Peter E. Nielsen

Fetal heart rate changes after intrathecal sufentanil or epidural bupivicaine for labor analgesia: Incidence and clinical significance

The objective of this study was to compare the incidence of intrapartum fetal heart tracing (FHT) abnormalities and the obstetric outcome after intrathecal sufentanil (ITS) versus epidural bupivacaine (EB).During the period from April to September 1994, 129 patients who met inclusion criteria were prospectively identified during labor at a single university-affiliated hospital. Inclusion criteria included: singleton, gestational age >or=to36 wk, and cephalic presentation. In the ITS group, epidural anesthesia was not administered before 60 min after ITS. Sixty-five consecutive ITS patients were compared to 64 consecutive EB patients. Each FHT was reviewed independently by two obstetricians blinded to the type of analgesia. The FHT characteristics evaluated included baseline rate, variability, and periodic changes. No differences in the incidence of clinically significant FHT abnormalities (recurrent late decelerations and/or bradycardia) were observed between the two groups (ITS 21.5% versus EB 23.4%). The rates of clinically significant FHT abnormalities in both groups was not different when patients with hypotension and medical complications were excluded (16.9% vs 17.1%). In addition, equal rates of hypotension (18.5% vs 17.2%) were noted between the groups. In both groups there was a significantly higher risk of cesarean section in patients whose previously normal FHT became abnormal postanalgesia when compared to patients without a new onset FHT abnormality (ITS 28.6% [4/14] versus 2.0% [1/51], P < 0.01; EB 33.3% [5/15] versus 8.2% [4/49], P < 0.05). This increased risk was associated with an increase in cesarean section for nonreassuring FHT in both groups (ITS 14.3% [2/14] versus 0% [0/51], P = 0.04; EB 13.3% [2/15] versus 0% [0/49], P = 0.05). These results support the conclusion that the incidence of clinically significant FHT abnormalities and hypotension is equivalent in patients receiving ITS when compared to EB within the first hour of administration. During this period, patients should have continuous FHT monitoring since a new onset FHT abnormality unveils and alerts the physicians to a possible compromised fetal condition and a corresponding increased risk of cesarean section. (Anesth Analg 1996;83:742-6)

Clinical guidelines for occupational lifting in pregnancy: evidence summary and provisional recommendations

Empirically based lifting criteria established by the National Institute for Occupational Safety and Health (NIOSH) to reduce the risk of overexertion injuries in the general US working population were evaluated for application to pregnant workers. This report proposes criteria to guide decisions by medical providers about permissible weights for lifting tasks performed at work over the course of an uncomplicated pregnancy. Our evaluation included an extensive review of the literature linking occupational lifting to maternal and fetal health. Although it has been 29 years since the American Medical Associations Council on Scientific Affairs published its report on the Effects of Pregnancy on Work Performance, these guidelines continue to influence clinical decisions and workplace policies. Provisional clinical guidelines derived from the NIOSH lifting criteria that account for recent evidence for maternal and fetal health are presented and aim to improve the standard of care for pregnant workers.

Effect of Epidural Analgesia on Fundal Dominance during Spontaneous Active-Phase Nulliparous Labor

Background The purpose of this investigation was to determine if epidural analgesia, established during active phase labor, results in elimination or reversal of fundal dominance (lower uterine segment pressure equal to or greater than fundal pressure). Methods Upper and lower uterine segment intrauterine pressures were prospectively evaluated for 50 min before and 50 min after epidural analgesia using 0.25% bupivacaine in 11 nulliparous women in spontaneous active labor. A total of 958 contractions were evaluated. Results No significant differences were found in the number of contractions in the interval before epidural analgesia compared to after epidural analgesia. Significantly greater pressure readings were recorded in the upper segment than in the lower segment (consistent with fundal dominance) both before and after epidural analgesia (P < 0.01). In addition, fundal dominance increased after epidural analgesia when compared to the preanalgesia period (P < 0.01). Conclusions Fundal dominance is present both before and after active phase epidural analgesia and is increased during the immediate 50‐min postanalgesia period.

Elective Induction of Labor Compared With Expectant Management of Nulliparous Women at 39 Weeks of Gestation: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether the elective induction of labor in nulliparous women with an unfavorable cervix affects the cesarean delivery rate. METHODS: We conducted a randomized controlled trial at a tertiary care medical center. Nulliparous woman between 38 0/7 and 38 6/7 weeks of gestation who were least 18 years of age with a singleton gestation and a Bishop score of 5 or less were randomized to elective induction of labor or expectant management. The induction of labor group was induced within 1 week of enrollment but not before 39 0/7 weeks of gestation. The control group continued routine prenatal care with admission for labor or obstetric indication. The primary outcome was cesarean delivery. Assuming a 20% rate in women in a control group, 80% power, and a goal to detect a twofold increase to 40% in the induction of labor group, 162 patients were needed. RESULTS: From March 2010 to February 2014, 82 patients were randomly allocated to induction of labor and 80 to expectant management. Baseline characteristics were similar between groups. The cesarean delivery rate in the induction of labor group was 30.5% (25/82) compared with 17.7% (14/79) in the expectant management group (relative risk 1.72, 95% confidence interval 0.96–3.06). CONCLUSION: In nulliparous women with a Bishop score of 5 or less, elective induction after 39 0/7 weeks of gestation compared with expectant management of pregnancy did not double the rate of cesarean delivery. CLINICAL TRIAL REGISTRACTION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01076062. LEVEL OF EVIDENCE: I

Elective Induction of Nulliparous Labor at 39 Weeks of Gestation: A Randomized Clinical Trial

INTRODUCTION: Elective induction of labor is common despite the paucity of prospective data on maternal and neonatal outcomes. The objective of this study was to investigate the effect of induction of labor, at 39 weeks of gestation, on the frequency of cesarean delivery in nulliparous women with an unfavorable cervix compared with expectant management. METHODS: Nulliparous women aged 18–40 years with an uncomplicated pregnancy and a Bishop score of 5 or less receiving care at single medical center were assigned to induction of labor at 39 weeks of gestation or to expectant management in a parallel group randomized clinical trial. Maternal and neonatal outcome data were analyzed for 156 women. RESULTS: Cesarean delivery occurred in 24 of 78 (30.7%) patients in the induction of labor group and in 14 of 78 (18%) patients in the expectant management group (relative risk 1.7, 95% confidence interval 0.96–3.06, P=.07). Time from admission to delivery was longer in the induction of labor group. Meconium-stained amniotic fluid occurred more often in the expectant management group. There were no differences observed in the frequency of other outcomes. CONCLUSIONS: Cesarean deliveries in nulliparous women with an unfavorable cervix were not increased in those electively induced at 39 weeks of gestation compared with those expectantly managed. Further investigation into the clinical use of elective induction is warranted in larger multicenter trials. Based on this study, concern over maternal and neonatal outcomes including mode of delivery should not be perceived as stumbling blocks to further study of this commonly used yet understudied intervention.

Unintended pregnancy among active-duty servicewomen and veterans

TO THE EDITORS: We applaud the efforts made by the auhors to review the published literature on unintended pregancy and highlight these outcomes in active-duty serviceomen and veterans. We also recognize that the rate of nintended pregnancy has remained at approximately 50% in he United States for at least the past 15 years and remains one f the highest among industrialized nations. In addition, the enters for Disease Control and Prevention reports that the ercentage of births occurring within 24 months of a previous irth increased from 11% in 1995 to 21% in 2002, which is oving in the opposite direction from the Healthy People 2010 arget rate of 6%. Military obstetrician/gynecologists remain committed to both improving patient education and optimizing use of available contraceptive methods in order to reduce the rate of unintended pregnancy, consistent with the Healthy People 2010 goal of 30%. While we agree that improvements n patient education and more consistent use of contraception re necessary to reduce this rate, especially in women of ounger age, unmarried status, and lower educational levels, e dispute the claim by the authors that there is limited proider knowledge regarding available contraceptive methods. Military physicians have extensive knowledge of contraception and family planning, and have provided comprehensive education and educational materials to servicewomen, their leaders, and providers for many years. This includes a long-standing deployment readiness guide first published by the US Army Public Health Command in 2001 (and updated in June 2010) that specifically addresses these issues in an easy-to-understand format. In addition, the US Army Surgeon General has ecently convened a Women’s Health Task Force that is acively working on improving products and processes to enance education and training on a variety of women’s health are topics for servicewomen. We appreciate the efforts of both ilitary and civilian physicians to continue diligently providng contraception education to both servicewomen and the pouses of active-duty servicemen to reduce unintended pregancies. In addition, initiatives to reduce both occasional and hort-term non-use of contraception, which remains a comon problem in the United States, are also required. The miltary health care system and military obstetrician/gynecologists emain committed to these enterprises, along with our Departent of Veterans Affairs and civilian colleagues.

Self-Reported Changes in Comfort Level With Basic OB/GYN Procedures After Deployment

OBJECTIVE To assess the specialty-specific procedures and clinical encounters U.S. Army obstetrician/gynecologist (OB/GYN) providers felt were affected by deployment and identify skills and areas that may benefit from postdeployment training. METHODS Active duty Army OB/GYN physicians were invited to participate in an anonymous web-based survey to rate their comfort level and experience performing specialty-specific procedures before and after military deployment. Physicians rated their comfort level on a 5-point Likert scale (1 = very uncomfortable to 5 = completely comfortable). Statistical analysis included Pearson χ(2) and McNemars χ(2) with a p value of <0.05 considered significant. RESULTS Of the 100 physicians eligible to complete the survey, 66 responded (response rate = 66%). Their responses demonstrated a statistically significant perception of decline in their comfort level with nearly every obstetric and gynecologic procedure and clinical encounter evaluated. CONCLUSION Time away from regular clinical practice during deployment results in providers feeling less comfortable with many common OB/GYN procedures and clinical situations. Although these results are not a measure of actual performance, this information helps define targets to focus refresher training for providers who leave their normal scope of practice for deployment. These findings apply to civilian providers leaving practice for other reasons as well.

333: Admission pulse pressure is a novel predictor of fetal heart rate abnormalities following initial dosing of a labor epidural: a retrospective cohort study

have an Apgar of 7 at 5min (p 0.5), a cord pH of 7.1 (p 0.5) or require admission to the neonatal unit (p 0.47) regardless of onset of labor. CONCLUSION: This study represents robust and reliable data relating to IOL in multiparous twin pregnancies. Women who were induced were more likely to be older, and deliver larger infants. IOL did not carry an increased risk of Cesarean or instrumental delivery. There was also no evidence of increased maternal or neonatal morbidity associated with IOL.