Titrated oral misoprostol versus static regimen of oral misoprostol for induction of labour: a systematic review and meta-analysis.

We aimed to conduct a systematic review and meta-analysis to compare the efficacy and safety of titrated oral misoprostol versus static oral misoprostol for labour induction. We searched for the available randomised clinical trials (RCTs) in the Cochrane Library, PubMed, ISI web of science, Scopus, and ClinicalTrials.gov. We included RCTs compared titrated oral misoprostol versus static regimen of oral misoprostol during labour induction. Our main outcomes were vaginal and caesarean delivery rates, uterine tachysystole, misoprostol side effects, and neonatal adverse events. Three RCTs met our inclusion criteria with a total number of 360 patients. The vaginal delivery rate did not significantly differ between both groups (p = 0.49). Titrated oral misoprostol was associated with significant increase in the caesarean delivery rate compared to static oral misoprostol (p = 0.04). Moreover, titrated oral misoprostol led to significant increase in the uterine tachysystole and misoprostol side effects (p = 0.01 & p = 0.003, respectively). There were no differences among both groups regarding different neonatal adverse events. In conclusion, titrated oral misoprostol increases the incidence of caesarean delivery, uterine tachysystole, and misoprostol side effects with a similar vaginal delivery rate compared to static dose misoprostol. Thus, static oral misoprostol should be used instead of titrated oral misoprostol during labour induction. Impact StatementWhat is already known on this subject? Different studies have evaluated titrated oral misoprostol administration for induction of labour and proved their efficacy in comparison with other induction methods. However, there is controversy among the published studies between titrated oral misoprostol and static oral misoprostol during induction of labour. A recent study concluded that hourly titrated misoprostol and static oral misoprostol are equally safe and effective when utilised for induction of labour with no fear of any adverse events. However, another study recommended static oral misoprostol administration for labour induction as it was linked to a lower caesarean section incidence, fewer drug side effects, and decline in complication rates in comparison with titrated oral misoprostol.What the results of this study add? Titrated oral misoprostol increases the incidence of caesarean delivery, uterine tachysystole, and misoprostol side effects with a similar vaginal delivery rate compared to static dose misoprostol.What the implications are of these findings for clinical practice and/or further research? Static oral misoprostol should be used instead of titrated oral misoprostol during labour induction. More future trials are required to confirm our findings.

Improving labour progression among women with epidural anesthesia following use of a birthing ball: a review of recent literature.

Epidural anaesthesia is an effective form of pain relief during vaginal deliveries. However, neuraxial anaesthesia may slow the progression of labour. The assumption that epidurals lead to increased caesarean sections is also a topic of current debate. A holistic approach with the use of a birthing ball has been advocated as a potential modality to decrease labouring times and, therefore, reduce progression to caesarean section. Birthing balls aim to increase pelvic outlet opening, which facilitates labouring. Our aim is to review recent literature pertaining to birthing balls and their role in improving quality and outcomes of vaginal deliveries in patients with epidurals.IMPACT STATEMENTWhat is already known on the subject? Epidural anaesthesia may slow the progression of labour. It has been hypothesised that slowing progression of labour is associated with increased rates of vacuum and forceps delivery. Most common clinical indication for caesarean section is failure to progress during labour. Birthing Balls have been shown to quicken the progression of labour, theoretically reducing caesarean sections with those with epidurals.What do the results of the study add? Several studies have demonstrated a reduced duration of first and second stage of labour among women with epidural anaesthesia, but the existing literature is limited, and interpretation of results may be restricted by generalizability and inherent study biases. The objective of this article is to review existing literature and highlight the potential clinical utility of birthing balls in current obstetric practice.What are the implications of these findings for clinical practice and further research? Use of birthing balls has been advocated to decrease labouring time and therefore reduce progression to caesarean section. Larger studies or meta-analysis would be required to confirm potential benefits of birthing ball use.

Human Chorionic Gonadotropin Has Anti-Inflammatory Effects at the Maternal-Fetal Interface and Prevents Endotoxin-Induced Preterm Birth, but Causes Dystocia and Fetal Compromise in Mice.

Human chorionic gonadotropin (hCG) is implicated in the maintenance of uterine quiescence by down-regulating myometrial gap junctions during pregnancy, and it was considered as a strategy to prevent preterm birth after the occurrence of preterm labor. However, the effect of hCG on innate and adaptive immune cells implicated in parturition is poorly understood. Herein, we investigated the immune effects of hCG at the maternal-fetal interface during late gestation, and whether this hormone can safely prevent endotoxin-induced preterm birth. Using immunophenotyping, we demonstrated that hCG has immune effects at the maternal-fetal interface (decidual tissues) by: 1) increasing the proportion of regulatory T cells; 2) reducing the proportion of macrophages and neutrophils; 3) inducing an M1 → M2 macrophage polarization; and 4) increasing the proportion of T helper 17 cells. Next, ELISAs were used to determine whether the local immune changes were associated with systemic concentrations of progesterone, estradiol, and/or cytokines (IFNgamma, IL1beta, IL2, IL4, IL5, IL6, IL10, IL12p70, KC/GRO, and TNFalpha). Plasma concentrations of IL1beta, but not progesterone, estradiol, or any other cytokine, were increased following hCG administration. Pretreatment with hCG prevented endotoxin-induced preterm birth by 44%, proving the effectiveness of this hormone as an anti-inflammatory agent. However, hCG administration alone caused dystocia and fetal compromise, as proven by Doppler ultrasound. These results provide insight into the mechanisms whereby hCG induces an anti-inflammatory microenvironment at the maternal-fetal interface during late gestation, and demonstrate its effectiveness in preventing preterm labor/birth. However, the deleterious effects of this hormone on mothers and fetuses warrant caution.

Analgesia epidural en obstetricia: ¿cómo afecta al desarrollo y finalización del parto? / Epidural analgesia in obstetrics: Is there an effect on labor and delivery?

Introducción: La analgesia epidural es el estándar de la analgesia obstétrica, pero se le atribuye una posible influencia en la dinámica del parto que puede provocar un aumento de los partos instrumentados y cesáreas. Nuestro objetivo fue valorar en una cohorte de pacientes obstétricas la finalización del parto en relación con el tipo de analgesia empleado. Pacientes y método: Estudio prospectivo de cohorte de gestantes a término divididas en 2 grupos. El grupo A recibió analgesia epidural y el grupo B no recibió analgesia epidural. Se compararon las variables demográficas materno-fetales, obstétricas y tipo de parto en cada grupo y se estudiaron la influencia de la analgesia epidural y las causas probables que provocaron partos distócicos. Resultados: Se incluyeron 602 pacientes: 462 en grupo A y 140 en grupo B. La analgesia epidural se relacionó con una mayor tasa de partos instrumentales pero no de cesáreas (p < 0,01), mayor necesidad de oxitócicos (30,7% en grupo A vs 0% en grupo B, p < 0,001) y una mayor duración de las fases del parto (fase de dilatación 6,4 ± 4,2 h en grupo A frente a 4,7 ± 3,5 h en grupo B y fase expulsivo 1,0 ± 0,6 h frente a 0,7 ± 0,6 h, p < 0,01), sin influir en la tasa de desgarros, episiotomías ni otras variables. La mayor duración del primer (OR 1,2 IC95% 1,1-1,3) y segundo estadios del parto (OR 2,3 IC95% 1,3-3,9) del trabajo de parto y la obesidad materna (OR: 1,1 IC95% 0,9-1,2) se relacionaron con aumento del riesgo de partos distócicos, mientras que la multiparidad e iniciar la analgesia epidural con una presentación en el I plano de Hodge o superior lo disminuyeron 2,7 y 3,03 veces respectivamente. Discusión: Pese a que clásicamente se ha relacionado la analgesia epidural con un aumento de partos distócicos, en nuestra cohorte dicha influencia es discutible. El posible incremento pareció deberse a factores obstétricos como mayor duración de los estadios del parto, mayor índice de masa corporal y la primiparidad(AU)

Background and objective: Epidural analgesia is routinely used in obstetrics but has been blamed for possible effects on labor that lead to greater use of instruments or conversion to cesarean delivery. We aimed to assess this possibility in a cohort of obstetric patients receiving or not receiving epidural analgesia. Patients and methods: Prospectively enrolled full-term obstetric patients were distributed in 2 groups according to whether they received epidural analgesia or not. We compared maternal and fetal characteristics, obstetric variables, and type of delivery between groups to record the likely causes of difficult labor and delivery and detect a possible influence of epidural analgesia. Results: Of a total of 602 patients, 462 received epidural analgesia and 140 did not. Epidural analgesia was related to a higher rate of use of instruments but not cesareans (P<.01) and more frequent need for oxytocin (30.7% of the epidural analgesia group vs 0% of the group receiving no epidural analgesia, P<.001). The women receiving analgesia also had a longer mean (SD) duration of the dilatation phase of labor (6.4 [4.2] hours in the epidural group vs 4.7 [3.5] hours in the no-epidural group, P<.01) and of the expulsion phase (1.0 [0.6] hours vs 0.7 [0.6] hours, respectively; P<.01). We observed no effects on the incidence of tearing, rate of episiotomy, or other variables. Predictors of instrumentation or conversion to cesarean delivery were longer duration of the first phase (odds ratio [OR] 1.2; 95% confidence interval [CI], 1.1-1.3), longer duration of the second phase (OR 2.3; 95% CI, 1.3-3.9), and maternal obesity (OR, 1.1; 95% CI, 0.9-1.2). Previous deliveries and initiation of epidural analgesia after the fetus has reached Hodge’s first plane decreased risk 2.7-fold and 3.03-fold, respectively. Conclusions: Although epidural analgesia has traditionally been associated with a higher incidence of difficult labor and delivery, this association was not unequivocally evident in this cohort of patients. The apparent increase seems to be attributable to such obstetric factors as longer duration of stages of labor, higher body mass index, and first delivery(AU)

Effect of administration of a controlled-release monensin capsule on incidence of calving-related disorders, fertility, and milk yield in dairy cows.

OBJECTIVE: To determine the effect of a controlled-release monensin capsule administered at cessation of lactation on incidence of calving-related disorders, fertility, and milk yield in dairy cows. ANIMALS: 290 dairy cows treated with monensin and 290 untreated control cows. PROCEDURE: Treated cows received a capsule that released monensin at 335 mg/d for 95 days. Incidence of calving-related disorders; daily milk yield up to 20 days postpartum; test-day milk yield, fat, protein, and mature-equivalent 305-day milk production; and body condition score at calving were determined. Reproductive variables were conception rate at first service, pregnancy rate, and calving-to-conception interval. RESULTS: Cows treated with monensin were 2.1 times as likely to develop dystocia and 0.8 times as likely to develop metritis as control cows. For milk yield, there was an interaction of treatment X time X parity. In multiparous cows, monensin significantly improved milk yield at test days 4 and 7. In addition, monensin increased body condition score at calving. CONCLUSIONS AND CLINICAL RELEVANCE: Despite increasing the likelihood of developing dystocia and metritis, administration of monensin improved the lactational performance of multiparous cows and may be a promising additive for use at the time of cessation of lactation.

Does epidural analgesia cause dystocia?

STUDY OBJECTIVE: To analyze the effects of epidural analgesia for labor when dystocia occurs. DESIGN: Retrospective cohort study. SETTING: Academic health center. PATIENTS: 641 low risk, nulliparous women in spontaneous labor. INTERVENTIONS: 406 (63%) women received epidurals analgesia and 253 (37%) did not. Sixty women (9.4%) required an abdominal delivery for dystocia. MEASUREMENTS AND MAIN RESULTS: Women receiving epidural analgesia were more likely to be white, receive care from an attending physician, need labor augmentation, and deliver a heavier infant. Multivariate analysis identified five variables predictive of dystocia and abdominal delivery: pitocin augmentation odds ratio (O.R.) = 3.9 (2.0 to 7.6), duration of labor more than 20 hours O.R. = 2.4 (1.3 to 4.4), high epidural dose O.R. = 2.2 (1.2 to 4.1), birthweight over 4,000 grams O.R. = 2.0 (1.0 to 4.2), and early placement of epidural O.R. = 1. 9 (1.0 to 3.5). Repeating the regression after excluding the 20 women who developed abnormal labor prior to epidural placement (18 of 20 women had protracted dilatation) demonstrated that pitocin augmentation O.R. = 4.0 (1.8 to 4.), high epidural dose O.R. = 3.0 (1.9 to 6.2), duration of labor greater than 20 hours O.R. = 2.7 (1.3 to 5.7), and birthweight over 4,000 grams O.R. = 2.1 (0. 9 to 4.8) were associated with dystocia. CONCLUSION: Epidural analgesia appears to be a marker of abnormal labor rather than a cause of dystocia. High concentration anesthetics and epinephrine should be avoided, as they may influence labor. Randomized, controlled trials of this technique will be difficult to do; our work should reassure patients and their clinicians that epidural analgesia does not adversely affect labor.

Probable función de las vías serotoninérgicas del tallo cerebral en el trabajo de parto en la rata / Probable function of serotonergic pathways of the brainstem in parturition labor in the ratas

La aplicación de serotonina (5-HT) en el núcleo del tracto solitario (NTS) de la rata grávida a término produjo distocia, la que consistió en la supresión del parto o bien, en el retraso del mismo (7-30 horas). En relación a la salud de los productos, en el primer caso, todos los productos murieron en el útero, mientras que en el segundo, una parte de ellos murió durante el trabajo de parto (30-70 por ciento). En contraste, en las ratas del grupo control el parto ocurrió en la fecha esperada o bien, con un ligero retraso (2-4 horas), pero en ambos casos, los productos nacieron normales. Finalmente, dicha distocia probablemente se debe a la disfunción de los sistemas eferentes ocitocinérgico, tanto el humoral magnocelular, como el neural parvocelular, ya sea por la inhibición que ocurre en el NTS, lo que interrumpe la información proveniente principalmente del cérvix uterino o bien por la activación de la vías serotoninérgicas centrales. Esto probablemente disminuye la actividad eléctrica del núcleo supraquiasmático (NSQ), lo que a su vez, produciría una disfunción del núcleo paraventricular (NPV)

[Planned delivery by oxytocin infusion in relation to cephalic dystocia].

To investigate the effect of initiating labor by oxytocin infusion on the outcome of delivery in cephalic presentation, the dystocia rate and final modes of delivery were analyzed in 3,090 cases of head presentation using oxytocin infusion and 2,982 cases with spontaneous onset of labor as control group. The results showed that 562 of the cases using oxytocin developed cephalic dystocia, a rate of 18.2%, while 371(12.4%) of the control group had dystocia. Besides, cephalic dystocia, rates of episiotomy, vacuum extraction and cesarean section were all significantly higher in the oxytocin group than those in the control (P < 0.005). Data also showed that the higher dosage, the more frequency and the longer time of pitocin infusion the higher the rate of dystocia.

Use of a beta 2-adrenergic stimulant (clenbuterol) for eliminating night-time calving.

To determine whether beta 2-adrenergic stimulant (clenbuterol) would exhibit beneficial effects upon the elimination of night-time calving, 42 Holstein Friesian cows and heifers at the first stage of labour were injected intramuscularly twice with clenbuterol; 300 micrograms at 18:00 and 210 micrograms at 22:00. Other 26 cows and heifers of the same breed at the first stage of labour at 18:00 were not treated and served as controls. All of the treated animals, but one, calved after 5:00 in the next morning, showing a peak of parturition between 5:00 and 10:00. In contrast to this, 42% of the control animals calved at night between 22:00 and 5:00. Thus, the double administrations of clenbuterol were shown to be effective for eliminating night-time calving. The cows treated with clenbuterol tended to show lower incidences of dystocia and retained placenta and a higher first insemination conception rate than the control animals. No adverse effects of the treatment on the viability of newborn calves and milk yields were observed.

Effects of bromocriptine and perphenazine on prolactin and progesterone concentrations in pregnant pony mares during late gestation.

Pregnant pony mares in Group A (n = 4) received i.m. injections at 07:00 and 17:00 h of 0.8 mg bromocriptine/kg body weight 0.75 per day beginning on Day 295 of gestation and continuing until parturition. Group B (n = 4) was treated similarly, but perphenazine was administered orally at 0.375 mg/kg body weight twice a day beginning on Day 305 of gestation and continuing until parturition. Mares in Group C (n = 3) received i.m. injections of saline. Mean plasma prolactin and progesterone concentrations were greater (P less than 0.05) for mares in Group C than in Groups A and B from 295 to 309 days of gestation. From 305 days of gestation, plasma prolactin and progesterone concentrations were greater (P less than 0.05) in Group B and C than in Group A mares. Progesterone and prolactin concentrations increased over this period for Group B and Group C mares, but remained constant in Group A mares. From 10 days pre partum through foaling, mares in Group A had lower progesterone (P less than 0.05) and prolactin (P less than 0.01) concentrations than Group B and C mares. All mares in Group A were agalactic at foaling, while all mares in Groups B and C had normal milk secretion. Gestation was longer (P less than 0.05) in Group A than in Group C mares. In Group A, 2 mares retained the placenta for greater than 3 h, 3 mares had dystocia and all 4 mares had thickened, haemorrhagic placentae.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of prenatal trenbolone acetate treatment on lamb performance and carcass characteristics.

Forty-three pregnant Dorset and Dorset crossbred ewes were assigned randomly to a control group or implanted with either 300 mg trenbolone acetate (Low TBA) or 1,200 mg trenbolone acetate (High TBA) between d 40 and 60 of gestation. Adjusted weaning weights for ewe lambs were 23.3% less (P less than .10) with vs without TBA treatments. Postweaning ADG of ewe lambs was lower (P less than .05) but ADG of ram lambs was greater (P less than .05) for high TBA vs low TBA. Ewe lambs receiving high TBA had 19% less (P less than .05) gain per unit of feed than those receiving low TBA. Days on test for ewe lambs was greater (P less than .05) due to TBA treatment and for high TBA vs low TBA. Days on test for ram lambs was decreased (P less than .05) due to high TBA compared to low TBA. Subcutaneous fat over the ribeye and lower rib were greater (P less than .05) for high-TBA ewe lambs vs low-TBA ewe lambs. Percentage kidney and pelvic fat of ewe lambs was lower (P less than .05) due to TBA treatments. Ribeye area per unit of carcass weight was lower (P less than .05) in high-TBA ewe lambs vs low-TBA ewe lambs. Yield grade of ewe lambs was lower (P less than .05) for low TBA vs high TBA. Prenatal trenbolone acetate treatment of ewe lambs did not improve their subsequent postnatal growth performance and carcass traits. In addition, TBA implantation of the pregnant ewe produced dystocia and less milk production, as evidenced by the need for more lambs to be grafted.

Effects of epidural analgesia: some questions and answers.

The effects of epidural analgesia on first labors have been studied by Thorp and colleagues. One study has been published and is the subject of a question-and-answer discussion, presented here. In this study 711 consecutive nulliparous women at term, with spontaneous onset of labor and cephalic presentation, were divided into one group (n = 447) who received epidural analgesia in labor and another group (n = 264) who received narcotics or no analgesia. The frequency of cesarean section for dystocia was significantly greater (p less than 0.005) in the epidural group (10.3%) than in the nonepidural group (3.8%), even after selection bias was corrected and the variables of maternal age and race; gestational age; cervical dilatation on admission; use, duration, and maximum infusion rate of oxytocin; labor duration; presence of meconium; and birth weight were controlled. For both groups the frequency of cesarean section for fetal distress was similar (p less than 0.20), and the frequency of low Apgar scores at 5 minutes and cord blood gas values showed no significant differences. The authors concluded that "epidural analgesia in labor may increase the incidence of cesarean section for dystocia in nulliparous women".

Long-term performance and health cows experimentally exposed to polybrominated biphenyls.

Fifteen Holstein cows were studied for up to 15 00 days to determine whether exposure to polybrominated biphenyls produced latent or subtle toxicosis not evident in previous acute or short studies. Animals for these long studies came from three groups given 0, .25, or 250 mg of fireMaster BP-6 per day for 60 days in 1975. Another group that received 250 mg of BP-6 for 180 or 202 days in 1976 also was studied. Individual animals were in their second, third, or fourth lactations. Milk production was not different among experimental groups, and mature body weights were similar. Increases in the amount or duration of exposure did not increase number of infections, dysfunctions, or general injuries. Exposure to 250 mg/day for 60, 180, or 202 days increased frequencies of reproductive disorders at parturition, particularly related to and following a high incidence of dystocia. A contributing factor to dystocia was larger birth weights of calves from cows exposed to 250 mg daily as compared to calves from cows exposed to 0 or .25 mg polybrominated biphenyls. Although reproductive dysfunctions required more veterinary care, numbers of services per conception were not different among groups.

Macrosomia. A proposed indication for primary cesarean section.

Fetal macrosomia (birthweight equal to or in excess of 4500 g) in a study of 110 affected infants was associated with excessive maternal weight, prolonged gestation, white race, multiparity, maternal diabetes, male fetus, and a previous macrosomic infant. The two most common obstetric complications associated with fetal macrosomia were postpartum hemorrhage and shoulder dystocia. One-minute Apgar score was less than 7 in 10.9% of the macrosomic infants, in contrast to 6.3% for the smaller infants studied as controls. The low fetal mortality rate (1.8%) was attributed to a 22.5% cesarean rate for the macrosomia group. Even more frequent use of abdominal delivery might further reduce obstetric and neonatal complications for macrosomic infants.