Manipulative Reduction for Abnormal Uterine Inclination in Vaginal Delivery.

OBJECTIVE: To investigate the manipulative reduction in abnormal uterine inclination in vaginal delivery. METHODS: With the independently developed uterine inclination surveyor, 40 primiparas with abnormal uterine inclination were randomly divided into two groups: treatment group (Group A, 20 cases) and control group (Group B, 20 cases). The general condition of the primipara, the labor stages, the changes in uterine inclination after treatment, postpartum hemorrhage at 2 hours, and the general condition of fetuses were observed to study the therapeutic value of manual reduction in abnormal uterine inclination. RESULT: In the control group, one uterine inclination was not corrected with the change in labor process, and the pregnancy was terminated due to stagnation of the active phase. In the first stage of labor, the time spent in the treatment group (393.4 ± 31.3 mins) was significantly lower than that in the control group (440.7 ± 34.9 mins) (P = 0.001). Compared with the control group (49.8 ± 6.5 mins), the treatment group (42.6 ± 7.2 mins) also exhibited a significantly shortened second stage of labor (P = 0.02). Sixteen cases (16/20) in the treatment group returned to normal after manual reduction, and 9 cases (9/20) in the control group returned to normal with the progression of natural labor. Manual reduction could be used as an option to treat abnormal uterine inclination (P = 0.01). There was no significant difference in the third stage of labor (P = 0.2), 2-hour postpartum hemorrhage (P = 0.35), Apgar score (P = 0.64), or body weight (P = 0.76) between the two groups. CONCLUSION: Manual reduction in the treatment of abnormal uterine inclination has obvious effects, shortens the birth process, and is safe for the fetus.

Salivary cortisol as a non-invasive approach to assess stress in dystocic dairy calves.

The intensity and the magnitude of saliva cortisol responses were investigated during the first 48 h following birth in newborn dairy calves which underwent normal (eutocic, EUT, n = 88) and difficult (dystocic, DYS, n = 70) calvings. The effects of parity and body condition of the dam, the duration of parturition, the time spent licking the calf, the sex and birth weight of the calf were also analyzed. Neonatal salivary cortisol concentrations were influenced neither by factors related to the dam (parity, body condition) nor the calf (sex, birth weight). The duration of parturition and the time spent licking the calf also had no effect on salivary cortisol levels. Salivary cortisol concentrations increased rapidly after delivery in both groups to reach their peak levels at 45 and 60 min after delivery in EUT and DYS calves, respectively supporting that the birth process means considerable stress for calves and the immediate postnatal period also appears to be stressful for newborn calves. DYS calves exhibited higher salivary cortisol concentrations compared to EUT ones for 0 (P = 0.022), 15 (P = 0.016), 30 (P = 0.007), 45 (P = 0.003), 60 (P = 0.001) and 120 min (P = 0.001), and for 24 h (P = 0.040), respectively. Peak levels of salivary cortisol and the cortisol release into saliva calculated as AUC were higher in DYS than in EUT calves for the 48-h of the sampling period (P = 0.009 and P = 0.003, respectively). The greater magnitude of saliva cortisol levels in DYS calves compared to EUT ones suggest that difficult parturition means severe stress for bovine neonates and salivary cortisol could be an opportunity for non-invasive assessment of stress during the early neonatal period in cattle.

Association between age at first calving and lactation performance, lactation curve, calving interval, calf birth weight, and dystocia in Holstein dairy cows.

In the present study, records on 115,291 heifers distributed in 113 herds were used to investigate the association between age at the first calving (AFC) and lactation performance, lactation curve, the length of the first calving interval (CI), calf birth weight (CBW), and the incidence of dystocia in Holstein heifers in Iran. Based on the AFC, the heifers were classified into eight classes: AFC of 541 to 690 d, 691 to 720 d, 721 to 750 d, 751 to 780 d, 781 to 810 d, 811 to 840 d, 841 to 900 d, and 901 to 1200 d (AFC1 to AFC8, respectively). Multiple regression mixed models were used to investigate the association between AFC and lactation curve parameters, partial and 305-d lactation performance, 100- and 305-d SCS, and the length of the first calving (CI) interval. The mean (SD) and median AFC across all heifers was 760.2 (74.01) and 750 d, respectively. Of 115,291 heifers included, 28,192 and 7,602 heifers were, respectively, ≤ 720 and > 900 d when calving for the first time. More than 44% of the heifers were at 691 to 750 d (23 to 25 months) of age when calving for the first time. An increased AFC was associated with increased partial and 305-d lactation performance, 100- and 305-d SCS, initial milk yield, milk production at the peak of lactation, upward and downward slopes of the lactation curve. The 305-d fat percentage was associated with AFC; however, there was no association between AFC and 305-d protein percentage. An increased AFC was also associated with decreased milk production persistency, delayed peak time, longer CI, and higher calf birth weight. Compared to heifers calving for the first time between 691 to 780 d (23 to 26 months) of age, both increasing and decreasing AFC were associated with increased risk of dystocia. Controlling AFC is an important management factor in achieving a lower risk of dystocia, higher lactation performance, lower SCS, and shorter length of the calving interval.

Ggps1 deficiency in the uterus results in dystocia by disrupting uterine contraction.

Dystocia is a serious problem for pregnant women, and it increases the cesarean section rate. Although uterine dysfunction has an unknown etiology, it is responsible for cesarean delivery and clinical dystocia, resulting in neonatal morbidity and mortality; thus, there is an urgent need for novel therapeutic agents. Previous studies indicated that statins, which inhibit the mevalonate (MVA) pathway of cholesterol synthesis, can reduce the incidence of preterm birth, but the safety of statins for pregnant women has not been thoroughly evaluated. Therefore, to unambiguously examine the function of the MVA pathway in pregnancy and delivery, we employed a genetic approach by using myometrial cell-specific deletion of geranylgeranyl pyrophosphate synthase (Ggps1) mice. We found that Ggps1 deficiency in myometrial cells caused impaired uterine contractions, resulting in disrupted embryonic placing and dystocia. Studies of the underlying mechanism suggested that Ggps1 is required for uterine contractions to ensure successful parturition by regulating RhoA prenylation to activate the RhoA/Rock2/p-MLC pathway. Our work indicates that perturbing the MVA pathway might result in problems during delivery for pregnant females, but modifying protein prenylation with supplementary farnesyl pyrophosphate or geranylgeranyl pyrophosphate might be a strategy to avoid side effects.

HYPOXIA AND REPRODUCTIVE HEALTH: Hypoxia and labour.

Intermittent myometrial hypoxia is a normal feature of labour, as the powerful contractions compress blood vessels. In this review, we focus on the relation between hypoxia, myometrial metabolism, and contractility. We dissect how hypoxia can feedback and limit an ongoing contraction and help prevent foetal distress. The mechanisms involve acidification from lactate, decreased excitability, and a fall of intracellular calcium concentration. As this cycle of contraction and relaxation repeats in labour, the hypoxia also engenders mechanisms that increase force; hypoxia-induced force increase, HIFI. We also discuss the role of the myometrial blood vessels in dysfunctional labour, which is associated with lactic acidosis. In synthesising these studies, we have attempted to unify findings by considering the importance of experimental protocols and finding direct mechanistic evidence from human myometrium or in vivo studies. We have made suggestions for future studies to fill the holes in our understanding and speed up the translation of our knowledge to improve births for mothers and babies everywhere.

Hyponatraemia reversibly affects human myometrial contractility. An in vitro pilot study.

BACKGROUND: In a previous study we found a significant correlation between dystocia and hyponatraemia that developed during labour. The present study examined a possible causal relationship. In vitro studies often use area under the curve (AUC) determined by frequency and force of contractions as a measure of myometrial contractility. However, a phase portrait plot of isometric contraction, obtained by plotting the first derivate of contraction against force of contraction, could indicate that bi-or multiphasic contractions might be less effective compared to the smooth contractions. MATERIAL AND METHODS: Myometrial biopsies were obtained from 17 women undergoing elective caesarean section at term. Each biopsy was divided into 8 strips and mounted isometrically in a force transducer. Seven biopsies were used in the first part of the study when half of the strips were immersed in the hyponatraemic study solution S containing Na+ 120 mmol/L and observed for 1 hour, followed by 1 hour in normonatraemic control solution C containing Na+ 136 mmol/L, then again in S for 1 hour, and finally 1 hour in C. The other half of the strips were studied in reverse order, C-S-C-S. The remaining ten biopsies were included in the second part of the study. Response to increasing doses of oxytocin (OT) in solutions S and C was studied. In the first part of the study we calculated AUC, and created phase portrait plots of two different contractions from the same strip, one smooth and one biphasic. In both parts of the study we registered frequency and force of contractions, and described appearance of the contractions. RESULTS: First part of the study: Mean (median) contractions per hour in C: 8.7 (7.6), in S 14,3 (13). Mean (SD) difference between groups 5.6 (4.2), p = 0.018. Force of contractions in C: 11.8 (10.2) mN, in S: 10.8 (9.2) mN, p = 0.09, AUC increased in S; p = 0.018. Bi-/multiphasic contractions increased from 8% in C to 18% in S, p = 0.001. All changes were reversible in C. Second part of the study: Frequency after OT 1.65 x 10-9 M in C:3.4 (2.9), in S: 3.8 (3.2), difference between groups: p = 0.48. After OT 1.65 x 10-7 M in C: 7.8 (8.9), increase from previous OT administration: p = 0.09, in S: 8.7 (9.0), p = 0.04, difference between groups, p = 0.32. Only at the highest dose of OT dose was there an increase in force of contraction in S, p = 0.05, difference between groups, p = 0.33. Initial response to OT was more frequently bi/multiphasic in S, reaching significance at the highest dose of OT(1.65 x 10-7 M), p = 0.015. when almost all contractions were bi/multiphasic. CONCLUSION: Hyponatraemia reversibly increased frequency of contractions and appearance of bi-or multiphasic contractions, that could reduce myometrial contractility. This could explain the correlation of hyponatraemia and instrumental delivery previously observed. Contractions in the hyponatraemic solution more frequently showed initial multiphasic contractions when OT was added in increasing doses. Longer lasting labours carry the risk both of hyponatraemia and OT administration, and their negative interaction could be significant. Further studies should address this possibility.

The behavior of dairy cattle in late gestation: Effects of parity and dystocia.

The aim of this study was to objectively assess, using an automated behavioral monitoring system, any behavioral differences between primiparous and multiparous cows before calving, and to quantify any behavioral differences between assisted (dystocic) and unassisted (eutocic) calvings. Data were collected from 32 multiparous and 12 primiparous Holstein dairy cattle to describe normal calving behavior and parity differences. To quantify behavior related to calving difficulty, the data from 14 animals that had dystocia at calving were matched to cows that had an eutocic calving based on parity, locomotion score, calf breed, calf sex, month, and year of calving. An IceQube (IceRobotics Ltd., South Queensferry, United Kingdom) was fitted to the right hind leg of cows 4 wk before their expected calving date. Data for lying time, standing time, number of steps, motion index (total motion), and the total number of standing and lying bouts (postural transitions) were automatically collected and summed into 15-min blocks. Behavioral variables were summarized into 2-h periods and 24-h periods before analyses. Mixed-effect models were used to analyze cow behavior in the last 4 d before calving (d -4 to -1), and on the day of calving. In the 4 d before calving, compared with multiparous cows, primiparous cows lay down an average 2.8 h/d less, had 9.1 more postural transitions/d (37.7 ± 1.2 vs. 27.6 ± 0.7), walked 172 more steps/d, and had a higher motion index (2,673.2 vs. 1,981.5 units/d). There was an effect of 2-h period on all behavioral variables on the day of calving. No indicator of calving difficulty was found on the day of calving, nor the days leading up to calving. These findings suggest that parity should be considered when predicting the day of calving, and changes in cow behavior on the day of calving could be used to identify calving cows, and to predict the time of calving.

Success of trial of labor in women with a history of previous cesarean section for failed labor induction or labor dystocia: a retrospective cohort study.

BACKGROUND: The rates of cesarean section (CS) are increasing worldwide leading to an increased risk for maternal and neonatal complications in the subsequent pregnancy and labor. Previous studies have demonstrated that successful trial of labor after cesarean (TOLAC) is associated with the least maternal morbidity, but the risks of unsuccessful TOLAC exceed the risks of scheduled repeat CS. However, prediction of successful TOLAC is difficult, and only limited data on TOLAC in women with previous failed labor induction or labor dystocia exists. Our aim was to evaluate the success of TOLAC in women with a history of failed labor induction or labor dystocia, to compare the delivery outcomes according to stage of labor at time of previous CS, and to assess the risk factors for recurrent failed labor induction or labor dystocia. METHODS: This retrospective cohort study of 660 women with a prior CS for failed labor induction or labor dystocia undergoing TOLAC was carried out in Helsinki University Hospital, Finland, between 2013 and 2015. Data on the study population was obtained from the hospital database and analyzed using SPSS. RESULTS: The rate of vaginal delivery was 72.9% and the rate of repeat CS for failed induction or labor dystocia was 17.7%. The rate of successful TOLAC was 75.6% in women with a history of labor arrest in the first stage of labor, 73.1% in women with a history of labor arrest in the second stage of labor, and 59.0% in women with previous failed induction. The adjusted risk factors for recurrent failed induction or labor dystocia were maternal height < 160 cm (OR 1.9 95% CI 1.1-3.1), no prior vaginal delivery (OR 8.3 95% CI 3.5-19.8), type 1 or gestational diabetes (OR 1.8 95% CI 1.0-3.0), IOL for suspected non-diabetic fetal macrosomia (OR 10.8 95% CI 2.1-55.9) and birthweight ≥4500 g (OR 3.3 95% CI 1.3-7.9). CONCLUSIONS: TOLAC is a feasible option to scheduled repeat CS in women with a history of failed induction or labor dystocia. However, women with no previous vaginal delivery, maternal height < 160 cm, diabetes or suspected neonatal macrosomia (≥4500 g) may be at increased risk for failed TOLAC.

Influence of denaverine hydrochloride on calving ease in Holstein-Friesian heifers.

Calving is assumed to be an exhausting and painful event. A drug that eases the calving procedure and alleviates pain would help cows, especially those suffering from dystocia. In a randomized, controlled, and blinded trial, we measured the effect of denaverine hydrochloride on physical and physiological calving parameters. Eighty-three Holstein-Friesian heifers were included in the analysis. Pulling force was measured using a digital force gauge interposed between the calf and a mechanical calf puller. The concentration of cortisol was measured in serum before and after parturition. There was no effect of treatment group on calving modality (i.e., spontaneous vs. assisted calving), duration of calving, and cortisol concentration. The area under the curve of pulling force × time (n = 44), however, was significantly smaller in the treatment group compared with the placebo group. Also, duration of calving assistance was numerically shorter in the treatment group compared with the placebo group. The results provide evidence that calving ease can be influenced by denaverine hydrochloride during calving assistance.

Evaluating Fundal Dominant Contractions on Spatiotemporal Electrohysterography as a Marker for Effective Labor Contractions.

OBJECTIVE: To evaluate if fundal (F) dominance of the electrohysterogram is associated with vaginal delivery and lack of F dominance is associated with cesarean for labor dystocia. STUDY DESIGN: We conducted a prospective cohort study of nulliparous women in spontaneous labor at ≥36 weeks. Clinicians were blinded to electrohysterography data which were in addition to standard cardiotocography. All contractions in the hour preceding diagnosis of complete cervical dilation (for women delivering vaginally) or the hour preceding the decision for cesarean were analyzed. RESULTS: Of 224 patients, 167 had evaluable data. The proportion of F dominant contractions was not different for women undergoing cesarean for labor dystocia (n = 11) compared with all others (n = 156)-88.7 ± 10.2 versus 86.0 ± 11.4%; p = 0.44. Results were similar when comparing the cesarean for labor dystocia group to those undergoing cesarean for other indications (n = 10) and vaginal deliveries (n = 146)-88.7 ± 10.2 versus 86.5 ± 10.0 versus 85.9 ± 11.5%; p = 0.74. CONCLUSION: We were unable to confirm our earlier finding that F dominance of the electrohysterogram is associated with vaginal delivery and lack of F dominance is associated with cesarean for dystocia.

A Holstein-Friesian dairy farm survey of postparturient factors influencing the days to first AI and days open in Hungary.

The authors monitored the postpartum period during the first seven weeks after calving at a Holstein-Friesian dairy farm in Hungary. Calvings occurred between 2013 and 2015 in three periods from June to November each year (n = 314). Data were collected from the farm record and ultrasonographic examinations were performed between 22 to 28 and 43 to 49 days in milk (DIM), respectively. The animals were followed until successful artificial insemination (AI), i.e. until becoming pregnant or until culling, but at most at 365 DIM. The prevalence of dystocia, twin calving, stillbirth rate and retained fetal membranes (RFM) was 23.2%, 3.8%, 3.5%, and 34.4%, respectively. Altogether 38.9% of the cows (n = 122) had bacterial complications of involution in the first 49 DIM. The prevalence of Grade 2 clinical (puerperal) metritis (CM) was 20.1% within 5 DIM, 10.5% between 6 to 10 DIM and 13.1% from 11 to 20 DIM, while 9.9% of the cows had clinical endometritis (CEM) between 21 and 28 DIM and 1.3% of the cows between 42 and 49 DIM, respectively. Pyometra was diagnosed in 1% of the cows between 21 and 28 DIM and 0.3% between 42 to 49 DIM, respectively. About 80% (80.6%) of the cows were inseminated at least once (n = 253). The success rate of the first AI was 26.9% (n = 68). Dystocia, twin calving, RFM, CM, CEM and cyclicity had no significant effect on the days between calving and first AI, however, according to the Kaplan-Meier analysis stillbirth significantly increased the number of days from calving to first AI (P = 0.039). According to the Kaplan- Meier analysis dystocia, twin calving, stillbirth, RFM, and cyclicity had no effect on the days open. In cows with CM developed within 5 DIM or with CEM diagnosed between 21 and 28 DIM the number of days open significantly decreased (P = 0.009 and P = 0.007, respectively), which confirms the importance of early diagnosis and treatment of uterine diseases. Similar surveys should be conducted to discover the risk factors for reproductive diseases in order to decrease the reproductive losses in dairy farms.

A functional role for AMPK in female fertility and endometrial regeneration.

Adenosine monophosphate-activated protein kinase (AMPK) is a highly conserved heterotrimeric complex that acts as an intracellular energy sensor. Based on recent observations of AMPK expression in all structures of the female reproductive system, we hypothesized that AMPK is functionally required for maintaining fertility in the female. This hypothesis was tested by conditionally ablating the two catalytic alpha subunits of AMPK, Prkaa1 and Prkaa2, using Pgr-cre mice. After confirming the presence of PRKAA1, PRKAA2 and the active phospho-PRKAA1/2 in the gravid uterus by immunohistochemistry, control (Prkaa1/2 fl/fl ) and double conditional knockout mice (Prkaa1/2 d/d ) were placed into a six-month breeding trial. While the first litter size was comparable between Prkaa1/2 fl/fl and Prkaa1/2 d/d female mice (P = 0.8619), the size of all subsequent litters was dramatically reduced in Prkaa1/2 d/d female mice (P = 0.0015). All Prkaa1/2 d/d female mice experienced premature reproductive senescence or dystocia by the fourth parity. This phenotype manifested despite no difference in estrous cycle length, ovarian histology in young and old nulliparous or multiparous animals, mid-gestation serum progesterone levels or uterine expression of Esr1 or Pgr between Prkaa1/2 fl/fl and Prkaa1/2 d/d female mice suggesting that the hypothalamic-pituitary-ovary axis remained unaffected by PRKAA1/2 deficiency. However, an evaluation of uterine histology from multiparous animals identified extensive endometrial fibrosis and disorganized stromal-glandular architecture indicative of endometritis, a condition that causes subfertility or infertility in most mammals. Interestingly, Prkaa1/2 d/d female mice failed to undergo artificial decidualization. Collectively, these findings suggest that AMPK plays an essential role in endometrial regeneration following parturition and tissue remodeling that accompanies decidualization.

Clinical features of a fatal shoulder dystocia: The hypovolemic shock hypothesis.

Shoulder dystocia is a rare but severe obstetric complication associated with an increased risk of brachial plexus palsies, fractures of the clavicle and humerus, hypoxic-ischemic encephalopathy and, rarely, neonatal death. Here we describe a fatal case of shoulder dystocia in a term newborn, although labor was uneventful, fetal heart rate tracing was normal until the delivery of the head and the head-to-body delivery interval (HBDI) occurred within 5 min. Full resuscitation was performed for 35 min without success. Hemoglobin concentration evaluated on the umbilical cord still attached to the placenta was within normal range, while neonatal venous hemoglobin concentration blood gases at 9 min of life showed severe metabolic acidosis and anemia. As previously described by others, our case supports the hypothesis of a hypovolemic shock as the cause of neonatal death, probably due to acute placental retention of fetal blood. The death of the newborn following shoulder dystocia is an event that still presents numerous gaps in knowledge. Further research should focus on.

Population-Based Risk Factors for Shoulder Dystocia.

OBJECTIVE: To re-examine the risk factors for shoulder dystocia given the increasing rates of obesity and diabetes in pregnant women. DESIGN: Retrospective observational study. SETTING: Five hospitals located in Wisconsin, Florida, Maryland, Michigan, and Alabama. PARTICIPANTS: We evaluated 19,236 births that occurred between April 1, 2011, and July 25, 2013. METHODS: Data were collected from electronic medical records and used to evaluate the risk of shoulder dystocia. Data were analyzed using a generalized linear mixed model, which controlled for clustering due to site. RESULTS: When insulin was prescribed, gestational diabetes was associated with an increased risk of shoulder dystocia (odds ratio = 2.10, 95% confidence interval [1.01, 4.37]); however, no similar association was found with regard to gestational diabetes treated with glycemic agents or through diet. Use of epidural anesthesia was associated with an increased risk for shoulder dystocia (odds ratio = 3.47, 95% confidence interval [2.72, 4.42]). Being Black or Hispanic, being covered by Medicaid or having no insurance, infant gestational age of 41 weeks or greater, and chronic diabetes were other significant risk factors. CONCLUSION: With the changing characteristics of pregnant women, labor and birth clinicians care for more pregnant women who have an increased risk for shoulder dystocia. Our findings may help prospectively identify women with the greatest risk.

Defining and Managing Normal and Abnormal Second Stage of Labor.

The American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 49 on Dystocia and Augmentation of Labor defines a prolonged second stage as more than 2 hours without or 3 hours with epidural analgesia in nulliparous women, and 1 hour without, or 2 hours with epidural in multiparous women. This definition diagnoses 10% to 14% of nulliparous and 3% to 3.5% of multiparous women as having a prolonged second stage. Although current labor norms remained largely based on data established by Friedman in the 1950s, modern obstetric population and practice have evolved with time.

A comparison of 4 predictive models of calving assistance and difficulty in dairy heifers and cows.

The aim of this study was to build and compare predictive models of calving difficulty in dairy heifers and cows for the purpose of decision support and simulation modeling. Models to predict 3 levels of calving difficulty (unassisted, slight assistance, and considerable or veterinary assistance) were created using 4 machine learning techniques: multinomial regression, decision trees, random forests, and neural networks. The data used were sourced from 2,076 calving records in 10 Irish dairy herds. In total, 19.9 and 5.9% of calving events required slight assistance and considerable or veterinary assistance, respectively. Variables related to parity, genetics, BCS, breed, previous calving, and reproductive events and the calf were included in the analysis. Based on a stepwise regression modeling process, the variables included in the models were the dam's direct and maternal calving difficulty predicted transmitting abilities (PTA), BCS at calving, parity; calving assistance or difficulty at the previous calving; proportion of Holstein breed; sire breed; sire direct calving difficulty PTA; twinning; and 2-way interactions between calving BCS and previous calving difficulty and the direct calving difficulty PTA of dam and sire. The models were built using bootstrapping procedures on 70% of the data set. The held-back 30% of the data was used to evaluate the predictive performance of the models in terms of discrimination and calibration. The decision tree and random forest models omitted the effect of twinning and included only subsets of sire breeds. Only multinomial regression and neural networks explicitly included the modeled interactions. Calving BCS, calving difficulty PTA, and previous calving assistance ranked as highly important variables for all 4 models. The area under the receiver operating characteristic curve (ranging from 0.64 to 0.79) indicates that all of the models had good overall discriminatory power. The neural network and multinomial regression models performed best, correctly classifying 75% of calving cases and showing superior calibration, with an average error in predicted probability of 3.7 and 4.5%, respectively. The neural network and multinomial regression models developed are both suitable for use in decision-support and simulation modeling.