Fatores clínicos do bem-estar de mulheres em parturição: perspectivas deontológicas e da bioética principialista / Clinical factors of women in labor well-being: deontological and bioethical principlism perspectives / Factores clínicos del bienestar de la mujer en trabajo de parto: perspectivas deontológicas y de la bioética principialista

Objetivo: avaliar os fatores clínicos associados ao bem-estar das mulheres durante o trabalho de parto e parto à luz da bioética principialista e da deontologia. Método: estudo transversal com abordagem quantitativa. Participaram 396 puérperas internadas em um hospital municipal do sudoeste da Bahia, e os dados foram coletados no período de janeiro a maio de 2023, após aprovação do comitê de ética em pesquisa. Os dados foram organizados no software Excel e analisados via SPSS v.25. a partir da regressão logística multinomial. Resultados: a maior parte da amostra apresentou bem-estar com assistência em saúde, mulheres que tiveram parto realizado por profissionais não médicos apresentaram mais chances de níveis de bem-estar "adequado". E mulheres que não tiveram a via de parto cesárea apresentaram aumento de chances de bem-estar. Conclusão: é necessário que os profissionais reflitam sobre suas ações, condicionando-as à humanização no parto, em observância aos princípios bioéticos.

Objective: to evaluate the clinical factors associated with women's well-being during labor and delivery in the light of bioethics principlism and deontology. Method: a cross-sectional study with a quantitative approach was conducted. It involved 396 postpartum women admitted to a municipal hospital in the southwest of Bahia. Data were collected from January to May 2023, after approval from the research ethics committee. The data were tabulated using Excel software and analyzed using SPSS v.25 through Multinomial Logistic Regression. Results: majority of the sample exhibited well-being with health care assistance. Women who underwent delivery performed by non-medical professionals showed higher chances of "adequate" levels of well-being. Additionally, women who did not undergo cesarean delivery showed increased chances of well-being. Conclusion: It is necessary for professionals to reflect on their actions, conditioning them to the humanization of childbirth, according to bioethical principles.

Objetivo: evaluar los factores clínicos asociados al bienestar de la mujer durante el trabajo de parto y parto a la luz de la bioética y la deontología principialista. Método: estudio transversal con enfoque cuantitativo. Incluyó 396 puérperas ingresadas en un hospital municipal del suroeste de Bahía. Recolección de datos de enero a mayo de 2023, con aprobación del comité de ética en investigación. Los datos se tabularon en el software Excel y se analizaron mediante SPSS v.25. utilizando regresión logística multinomial. Resultados: la mayoría de las participantes de la muestra presentó bienestar con la atención para la salud; las que tuvieron partos realizados por profesionales no médicos tenían más probabilidades de tener niveles "adecuados" de bienestar; las que no tuvieron parto por cesárea tenían mayores probabilidades de tener bienestar. Conclusión: es necesario que los profesionales reflexionen sobre sus acciones y las adecuen para humanizar el parto, respetando los principios bioéticos.

Real-time analgesic efficacy and factors determining drug requirements of combined spinal-epidural analgesia for labor: a prospective cohort study.

PURPOSE: Combined spinal-epidural analgesia (CSEA) is effective but not sufficient for labor pain. This study was conducted to assess the real-time analgesic efficacy, side effects of anesthetic drug dosage, and maternal satisfaction in labor to provide reference for the optimization of labor analgesia. METHODS: This was a prospective, cohort, single-center study that included 3020 women who received CSEA for labor analgesia. The visual analogue scale (VAS) for labor pain, real-time anesthetic drug dosage, side effects, adverse labor outcomes, factors influencing average drug dosage, and maternal satisfaction with CSEA were assessed. RESULTS: Overall, the VAS labor pain score was lowest at the first hour after the anesthesia was given. After 4 h for primiparas and 3 h for multiparas, the VAS score was greater than 3 but the anesthetic drug dosage did not reach the maximum allowed dosage at the same time. The average anesthetic drug dosage was positively correlated with fever, urinary retention, uterine atony, prolonged active phase, prolonged second stage, assisted vaginal delivery, and postpartum hemorrhage. The average anesthetic drug dosage was the highest in women ≤ 20 years old, those with a body mass index (BMI) ≥ 24.9 kg/m2, and those with a primary or secondary education level. CONCLUSION: Appropriate age guidance and emphasis on education of labor analgesia, weight management during pregnancy, and real-time anesthetic dosage adjustment during labor based on VAS pain score may have positive effects on the satisfaction of labor analgesia. CLINICAL TRIAL NUMBER AND REGISTRY: Clinicaltrials.gov (ChiCTR2100051809).

Effect of acidic vaginal pH on the efficacy of dinoprostone (PGE2) vaginal tablet for labor induction in full term pregnant women: a randomized controlled trial.

OBJECTIVES: There is controversial evidence that acidification of vaginal pH may increase the efficacy of vaginal prostaglandins in labor induction, with research being mainly focused on misoprostol. This study aims to evaluate the impact of this intervention on the progress of labor induction with dinoprostone (PGE2) vaginal tablet. METHODS: This double-blind, parallel-group, randomized study was conducted between October 2021 and December 2022 at Alexandra General Hospital, Athens, Greece. A total of 230 women with singleton, full term pregnancy that were scheduled for labor induction were randomly divided into two groups: Group A, who received acidic vaginal wash (5 % acetic acid) and Group B, who received a normal saline vaginal wash. Afterwards, participants received a vaginal tablet of 3 mg dinoprostone every 6 h (maximum two doses). RESULTS: There were no statistically significant differences in mode of delivery, duration of different labor stages, Bishop score changes and possible complications. Participants in the acidification group needed less often labor augmentation with oxytocin and epidural anesthesia (p=0.03). CONCLUSIONS: Vaginal acidification seems to have no effect on the efficacy of the dinoprostone vaginal tablet. Even though it may reduce the need for oxytocin augmentation, there is no apparent benefit on clinical outcomes, such as reduction in cesarean section rates or shorter labor duration. Future research is necessary in order to validate these findings.

Short stature and vaginal dinoprostone as independent predictors of composite maternal-newborn adverse outcomes in induction of labor after one previous cesarean: a retrospective cohort study.

BACKGROUND: The rates of labor induction and cesarean delivery is rising worldwide. With the confluence of these trends, the labor induction rate in trials of labor after cesarean can be as high as 27-32.7%. Induction of labor after one previous cesarean (IOLAC) is a high-risk procedure mainly due to the higher risk of uterine rupture. Nevertheless, the American College of Obstetricians and Gynecologists considers IOLAC as an option in motivated and informed women in the appropriate care setting. We sought to identify predictors of a composite of maternal and newborn adverse outcomes following IOLAC. METHODS: The electronic medical records of women who delivered between January 2018 to September 2022 in a Malaysian university hospital were screened to identify cases of IOLAC. A case is classified as a composite adverse outcome if at least one of these 11 adverse outcomes of delivery blood loss ≥ 1000 ml, uterine scar complications, cord prolapse or presentation, placenta abruption, maternal fever (≥ 38 0C), chorioamnionitis, intensive care unit (ICU) admission, Apgar score < 7 at 5 min, umbilical artery cord artery blood pH < 7.1 or base excess ≤-12 mmol/l, and neonatal ICU admission was present. An unplanned cesarean delivery was not considered an adverse outcome as the practical management alternative for a clinically indicated IOLAC was a planned cesarean. Bivariate analysis of participants' characteristics was performed to identify predictors of their association with composite adverse outcome. Characteristics with crude p < 0.10 on bivariate analysis were incorporated into a multivariable binary logistic regression analysis model. RESULTS: Electronic medical records of 19,064 women were screened. 819 IOLAC cases and 98 cases with composite adverse outcomes were identified. Maternal height, ethnicity, previous vaginal delivery, indication of previous cesarean, indication for IOLAC, and method of IOLAC had p < 0.10 on bivariate analysis and were incorporated into a multivariable binary logistic regression analysis. After adjustment, only maternal height and IOLAC by vaginal dinoprostone compared to Foley balloon remained significant at p < 0.05. Post hoc adjusted analysis that included all unplanned cesarean as an added qualifier for composite adverse outcome showed higher body mass index, short stature (< 157 cm), not of Chinese ethnicity, no prior vaginal delivery, prior cesarean indicated by labor dystocia, and less favorable Bishop score (< 6) were independent predictors of the expanded composite adverse outcome. CONCLUSION: Shorter women and IOLAC by vaginal dinoprostone compared to Foley balloon were independently predictive of composite of adverse outcome.

Shorter stature and dinoprostone labor induction are independent predictors of a composite maternal-newborn adverse outcome excluding unplanned cesarean delivery.

Exploring the mystical relationship between the Moon, Sun, and birth rate.

OBJECTIVE: The Moon has a noticeable influence on the Earth due to its gravity, the most visible manifestation of which are tides. We aimed to see if the Moon's daily cycle, like the Sun's, affects the prevalence and incidence of childbirth. METHODS: In this retrospective cohort study, we examined all deliveries at the Academic Hospital of Udine between 2001 and 2019. All consecutive singleton pregnancies with spontaneous labor and vaginal delivery were included. RESULTS: During the period, 13,349 singleton pregnancies with spontaneous labor and vaginal delivery were delivered in 6939 days. A significantly higher prevalence of deliveries was found with the Moon above the horizon (50.63% vs. 49.37%, p < 0.05). Moreover, during the day, there was a significantly higher prevalence of deliveries than during nighttime (53.74% vs. 45.79%, p < 0.05). Combining the Moon and Sun altitude, the majority of deliveries were registered when both were above the horizon (27.39% vs. 26.13%, 23.25%, or 23.24%, p < 0.05). These findings were confirmed in multivariate analysis after adjusting for parity, gestational age, or season. We found no correlation between birth and the Moon phase. CONCLUSIONS: Our data support the interaction of the Moon and the Sun in determining the time of birth. More research is needed to understand these phenomena and improve our understanding of labor initiation mechanisms.

Normal Pregnancy Care and Physiology and Select Pregnancy Complications: A Flipped Classroom Case for the OB/GYN Clerkship.

Introduction: This module teaches core knowledge and skills for undergraduate medical education in reproductive health, providing instruction in the management of normal and abnormal pregnancy and labor utilizing interactive small-group flipped classroom methods and case-based instruction. Methods: Advance preparation materials were provided before the education session. The 2-hour session was facilitated by clinical educators using a faculty guide. Using voluntary surveys, we collected data to measure satisfaction among obstetrics and gynecology clerkship students and facilitators following each education session. Results: Capturing six clerkships spanning 9 months, 116 students participated, and 64 students completed the satisfaction survey, with 97% agreeing that the session was helpful in applying knowledge and principles to common clinical scenarios. Most students (96%) self-reported that they achieved the session's learning objectives utilizing prework and interactive small-group teaching. Nine clinical instructors completed the survey; all agreed the provided materials allowed them to facilitate active learning, and the majority (89%) agreed they spent less time preparing to teach this curriculum compared to traditional didactics. Discussion: This interactive flipped classroom session meets clerkship learning objectives related to the management of pregnancy and labor using standardized materials. The curriculum reduced preparation time for clinical educators as well.

Migrant women's experiences of community-based doula support during labor and childbirth in Sweden. A mixed methods study.

OBJECTIVE: To describe migrant women's experiences of bilingual community-based doulas (CBD) contribution to care in relation to labor and birth. METHODS: Mixed methods study combining quantitative data from 82 women who received CBD-support within a randomized controlled trial and qualitative data from semi-structured interviews with a sub-sample of 12 women from the same study arm. Descriptive analyses were used for quantitative data and content analysis for the manifest and latent content of the qualitative data. Quantitative findings were categorized according to qualitative findings. RESULTS: The women expressed how CBDs played an essential role in the response to their basic emotional, informational, and physical support needs, when no other female family member was available. Three main categories emerged from the analysis of interviews: The doulas help women feel safe and calm - providing support before, during and after childbirth; The doulas' support role fills the void left by a deeply missed family, mother or sister; and The doulas assist women in achieving autonomy through communication support and advocacy. More than half of women reported feeling involved during labor and birth (56.8%), most valued CBD positively (such as being competent, calm, secure, considerate, respectful, encouraging, supportive) (40.8%-80.3%), that CBD had interpreted (75.6%), facilitated communication with the midwife (60,3%), comforted the woman (57.7%) and reduced anxiety (48,7%). Few reported negative CBD-characteristics (1.3-9.2%). Nevertheless, 61.7% of women felt frightened sometime during labor and birth, which made it even more important to them that the doula was there. Few women (21.8%) reported that the CBD had supported her partner but expressed so in the interviews. CONCLUSION: Through an essential contribution in responding to migrant women's basic emotional, informational, and physical needs, bilingual community-based doulas have the potential to improve migrant women's experience of care during labour and birth. However, more focus on the quality of CBD-support to partners seem necessary.

Epidural Block in a Patient With Melkersson-Rosenthal Syndrome: A Case Report.

This case report describes the first known application of an epidural block for labor analgesia in a patient with Melkersson-Rosenthal syndrome (MRS), a rare disorder that may present sudden and threatening airway complications. A tailored epidural protocol effectively mitigated symptom exacerbation, facilitating a complication-free vaginal delivery. This report not only enriches the sparse literature on anesthesia in patients with MRS but also provides a crucial review of perioperative considerations for administering either general or regional anesthesia in similar cases.

Prevalence Rate, Probable Causes, and Perinatal Outcomes in Women With Oligohydramnios in Labor.

BACKGROUND: Oligohydramnios is a common clinical condition among pregnant women. It has direct effects on maternal and fetal outcomes. The related complications in women with oligohydramnios have not been determined sufficiently in developing countries yet. This study aimed to determine the prevalence, portable causes, and perinatal outcomes among women with oligohydramnios. METHODOLOGY: In this follow-up cross-sectional study, pregnant women with oligohydramnios were monitored until delivery at the Duhok Maternity Teaching Hospital to assess the outcomes of oligohydramnios between May 2022 and May 2023. The patients of this study were included through a purposive sampling technique. RESULTS: More than half (121, 60.5%) of the participants were aged between 20 and 29 years. The gravidity range of the studied pregnant women was 1-9. A total of 156 (78.0%) women have had a history of one to three pregnancies. More than half (102, 51.0%) of studied pregnant women were nulliparous. The study found that 92 (46.0%) had preterm births and the remaining women had term births (108, 54.0%). The most common medical problems among studied pregnant women with oligohydramnios were hypertension (14, 7.0%) and hyperthyroidism (7, 3.5%), and the most common surgical problems were cesarean section (30, 15.0%) and appendectomy (14, 7.0%). The highest prevalence of AFI was 3 cm (84, 42.0%) and 4 cm (82, 41.0%) followed by 2 cm (34, 17.0%). The most prevalent ultrasound finding was fetal hypoxia in 41 (21.5%) women. Most patients' Doppler ultrasound was normal (150, 75.0%).  The study found that 187 (93.5%) pregnancies ended with the birth of live babies and 6.5% (13) of the newborns died. Only three newborn babies (1.5%) reported with low Apgar scores. Low birth weight was reported in 56 (28.0%) newborn babies. The proportion of cesarean sections among women was 94 (47.0%). A total of 117 (58.5%) newborn babies were admitted to the neonatal intensive care unit (NICU) for intensive care. CONCLUSIONS: This study showed that a considerable percentage of women with oligohydramnios were older; had higher gravida, parity, and preterm pregnancies; and had previous cesarean section scars. The most common fetal complications were fetal hypoxia, death, low birth weight, and NICU admission. The most common maternal complication was cesarean section.

Computational Modeling Interpretation Underlying Elevated Risk-Taking Propensity in the Dynamic Risky Investment Process of Non-Labor Income.

Introduction: Money source influences risk-taking behaviors. Although studies consistently indicated that individuals demonstrate a higher propensity to make risky investments when utilizing non-labor income as opposed to labor income, explanations as to why non-labor income leads to continuously blowing money into risky investments are scarce. Methods: The current study leverages a computational modeling approach to compare the differences in the dynamic risk investment process among individuals endowed with income from different sources (ie, non-labor income vs labor income) to understand the shaping force of higher risk-taking propensity in individuals with non-labor income. A total of 103 participants were recruited and completed the Balloon Analogue Risk Task (BART) with an equal monetary endowment, either as a token for completion of survey questionnaires (representing labor income) or as a prize from a lucky draw game (representing non-labor income). Results: We found that individuals endowed with non-labor income made more risky investments in BART compared to those with labor income. With computational modeling, we further identified two key differences in the dynamic risk investment processes between individuals endowed with labor and those with non-labor income. Specifically, individuals endowed with non-labor income had a higher preset expectation for risk-taking and displayed desensitization towards losses during risk investments, in contrast to individuals with labor income. Discussion: This study contributed to a better understanding of the psychological mechanisms of why individuals make more risk-taking behaviors with non-labor income, namely higher preset expectations of risk-taking and desensitization towards losses. Future research could validate these findings across diverse samples with varying backgrounds and adopt different manipulations of labor and non-labor income to enhance the external validity of our study.

Cognitive household labor: gender disparities and consequences for maternal mental health and wellbeing.

PURPOSE: Although the division of unpaid household labor has been studied as a driver of global gender inequity, the cognitive dimension of household labor-planning, anticipating, and delegating household tasks-has received less empirical investigation. Cognitive household labor represents a form of invisible and often unacknowledged domestic work that has been challenging to measure. METHODS: Within 322 mothers of young children, we assessed the division of both cognitive ("planning") and physical ("execution") household labor within 30 common household tasks using a self-report measure. RESULTS: We found that while mothers did more of the overall domestic labor than their partners, the division of cognitive labor was particularly gendered, such that women's share of cognitive labor was more disproportionate than physical household labor. We found that cognitive labor was associated with women's depression, stress, burnout, overall mental health, and relationship functioning. CONCLUSIONS: This study is one of the first to investigate cognitive labor quantitatively, and the first to investigate cognitive and physical dimensions within the same household tasks. Understanding how cognitive labor affects mothers' mental wellbeing has important implications for both practice and policy.

The Labor Market Integration of Women Having Suffered Gender Violence: Some Critical Questions.

The integration of women victims of gender-based violence (WVGBV) in the labor market is key to women's autonomy and empowerment. After pursuing some personal stability in different domains (emotional, physical, relational, etc.), these women require a further step toward recovery, which is often related to financial independence and, therefore, to their integration in the labor market. In this article, we describe the results of a study that focused on the actions aimed at integrating WVGBV into the labor market in the region of Andalusia (Spain). Based on a qualitative methodology, we collected the narratives and perspectives of the different actors involved in these processes (public administrations, nongovernmental organizations, the business world, and the WVGBV). The results revealed a series of deficiencies in social intervention methodologies that can sometimes lead to greater social exclusion. In conclusion, we believe that more participatory methodologies in their design, incorporating the views of woman themselves, are necessary.

Earlier routine induction of labor-Consequences on mother and child morbidity.

A growing number of birth interventions had led to a concern for potential health consequences. This study investigates the consequences of earlier routine labor induction. It exploits a natural experiment caused by the introduction of new Danish obstetric guidelines in 2011. Consequently, routine labor induction was moved forward from 14 to 10-13 days past the expected due date (EDD) and extended antenatal surveillance was introduced from 7 days past the EDD. Using administrative data, I find that affected mothers on average had a 9-11 percentage points (32%-38%) higher risk of being induced the following years. Yet, mother and child short- and medium-term morbidity were largely unaffected.

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.

The causal effect of mental health on labor market outcomes: The case of stress-related mental disorders following a human-made disaster.

As disasters increase due to climate change, population density, epidemics, and technology, information is needed about postdisaster consequences for people's mental health and how stress-related mental disorders affect multiple spheres of life, including labor-market attachment. We tested the causal hypothesis that individuals who developed stress-related mental disorders as a consequence of their disaster exposure experienced subsequent weak labor-market attachment and poor work-related outcomes. We leveraged a natural experiment in an instrumental variables model, studying a 2004 fireworks factory explosion disaster that precipitated the onset of stress-related disorders (posttraumatic stress disorder, anxiety, and depression) among individuals in the local community (N = 86,726). We measured labor-market outcomes using longitudinal population-level administrative data: sick leave, unemployment benefits, early retirement pension, and income from wages from 2007 to 2010. We found that individuals who developed a stress-related disorder after the disaster were likely to go on sickness benefit, both in the short- and long-term, were likely to use unemployment benefits and to lose wage income in the long term. Stress-related disorders did not increase the likelihood of early retirement. The natural experiment design minimized the possibility that omitted confounders biased these effects of mental health on work outcomes. Addressing the mental health and employment needs of survivors after a traumatic experience may improve their labor-market outcomes and their nations' economic outputs.

Accidental uterine extensions in cesarean deliveries - outcome of subsequent pregnancy.

OBJECTIVES: To explore the obstetric, maternal and neonatal outcome in the subsequent pregnancy after a pregnancy with an accidental uterine extension (AUE) during cesarean delivery (CD), as well as the relationship between the different types of AUE (inferior, lateral and superior). METHODS: A retrospective cohort study of all CD with AUE in a tertiary medical center between 01/2011-01/2022. Women with a prior CD with AUE were compared to a 1:3 ratio matched control group of women with a prior CD without AUE. All AUE were defined in their direction, size and mode of suturing. CD with deliberate uterine extensions were excluded. We evaluated obstetric, maternal and neonatal outcomes in the subsequent pregnancy after a pregnancy with AUE during CD. RESULTS: Comparing women with a prior CD with AUE (n=177) to the matched control group of women with a prior CD without AUE (n=528), we found no significant differences in proportions of uterine rupture or any other major complication or adverse outcome between the groups. There were no significant differences in the outcomes of the subsequent pregnancy in relation to the characteristics of the AUE (direction, size and mode of suturing). CONCLUSIONS: Subsequent pregnancies after AUE are not associated with higher maternal or neonatal adverse outcomes including higher proportions of uterine rupture compared to pregnancies without previous AUE. Different characteristics of the AUE do not impact the outcome.

Video analysis of real-life shoulder dystocia to assess technical and non-technical performance.

INTRODUCTION: Managing obstetric shoulder dystocia requires swift action using correct maneuvers. However, knowledge of obstetric teams' performance during management of real-life shoulder dystocia is limited, and the impact of non-technical skills has not been adequately evaluated. We aimed to analyze videos of teams managing real-life shoulder dystocia to identify clinical challenges associated with correct management and particular non-technical skills correlated with high technical performance. MATERIAL AND METHODS: We included 17 videos depicting teams managing shoulder dystocia in two Danish delivery wards, where deliveries were initially handled by midwives, and consultants were available for complications. Delivery rooms contained two or three cameras activated by Bluetooth upon obstetrician entry. Videos were captured 5 min before and after activation. Two obstetricians assessed the videos; technical performances were scored as low (0-59), average (60-84), or high (85-100). Two other assessors evaluated non-technical skills using the Global Assessment of Team Performance checklist, scoring 6 (poor) to 30 (excellent). We used a spline regression model to explore associations between these two score sets. Inter-rater agreement was assessed using interclass correlation coefficients. RESULTS: Interclass correlation coefficients were 0.71 (95% confidence interval 0.23-0.89) and 0.82 (95% confidence interval 0.52-0.94) for clinical and non-technical performances, respectively. Two teams had low technical performance scores; four teams achieved high scores. Teams adhered well to guidelines, demonstrating limited head traction, McRoberts maneuver, and internal rotation maneuvers. Several clinical skills posed challenges, notably recognizing shoulder impaction, applying suprapubic pressure, and discouraging women from pushing. Two non-technical skills were associated with high technical performance: effective patient communication, with teams calming the mother and guiding her collaboration during internal rotational maneuvers, and situation awareness, where teams promptly mobilized all essential personnel (senior midwife, consultant, pediatric team). Team communication, stress management, and task management skills were not associated with high technical performance. CONCLUSIONS: Videos capturing teams managing real-life shoulder dystocia are an effective tool to reveal challenges with certain technical and non-technical skills. Teams with high technical performance are associated with effective patient communication and situational awareness. Future training should include technical skills and non-technical skills, patient communication, and situation awareness.

Recommendations for the Management of High-Risk Cardiac Delivery: ACC Cardiovascular Disease in Women Committee Panel.

Maternal mortality is a major public health crisis in the United States. Cardiovascular disease (CVD) is a leading cause of maternal mortality and morbidity. Labor and delivery is a vulnerable time for pregnant individuals with CVD but there is significant heterogeneity in the management of labor and delivery in high-risk patients due in part to paucity of high-quality randomized data. The authors have convened a multidisciplinary panel of cardio-obstetrics experts including cardiologists, obstetricians and maternal fetal medicine physicians, critical care physicians, and anesthesiologists to provide a practical approach to the management of labor and delivery in high-risk individuals with CVD. This expert panel will review key elements of management from mode, timing, and location of delivery to use of invasive monitoring, cardiac devices, and mechanical circulatory support.

Effect of dural puncture epidural block technique on fetal heart rate variability during labor analgesia.

PURPOSE: To explore the effect of dural puncture epidural (DPE) block technique on fetal heart rate variability (HRV) during labor analgesia. METHODS: Sixty full-term primiparas who were in our hospital from April 2021 to October 2021 were selected and randomized into epidural analgesia (CEA) and dural puncture epidural analgesia (DPEA) groups (n = 30). After a successful epidural puncture, routine epidural catheter (EC) was performed in CEA group, and spinal anesthesia needle (as an EC) was used to puncture the dura mater to subarachnoid space in DPE group. Anesthetics were injected through EC. The time when the temperature sensation plane reached T10 (W1) and visual analog pain score (VAS), baseline heart rate score, amplitude variation score, cycle variation score, acceleration score, deceleration score, and total score of the first contraction after W1 were recorded. Apgar scores at 1 min, 5 min, and 10 min of neonates after delivery were recorded. RESULTS: The onset time of anesthesia in CEA group was significantly longer than that in DPEA group (p < .05). However, there are no significant differences in W1, VAS, baseline heart rate score, amplitude variation score, cycle variation score, acceleration score, deceleration score, and total score of the first contraction after W1 between the two groups (p > .05). Moreover, the Apgar scores at 1 min, 5 min and 10 min of neonates after delivery were not notably different between the two groups (p > .05). CONCLUSION: Compared with CEA, DPE block technique in labor analgesia relieves maternal pain without adverse effects on fetal HRV and newborns.

Programmed Intermittent Epidural Bolus Reduces Workloads in Labor Analgesia: A Single Center's Experience.

Background and Objectives: Labor epidural analgesia can be maintained through programmed intermittent epidural bolus (PIEB), continuous epidural infusion (CEI), or patient-controlled epidural analgesia (PCEA). Our department changed from CEI+PCEA to PIEB+PCEA as the maintenance method. The higher hourly dose setting in the current regimen brought to our concern that side effects would increase with proportional staff workloads. This study aimed to investigate the validity of our proposal that PIEB+PCEA may function as a feasible tool in reducing the amount of work in the obstetrics anesthesia units. Materials and methods: This 2-year retrospective review included parturients with vaginal deliveries under epidural analgesia. We compared the staff burden before and after the switch from CEI (6 mL/h, PCEA 6 mL lockout 15 min, group A) to PIEB (8 mL/h, PCEA 8 mL lockout 10 min, group B). The primary outcome was the difference of proportion of parturients requiring unscheduled visits between groups. Side effects and labor and neonatal outcomes were compared. Results: Of the 694 parturients analyzed, the proportion of those requiring unscheduled visits were significantly reduced in group B (20.8% vs. 27.7%, chi-square test, p = 0.033). The multivariate logistic regression showed that PIEB was associated with fewer unscheduled visits than CEI (OR = 0.53, 95% CI [0.36-0.80], p < 0.01). Group B exhibited a significantly lower incidence of asymmetric blockade, as well as motor blockade. In nulliparous subjects, obstetric anal sphincter injury occurred less frequently when PIEB+PCEA was used. Significantly more multiparous women experienced vacuum extraction delivery in group B than in group A, and they had a longer second stage of labor. Conclusions: The PIEB+PCEA protocol in our study reduced workloads in labor epidural analgesia as compared to CEI+PCEA, despite that a higher dose of analgesics was administered. Future studies are warranted to investigate the effect of manipulating the PIEB settings on the labor outcomes.