 0.01).. The frequency of emergency cesarean section was reduced after implementing judicious use of oxytocin augmentation. Our findings may be of interest in the ongoing discussion of how the balanced use of oxytocin for labor augmentation can best be achieved.

Topics: Adult; Anal Canal; Cesarean Section; Clinical Protocols; Dystocia; Emergencies; Female; Fetal Blood; Fetal Distress; Humans; Hydrogen-Ion Concentration; Infant, Newborn; Labor, Obstetric; Lacerations; Norway; Oxytocics; Oxytocin; Postpartum Hemorrhage; Pregnancy; Time Factors

The association between birth position and obstetric anal sphincter injury (OASIS) in spontaneous vaginal deliveries is unclear.. The study was based on the Stockholm-Gotland Obstetric Database (Sweden) from Jan 1(st) 2008 to Oct 22(nd) 2014 and included 113 279 singleton spontaneous vaginal births with no episiotomy. We studied risk of OASIS with respect to the following birth positions: a) sitting, b) lithotomy, c) lateral, d) standing on knees, e) birth seat, f) supine, g) squatting, h) standing and i) all fours. All analyses were stratified for parity. General linear models were used to calculate risk ratios (RR) adjusted for maternal, pregnancy and fetal characteristics.. The rates of OASIS among nulliparous women, parous women and women undergoing vaginal birth after a caesarean (VBAC) were 5.7%, 1.3% and 10.6%, respectively. The rates varied by birth position: from 3.7 to 7.1% in nulliparous women, 0.6% to 2.6% in parous women and 5.6% to 18.2% in women undergoing VBAC. Regardless of parity, the lowest rates were found among women giving birth in standing position and the highest rates among women birthing in the lithotomy position. Compared with sitting position, the lithotomy position involved an increased risk of OASIS among nulliparous (adjusted RR 1.17, 95% CI 1.06-1.29) and parous women (adjusted RR 1.66, 95% CI 1.35-2.05). Birth seat and squatting position involved an increased risk of OASIS among parous women (adjusted RR [95% CI] 1.36 [1.03-1.80] and 2.16 [1.15-4.07], respectively). Independent risk factors for OASIS were maternal age, head circumference ≥35 cm, birth weight ≥4000 g, length of gestation ≥ 40 weeks, prolonged second stage of labour, non-occiput anterior presentation and oxytocin augmentation.. Compared with sitting position, lateral position has a slightly protective effect in nulliparous women whilst an increased risk is noted among women in the lithotomy position, irrespective of parity. Squatting and birth seat position involve an increase in risk among parous women.

Topics: Adult; Anal Canal; Birth Weight; Cephalometry; Female; Gestational Age; Humans; Labor Presentation; Lacerations; Maternal Age; Obstetric Labor Complications; Oxytocics; Oxytocin; Parity; Patient Positioning; Pregnancy; Prevalence; Risk Assessment; Risk Factors; Sweden; Vaginal Birth after Cesarean

To analyze outcomes after second-stage labor beyond 3 hours and determine if prolonged second stages were intentional.. Retrospective cohort analysis of maternal and neonatal outcomes in nulliparous women based on second-stage duration. Medical records were reviewed for management decisions in women with second stages ≥4 hours; all other outcomes were accessed via computerized obstetric database.. Second stage exceeding 3 hours occurred in 1489 (7%) of 21,991 pregnancies analyzed. Of the 427 (2%) with second stages ≥4 hours, 315 (74%) reached 4 hours unintentionally, after a decision for operative delivery had been made. Only 34 (8%) women were intentionally allowed to continue second-stage labor beyond 4 hours, and half of these ultimately required cesarean. Indices of maternal and neonatal morbidity were significantly increased when second stages exceeded 3 hours.. Most second stages reaching 4 hours are unintentional, occurring while awaiting an previously decided upon operative delivery. Maternal and neonatal morbidities are significantly increased with second stages beyond 3 hours.

Topics: Adolescent; Adult; Analgesia, Epidural; Analgesia, Obstetrical; Blood Transfusion; Cesarean Section; Chorioamnionitis; Cohort Studies; Female; Fetal Monitoring; Fever; Heart Rate, Fetal; Humans; Hypovolemia; Hysterectomy; Labor Stage, Second; Lacerations; Oxytocics; Oxytocin; Parity; Perineum; Pregnancy; Retrospective Studies; Time Factors; Young Adult

The aim of this study was to determine if epidural analgesia is associated with increased risk of obstetric lacerations during spontaneous vaginal delivery. Furthermore we assessed the effect of epidural analgesia on maternal and neonatal parameters. This multicenter study consisted of an analysis of data from the delivery databases of the University Hospital of Vienna and the Semmelweis Women's Hospital Vienna. This study was restricted to a sample that included all women with uncomplicated pregnancy, a gestational age >37(th) weeks and a pregnancy with cephalic presentation. Epidural analgesia was set during the first stage of labour. Techniques and management styles of epidural analgesia were the same in both hospitals. No statistically significant association was found between epidural analgesia and the occurrence of perineal tears (p=0.83), vaginal (p=0.37) or labial trauma (p=0.11). Furthermore the results demonstrated a statistically significant higher rate of primiparous women using epidural analgesia (p=0.001). A statistically significant prolonged second stage of labour was observed in women undergoing epidural analgesia (p=0.0001). Episiotomy was statistically significant more frequent in women requiring epidural analgesia (p=0.0001). Women who were treated with epidural analgesia were more likely to have labour augmented with oxytocin (p=0.001). No statistically significant differences in neonatal outcomes determined by APGAR score (p=0.84) and cord pH (p=0.23) were observed between the two groups. Women undergoing epidural analgesia demonstrated a prolonged second stage of labour, a higher rate of episiotomy and an increased use of oxytocin to augment labour. Some of these adverse effects might be caused by the higher rate of primiparous women using epidural analgesia. However, epidural analgesia showed no evidence of a detrimental effect on the integrity of the birth-canal in spontaneous vaginal delivery. In our opinion it is a save and effective method of pain relief during labour.

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Delivery, Obstetric; Episiotomy; Female; Humans; Infant, Newborn; Labor Stage, Second; Lacerations; Oxytocin; Perineum; Pregnancy; Pregnancy Outcome; Risk Factors; Time Factors

To refine the indications of bilateral hypogastric artery ligation (BHAL) and angiographic selective embolisation (ASE) in intractable obstetric haemorrhage.. an audit study.. Tertiary care university hospital.. Retrospective analysis of 61 cases of obstetric intractable post partum haemorrhage (PPH) initially managed either by hysterectomy or a conservative approach in a tertiary referral centre between 1983 and 1998. Procedures were reviewed as a primary (P) or secondary (S) attempt to arrest the haemorrhagic process.. Ten hysterectomies (5 P, 5 S), 49 BHAL (48 P, 1 S) and 9 ASE (8 P, 1S) were successfully performed in arresting the haemorrhagic process. There were 7 maternal deaths, 5 following hysterectomy and 2 following a conservative approach. Atony of the uterus was the main cause of haemorrhage (n=21) and genital tract laceration was associated with the worst prognosis. Time-elapse between delivery and surgery appears to be the main prognostic factor. Nine patients became pregnant 1 to 4 years later following a conservative approach.. ASE seems to be indicated in haemodynamically stable patients with birth canal trauma or uterine atony and clotting anomalies. BHAL is indicated when haemorrhage occurs after a cesarean section or when the patient is haemodynamically unstable. BHAL should be taught to Junior doctors in an attempt to decrease the number of patients transferred in tertiary referral centers for intractable PPH. This might also decrease the number of hysterectomies in intractable PPH.

Topics: Adult; Blood Transfusion; Cesarean Section; Dinoprostone; Embolization, Therapeutic; Fatal Outcome; Female; Genitalia, Female; Humans; Hysterectomy; Iliac Artery; Lacerations; Ligation; Medical Audit; Oxytocin; Postpartum Hemorrhage; Pregnancy; Prognosis; Retrospective Studies; Time Factors; Uterine Rupture

Topics: Cervix Uteri; Female; Humans; Labor, Induced; Labor, Obstetric; Lacerations; Oxytocin; Pregnancy; Work