Transcervical uterine flushing and embryo transfer in sheep: Morphophysiological basis for approaches currently used, major challenges, potential improvements, and new directions (alas, including some old ideas).

At present, the success of non-surgical embryo recovery (NSER) and transfer (NSET) hinges upon the cervical passage of catheters, but penetration of the uterine cervix in ewes is problematic due to its anatomical structure (i.e., long and narrow cervical lumen with misaligned folds and rings). It is a major obstacle limiting the widespread application of NSER and NSET in sheep. While initial attempts to traverse the uterine cervix focused on adapting or re-designing insemination catheters, more recent studies demonstrated that cervical relaxation protocols were instrumental for transcervical penetration in the ewe. An application of such protocols more than tripled cervical penetration rates (currently at 90-95 %) in sheep of different breeds (e.g., Dorper, Lacaune, Santa Inês, crossbred, and indigenous Brazilian breeds) and ages/parity. There is now sufficient evidence to suggest that even repeatedly performed cervical passages do not adversely affect overall health and reproductive function of ewes. Despite these improvements, appropriate selection of donors and recipients remains one of the most important requirements for maintaining high success rates of NSER and NSET, respectively. Non-surgical ovine embryo recovery has gradually become a commercially viable method as even though the procedure still cannot be performed by untrained individuals, it is inexpensive, yields satisfactory results, and complies with current public expectations of animal welfare standards. This article reviews critical morphophysiological aspects of transcervical embryo flushing and transfer, and the prospect of both techniques to replace surgical methods for multiple ovulation and embryo transfer (MOET) programs in sheep. We have also discussed some potential pharmacological and technical developments in the field of non-invasive embryo recovery and deposition.

Effects of epidural analgesia at 1 cm cervical dilatation on multiparae: A retrospective cohort study using propensity score-matching.

OBJECTIVE: The aim of the present study was to investigate the effects of epidural analgesia (EA) administered at cervical dilatation of 1 cm on multiparae who underwent vaginal delivery. METHODS: This propensity score-matched retrospective cohort research was conducted between 2021 and 2022. All the singleton multiparae who had previous successful vaginal deliveries and epidural analgesia during this delivery were screened for eligibility. The primary outcome was the effect of EA on the duration of labor. The main secondary outcomes included the incidence of cesarean delivery and umbilical arterial pH. RESULTS: This study incorporated 686 multiparae who were divided into two cohorts: EA 1 (cervical dilatation = 1 cm, n = 166) and EA 2 (cervical dilatation >1 cm, n = 520). In the propensity score-matched cohort (including 164 women in each group), there were no statistically significant differences in the incidence of cesarean delivery (4 [2.4%] vs 4 [2.4%], P = 1.000), umbilical arterial pH (7.28 ± 0.06 vs 7.28 ± 0.07, P = 0.550) and other secondary outcomes between the two groups. Based on a comparative assessment of the women who delivered vaginally to the Kaplan-Meier curves and propensity score-matching (including 160 women in each group), there was no statistical significance in the duration of the first, second and third stages of labor (log rank P, P = 0.811; P = 0.413; P = 0.773, respectively). CONCLUSION: Initiation of epidural analgesia at cervical dilatation of 1 cm in multiparae did not cause adverse effects with regard to the duration of labor, increased cesarean deliveries, and bad neonatal outcomes.

Pregnancy state before the onset of labor: a holistic mechanical perspective.

Successful pregnancy highly depends on the complex interaction between the uterine body, cervix, and fetal membrane. This interaction is synchronized, usually following a specific sequence in normal vaginal deliveries: (1) cervical ripening, (2) uterine contractions, and (3) rupture of fetal membrane. The complex interaction between the cervix, fetal membrane, and uterine contractions before the onset of labor is investigated using a complete third-trimester gravid model of the uterus, cervix, fetal membrane, and abdomen. Through a series of numerical simulations, we investigate the mechanical impact of (i) initial cervical shape, (ii) cervical stiffness, (iii) cervical contractions, and (iv) intrauterine pressure. The findings of this work reveal several key observations: (i) maximum principal stress values in the cervix decrease in more dilated, shorter, and softer cervices; (ii) reduced cervical stiffness produces increased cervical dilation, larger cervical opening, and decreased cervical length; (iii) the initial cervical shape impacts final cervical dimensions; (iv) cervical contractions increase the maximum principal stress values and change the stress distributions; (v) cervical contractions potentiate cervical shortening and dilation; (vi) larger intrauterine pressure (IUP) causes considerably larger stress values and cervical opening, larger dilation, and smaller cervical length; and (vii) the biaxial strength of the fetal membrane is only surpassed in the cases of the (1) shortest and most dilated initial cervical geometry and (2) larger IUP.

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 presence of estradiol benzoate in the cervical relaxation treatment for non-surgical embryo collection does not impair embryonic morphological quality, cryosurvival, and gene expression profile.

Non-surgical embryo recovery (NSER) is usually preceded by a cervical relaxation in ovine donors, based on estradiol benzoate (EB), prostaglandin (PGF), and oxytocin (OT). However, it is hypothesized that, due to poorly understood mechanisms, EB can result in embryotoxic actions. To evaluate this, 20 min before NSER superovulated sheep were induced to cervical relaxation with 0.0 (G0.0), 0.5 (G0.5), or 1.0 mg (G1.0) of EB associated with 37.5 µg of PGF 16 h before NSER and 50 IU of OT. In doing so, the efficiency and duration of the NSER procedure showed no compromise (P > 0.05). Additionally, the presence of EB did not affect (P > 0.05) the embryo's morphological quality, the development dynamics, or the abundance of transcripts associated with embryonic quality (OCT4 and NANOG), cellular stress (HSP90 and PRDX1), and apoptosis (BCL2 and BAX). A similar result (P > 0.05) was also observed when comparing embryonic cryosurvival at 24 (52.0, 52.0, and 54.0) and 48 h (60.0, 54.0, and 58.0) of in vitro culture (G0.0, G0.5, and G1.0, respectively). Thus, we can conclude that EB use does not compromise embryonic quality and cryoresistance.

New labor curves of dilation and station to improve the accuracy of predicting labor progress.

BACKGROUND: The diagnosis of failure to progress, the most common indication for intrapartum cesarean delivery, is based on the assessment of cervical dilation and station over time. Labor curves serve as references for expected changes in dilation and fetal descent. The labor curves of Friedman, Zhang et al, and others are based on time alone and derived from mothers with spontaneous labor onset. However, labor induction is now common, and clinicians also consider other factors when assessing labor progress. Labor curves that consider the use of labor induction and other factors that influence labor progress have the potential to be more accurate and closer to clinical decision-making. OBJECTIVE: This study aimed to compare the prediction errors of labor curves based on a single factor (time) or multiple clinically relevant factors using two modeling methods: mixed-effects regression, a standard statistical method, and Gaussian processes, a machine learning method. STUDY DESIGN: This was a longitudinal cohort study of changes in dilation and station based on data from 8022 births in nulliparous women with a live, singleton, vertex-presenting fetus ≥35 weeks of gestation with a vaginal delivery. New labor curves of dilation and station were generated with 10-fold cross-validation. External validation was performed using a geographically independent group. Model variables included time from the first examination in the 20 hours before delivery; dilation, effacement, and station recorded at the previous examination; cumulative contraction counts; and use of epidural anesthesia and labor induction. To assess model accuracy, differences between each model's predicted value and its corresponding observed value were calculated. These prediction errors were summarized using mean absolute error and root mean squared error statistics. RESULTS: Dilation curves based on multiple parameters were more accurate than those derived from time alone. The mean absolute error of the multifactor methods was better (lower) than those of the single-factor methods (0.826 cm [95% confidence interval, 0.820-0.832] for the multifactor machine learning and 0.893 cm [95% confidence interval, 0.885-0.901] for the multifactor mixed-effects method and 2.122 cm [95% confidence interval, 2.108-2.136] for the single-factor methods; P<.0001 for both comparisons). The root mean squared errors of the multifactor methods were also better (lower) than those of the single-factor methods (1.126 cm [95% confidence interval, 1.118-1.133] for the machine learning [P<.0001] and 1.172 cm [95% confidence interval, 1.164-1.181] for the mixed-effects methods and 2.504 cm [95% confidence interval, 2.487-2.521] for the single-factor [P<.0001 for both comparisons]). The multifactor machine learning dilation models showed small but statistically significant improvements in accuracy compared to the mixed-effects regression models (P<.0001). The multifactor machine learning method produced a curve of descent with a mean absolute error of 0.512 cm (95% confidence interval, 0.509-0.515) and a root mean squared error of 0.660 cm (95% confidence interval, 0.655-0.666). External validation using independent data produced similar findings. CONCLUSION: Cervical dilation models based on multiple clinically relevant parameters showed improved (lower) prediction errors compared to models based on time alone. The mean prediction errors were reduced by more than 50%. A more accurate assessment of departure from expected dilation and station may help clinicians optimize intrapartum management.

Comparison of two emergency cervical cerclage techniques in twin pregnancies: A retrospective cohort study matched with cervical dilation.

OBJECTIVES: This retrospective cohort study aimed to assess the efficacy of emergency cervical cerclage (ECC) performed with the combined McDonald-Shirodkar technique in twin pregnancies between 18 and 26 weeks of pregnancy with painless cervical dilation 1 to 6 cm. METHODS: A retrospective cohort study matched with the degree of cervical dilation was conducted. The study group (case group) included women with twin pregnancies undergoing combined McDonald-Shirodkar approach with cervical dilation ≥1 cm between 18 to 26 weeks of gestation at four institutions, from December 2015 to December 2022. To minimize confounding factors, we elucidated the causality structure using a directed acyclic graph and performed 1:1 case-control matching. A control group underwent the McDonald approach. The primary outcome was gestational age (GA) at delivery. The secondary outcomes were pregnancy latency; the rates of spontaneous preterm birth at <28, <30, <32, and <34 weeks; and neonatal outcomes. Additional subanalysis was performed by dividing the patients into two subgroups of women with cervical dilation ≥3 cm and <3 cm. RESULTS: A total of 84 twin pregnancies were managed with either the combined McDonald-Shirodkar approach (case group: n = 42) or the McDonald approach (control group: n = 42). Demographic characteristics were not significantly different in the two groups (P > 0.05). After adjusting for confounders that were represented by a directed acyclic graph, median GA at delivery was significantly higher (30.5 vs 27 weeks; Bate: 3.40 [95% confidence interval (CI), 2.13-4.67], P < 0.001) and median pregnancy latency was significantly longer (56 vs 28 days; Bate: 24.04 [95% CI, 13.31-34.78], P < 0.001) in the case group compared with the control group. Rates of spontaneous preterm birth at <28, <30, <32, and <34 weeks were significantly lower in the case group than in the control group. For neonatal outcomes, there was higher birth weight (1543.75 vs 980 g; Bate: 420.08 [95% CI, 192.18-647.98], P < 0.001) and significantly lower overall perinatal mortality (7.1% vs 31%; adjusted odds ratio, 0.16 [95% CI, 0.04-0.70], P = 0.014) in the case group compared with the control group. When cervical dilation was ≥3 cm, the combined McDonald-Shirodkar procedure can significantly reduce perinatal mortality (8.3% vs 46.7%; adjusted odds ratio, 0.09 [95% CI, 0.01-0.77], P = 0.028), significantly decrease the risk of delivery at <28 and <30 weeks, and prolong GA at delivery and pregnancy latency compared with the McDonald procedure. CONCLUSIONS: ECC performed with the combined McDonald-Shirodkar procedure in women with twin pregnancies who have cervical dilation 1 to 6 cm in midtrimester pregnancy may reduce the rate of spontaneous preterm birth and improve perinatal and neonatal outcomes compared with the McDonald procedure, especially for twin pregnancies in women with cervical dilation of 3 to 6 cm and prolapsed membranes.

The use of cervical cerclage in asymptomatic twin pregnancies with cervical shortening or dilation: a twelve-year retrospective cohort study.

BACKGROUND: To identify the effect and optimal time of cervical cerclage in asymptomatic twin pregnancies with cervical shortening or dilation. METHODS: This observational retrospective study enrolled all women with asymptomatic twin pregnancies who were diagnosed with asymptomatic cervical shortening or dilation at the Second Affiliated Hospital of Wenzhou Medical University between 2010 and 2022. Women included were allocated into the cerclage group (n = 36) and the no cerclage group (n = 22). The cerclage group was further divided into the cerclage group (< 24 weeks group) and the cerclage group (24-28 weeks group) according to the time of cerclage. The no cerclage group was further divided into no cerclage group (< 24 weeks group) and no cerclage group (24-28 weeks group) according to the time of ultrasound-indicated or physical exam indicated cerclage. The rates of PTB < 24, 28, 32 and 34 weeks of gestation, maternal and neonatal outcomes were compared among the groups. RESULTS: The gestational age (GA) at delivery was higher (P = 0.005) and the interval time between the presentation of the indicated cerclage and delivery was longer in the cerclage group (P < 0.001). The rates of PTB before 28, 32, and 34 weeks of gestation, caesarean section and stillbirth were lower in the cerclage group (P < 0.05). The birthweight of the twins was higher in the cerclage group (P = 0.012). Admissions to the NICU were more frequent in pregnancies with no cerclage (P = 0.008). Subgroup analysis showed that the interval time between the presentation and delivery was longer in the cerclage group (< 24 weeks) (P < 0.001). The GA at delivery and the birthweight of the twins were significantly higher in the cerclage group (< 24 weeks) (P < 0.001). No differences were found in the GA at presentation, the GA at delivery, the interval time between the presentation to delivery and birthweight between the cerclage group (24-28 weeks group) and the control group (24-28 weeks group) (P > 0.05). CONCLUSIONS: Cerclage appears to prolong the GA at delivery and the interval time between the presentation to delivery, and may reduce the incidence of PTB before 28, 32 and 34 weeks of gestation and adverse perinatal outcomes in asymptomatic twin pregnancies with cervical shortening or dilation. Cerclage before 24 weeks of gestation showed longer GA at delivery, longer interval time between the presentation to delivery and higher birthweight of the twins. The GA at presentation, the GA at delivery, the interval time between the presentation to delivery and birthweight in women with cerclage at 24-28 weeks were similar to those in women without cerclage at 24-28 weeks.

Review: Non-surgical artificial insemination and embryo recovery as safe tools for genetic preservation in small ruminants.

Artificial insemination (AI) and in vivo embryo production (or multiple ovulation and embryo transfer, MOET) programs are both instrumental in accelerating the propagation of genetically and economically superior goats and sheep. The aim of this review was to present the current gestalt of non-surgical AI and embryo recovery (NSER) procedures in small ruminants. Small body size, precluding rectal palpation, and highly limited penetrability of the uterine cervix in ewes are the major reasons for the scarce use of non-surgical assisted reproduction techniques in this species. As a result, AI and embryo recovery techniques in sheep mainly involve laparoscopy or laparotomy (LAP). In does, however, the Embrapa method of AI allows for successful intrauterine deposition of semen, resulting in pregnancy rates from 50 to 80% under field conditions (>3 000 goats inseminated) when frozen-thawed semen is used. After the administration of prostaglandin F2α (PGF2α), non-surgical (transcervical) embryo recovery is also feasible in goats, with the cervical penetration rate approaching 100%. There is a paucity of information on the efficacy of non-surgical AI using frozen semen in sheep, but the results are satisfactory with fresh, cooled, or chilled ram semen. An application of the NSER technique in ewes has greatly improved over the last decade, and cervical penetration rates of ∼90% can be achieved when a hormonal cervical dilation protocol using PGF2α, oxytocin, and/or estradiol ester (e.g., estradiol benzoate) is applied. In some genotypes of sheep, sufficient cervical dilation can be induced without estradiol ester included in the protocol. Several studies indicated that recovery of transferable quality ovine embryos using NSER is comparable to that employing a ventral midline laparotomy, and NSER is evidently a method of choice when animal welfare is concerned. Considering both the number of retrievable embryos and animal well-being, the NSER is a viable alternative for surgical procedures. With further developments, it has the makings of a primary, if not exclusive, embryo recovery technique in small ruminants worldwide.

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.

Monitoring uterine contractions during labor: current challenges and future directions.

Organ-level models are used to describe how cellular and tissue-level contractions coalesce into clinically observable uterine contractions. More importantly, these models provide a framework for evaluating the many different contraction patterns observed in laboring patients, ideally offering insight into the pitfalls of currently available recording modalities and suggesting new directions for improving recording and interpretation of uterine contractions. Early models proposed wave-like propagation of bioelectrical activity as the sole mechanism for recruiting the myometrium to participate in the contraction and increase contraction strength. However, as these models were tested, the results consistently revealed that sequentially propagating waves do not travel long distances and do not encompass the gravid uterus. To resolve this discrepancy, a model using 2 mechanisms, or a "dual model," for organ-level signaling has been proposed. In the dual model, the myometrium is recruited by action potentials that propagate wave-like as far as 10 cm. At longer distances, the myometrium is recruited by a mechanotransduction mechanism that is triggered by rising intrauterine pressure. In this review, we present the influential models of uterine function, highlighting their main features and inconsistencies, and detail the role of intrauterine pressure in signaling and cervical dilation. Clinical correlations demonstrate the application of organ-level models. The potential to improve the recording and clinical interpretation of uterine contractions when evaluating labor is discussed, with emphasis on uterine electromyography. Finally, 7 questions are posed to help guide future investigations on organ-level signaling mechanisms.

Effects of different timing selections of labor analgesia for primiparae on parturition and neonates.

OBJECTIVE: To explore the effects of labor analgesia for primiparae with different stages of cervical dilation on parturition and neonates. MATERIALS AND METHODS: In the past three years, 530 cases of primiparae who had delivered in the Second People's Hospital of Hefei and were eligible for a vaginal trial of parturition were enrolled as the research subjects. Of these, 360 puerperae had labor analgesia, and the remaining 170 were taken as the control group. Those given labor analgesia were divided into three groups based on the different stages of cervical dilation at that time. There were 160 cases in Group I (cervical dilation <3 cm), 100 cases in Group II (cervical dilation of 3-4 cm), and 100 cases in Group III (cervical dilation of 4-6 cm). The labor and neonatal outcomes were compared among the four groups. RESULTS: The first, second, and total stages of labor in the three groups receiving labor analgesia were all longer than in the control group, and the differences were statistically significant (p < 0.05 in all). Group I had the longest duration of each stage and the total stage of labor. The differences in labor stages and the total stage of labor were not statistically significant between Group II and Group III (P > 0.05). In the three groups with labor analgesia, the usage rate of oxytocin was higher than in the control group, and the differences were statistically significant (P < 0.05). The differences in the incidence of postpartum hemorrhage, the incidence of postpartum urine retention, and the episiotomy rate were not statistically significant among the four groups (P > 0.05). The differences in the neonatal Apgar score were not statistically significant among the four groups (P > 0.05). CONCLUSION: Labor analgesia might prolong the stages of labor but does not affect the neonatal outcomes. It would be optimal to conduct labor analgesia when cervical dilation reaches 3-4 cm.

Efficacy of emergency cervical cerclage in twin pregnancies and factors affecting the clinical effects of emergency cerclage.

OBJECTIVES: To estimate clinical effects of emergency cervical cerclage in twin pregnancies with cervical dilation ≥1.0 cm in mid-trimester of gestation and to identify risk factors after cerclage. METHODS: This retrospective cohort study included 99 twin pregnancies with cervical dilation ≥1cm in the mid-trimester of gestation at three institutions, from December 2015 through December 2021. The cases were treated with emergency cervical cerclage (52 cases) or expectant management (47 cases). Compare the pregnancy and neonatal outcomes of the two groups. Multiple logistic regression analysis was used to determine the independent risk factors associated with cerclage. RESULTS: Cerclage placement was associated with significantly longer gestation age and prolongation of the gestational latency (p < .05). In the cases, compared to expectant treatments, spontaneous preterm birth (sPTB) at <26, <28, <30, <32 weeks was significantly less frequent (p < .05). Pre-operation WBC > 11.55 × 109/L, CRP > 10.1 and cervical dilation >3.5 cm were found to be independent risk factors for delivery 28 weeks after cerclage. CONCLUSIONS: Cervical cerclage in twin pregnancies with cervical dilation ≥1.0 cm in mid-trimester of gestation may prolong pregnancy and gestation age, and improve pregnancy and neonatal outcomes compared with expectant management. The strongest predictor of sPTB before 28 weeks after ECC were pre-operation WBC >11.55 × 109/L, CRP > 10.1 and cervical dilation >3.5 cm.

Effects of epidural analgesia at 1 cm cervical dilatation on labor interventions in full-term primigravida: A retrospective cohort study.

OBJECTIVE: This study aimed to investigate the effects of epidural analgesia administered as early as cervical dilatation of 1 cm on labor interventions and maternal and neonatal outcomes. METHODS: This retrospective research recruited 1007 full-term primigravidas, who were distributed to two separate cohorts for eligibility: epidural analgesia 1 (cervical dilatation = 1 cm) and epidural analgesia 2 (cervical dilatation >1 cm). Labor interventions (artificial rupture of membranes and oxytocin administration) and duration of labor were the primary outcomes. RESULTS: The effect of initiation timing of epidural analgesia on artificial membrane rupture was not statistically significant (adjusted odds ratio [OR]: 0.85 [0.58-1.24], p > 0.05). Less oxytocin was used in the epidural analgesia 2 group compared with the epidural analgesia 1 group (the adjusted OR: 0.68 [0.49-0.95], p < 0.05). There were no significant differences in the median time to latent phase of labor, active phase of labor, second, and third stages of labor (p > 0.05). There were no significant differences in maternal and neonatal outcomes between the epidural analgesia 1 group and the epidural analgesia 2 group. CONCLUSION: Epidural analgesia could be administered at cervical dilatation = 1 cm.

Cervical Cerclage to Prevent Intrauterine Balloon Prolapse.

Intrauterine balloon prolapse sometimes occurs, and the intrauterine balloon must be reinserted. Furthermore, intrauterine balloon tamponade (IBT) failure can necessitate additional invasive procedures. We report a case of cervical cerclage with IBT for placenta previa with a cervical dilation. In our case, emergency cesarean section was performed at 35 + 4 weeks of gestation because of persistent hemorrhage. During the operation, we performed IBT to prevent further postpartum hemorrhage. However, immediately after the operation, uterine cervical dilatation was 6 cm, which resulted in cervical dilation and prolapse of the intrauterine balloon. Therefore, we performed cervical cerclage using absorbable sutures with IBT and blood transfusion. We speculated that the intrauterine balloon might have induced cervical canal ripening during the operation. Our case suggested that cervical cerclage with IBT is a useful method to prevent intrauterine balloon prolapse in cases with cervical dilation.

Cost-effectiveness of induction of labor at 39 weeks vs expectant management by cervical examination.

BACKGROUND: Previous analyses have demonstrated the cost effectiveness of elective induction of labor at 39 weeks of gestation for healthy nulliparous people. However, elective induction of labor is resource intensive, and optimal resource allocation requires a thorough understanding of which subgroups of patients will benefit most. OBJECTIVE: This study aimed to determine whether induction of labor at 39 weeks of gestation is more cost-effective in patients with favorable or unfavorable cervical examinations. STUDY DESIGN: We constructed 2 decision analysis models using TreeAge software: one modeling induction of labor at 39 weeks of gestation vs expectant management for a group of nulliparous patients with unfavorable cervical examinations and the other modeling induction of labor at 39 weeks of gestation vs expectant management for a group with favorable cervical examinations. Estimates of cost, probability, and health state utility were derived from the literature. Based on previous literature, we assumed that people with favorable cervical examinations would have a lower baseline rate of cesarean delivery and higher rates of spontaneous labor. RESULTS: In our base case analysis, induction of labor at 39 weeks of gestation was cost-effective for patients with unfavorable cervical examinations, but not for patients with favorable cervical examinations. The incremental cost per quality-adjusted life year was 50-fold lower for people with unfavorable cervical examinations ($2150 vs $115,100). Induction of labor resulted in 3885 fewer cesarean deliveries and 58 fewer stillbirths per 100,000 patients for those with unfavorable examinations, whereas induction of labor resulted in 2293 fewer cesarean deliveries and 48 fewer stillbirths with labor induction for those with favorable cervical examinations. The results were sensitive to multiple inputs, including the likelihood of cesarean delivery, the cost of induction, the cost of vaginal or cesarean delivery, and the probability of spontaneous labor. In Monte Carlo analysis, the base case findings held true for 64.1% of modeled scenarios for patients with unfavorable cervixes and 55.4% of modeled scenarios for patients with favorable cervixes. CONCLUSION: With a willingness-to-pay threshold of $100,000 per quality-adjusted life year, induction of labor at 39 weeks of gestation may be cost-effective for patients with unfavorable cervical examinations, but not for patients with favorable cervical examinations. This result was driven by the likelihood of labor in patients with favorable cervical examinations, and the resultant avoidance of prolonged pregnancy and its complications, including hypertensive disorders of pregnancy and stillbirths. Health systems may wish to prioritize patients with unfavorable cervical examinations for elective induction of labor at 39 weeks of gestation, which may be opposite to common practice.

Partogram of Grandmultiparous Parturients: A Multicenter Cohort Study.

Sparse and conflicting data exist regarding the normal partogram of grand-multiparous (GMP, defined as parity of 6+) parturients. Customized partograms may potentially lower cesarean delivery rates for protraction disorders in this population. In this study, we aim to construct a normal labor curve of GMP women and compare it to the multiparous (MP, defined as parity of 2-5) partogram. We conducted a multicenter retrospective cohort analysis of deliveries between the years 2003 and 2019. Eligible parturients were the trials of labor of singletons ≥37 + 0 weeks in cephalic presentation with ≥2 documented cervical examinations during labor. Exclusion criteria were elective cesarean delivery without a trial of labor, preterm labor, major fetal anomalies, and fetal demise. GMP comprised the study group while the MP counterparts were the control group. A total of 78,292 deliveries met the inclusion criteria, comprising 10,532 GMP and 67,760 MP parturients. Our data revealed that during the first stage of labor, cervical dilation progressed at similar rates in MPs and GMPs, while head descent was a few minutes faster in GMPs compared to MPs, regardless of epidural anesthesia. The second stage of labor was faster in GMPs compared to MPs; the 95th percentile of the second stage duration of GMPs (48 min duration) was 43 min less than that of MPs (91 min duration). These findings remained similar among deliveries with and without epidural analgesia or labor induction. We conclude that GMPs' and MPs' cervical dilation progression in the active phase of labor was similar, and the second stage of labor was shorter in GMPs, regardless of epidural use. Thus, GMPs' uterus function during labor corresponds, and possibly surpasses, that of MPs. These findings indicate that health providers can use the standard partogram of the active phase of labor when caring for GMP parturients.

Effects of different doses of estradiol benzoate used in a cervical relaxation protocol on the success of non-surgical embryo recovery and luteal function in superovulated ewes.

This study investigated the effectiveness of different doses of estradiol benzoate (EB) to promote cervical relaxation and their effects on luteal function and outcomes of non-surgical embryo recovery (NSER) in sheep. Multiparous (MULT) and nulliparous (NULL) crossbred Lacaune X Santa Inês ewes were superovulated and naturally bred. Seven days after progesterone withdrawal, females were randomly assigned to one of three distinct cervical relaxation protocols, consisting of i.m. treatment with 37.5 µg d-cloprostenol and different doses of EB: 0.0 mg (0.0EB group; n = 3 NULL and 14 MULT); 0.5 mg (0.5EB group; n = 4 NULL and 12 MULT) or 1.0 mg (1.0EB group, n = 6 NULL and 11 MULT) 16 h before NSER. All ewes received 50 IU of oxytocin 20 min before NSER (D17). Blood samples were collected and ultrasound exams (B-mode and color Doppler) were performed at two timepoints: immediately before d-cloprostenol and EB treatments and prior to NSER. Estrous behavior, corpora lutea count and NSER success outcomes were not affected by EB treatments nor parity (P > 0.05). Embryo recovery rate was greater for ewes in the 0.5EB group and in the NULL ewes (P < 0.05). Ovarian biometrics differed between the two evaluation timepoints in all groups (P < 0.05). Plasma estradiol increased over time, reaching a significant greater level in 1.0EB ewes compared to controls on D17 (P < 0.05), whereas progesterone concentrations decreased over time in all groups (P > 0.05). In conclusion, treatments did not affect NSER success but they did affect luteal function by altering P4 and E2 concentrations. Therefore, the NSER technique can be successfully performed in ewes with or without prior treatment with EB.

Proposed staging criteria for sonographic and physical exam for cervical changes at <24 weeks gestation to predict preterm birth.

Asymptomatic cervical changes, such as cervical length shortening and dilation, which often occur before spontaneous preterm birth, have been described well in singleton pregnancies with or without history of preterm birth. The current screening strategies available to identify patients at increased risk of spontaneous preterm birth include use of transvaginal ultrasound for cervical length assessment and for detection of a short cervical length (≤25 mm) before 24 weeks of gestation. Whether an additional evaluation of the cervix (ie, via speculum or manual exam) is indicated is often pondered by clinicians and may depend on how short the cervical length is and if there is a history of preterm birth. Based on expert opinion, we developed a novel staging system of asymptomatic cervical changes including the following: cervical length measurement, cervical and membrane appearance on speculum exam, and cervical dilation by manual exam. This staging system, if proven accurate, may aid in standardizing definitions for purposes of patient prognosis, evaluation of intervention efficacy, and clinical management.