Impact of first-trimester mechanical cervical dilatation during curettage on maternal and neonatal outcomes: A retrospective comparative study.

OBJECTIVE: Earlier studies have indicated a potential link between dilatation and curettage (D&C) and subsequent preterm delivery, possibly attributed to cervical damage. This study examines outcomes in pregnancies subsequent to first-trimester curettage with and without cervical dilatation. METHODS: A retrospective cohort study was conducted on women who conceived after undergoing curettage due to a first trimester pregnancy loss. Maternal and neonatal outcomes of the subsequent pregnancy were compared between two groups: women who underwent cervical dilatation before their curettage and those who had curettage without dilatation. The primary outcome assessed was the rate of preterm delivery at the subsequent pregnancy, and secondary outcomes included other adverse maternal and neonatal outcomes. Univariate analysis was performed, followed by multiple logistic regression models to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: Among the 1087 women meeting the inclusion criteria during the study period, 852 (78.4 %) underwent first-trimester curettage with cervical dilatation, while 235 (21.6 %) opted for curettage only. No significant maternal or neonatal different outcomes were noted between the study groups, including preterm delivery (5.5 % vs. 3.5 %, p = 0.16), fertility treatments, placental complications, and mode of delivery. However, deliveries following D&C were associated with higher rates of small for gestational age neonates (7.6 % vs. 3.8 %, p = 0.04). Multivariate analysis revealed that cervical dilation before curettage was not significantly linked to preterm delivery [adjusted odds ratio 0.64 (0.33-1.26), p = 0.20]. CONCLUSION: The use of cervical dilatation during a curettage procedure for first trimester pregnancy loss, does not confer additional risk of preterm delivery. Further studies are needed to reinforce and validate these results.

Expectant management vs. cerclage in cases with prolapsed or visible membranes in the second trimester: is 24 weeks gestation threshold critical?

OBJECTIVES: The aim of this study was to compare the efficacy of cervical cerclage with spontaneous follow-up strategy on pregnancy duration and neonatal outcomes in women with visible or prolapsed fetal membranes. METHODS: Patients who were referred to a single tertiary care centre between 1st January 2017 and 31st December 2022 were included in this comparative, retrospective cohort study. Patients were divided into two groups, those undergoing cerclage and those followed with no-cerclage. The range of pregnancy weeks for cerclage is between 18th and 27+6 weeks. RESULTS: A total of 106 cases were reviewed and nine were excluded. Based on shared decision making, cervical cerclage was performed in 76 patients (78.3 %) and 21 patients (21.6 %) were medically treated in no-cerclage group if there was no early rupture of the fetal membranes. The gestational age at delivery was 29.8 ± 6 [Median=30 (19-38)] weeks in the cerclage group and 25.8 ± 2.9 [Median=25 (19-32)] weeks in the no-cerclage group (p=0.004). Pregnancy prolongation was significantly longer in the cerclage group compared to the no-cerclage group (55 ± 48.6 days [Median=28 (3-138)] vs. 12 ± 17.9 days [Median=9 (1-52)]; p<0.001). Take home baby rate was 58/76 (76.3 %) in cerclage group vs. 8/21 (38 %) in no-cerclage group. In the post-24 week cerclage group the absolute risk reduction for pregnancy loss was 50 % (95 % CI=21.7-78.2). CONCLUSIONS: Cervical cerclage applied before and after 24 weeks (until 27+6 weeks) increased take home baby rate in women with visible or prolapsed fetal membranes without increasing adverse maternal outcome when compared with no-cerclage group.

The association between the degree of cervical dilatation before ultrasound and physical examination indicated cerclage and subsequent neonatal outcomes.

INTRODUCTION: Preterm identification of cervical dilation in pregnant women leads to the application of emergency cervical cerclage with an expectation of achieving term delivery. However, this is not always feasible. Short- and long-term neonatal complications post-preterm birth pose a significant challenge. It is crucial to anticipate potential complications and understand the possibilities of postpartum development as they can be encountered. We aimed to evaluate the effect of the degree of cervical dilatation before ultrasound and physical examination-indicated cerclage in singleton pregnancies presenting with premature cervical dilatation with bulging fetal membranes (rescue cerclage) on subsequent neonatal outcomes. MATERIALS AND METHODS: In this retrospective clinical study, over a 10-year period between January 2009 and January 2019, 72 singleton pregnancies undergoing rescue cerclage were included and divided into two groups according to pre-cerclage cervical dilatation: Group 1 (n = 33) and Group 2 (n = 39) with cervical dilatation ≤3 cm and >3 cm, respectively. Latency period for pregnancy prolongation, gestational age at delivery, birth weight, and neonatal morbidity and mortality were compared across the groups. Logistic regression was used to delineate the independent effect of cervical dilatation at cerclage placement on neonatal mortality. RESULTS: Group 2 had a higher delivery rate at ≤28 weeks' gestation (p = 0.007) and lower birth weight (p = 0.002) compared to Group 1, with an increased mean latency period in Group 2 (90 ± 55 days versus 52 ± 54 days, p = 0.005). The newborn intensive care unit (NICU) requirement, respiratory distress syndrome (RDS), neonatal jaundice and sepsis, and retinopathy of prematurity (ROP) were more frequent in Group 2. Neonatal mortality rate was higher (52.6% versus 24.2%, p = 0.015) and intact survival was lower (23.1% versus 48.4%, p = 0.013) in Group 2, whereas rates of cerebral palsy (8% and 9%, respectively) were similar between the groups (p = 0.64). CONCLUSION: Advanced cervical dilatation (>3 cm) during physical examination-indicated cerclage in singleton pregnancies is associated with earlier delivery, leading to increased neonatal morbidity and mortality when compared with pregnancies having lesser degrees of cervical dilatation at cerclage. However, short-term poor neurological outcomes seem comparable.

Implementation of sonopartogram: multicenter feasibility study.

OBJECTIVES: Well-established clinical practice for assessing progress in labor involves routine abdominal palpation and vaginal examination (VE). However, VE is subjective, poorly reproducible and painful for most women. In this study, our aim was to evaluate the feasibility of systematically integrating transabdominal and transperineal ultrasound assessment of fetal position, parasagittal angle of progression (psAOP), head-perineum distance (HPD) and sonographic cervical dilatation (SCD) to monitor the progress of labor in women undergoing induction of labor (IOL). We also aimed to determine if ultrasound can reduce women's pain during such examinations. METHODS: Women were recruited as they presented for IOL in three maternity units. Ultrasound assessments were performed in 100 women between 37 + 0 and 41 + 6 weeks' gestation. A baseline combined transabdominal and transperineal scan was performed, including assessment of fetal biometry, umbilical artery and fetal middle cerebral artery Doppler, amniotic fluid index, fetal spine and occiput positions, psAOP, HPD, SCD and cervical length. Intrapartum scans were performed instead of VE, unless there was a clinical indication to perform a VE, according to protocol. Participants were asked to indicate their level of pain by verbally giving a pain score between 0 and 10 (with 0 representing no pain) during assessment. Repeated measures data were analyzed using mixed-effect models to identify significant factors that affected the relationship between psAOP, HPD, SCD and mode of delivery. RESULTS: A total of 100 women were included in the study. Of these, 20% delivered by Cesarean section, 65% vaginally and 15% by instrumental delivery. There were no adverse fetal or maternal outcomes. A total of 223 intrapartum ultrasound scans were performed in 87 participants (13 women delivered before intrapartum ultrasound was performed), with a median of two scans per participant (interquartile range (IQR), 1-3). Of these, 76 women underwent a total of 151 VEs with a median of one VE per participant (IQR, 0-2), with no significant difference between vaginal- or Cesarean-delivery groups. After excluding those with epidural anesthesia during examination, the median pain score for intrapartum scans was 0 (IQR, 0-1) and for VE it was 3 (IQR, 0-6). Cesarean delivery was significantly associated with a slower rate of change in psAOP, HPD and SCD. CONCLUSIONS: Comprehensive transabdominal and transperineal ultrasound assessment can be used to assess progress in labor and can reduce the level of pain experienced during examination. Ultrasound assessment may be able to replace some transabdominal and vaginal examinations during labor. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The use of bubble charts in analyzing second stage cesarean delivery rates.

BACKGROUND: The incidence of second stage cesarean delivery has been rising globally because of the failure or the anticipated difficulty of performing instrumental delivery. Yet, the best way to interpret the figure and its optimal rate remain to be determined. This is because it is strongly influenced by the practice of other 2 modes of birth, namely cesarean delivery performed before reaching the second stage and assisted vaginal birth during the second stage. In this regard, a bubble chart that can display 3-dimensional data through its x-axis, y-axis, and the size of each plot (presented as a bubble) may be a suitable method to evaluate the relationship between the rates of these 3 modes of births. OBJECTIVE: This study aimed to conduct an epidemiologic study on the incidence of second stage cesarean deliveries rates among >300,000 singleton term births in 10 years from 8 obstetrical units and to compare their second stage cesarean delivery rates in relation to their pre-second stage cesarean delivery rates and assisted vaginal birth rates using a bubble chart. STUDY DESIGN: The territory-wide birth data collected between 2009 and 2018 from all 8 public obstetrical units (labelled as A to H) were reviewed. The inclusion criteria were all singleton pregnancies with cephalic presentation that were delivered at term (≥37 weeks' gestation). Pre-second stage cesarean delivery rate was defined as all elective cesarean deliveries and those emergency cesarean deliveries that occurred before full cervical dilatation was achieved as a proportion of the total number of births. The second stage cesarean delivery rate and assisted vaginal birth rate were calculated according to the respective mode of delivery as a proportion of the number of cases that reached full cervical dilatation. The rates of these 3 modes of births were compared among the parity groups and among the 8 units. Using a bubble chart, each unit's second stage cesarean delivery rate (y-axis) was plotted against its pre-second stage cesarean delivery rate (x-axis) as a bubble. Each unit's second stage cesarean delivery to assisted vaginal birth ratio was represented by the size of the bubble. RESULTS: During the study period, a total of 353,434 singleton cephalic presenting term pregnancies were delivered in the 8 units, and 180,496 (51.1%) were from nulliparous mothers. When compared with the multiparous group, the nulliparous group had a significantly lower pre-second stage cesarean delivery rate (18.58% vs 21.26%; P<.001) but a higher second stage cesarean delivery rate (0.79% vs 0.22%; P<.001) and a higher assisted vaginal birth rate (17.61% vs 3.58%; P<.001). Using the bubble of their averages as a reference point in the bubble chart, the 8 units' bubbles were clustered into 5 regions indicating their differences in practice: unit B and unit H were close to the average in the center. Unit A and unit F were at the upper right corner with a higher pre-second stage cesarean delivery rate and second stage cesarean delivery rate. Unit D and unit E were at the opposite end. Unit C was at the upper left corner with a low pre-second stage cesarean delivery rate but a high second stage cesarean delivery rate, whereas unit G was at the opposite end. Unit C and unit G were also in the extremes in terms of pre-second stage cesarean delivery to assisted vaginal birth ratio (0.09 and 0.01, respectively). Although some units seemed to have very similar second stage cesarean delivery rates, their obstetrical practices were differentiated by the bubble chart. CONCLUSION: The second stage cesarean delivery rate must be evaluated in the context of the rates of pre-second stage cesarean delivery and assisted vaginal birth. A bubble chart is a useful method for analyzing the relationship among these 3 variables to differentiate the obstetrical practice between different units.

Self-Traction During Mechanical Cervical Dilatation, Acceptability, Feasibility and Satisfaction of its Application: A Pilot Study.

This study aims to measure acceptability, feasibility, and satisfaction with self-traction during mechanical cervical dilatation to induce labour and to explore its effects on pain and the process of labour and delivery. 60 parturients were randomly assigned to self-traction or regular traction. Participants completed questionnaires about sociodemographic characteristics, acceptability, and satisfaction. Self-traction participants reported significantly higher acceptability (P = 0.026), and adequacy (P = 0.018). They also reported satisfaction with the procedure. A group comparison regarding feasibility, pain, and the process of labour and delivery showed no significant difference. Self-traction is an acceptable and feasible intervention for full-term parturients.

Transvaginal cerclage for prevention of preterm birth in twin pregnancies with cervical dilatation or shortening: A prospective observational study.

OBJECTIVE: To investigate the efficacy of transvaginal cerclage in twin pregnancies with cervical shortening, and to narrow the threshold cervical length for transvaginal cerclage. METHODS: This is a prospective cohort study and 177 twin pregnancies with asymptomatic cervical dilatation or cervical length of 15 mm or less between 16+0 and 25+6 weeks of pregnancy were included. Patients independently chose either transvaginal cerclage (n = 129) or no cerclage treatment (n = 48) after being consulted on the risk and potential benefit of transvaginal cerclage. The primary outcome measures were gestational age at delivery and neonatal survival rate. RESULTS: Compared with the no cerclage group, the cerclage group exhibited a higher gestational age at delivery (32.1 ± 4.5 vs 28.3 ± 6.2 weeks, P < 0.001) and a higher neonatal survival rate (86.4% vs 47.9%, P < 0.001). Subgroup analysis showed that in twin pregnancies with cervical dilatation or cervical length less than 10 mm, the cerclage group had significantly higher gestational age at delivery (31.3 ± 4.6 vs 23.4 ± 4.3 weeks, P < 0.001) and a higher neonatal survival rate (123 [85.4%] vs 4 [9.1%], P < 0.001) than the no cerclage group, but in twins when cervical length was 10-15 mm, the two measures were similar between the two groups. CONCLUSION: Transvaginal cerclage may provide benefits for twins when cervical dilatation or cervical length is less than 10 mm, but its efficacy might not extend to twins when the cervical length is 10-15 mm. Further evidence is needed to confirm the efficacy of transvaginal cerclage for twin pregnancies with a short cervix.

Level of agreement between midwives and obstetricians performing ultrasound examination during labor.

OBJECTIVE: To evaluate the level of agreement between ultrasound measurements to evaluate fetal head position and progress of labor by attending midwives and obstetricians after appropriate training. METHODS: In this prospective study, women in the first stage of labor giving birth to a single baby in cephalic presentation at our Obstetric Unit between March 2018 and December 2019 were invited to participate; 109 women agreed. Transperineal and transabdominal ultrasound was independently performed by a trained midwife and an obstetrician. Two paired measurements were available for comparisons in 107 cases for the angle of progression (AoP), in 106 cases for the head-to-perineum distance (HPD), in 97 cases for the cervical dilatation (CD), and in 79 cases for the fetal head position. RESULTS: We found a good correlation between the AoP measured by obstetricians and midwives (intra-class correlation coefficient [ICC] = 0.85; 95% confidence interval [CI] 0.80-0.89). There was a moderate correlation between the HPD (ICC = 0.75; 95% CI 0.68-0.82). There was a very good correlation between the CD measured (ICC = 0.94; 95% CI 0.91-0.96). There was a very good level of agreement in the classification of the fetal head position (Cohen's κ = 0.89; 95% CI 0.80-0.98). CONCLUSIONS: Ultrasound assessment of fetal head position and progress of labor can effectively be performed by attending midwives without previous experience in ultrasound.

The purple line and its association with cervical dilatation in labour: A systematic review and meta-analysis.

BACKGROUND: There is a growing body of evidence that the presence and length of the purple line could represent a non-invasive method of estimating and determining labour progress. OBJECTIVES: The primary outcome was to provide a systematic review and meta-analysis on the association between the purple line length and cervical dilatation in active labour. The secondary outcome was to determine the association between the purple line length and the fetal head descent, and to calculate the pooled mean length of the purple line at a cervical dilatation of 3-4 cm and at a cervical dilatation of 9-10 cm. SEARCH STRATEGY: We searched the Medline, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), Clinical Trials.gov and Cochrane Pregnancy and Childbirth's Trials Register databases from inception till March 25, 2023. SELECTION CRITERIA: We included observational studies of pregnant women in active first stage of labour who had their labour progress assessed with the use of regular vaginal examinations and who had the occurrence recorded and length of the purple line measured at the same time. DATA COLLECTION AND ANALYSIS: Two reviewers independently evaluated study eligibility. We used the random effects and fixed effects model for meta-analysis. MAIN RESULTS: There were six eligible studies included in the systematic review that reported on 982 women in total with the purple line appearing in 760 (77.3%) of cases. We found a moderate positive pooled correlation between the purple line length with cervical dilatation (r = +0.64; 95%CI: 0.41-0.87) and fetal head descent (r = +0.50; 95%CI: 0.32-0.68). For women either in spontaneous or induced labour, the pooled mean length of the purple line was more than 9.4 cm when the cervical dilatation was 9-10 cm, whereas it was more than 7.3 cm when the cervical dilatation was 3-4 cm. CONCLUSIONS: The purple line is a non-invasive method that may potentially be used as an adjunct in labour progress assessment.

New insights on labor progression: a systematic review.

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.

The sonopartogram.

The assessment of labor progress from digital vaginal examination has remained largely unchanged for at least a century, despite the current major advances in maternal and perinatal care. Although inconsistently reproducible, the findings from digital vaginal examination are customarily plotted manually on a partogram, which is composed of a graphical representation of labor, together with maternal and fetal observations. The partogram has been developed to aid recognition of failure to labor progress and guide management-specific obstetrical intervention. In the last decade, the use of ultrasound in the delivery room has increased with the advent of more powerful, portable ultrasound machines that have become more readily available for use. Although ultrasound in intrapartum practice is predominantly used for acute management, an ultrasound-based partogram, a sonopartogram, might represent an objective tool for the graphical representation of labor. Demonstrating greater accuracy for fetal head position and more objectivity in the assessment of fetal head station, it could be considered complementary to traditional clinical assessment. The development of the sonopartogram concept would require further undertaking of serial measurements. Advocates of ultrasound will concede that its use has yet to demonstrate a difference in obstetrical and neonatal morbidity in the context of the management of labor and delivery. Taking a step beyond the descriptive graphical representation of labor progress is the question of whether a specific combination of clinical and demographic parameters might be used to inform knowledge of labor outcomes. Intrapartum cesarean deliveries and deliveries assisted by forceps and vacuum are all associated with a heightened risk of maternal and perinatal adverse outcomes. Although these outcomes cannot be precisely predicted, many known risk factors exist. Malposition and high station of the fetal head, short maternal stature, and other factors, such as caput succedaneum, are all implicated in operative delivery; however, the contribution of individual parameters based on clinical and ultrasound assessments has not been quantified. Individualized risk prediction models, including maternal characteristics and ultrasound findings, are increasingly used in women's health-for example, in preeclampsia or trisomy screening. Similarly, intrapartum cesarean delivery models have been developed with good prognostic ability in specifically selected populations. For intrapartum ultrasound to be of prognostic value, robust, externally validated prediction models for labor outcome would inform delivery management and allow shared decision-making with parents.

Cervical dilatation at diagnosis of active phase of labour determines the mode of delivery and peripartum outcomes: a retrospective study in a single tertiary centre in Malaysia.

BACKGROUND: There is an increasing trend of Caesarean section rate in Malaysia. Limited evidence demonstrated the benefits of changing the demarcation of the active phase of labour. METHODS: This was a retrospective study of 3980 singletons, term pregnancy, spontaneous labouring women between 2015 and 2019 comparing outcomes between those with cervical dilation of 4 versus 6 cm at diagnosis of the active phase of labour. RESULTS: A total of 3403 (85.5%) women had cervical dilatation of 4 cm, and 577 (14.5%) at 6 cm upon diagnosis of the active phase of labour. Women in 4 cm group were significantly heavier at delivery (p = 0.015) but significantly more multiparous women were in 6 cm group (p < 0.001). There were significantly fewer women in the 6 cm group who needed oxytocin infusion (p < 0.001) and epidural analgesia (p < 0.001) with significantly lower caesarean section rate (p < 0.001) done for fetal distress and poor progress (p < 0.001 both). The mean duration from diagnosis of the active phase of labour until delivery was significantly shorter in the 6 cm group (p < 0.001) with lighter mean birth weight (p = 0.019) and fewer neonates with arterial cord pH < 7.20 (p = 0.047) requiring neonatal intensive care unit admissions (p = 0.01). Multiparity (AOR = 0.488, p < 0.001), oxytocin augmentation (AOR = 0.487, p < 0.001) and active phase of labour diagnosed at 6 cm (AOR = 0.337, p < 0.001) reduced the risk of caesarean delivery. Caesarean delivery increased the risk of neonatal intensive care admission by 27% (AOR = 1.73, p < 0.001). CONCLUSIONS: Active phase of labour at 6 cm cervical dilatation is associated with reduced primary caesarean delivery rate, labour intervention, shorter labour duration and fewer neonatal complications.

The active phase of labor.

The active phase of labor begins at various degrees of dilatation when the rate of dilatation transitions from the relatively flat slope of the latent phase to a more rapid slope. No diagnostic manifestations demarcate its onset, other than accelerating dilatation. It ends with apparent slowing of dilatation, a deceleration phase, which is usually short in duration and frequently undetected. Several aberrant labor patterns can be detected during the active phase, including protracted dilatation, arrest of dilatation, prolonged deceleration phase and failure of descent. Underlying factors may include cephalopelvic disproportion, excessive neuraxial block, poor uterine contractility, fetal malpositions, malpresentations, uterine infection, maternal obesity, advanced maternal age and previous cesarean delivery. When an active-phase disorder is identified, cesarean delivery is justifiable if there is compelling clinical evidence of disproportion. A prolonged deceleration disorder is strongly associated with disproportion and second stage abnormalities. Shoulder dystocia may occur if vaginal delivery eventuates. This review discusses several issues raised by the introduction of new clinical practice guidelines for labor management.

Doppler indices of uterine arteries and mRNA transcripts of hormone receptors in cervix vis-à-vis dilatation therapy in buffaloes affected with incomplete cervical dilatation associated with uterine torsion.

The present study aimed to investigate the Doppler indices and mRNA transcripts of hormone receptors in relation to the response of dilatation therapy in incomplete cervical dilatation (ICD) associated with uterine torsion in buffaloes. Out of 36 successfully detorted uterine torsion cases, eight buffaloes revealed a fully dilated cervix, while the remaining 28 had ICD, and subjected to dilatation therapy (500 µg cloprostenol + 2 mg estradiol benzoate + 80 mg valethamate bromide + 50 IU oxytocin + 250 mL calcium borogluconate). The responses of dilatation therapy were assessed in 26 buffaloes as one died, and one could not follow up. Doppler indices of middle uterine arteries on trans-rectal ultrasound were evaluated pre- and 30-60 min post-detorsion. Cervical tissue biopsies were collected from 16 buffaloes to study mRNA transcripts of hormone receptors. The duration, degree, location of uterine torsion, fetal viability, consistency of the cervix, relaxation of pelvic ligaments, udder engorgement, and gestation length were also recorded to evaluate the response of dilatation therapy. The 73.08% (19/26) buffaloes responded to the therapy with a duration ranging from 2 to 56 hrs (18.41 ± 4.11). The significantly increased blood flow volume (BFV) and time-average peak velocity (TAP) while the significantly reduced resistive index (RI) and pulsatility index (PI) in an ipsilateral middle uterine artery (MUA) at post-detorsion were observed in dilation therapy responded than the not-responded group. The mRNA transcripts of estradiol receptors-α (ESR1), prostaglandin receptors (PTGFR), and oxytocin receptors (OXTR) were upregulated by 7.47, 6.63, and 8.72-fold in the ICD group, respectively. The Doppler indices along with duration of illness, location of uterine torsion, consistency of the cervix, and udder engorgement can be used to predict the response of dilatation therapy in ICD associated with uterine torsion. The upregulated mRNA expression of ESR1, PTGFR and OXTR is mandatory for success of dilatation therapy.

Development and Application of "Cervical Dilatation Model for Teaching and Training".

Background: Each year nursing schools pay more for teaching equipment at the nursing laboratory to improve practical skills. The development of the cervical dilatation model for teaching to reduce teaching and training costs is essential. This research aimed at developing a kind of cervical dilatation model for teaching and training. Methods: Developing a cervical dilatation model for teaching and training with the same structure and operation configuration is like the cervical dilatation model in laboratory practices of nursing. The appearance, structure, and operating accessories were developed from the original. The differences between the original cervical dilatation model and the cervical dilatation model for teaching and training are as follows: the original cervical dilatation model has only vaginal and fetal skulls of various sizes but the cervical dilatation model for teaching and training content follows vaginal, ischial spine, fetal skulls of various sizes, and cervical dilation and effacement. We then compare the teaching effect of the cervical dilatation model for teaching and training with the original cervical dilatation model (including knowledge, vaginal exam scores, and satisfaction after training). Results: There was no significant difference in the knowledge and vaginal examination scores of the experimental group and control group before training. The vaginal examination scores in the experimental group were higher than those in the control group and scored before, immediately after, and two weeks after the intervention was statistically significantly higher than before training at 0.05 (68.86 ± 3.89, 88.10 ± 2.52, 91.06 ± 1.33) and the trainees had maximum satisfaction in the training. Conclusion: The cervical dilatation model for teaching and training was highly efficient, and knowledge and practice among nursing students in the intervention group increased after training. The cervical dilatation model for teaching and training could help reduce the cost of teaching equipment, increase teaching and training resources, and improve the trainee's knowledge and practice skills.

A randomised comparative study of sublingual and vaginal misoprostol for cervical priming before minor gynaecological procedures.

This study aimed to compare the effect of misoprostol using vaginal or sublingual routes on the non-pregnant uterine cervix prior to minor gynaecological procedures. One hundred and forty women were randomised 1:1 into two groups: A and B. Group A received misoprostol 400 mcg vaginally and pyridoxine 40 mg sublingually and Group B received misoprostol 400 mcg sublingually and pyridoxine 40 mg vaginally 4 h prior to procedure. The outcomes studied were maximum size of Hegar's dilator that could be inserted into the cervix without any resistance, ease of dilatation, need and time required for further dilatation, side effects and complications. Baseline cervical dilatation was significantly more in Group A than Group B. Need for further dilatation and time required for further dilatation were also significantly less in Group A than Group B. Thus, we conclude that vaginal misoprostol is more effective than sublingual misoprostol in cervical priming before minor gynaecological procedures. Clinical Trial Registration Number: www.ctri.nic.in; CTRI/2018/07/015080 IMPACT STATEMENTWhat is already known on this subject? Cervical priming has been shown to result in shorter operative time, easier mechanical dilatation, reduced incidence of complications and blood loss when used prior to surgical abortion and has been recommended as a standard practice in various national and international guidelines for safe abortion practices. Misoprostol has many advantages over other ripening agents like osmotic dilators, other prostaglandins and mifepristone. Misoprostol can be given through oral, sublingual, vaginal, buccal and rectal routes. Use of misoprostol has been found to improve cervical dilatation, reduce need of further dilatation and ease of dilatation without many complications when compared to placebo for cervical priming of non-pregnant cervix. Studies comparing vaginal and sublingual routes have shown no significant difference for cervical ripening in pregnant women.What the results of this study add? We found that vaginal misoprostol for cervical priming was more effective than sublingual misoprostol in reaching a higher baseline cervical dilatation, with reduced need and time required for further dilatation before minor gynaecological procedures, although the ease of dilatation was similar in both groups. This effect of vaginal misoprostol was more marked in premenopausal women.What the implications are of these findings for clinical practice and/or further research? The results of our study are at variance with other studies done on use of misoprostol via the vaginal or sublingual routes, and hence it is imperative that large multi-center studies be performed to bring about consensus on the topic.

Risk factors for mediolateral episiotomy at a tertiary hospital: a cross-sectional study

SUMMARY OBJECTIVE: The main aim of this study was to assess the associated factors for selective mediolateral episiotomy at a tertiary, academic hospital. METHODS: A retrospective cohort analysis between 2017 and 2019 was performed. The primary outcome was the prevalence of selective mediolateral episiotomy. Independent variables were maternal, intrapartum, and neonatal characteristics. A significance level of 5% was established, and univariate and multivariate analyses with logistic regression models were performed. RESULTS: From 2,761 vaginal deliveries eligible for inclusion during this period, the prevalence of selective mediolateral episiotomy was 18.7%. Univariate analysis has shown that non-white women were protective factors (OR=0.77 [0.63-0.96]; p=0.02) for episiotomy; primiparity (OR=2.61 [2.12-3.21]; p<0.01), number of vaginal examinations between 6-10 repetitions (OR=3.16 [2.48-4.01]; p<0.01) and 11-20 repetitions (OR=5.40 [3.69-7.90]; p<0.01), longer second stage duration (OR=1.01 [1.00-1.02]; p<0.01), and women with gestational age more than 37 weeks were risk factors. Multivariate analysis reported that second stage duration (AOR=1.01 [1.00-1.03]; p<0.01), primiparity (AOR=2.03 [1.34-3.06]; p<0.01), and number of vaginal examinations between 6-10 repetitions (AOR=2.36 [1.50-3.70]; p<0.01) and 11-20 repetitions (AOR=3.29 [1.74-6.20]; p<0.01) were remained as risk factors for selective mediolateral episiotomy. CONCLUSION: A higher number of vaginal examinations during labor (over six repetitions), longer duration of second stage labor, and primiparity were risk factors associated with selective mediolateral episiotomy.

A force-measuring device combined with ultrasound-based elastography for assessment of the uterine cervix.

INTRODUCTION: In this feasibility study, we hypothesize that the evaluation of cervical biomechanical strength can be improved if cervical length measurement is supplemented with quantitative elastography, which is a technique based on conventional ultrasound elastography combined with a force-measuring device. Our aims were to: (a) develop a force-measuring device; (b) introduce a cervical elastography index (CEI) and a cervical strength index (CSI; defined as cervical length × CEI); (c) evaluate how these indexes assess the cervical softening that takes place during normal pregnancy; and (d) how these indexes predict the cervical dilatation time from 4 to 10 cm. MATERIAL AND METHODS: An electronic force-measuring device was mounted on the handle of the transvaginal probe, allowing for force measurement when conducting elastography. The study group concerned with normal cervical softening included 44 unselected pregnant women. Outcomes were CEI and CSI at different gestational ages. The study group for labor induction included 26 singleton term pregnant women admitted for labor induction. Outcome was defined as cervical dilatation time from 4 to 10 cm. Elastography measured the changes in mean gray value (intensity) during manual compressions. Region of interest was set within the anterior cervical lip. RESULTS: We found that the mean of all variables regarding cervical softening decreased from early to late pregnancy: ie cervical length from 34 to 29 mm, CEI from 0.17 to 0.11 N, and CSI from 5.9 to 3.1 N mm. Moreover, the cervical dilatation time during labor induction was associated with CEI, although not statistically significantly (area under the ROC curve of 0.67), but not with the Bishop score, the cervical length, or the CSI. CONCLUSIONS: We propose that quantitative elastography based on changes in the intensity of the B-mode ultrasound recording, in combination with a force-measuring device on the handle of the vaginal probe, deserves further investigation as an approach for evaluation of cervical biomechanical strength.

Predictors of cerclage failure in singleton pregnancies with a history of preterm birth and a sonographic short cervix.

OBJECTIVE: To identify predictors of ultrasound-indicated cerclage failure in singleton pregnancies for preventing extremely preterm birth. METHODS: A retrospective cohort study included 96 singleton pregnancies with ultrasound-indicated McDonald cerclage in women with previous preterm birth (PTB) and cervical shortening. Descriptive statistics were calculated at baseline and logistic regression analyses were performed to identify the factors associated with cerclage failure. RESULTS: In all, 28 (29%) of the women had a preterm delivery at before 28 weeks. Multivariate analysis identified cervical dilatation, non-cephalic presentation, and platelet-lymphocyte ratio (PLR) as independent predictors of cerclage failure (odds ratio [OR] 3.12, 95% CI [confidence interval] 1.01-9.66; OR 5.81, 95% CI 1.04-32.53; OR 1.02, 95% CI 1.01-1.03, respectively). The efficacy of these predictors was evaluated using a receiver operating characteristics curve. The area under the curve was 0.87 (95% CI 0.78-0.96, P < 0.001) with a sensitivity of 78.6% and specificity of 88.2%. CONCLUSION: Our findings indicated that cervical dilatation, fetal presentation, and PLR were valuable predictors of cerclage failure in singleton pregnancies with a history of PTB and a sonographic short cervix. The results can be potentially used to assess the prognosis of patients after cerclage and alert clinicians to consider enhanced surveillance and administration of individuals at an increased risk.