Passive second stage of labor: Does a fourth hour increase maternal morbidity in nulliparous patients at term with epidural?

OBJECTIVES: Prolonging the passive second stage of labor could increase vaginal birth rate, but the data concerning maternal and fetal morbidity are contradictory. The French guidelines did not specify a maximum duration of the passive second stage. Our objective was to assess if allowing a 4th hour after full dilatation before pushing increased maternal morbidity, compared to 3 h after full dilatation. STUDY DESIGN: This single-center, retrospective, observational cohort study took place from January 1-December 31, 2020, in a tertiary maternity unit. All consecutive term nulliparous women who delivered under epidural anesthesia and without pathological fetal heart rate and reaching a second-stage passive phase of labor lasting at least 3 h were included. We compared 2 groups according to the duration of the passive second stage: "3-hour group" and "4-hour group". In the "3-hour group," featuring a second-stage passive phase of up to 3 h, pushing is initiated for favorable conditions, while a cesarean section is performed if conditions are deemed unfavorable. In the "4-hour group", obstetric conditions not justifying immediate pushing after three hours, and the obstetric team believed that an additional hour of expectant management could lead to a successful vaginal delivery. The principal endpoint was a composite criterion of maternal morbidity including obstetric anal sphincter injuries, postpartum hemorrhage, transfusion and intrauterine infection. RESULTS: We included 111 patients in the "4-hour group" and 349 in the "3-hour group". Composite maternal morbidity did not increase in the "4-hour group" compared to the "3-hour group" (21 (18.9 %) versus 61 (17.5 %); p = 0.73). Neonatal morbidity was similar between the two groups. In the "4-hour group, 91 (82 %) patients had vaginal deliveries", 62 (55,9 %) by spontaneous vaginal delivery and 29 (26,1 %) with instrumental assistance. CONCLUSION: For selected patients, waiting for 4 h at full dilation can be beneficial due to the high rate of vaginal delivery and low incidence of maternal and fetal complications.

The interrelation between microbial immunoglobulin coating, vaginal microbiota, ethnicity, and preterm birth.

BACKGROUND: Vaginal microbiota composition is associated with spontaneous preterm birth (sPTB), depending on ethnicity. Host-microbiota interactions are thought to play an important underlying role in this association between ethnicity, vaginal microbiota and sPTB. METHODS: In a prospective cohort of nulliparous pregnant women, we assessed vaginal microbiota composition, vaginal immunoglobulins (Igs), and local inflammatory markers. We performed a nested case-control study with 19 sPTB cases, matched based on ethnicity and midwifery practice to 19 term controls. RESULTS: Of the 294 included participants, 23 pregnancies ended in sPTB. We demonstrated that Lactobacillus iners-dominated microbiota, diverse microbiota, and ethnicity were all independently associated with sPTB. Microbial Ig coating was associated with both microbiota composition and ethnicity, but a direct association with sPTB was lacking. Microbial IgA and IgG coating were lowest in diverse microbiota, especially in women of any ethnic minority. When correcting for microbiota composition, increased microbial Ig coating correlated with increased inflammation. CONCLUSION: In these nulliparous pregnant women, vaginal microbiota composition is strongly associated with sPTB. Our results support that vaginal mucosal Igs might play a pivotal role in microbiota composition, microbiota-related inflammation, and vaginal community disparity within and between ethnicities. This study provides insight in host-microbe interaction, suggesting that vaginal mucosal Igs play an immunomodulatory role similar to that in the intestinal tract. Video Abstract.

Parous women perform less moderate to vigorous physical activity than their nulliparous peers: a population-based study in Denmark.

OBJECTIVES: The World Health Organization (WHO) highlights parous women as a key population for monitoring trends of physical activity (PA). We aimed to estimate the proportion of Danish women non-adhering to WHO PA guidelines in parous women compared with nulliparous women and to describe leisure-time PA intensity in each of these groups. STUDY DESIGN: Cross-sectional study. METHODS: This population-based study builds on a sample of 27,668 women aged 16-40 years from the Danish National Health Survey 2021. These data were linked with childbirth data from the Danish National Birth Registry. The primary outcome was self-reported weekly hours of moderate to vigorous leisure-time PA (MVPA) dichotomized into: (i) adhering to WHO guidelines for MVPA or (ii) not adhering to WHO guidelines for MVPA. Binomial regression analysis was used to calculate prevalence proportions (PP) and prevalence proportion ratios (PPR). RESULTS: Of the 27,668 women, a total of 20,022 were included; 9338 (46.6%) parous women and 10,684 (53.4%) nulliparous women. The PP of women non-adhering to WHO PA guidelines was 63.8% (95% CI 62.9-64.8) for parous and 51.3% (95% CI 50.4-52.3) for nulliparous women, corresponding to a PPR of 1.24 (95% CI 1.21; 1.27). CONCLUSIONS: The proportion of parous women who did not adhere to WHO PA guidelines for MVPA was 24% higher than that of nulliparous women. This highlights parous women as a subgroup of the adult population at increased risk of non-adherence to WHO PA guidelines. These findings call for future research to inform new strategies aiming to promote PA in parous women.

Development and validation of a clinical model to predict preconception risk of gestational diabetes mellitus in nulliparous women: A retrospective cohort study.

OBJECTIVE: To develop and validate a model to predict the preconception risk of gestational diabetes mellitus (GDM) in nulliparous women. METHODS: This was a retrospective cohort study. A total of 1565 women in early pregnancy who underwent preconception health examinations in the Women and Children's Hospital of Chongqing Medical University between January 2020 and June 2021 were invited to participate in a questionnaire survey. Logistic regression analysis was performed to determine the preconception risk factors for GDM. These factors were used to construct a model to predict GDM risk in nulliparous women. Then, the model was used to assess the preconception risk of GDM in 1060 nulliparous women. RESULTS: Independent preconception risk factors for GDM included the following: age 35 years or greater, diastolic blood pressure 80 mm Hg or greater, fasting plasma glucose 5.1 mmol/L or greater, body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) 24 or greater, weight gain 10 kg or greater in the year before pregnancy, age of menarche 15 years or greater, three or more previous pregnancies, daily staple food intake 300 g or greater, fondness for sweets, and family history of diabetes. BMI less than 18.5, daily physical activity duration 1 h or greater, and high-intensity physical activity were protective factors. These factors were used to construct a model to predict GDM risk in nulliparous women, and the incidence of GDM significantly increased as the risk score increased. The area under the curve of the prediction model was 0.82 (95% confidence interval 0.80-0.85). CONCLUSION: The preconception GDM risk prediction model demonstrated good predictive efficacy and can be used to identify populations at high risk of GDM before pregnancy, which provides the possibility for preconception intervention.

Higher risk of preterm twin delivery among shorter nulliparous women.

OBJECTIVE: To determine if maternal height in nulliparous women influences pregnancy results in twin pregnancies. MATERIAL AND METHODS: Retrospective cohort analysis evaluating twin pregnancies followed at Centro Hospitalar Universitário Lisboa Central, between 1995 and 2020. Of the 2900 pregnancies followed in that period, 886 nulliparous women with dichorionic twin pregnancies were selected. Two groups were considered: A - maternal height <163 cm (

Dinoprostone tablet versus continuous vaginal insert (Propess®) for elective induction in low-risk nulliparous women at term.

OBJECTIVE: To evaluate the efficacy and safety of dinoprostone tablet and continuous vaginal insert (Propess®) in low-risk nulliparous women at term with insufficient cervical ripening receiving elective induction. MATERIALS AND METHODS: A retrospective study was conducted between March 2020 and February 2022 and included 230 women who underwent elective induction with dinoprostone tablet or vaginal insert. The primary endpoint was failure of induction. Secondary endpoints included time to vaginal delivery, vaginal delivery rate, as well as maternal and neonatal complications and adverse outcomes. RESULTS: No statistically significant differences were found between the two groups regarding the main outcome measures; however, the high responders had a significant higher proportion of hyperstimulation and non-reassuring fetal status. The high responder in the Propess group was statistically significant younger (31.68 ± 4.73 vs. 33.82 ± 4.39, p = 0.027), while they had a significantly lower BMI at delivery time of the tablet group (24.49 ± 2.24 vs. 27.42 ± 4.32, p = 0.024). Factors associated with success of vaginal delivery within 24 h (p = 0.015, OR = 0.9, 95%CI = 0.82-0.98) and the Cesarean section (p < 0.001, OR = 1.17, 95%CI = 1.08-1.27) was BMI at delivery time. CONCLUSION: Slow-release vaginal insert and dinoprostone tablet had similar efficacy and safety for elective induction in low risk nulliparous women at term. Women with younger maternal age or lower BMI at delivery time may have a better response to dinoprostone and had a significantly higher proportion of hyperstimulation and non-reassuring fetal status.

A Retrospective Comparative Study of the Effect of Controlled-Release Dinoprostone Vaginal Delivery System (Propess®) and Mechanical Methods for Cervical Ripening in Nulliparous Women in Late-Term Pregnancy.

OBJECTIVE: The effects of the controlled-release dinoprostone vaginal delivery system (Propess®) and mechanical methods for cervical ripening in nulliparous women in late-term pregnancy were compared retrospectively. METHODS: This retrospective comparative study included 46 nulliparous pregnant women (24 in the Propess® group and 22 in the mechanical methods groups) with a low Bishop score (≤1) who needed labor induction at 41 weeks of gestation. The primary outcome was the success rate of cervical ripening (= Bishop score >6 or vaginal delivery) by the next day following the insertion of Propess® only or mechanical cervical dilation only. In the cases in which cervical ripening was unsuccessful, other methods were performed, and the success rate of cervical ripening the day after was compared as the secondary outcome. RESULTS: As the primary outcome, there was not a significant difference in the success rate of cervical ripening between the Propess® and mechanical methods groups (21 vs. 22%, p = 0.88). As for the secondary outcomes, there was not a significant difference in the total success rate of cervical ripening between the two groups (75 (5+13/24) vs. 73 (5+11/22)%, p = 0.86)). Of the unsuccessful cervical ripening cases as secondary outcomes, the Bishop score of all was ≤2 on the second day of hospitalization. CONCLUSION: The combined use of Propess® and mechanical methods was effective for cervical ripening in nulliparous women with a low Bishop score in late-term pregnancy, regardless of order.

The impact of epidural analgesia on delivery mode in Robson class 1 women: a retrospective cohort study.

BACKGROUND: The use of epidural analgesia represents the gold standard for pain management during labor, but the influence of the use of epidural analgesia on delivery mode is not fully understood. OBJECTIVE: This study aimed to analyze the impact of epidural analgesia on the delivery mode, namely, cesarean delivery, vaginal delivery, and operative vaginal delivery rates, in Robson class 1 women. STUDY DESIGN: A retrospective cohort study was conducted on all Robson class 1 women who delivered from January 1, 2019, to December 31, 2019, in the University Hospital of Modena. The primary outcome was the delivery mode (cesarean delivery, vaginal delivery, and operative vaginal delivery rates), and the secondary outcomes were maternal, anesthesiologic, and neonatal effects of epidural analgesia (duration of labor, duration of the second stage of labor, Apgar score, and neonatal intensive care unit admission). RESULTS: A total of 744 women were included in the final analysis, of which 198 (26.6%) underwent epidural analgesia on request and 546 (73.4%) did not. In women with and without epidural analgesia, the cesarean delivery rate was 8.1% vs 7%, the vaginal delivery rate was 79.3% vs 81.1%, and the operative vaginal delivery rate was 12.6% vs 11.9%, respectively. A significant increase in both the first stage of labor (66.3±38.5 vs 43.8±38.8 minutes; P<.0001) and total duration of labor (328.0±206.7 vs 201.7±168.3 minutes; P<.0001) was found in women receiving epidural analgesia. No change was recorded in the second stage of labor. A shorter duration of labor was observed (P<.0001) when epidural analgesia was started earlier (dilation: 2-4 cm vs >4 cm). No significant difference in Apgar score and neonatal intensive care unit admission was found. CONCLUSION: The use of epidural analgesia was not associated with an increased risk of cesarean delivery or operative vaginal delivery in Robson class 1 women. Further investigations are needed to evaluate its impact on the duration of labor, namely the duration of the first stage of labor, and on the possible advantages of starting epidural analgesia at an early stage.

Previous pregnancy loss and gestational cardiovascular health: A prospective cohort of nulliparous women.

Objectives: To estimate the association of previous pregnancy loss with subsequent cardiovascular health during gestation and to examine the role of high-sensitivity C reactive protein (hs-CRP) in the association. Methods: A total of 2,778 nulliparous pregnant women were recruited between March 2015 and November 2020 in Hefei city, China. Their cardiovascular health (CVH) including prepregnancy body mass index (BMI), blood pressure, total cholesterol, fasting plasma glucose, and smoke status were recorded at 24-28 weeks' gestation, as well as their reproductive history. Multivariate linear and logistic regression were performed to examine the association of pregnancy loss with cardiovascular health. And the role of hs-CRP between pregnancy loss and CVH was assessed by the mediation analysis. Results: Compared with women who have no pregnancy loss, women with a history of spontaneous or induced abortions had higher BMI (ß, 0.72, 95% CI, 0.50 to 0.94) and fasting plasma glucose (ß, 0.04, 95% CI, 0.01 to 0.07), and had lower total CVH scores after adjusting for confounders (ß, -0.09, 95% CI, -0.18 to -0.01). CVH scores were most significantly decreased among women with 3 or more induced abortions (ß, -0.26, 95% CI, -0.49, -0.02). The contribution of pregnancy loss to poorer gestational CVH mediated by increased hs-CRP levels was 23.17%. Conclusion: Previous pregnancy loss was associated with poorer cardiovascular health during gestation, which may be mediated by their gestational inflammatory status. Exposure to miscarriage alone was not a significant predictor of poorer CVH.

Is gestational age at term a risk factor for ongoing pregnancies in nulliparous women: A prospective cohort study.

BACKGROUND: The results of American observational studies and 1 large, randomized trial show that elective induction of labor among nulliparous women can reduce cesarean delivery rates and suggest that gestational age at delivery may be a risk factor for cesarean delivery in pregnancies managed expectantly. However, data on the risk of cesarean delivery at term in ongoing pregnancies are sparse, especially in high-income countries, and further information is needed to explore the external validity of these previous studies. OBJECTIVE: This study aimed to evaluate the risk of cesarean delivery for each gestational week of ongoing pregnancy in nulliparous women with a singleton fetus in the cephalic presentation at term in a French population. STUDY DESIGN: This retrospective study was conducted in a perinatal network of 10 maternity units from January 1, 2016, to December 31, 2017, and included all nulliparous women with a singleton fetus in the cephalic presentation who gave birth at term (≥37 0/7 weeks of gestation). From the start of term (37 completed weeks) and at the start of each subsequent week of completed gestation (each week + 0 days), ongoing pregnancy was defined as that of a woman who was still pregnant and who gave birth at any time after that date. For each week of gestation for these ongoing pregnancies, the cesarean delivery rate was defined as the number of cesarean deliveries performed in each ongoing pregnancy group divided by the number of women in this group. Separate models for each week of gestation, adjusted by maternal characteristics and hospital status, were used to compare the cesarean delivery risk between ongoing pregnancies and those delivered the preceding week. The same methods were applied to subgroups defined according to the mode of labor onset. Odds ratios were calculated after adjusting for maternal age and educational level, presence of severe preeclampsia, and maternity unit status. RESULTS: The study included 11,308 nulliparous women, 2544 (22.5%) of whom had a cesarean delivery. These rates remained stable for ongoing pregnancies at 37 0/7, 38 0/7, and 39 0/7 weeks of gestation; the rates were 22.5% (95% confidence interval, 21.7-23.2), 22.6% (95% confidence interval, 21.8-23.3); and 22.7% (95% confidence interval, 21.9-23.6), respectively. The risk of cesarean delivery started to increase in ongoing pregnancies at 40 0/7 weeks of gestation (24.3%; 95% confidence interval, 23.1-25.4) and especially at 41 0/7 weeks of gestation (30.7%; 95% confidence interval, 28.9-32.5). Similar trends were also shown for all modes of labor onset and in every maternity unit. In univariate and multivariate analyses, ongoing pregnancy at or beyond 40 0/7 weeks of gestation was associated with a higher risk of cesarean delivery than pregnancy delivered the previous week: 24.3% of ongoing pregnancies at 40 0/7 weeks of gestation vs 19.9% of deliveries between 39 0/7 weeks of gestation and 39 6/7 weeks of gestation. The odds ratios were 1.28 (95% confidence interval, 1.15-1.44) or 30.4% of ongoing pregnancies at 41 0/7 weeks of gestation vs 1.73 (95% confidence interval, 1.51-1.96) or 19.6% of deliveries between 40 0/7 weeks of gestation and 40 6/7 weeks of gestation. CONCLUSION: Cesarean delivery rates increased starting at 40 0/7 weeks of gestation in ongoing pregnancies regardless of the mode of labor onset.

Risk factors for spontaneous preterm birth among healthy nulliparous pregnant women in the Netherlands, a prospective cohort study.

Introduction: Spontaneous preterm birth (sPTB) is a major contributor to neonatal morbidity and mortality worldwide. The pathophysiology of sPTB is poorly understood, in particular among nulliparous women without apparent medical or obstetric risk factors. Therefore, we aimed to identify risk factors for sPTB in healthy nulliparous women. Material and Methods: We performed a prospective cohort study. Recruitment took place from February 2014 to December 2016 in 16 community midwifery centers in the Netherlands. Eligibility criteria were: ≥18 years, no previous pregnancy >16 weeks of gestation, healthy singleton pregnancy, and antenatal booking <24 weeks of gestation. At study inclusion, participants completed a questionnaire, including details on lifestyle, work, and medical history. Cervical length was measured by vaginal ultrasound at the second-trimester anomaly scan. Detailed information concerning pregnancy and birth was collected via antenatal charts. We calculated the adjusted odds ratio (aOR) and 95% confidence intervals (CI) for various risk factors with correction for socioeconomic status (SES) using logistic regression and Firth's correction. Results: We included 363 women of whom pregnancy outcomes were available in 349 (96.1%) participants. The cervical length measurement was available for 225 (62.0%) participants. sPTB occurred in 26 women (7.5%). SES was associated with sPTB (OR: 3.7, 95%  CI: 1.6-8.5) in univariate analysis. First or second trimester vaginal bleeding (aOR: 3.6, 95% CI: 1.4-9.0) and urinary tract infection during pregnancy (aOR: 4.9, 95% CI: 1.7-13.9) were associated with sPTB in multivariate analysis. Conclusions: This prospective cohort confirms established risk factors for sPTB in nulliparous women deemed at low risk of sPTB.

Association between one-to-one midwifery care in the active phase of labour and use of pain relief and birth outcomes: A cohort of nulliparous women.

OBJECTIVE: To investigate the association between one-to-one midwifery care and birth outcomes with pain relief as the primary outcome. Secondary outcomes include obstetric and neonatal outcomes, such as mode of birth and Apgar score. DESIGN: A cohort study of women originally included in a cluster randomised trial. SETTING AND PARTICIPANTS: The analysis is based on data from The Labour Progression Study (LaPS), a cluster randomised controlled trial (RCT) including 7,277 women, conducted in fourteen obstetric units in Norway, between 2014 and 2017. The participants were nulliparous with a singleton full-term foetus in a cephalic presentation and spontaneous onset of labour. In this cohort, 7,103 women with information about on one-to-one midwifery care were included. MEASUREMENTS AND FINDINGS: Logistic regression analysis show that nulliparous women receiving one-to-one midwifery care in the active phase of labour are less likely to have an epidural analgesia, adjusted OR of 0.81 (95% CI 0.72,0.91), less likely to be given nitrous oxide, adjusted OR of 0.77 (95% CI 0.69,0.85), and they more often received massages, adjusted OR of 1.76 (95% CI 1.47,2.11), compared with women not receiving one-to-one midwifery care. Descriptive analyses show that women receiving one-to-one midwifery care in the active phase of labour are less likely to have a caesarean section (5.8% vs. 7.2%) and they are less likely to have an operative vaginal birth (16.5% vs. 23.7%). No significant differences were observed between the groups in terms of low Apgar scores at five minutes. KEY CONCLUSIONS: We found that one-to-one midwifery care in the active phase of labour may be associated with birth outcomes, including decreased use of epidural analgesia and a decreased rate of caesarean sections and operative vaginal birth. IMPLICATIONS FOR PRACTICE: The results of this study could encourage midwives to be present during the active phase of labour to promote physiological birth.

Does aging affect the elastic properties of the bladder and the urethra in nulliparous women: An ultrasound shear-wave elastography study.

OBJECTIVE: To investigate how aging and menopausal status in absence of pregnancy and childbirth affect the elasticity of the bladder and urethra. STUDY DESIGN: A single-center prospective observational study including nulliparous 10 pre- and 12 postmenopausal women. Data collection included baseline characteristics, physical examination data, questionnaire scores, PDFI and the Pelvic Floor Impact Questionnaire, and pelvic floor sonographic measurements as well as elastography measurements. The shear wave elastography (SWE) of tissue was measured using Kilopascal (kPa). The elastography measurements were taken over the rhabdosphincter, the suburethra smooth muscle, and the trigonal areas. RESULTS: A total of 22 nulliparous subjects were enrolled in the study. The cohort's mean age was 43.5 years, the mean body mass index (BMI) was 26.8, and 86% were of Caucasian ethnicity. The postmenopausal group was older and with higher BMI (p < 0.001 and p = 0.05). They also had higher scores in all the questionnaires (p < 0.05 for all) and did not demonstrate prolapse in any compartments. The SWE results for the whole group were 35.2 kPa in the rhabdosphincter measuring point, 40.2 kPa in the sub-urethra point, and 20.6 kPa in the trigone point. Comparing the premenopause and postmenopause groups, we found lower measurements in the rhabdosphincter area and equivocal measurements for the suburethral zone. No statistically significant differences were found between the groups CONCLUSIONS: The elastic properties of the different bladder components and the urethra change with age and menopause. Using elastic properties of the tissues, we can further explore both stress urinary incontinence and overactive bladder.

Nulliparous women with an unfavourable cervix at 41 weeks: Which women go into spontaneous labor during the expectant period?

CONTEXT: After 41 weeks, the labor induction term varies according to countries and obstetrical teams. The French recommendations are not to exceed 41 weeks 6 days. However, there are no data on the percentage of nulliparous women with an unfavorable cervix at 41 weeks going into spontaneous labor within five or six days. OBJECTIVE: The objective was to establish the rate of spontaneous labor within five days amongst nulliparous women with an unfavorable cervix at 41 weeks, and to identify the maternal and obstetrical factors associated with this spontaneous labor. MATERIALS AND METHODS: Retrospective study in a University Hospital Maternity between January 1st and December 31st 2017. All nulliparous women with a cephalic fetal presentation and unfavorable cervix at 41 weeks (Bishop ≤ 3) were included. The maximum term for induced labor was set at 41 weeks 5 days. The population was divided into two groups: spontaneous labor and induced labor (induction between 41 weeks and 41 weeks 4 days for medical indications or maternal wish and induction at 41 weeks 5 days for full term). The maternal and obstetrical characteristics of the two groups at 41 weeks were compared as well as the maternal and neonatal outcomes. RESULTS: The rate of spontaneous labor among the 269 women included was 38.3% (n = 103/269). At 41 weeks, the presence of painful uterine contractions and a Bishop score of 3 were associated with spontaneous labor within five days (p < 0.01). The Bishop score criteria most associated with spontaneous labor were cervical dilation and fetal station. The cesarean delivery rate was 20.4% in the group of women with spontaneous labor versus 41.0% in the group of induced labor (p < 0.01). There were no differences between the two groups in terms of neonatal outcome. CONCLUSION: Among nulliparous women with an unfavorable cervix at 41 weeks, almost 40 % will have a spontaneous onset of labor within five days. The only factors found to be associated with this onset of labor are the presence of painful uterine contractions and a higher Bishop score at 41 weeks.

Nomogram based on the final antepartum ultrasound features before delivery for predicting failed spontaneous vaginal delivery in nulliparous women.

Background: Accurate identification of nulliparous women with failed spontaneous vaginal delivery (SVD) is crucial to minimize the hazards associated with obstetrical intervention (OI). While abnormal labor progression can be identified with intrapartum ultrasonography, labor-related complications may be unavoidable due to the limited time window left to the obstetrician. Antepartum ultrasound enables sufficient obstetric planning. However, there is typically a longer gap between ultrasound assessment and delivery that often lowers the prediction accuracy compared to intrapartum ultrasonography. Objective: In this study, antepartum ultrasound assessment was included to each fetal ultrasound examination after 36 weeks of gestation until the onset of labor. We aim to establish a nomogram to predict the likelihood of failed SVD in nulliparous women using the last antepartum ultrasound findings before labor beginning. Methods: Of the 2,143 nulliparous women recruited, 1,373 were included in a training cohort and 770 in a validation cohort, based on their delivery date. Maternal and perinatal characteristics, as well as perinatal ultrasound parameters were collected. In the training cohort, the screened correlates of SVD failure were used to develop a nomogram for determining whether a nulliparous woman would experience SVD failure. This model was validated in both training and validation cohorts. Results: SVD failure affected 217 nulliparous women (10.13%). In the training cohort, SVD failure was independently associated with BMI [odds ratio (OR) = 1.636], FHC (OR = 1.194), CL (OR = 1.398), and PCA (OR = 0.824) (all P < 0.05). They constituted a nomogram to estimate the individual risk of SVD failure. The model obtained clinical net benefits in both the training and validation cohorts and was validated to present strong discrimination and calibration. Conclusion: The developed nomogram based on the last antepartum ultrasound findings may be helpful in avoiding OI and its related complications by assessing the likelihood of a failed SVD in nulliparous women.

Determining the Optimal Time Interval between Vaginal Dinoprostone Administration and Diagnostic Office Hysteroscopy in Nulliparous Women: A Randomized, Double-blind Trial.

STUDY OBJECTIVE: To determine the optimal timing of vaginal dinoprostone administration before office hysteroscopy (OH) in nulliparous women. DESIGN: Randomized, double-blind trial. SETTING: Tertiary referral hospital. PATIENTS: A total of 180 nulliparous women undergoing diagnostic OH. INTERVENTIONS: We randomly allocated the women to long-interval or short-interval dinoprostone groups: three mg dinoprostone was administered vaginally 12 hours before OH in the long-interval group and 3 hours before OH in the short-interval group. MEASUREMENTS AND MAIN RESULTS: The primary outcome was pain during OH measured using a 100-mm visual analog scale (0 = no pain; 100 = worst pain imaginable). The secondary outcomes were ease of hysteroscope passage, patient satisfaction score, and drug-related adverse effects. The patients in the long-interval dinoprostone group had lower pain scores during OH (p <.001). Contrarily, pain scores 30 minutes after the procedure were similar in both groups (p = .1). The patient satisfaction score was higher and clinicians found hysteroscope passage through the cervical canal easier and quicker in the long-interval dinoprostone group than in the short-interval group (p <.001, p = .003, and p <.001, respectively). Side effects were comparable in both study groups. CONCLUSION: Vaginal dinoprostone administered 12 hours before OH was more effective than that administered 3 hours before OH in reducing pain during OH in nulliparous women, with easier hysteroscope insertion, shorter procedure duration, and higher patient satisfaction score.

Low-dose acetylsalicylic acid does not modify maternal vascular reactivity in nulliparas.

OBJECTIVE: To assess if the low-dose acetylsalicylic acid (ASA) would be capable of modifying endothelial function throughout pregnancy in nulliparous patients. METHODS: A double-blind, randomized clinical trial with 277 were included. A total of 139 were orally administered 100 mg/day of ASA, and 138 received placebo. Endothelial function was assessed by flow-mediated dilation (FMD) in the brachial artery before the start of medication (11-14 weeks) and 20-24 and 30-34 weeks of gestation. The intervention was maintained until 34 weeks. The Mann-Whitney U test was used to compare the placebo and ASA groups. The comparison of FMD during pregnancy was performed using the Friedman test. RESULTS: The groups (ASA and placebo) were similar regarding to age, weight, height, and body mass index (BMI) (p > .005). The comparison of values of FMD (%) between placebo vs. ASA at 11 and 14 weeks (8.9 vs. 9.7%, p: .253), 20 and 24 weeks (8.8 vs. 10.7%, p: .152), and 30 and 34 weeks (10.7 vs. 9.8%, p: .314) did not show significant changes throughout pregnancy. We observed a significant prevalence of PE in the placebo regarding to ASA group [14 (10.2%) vs. 8 (5.8%), p: .171]. CONCLUSION: Acetylsalicylic acid did not modify the endothelial function assessed by FMD of the brachial artery during pregnancy in nulliparous women.

Extending the second stage of labor in nulliparous women with epidural analgesia: a cost-effectiveness analysis.

The objective of this study was to evaluate maternal outcomes with an extended second stage of labor and determine if an extended second stage is cost effective. This theoretical model evaluated expectant management to 4 h compared to delivery at 3 h in the setting of a prolonged second stage of labor in nulliparous women with epidural analgesia. In our theoretical cohort of 165,000 women, we found that an extended second stage resulted in 53,268 more spontaneous vaginal deliveries, 14,163 fewer operative vaginal deliveries, and 39,105 fewer cesarean deliveries. This approach also resulted in 1 fewer instance of maternal death. An extended second stage, however, led to 14,025 more cases of chorioamnionitis, 1699 more episodes of postpartum hemorrhage requiring transfusion, and 119 more severe perineal lacerations, suggesting that while an extended second stage of labor results in overall improved maternal outcomes, there are tradeoffs. Expectant management to 4 h was the dominant strategy in the model, as it saved over $114 million US dollars and resulted in 4000 additional QALYs over our theoretical cohort. Sensitivity analysis indicated that expectant management until 4 h was cost-effective as long as the probability of cesarean delivery at 4 h was below 41.8%, and was the dominant strategy below 38.2% (baseline input: 19.5%). Multivariable sensitivity analysis demonstrated that the model was robust over a wide range of assumptions. Expectant management of the second stage of labor until 4 h is a cost-effective strategy to prevent primary cesarean deliveries, decrease costs, and improve some maternal outcomes, despite tradeoffs.

Duration of labor induction in nulliparous women with hypertensive disorders of pregnancy and maternal and neonatal outcomes.

OBJECTIVE: The objective of this study was to quantify the association between duration of labor induction in nulliparous women with hypertensive disorders of pregnancy and maternal and neonatal morbidity. METHODS: This was a secondary analysis of a multicenter cohort study of 228,438 deliveries in 19 U.S. hospitals. The analysis included nulliparous women ≥18 years old with singleton gestation diagnosed with hypertensive disorders of pregnancy and undergoing induction of labor for that indication. Duration of labor induction, defined as time from admission to delivery, was examined by 4 h intervals from <12 h to ≥24 h in relation to maternal and neonatal composite outcomes. Maternal composite outcome included operative vaginal delivery, chorioamnionitis, blood transfusion, intensive care unit admission, placental abruption, 3rd or 4th degree perineal laceration, endometritis, postpartum hemorrhage, or venous thromboembolism. Neonatal composite outcome included neonatal intensive care unit (NICU) admission, respiratory distress syndrome, 5-minute Apgar score ≤7, seizure, infection, intrapartum meconium aspiration, intracranial hemorrhage, shoulder dystocia, and neonatal death. The trends in proportions of outcomes that occurred at different intervals were examined by Cochran-Armitage trend test. Relative risks were calculated with <12 h as the reference category and potential confounders adjusted by log-binomial or Poisson regression. Possible correlations within centers were taken into account using generalized estimating equations. RESULTS: A total of 3,990 women met inclusion criteria. The median labor duration was 19.8 h (interquartile range 12.9 h-27.9h), with 849 (21.3%) lasting <12 h and 1,426 (35.7%) >24 h. The frequency of composite maternal outcome was not associated with labor duration; however, the rates of chorioamnionitis (p < .001) and postpartum hemorrhage (p < .001) increased as labor duration increased. The frequency of composite neonatal outcome was greater with increasing labor duration (p < .001). After multivariable adjustment, duration of labor induction was associated with increased risks of maternal composite outcome after 24 h (aRR 1.39, 95% CI 1.20-1.62) and neonatal composite outcome after 24 h (aRR 1.32, 95% CI 1.11-1.56). CONCLUSIONS: In nulliparous women with hypertensive disorders of pregnancy, duration of labor induction was associated with increased risks for maternal and neonatal morbidity after 24 h.

An Exploratory Study of the Role of Birth Stories in Shaping Expectations for Childbirth among Nulliparous Black Women: Everybody is Different (but I'm Scared).

INTRODUCTION: Birth stories area source of information and vicarious experience for nulliparous women. Although health disparities research suggests that the childbirth experiences of Black women differ from those of white women, little research has been conducted about the nature of birth stories shared and their subsequent effect on expectations. METHODS: Pregnant nulliparous Black women were recruited from a women's health practice in the southeastern United States. Participants completed in-depth semistructured interviews about the birth stories they had previously heard and their thoughts about their own upcoming birth experiences. Interviews were audio-recorded and transcribed. Researchers applied the traditions of thematic analysis to identify emergent themes. RESULTS: Fourteen women participated in the study (mean age, 28 years). Women reported hearing birth stories from a variety of sources, most commonly mothers and friends. Stories heard generally included details about process, outcome, and social context that often acknowledged past racist hospital policies and experienced discrimination. Women were an active audience to birth stories and sought out stories from some sources, avoided stories from other sources, and used rhetorical strategies to mark stories as either more relatable or less relatable. Women's reported fears, expectations, and choices they planned to make reflected features of the birth stories that they had heard. DISCUSSION: Nulliparous women accessed and evaluated birth stories from others and applied knowledge received from those stories to their own experiences. Birth stories played an important role in shaping women's hopes, fears, expectations, and childbirth-related choices. Health care providers should inquire about the birth stories shared with their patients to gain a sense of their childbirth desires and expectations. An appreciation for the importance of knowledge learned from birth stories has the potential to reduce maternal health disparities by improving patient-provider communication through a shared understanding of the patient's goals and fears.