Journal of Pregnancy Risk factors for cephalopelvic disproportion in nulliparous women are especially important because they represent the. Cephalopelvic disproportion occurs when there is mismatch between the size of texts, articles from indexed journals, and references cited in published works. Cephalopelvic disproportion and caesarean section. G J Jarvis Articles from British Medical Journal are provided here courtesy of BMJ Publishing Group.
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Cephalopelvic disproportion and caesarean section.
To receive news and publication updates for Journal of Pregnancy, enter your email address in the box below. Nicholson and Lisa C. This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Present within each of these studies were nulliparous women with risk factors for cephalopelvic disproportion.
Risk factors for cephalopelvic disproportion in nulliparous women are especially important because they represent the precursors for the most common indication for primary cesarean delivery.
Labor management and clinical outcomes for each case are presented. A simple table summarizing induction rates and birth outcome rates of exposed versus nonexposed nulliparous women is also presented. Because the mode of delivery of the first birth substantially impacts birth options in later pregnancies, the impact of AMOR-IPAT on nulliparous patients is particularly important.
Determining the UL-OTDcpd in nulliparous patients, and carefully inducing each patient who has not entered labor by her UL-OTDcpd, may be an effective way of lowering rates of cesarean delivery in nulliparous women. Over the past two decades, national cesarean section rates have risen dramatically [ 1 ]. Inthis rate increased to Despite the fact that cesarean section deliveries are associated with increased risk of intra- and postpartum complications for both mothers and babies [ 3 ], no strategy to prevent cesarean delivery has been developed.
Cephalopelvic disproportion and caesarean section.
We recently completed two urban retrospective studies that demonstrated strong associations between exposure to an alternative method of care, called the Active Management of Risk in Pregnancy at Term AMOR-IPATand very low cesarean delivery rates [ 45 ]. AMOR-IPAT uses risk-driven prostaglandin-assisted preventive induction of labor to promote delivery before prenatal risk can develop into the two major indications for primary cesarean delivery: The prevention of primary cesarean delivery is especially important because the mode of delivery strongly impacts both the outcomes of the index pregnancy and the management and outcome of future pregnancies [ 67 ].
In each paper of this four-part series, we present three cases that outline the prenatal risks, clinical management, and birth outcomes of patients exposed to AMOR-IPAT.
This paper, the first of the series, focuses on nulliparous women with risk factors for CPD. The second paper will focus on nulliparous women with risk factors for UPI, the third on multiparous women with risk factors for CPD, and the fourth on multiparous women with risk factors for UPI.
We hope that these papers will shed some light on the inner workings of AMOR-IPAT and its potential to reduce, in a safe and preventive fashion, primary cesarean delivery rates.
Primary cesarean delivery is more common in nulliparous than multiparous women, and the mode of delivery of the first birth clearly has a major impact on future pregnancies. In addition, increasing rates of complications with repeat cesarean delivery have been associated with increasing number of previous cesarean deliveries [ 6 ]. The most common indication for primary cesarean delivery in nulliparous women is cephalopelvic disproportion CPD [ 8 ].
CPD usually refers to the condition where the fetal head is too large to fit through the maternal pelvis.
Most risk factors for CPD have an established odds ratio that quantifies its impact on cesarean delivery risk. In either case, if spontaneous labor has not started on or before the UL-OTDcpd, then preventive labor induction is recommended. These cases are followed by Table 1 that contains summary information concerning rates of labor induction, prostaglandin usage, and cesarean delivery in nulliparous women with risk factors for CPD in the first two urban studies of AMOR-IPAT.
Clearly, in the AMOR-IPAT exposed group, labor induction and the use of prostaglandin for cervical ripening were used more frequently, and cesarean delivery occurred less frequently.
Due to the combination of impending CPD and impending pre-eclampsia, she was scheduled for preventive induction at 38 weeks and 2 days estimated gestational age.
She presented to the hospital on the evening prior to her delivery, and her fetus was noted to have a vertex presentation. Her cervical exam was unchanged. One hour after the dinoprostone was removed, a pitocin drip was added to maintain and further augment her contractions. Cervical change started to occur about three hours later, that is, around noontime.
She was completely dilated hours later. She made steady progress with pushing, and her blood pressure remained within normal limits. She required external uterine massage, one dose of IM methergine and additional IV pitocin.
Her postpartum hemoglobin was 9. Both the mother and her infant were discharged to home on the second postpartum day in good condition. We believe that, had she been allowed to gestate past 40 week gestation, she would have had a baby weighing eight pounds or more and would have probably required a cesarean delivery for second stage arrest of labor.
A G1 P0 woman in her early 20s was known to have severe depression but otherwise had an uncomplicated past medical history. However, gestational sac measurement on this first ultrasound suggested an EDC that was six days later than the EDC provided by the fetal crown-rump length. Following a review of this information, her final composite EDC was based on the crown-rump length measurement as this balanced the other two estimates.
Her BMI at conception was Her one-hour gram glucola challenge was well within normal limits. The lower limit of her optimal time of delivery LL-OTD was estimated to be 38 weeks 0 days gestation. The patient requested elective induction as soon as possible because of the relatively large size of her fetus noted during the third ultrasound. She was offered preventive induction of labor at 38 weeks 1 day gestation due to multiple risk factors for CPD and she accepted this offer.
She presented to the hospital one week later at 38 weeks 1 days gestation. An NST was reactive, and she had normal vital signs.
Contractions started two hours later, and cervical change was first noted 5 hours after the start of her induction. Artificial rupture of membranes produced clear amniotic fluid.
She refused all analgesics. Over the next hour, her fetal heart tracing revealed mild intermittent late decelerations that were successfully treated with left lateral positioning and oxygen.
Her contraction frequency and strength began to fade in the late evening, and IV pitocin was started just before midnight. Thereafter, a regular contraction pattern returned. She pushed for about an hour and finally delivered an 8 pound 0 ounce infant over a small second degree perineal tear.
She and her infant had unremarkable postpartum courses, and both were discharged to home in good condition on postpartum day 2. We believe that, had her delivery been delayed for another weeks, the infant would have grown another 4—8 ounces [ 1011 ], and the chance of cesarean delivery for CPD would have been considerably higher.
In addition, the presence of late decelerations during this labor suggests that, had her delivery been delayed another weeks, with associated placental aging, the likelihood of fetal intolerance to labor requiring a cesarean delivery would have also increased. An year-old G2 P female had an uncertain last menstrual period, but a 19 week ultrasound was used to determine her EDC. A second ultrasound at around 27 weeks estimated gestational age suggested an EDC to two days earlier than previously estimated.
Due to concerns about the presence of multiple risk factors, and very significant journall of each risk factor, she was admitted at 38 weeks 3 days gestation for induction of labor for impending CPD.
Her fetus joufnal a vertex presentation. She received a hour course of dinoprostone per vagina pledget followed by 8 hours of IV pitocin augmentation. Her cervix appeared unchanged at the end of the first day, and the pitocin was stopped. She had supper and a shower, and a second dose of dinoprostone was placed.
Ten hours later, the dephalopelvic dose of dinoprostone was removed, and IV pitocin was restarted. Artificial rupture of membranes revealed clear amniotic fluid. An epidural catheter was placed for joudnal. Although some mild variable decelerations were noted, the fetal heart rate demonstrated good general variability. The patient continued to make slow progress. After achieving disproportin cervical dilatation, she pushed for about one hour. With the fetal head ceohalopelvic the perineum, several deep variable decelerations were noted.
A first-degree perineal tear was noted and repaired.
Especially in nulliparous women, a frequent impediment to the goal of an uncomplicated vaginal delivery is the presence of an unfavorable uterine cervix. We believe that PGE2 products are ideally suited for managing this potential impediment because they generally promote cervical ripening more than uterine contractility and this allows cervical ripening to occur before the onset of active labor. Other methods of cervical ripening PGE1, foley bulb catheters and laminaria are also available.
Our cases illustrate that the successful induction of a nulliparous woman with an unfavorable cervix often requires the investment of significant time on the part of both the patient and her providers. In approximately half of these inductions, multiple days and multiple doses of PGE2 were needed. However, this investment yields shorter overall hospital length of stay for mother and her baby due to reduced rates of cesarean delivery and NICU admission as well as reduction in levels of major adverse birth outcomes.
These cases illustrate several other important points. This is true for exposed patients who delivered following induction of labor before their UL-OTDcpd and for exposed patients who delivered following the spontaneous onset of labor before their UL-OTDcpd.
Of note, the two primary studies that these cases were drawn from showed slightly higher rates of operative vaginal delivery in the exposed groups and so the lower rates of major perineal injury in the exposed groups must have been the product of some other factors. Second, we have found that our group rates of thick meconium at rupture of membranes have been unusually low. Recent studies have confirmed that the presence of meconium at rupture of membranes is a risk factor for adverse neonatal outcomes [ 912 ].
Accordingly, if lower rates of thick meconium passage at rupture of membranes is a marker for improved uteroplacental health, then the lower rates of thick meconium passage seen with the use of AMOR-IAPT represents a secondary benefit from delivery relatively early in the term period of labor.
Third, if pregnancy dating has been well established with ultrasound, we do not rely on amniocentesis to confirm fetal lung maturity if preventive induction is performed after 37 weeks 6 days estimated gestational age. In patients preventively induced between 38 week 0 days and 38 week 6 days estimated gestational age, we have not seen increased rates of either NICU admission or problems related to fetal lung immaturity.
Fourth, the use of prostaglandins in the setting of preventive induction seems to be associated with a slight increase in the risk of postpartum uterine atony and higher postpartum blood loss. Indexed in Web of Science. Subscribe to Table of Contents Alerts.
Table of Contents Alerts. A Four-Part Case Series Over the past two decades, national cesarean section rates have risen dramatically [ 1 ]. Introduction to the Prevention of Cephalopelvic Dispropotion in Nulliparous Patients Primary cesarean delivery is more common in nulliparous than multiparous women, and the mode of delivery of the first birth clearly has a major impact on future pregnancies.
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