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Labour care must balance aspirations of parents with vigilance for unanticipated calamities. The 'on-site midwife-led primary care birth unit' facilitates this. The World Health Organization have replaced the traditional partograph with the 'Labour Care Guide'. An implementation project in Botswana included the mnemonic COPE: Companion, Oral fluids, Pain relief and Eliminate the supine position. The Parto-Ma project in Tanzania used guidelines, training and support to improve childbirth outcomes. We list labour practices supported by recent evidence, and highlight new developments. Foetal macrosomia increases risk but mistaken diagnosis increases caesarean births. Obstructed labour is a complex clinical diagnosis, and is difficult to predict. For shoulder dystocia prioritise delivery of the posterior shoulder, facilitated if needed by posterior axilla sling traction. 'Extended balloon labour induction' with two or three Foley catheters side by side, may reduce risks associated with uterine stimulants. Bedside ultrasound may facilitate the diagnosis of cephalic malpositions and malpresentations., (Copyright © 2024. Published by Elsevier Ltd.)

Purpose: Shoulder dystocia is an obstetric emergency with severe complications. Our objective was to evaluate the major pitfalls in the diagnostics of shoulder dystocia, diagnostic descriptions documented in medical records, use of obstetric maneuvers, and their correlations to Erb's and Klumpke's palsy and the use of ICD-10 code 066.0., Methods: A retrospective, register-based case-control study included all deliveries (n = 181 352) in Hospital District of Helsinki and Uusimaa (HUS) area in 2006-2015. Potential shoulder dystocia cases (n = 1708) were identified from the Finnish Medical Birth Register and the Hospital Discharge Register using ICD-10 codes O66.0, P13.4, P14.0, and P14.1. After thorough assessment of all medical records, 537 shoulder dystocia cases were confirmed. Control group consisted of 566 women without any of these ICD-10 codes., Results: The pitfalls in the diagnostic included suboptimal following of guidelines for making the diagnosis of shoulder dystocia, subjective interpretation of diagnostic criteria, and inexact or inadequate documentation in medical records. The diagnostic descriptions in medical record were highly inconsistent. The use of obstetric maneuvers was suboptimal among shoulder dystocia cases (57.5%). Overall, the use of obstetric maneuvers increased during the study period (from 25.7 to 97.0%, p < 0.001), which was associated with decreasing rate of Erb's palsy and increasing use of ICD-10 code O66.0., Conclusion: There are diagnostic pitfalls, which could be addressed by education regarding shoulder dystocia guidelines, by improved use obstetric maneuvers, and more precise documentation. The increased use of obstetric maneuvers was associated with lower rates of Erb's palsy and improved coding of shoulder dystocia., (© 2023. The Author(s).)

Purpose: The purpose of this document is to define labor and labor arrest and provide recommendations for the management of dystocia in the first and second stage of labor and labor arrest., Target Population: Pregnant individuals in the first or second stage of labor., Methods: This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one maternal-fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements., Recommendations: This Clinical Practice Guideline includes definitions of labor and labor arrest, along with recommendations for the management of dystocia in the first and second stages of labor and labor arrest. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence., (Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

To establish and verify a model for labour dystocia occurring in the active phase, this study retrospectively analysed the clinical data of primiparas with singleton cephalic full-term foetuses, who had delivered after a trial of labour. The Chi-square test, t -test, Mann-Whitney U test and multivariate logistic regression analysis were used for statistical analysis. Based on the model a nomogram was established using the R programming language. Multivariate logistic regression analysis showed that the foetal abdominal circumference, premature rupture of membranes (PROM), prolonged latent phase, foetal station and foetal position at the early stage of the active phase were independent factors influencing labour dystocia occurring in the active phase. The established model could effectively and accurately support clinicians in the early identification of labour dystocia to improve maternal and infant outcomes.Impact statement What is already known on this subject? Labour dystocia occurring during the active phase of the first stage, is the most commonly diagnosed as labour aberration. Previous studies have suggested that maternal age, body mass index, macrosomia and abnormal foetal position are the independent risk factors for labour dystocia. However, only the risk factors were reported, and few prediction models were established. What do the results of this study add? This study uses data in the real world to establish a prediction model of full-term singleton primipara with labour dystocia occurring in the active phase by logistic regression analysis. Foetal abdomen circumference, PROM, prolonged latent phase, the foetal station and foetal position at the early stage of the active phase are independent factors influencing labour dystocia that occurs in the active phase. In addition, a nomogram is established as a visual graph to predict the probability of it. What are the implications of these findings for clinical practice and/or further research? The nomogram based on the predictive model discarded complicated calculations and presented an easy visual graph-based method to predict the probability of labour dystocia occurring in the active phase. It helps to introduce interventions that could reduce the CS rate and occurrence of adverse maternal and foetal outcomes to ensure the safety of mothers and infants.

Background: Due to the rarity of shoulder dystocia, an obstetric emergency, it is difficult even for experts to develop the appropriate routine in this emergency. Regular further training is therefore recommended for obstetricians and midwives. Evidence is lacking on the extent to which e-learning as a teaching method can be successfully used to acquire these skills and put them into practice. The purpose of this study is to demonstrate how the learning objectives for shoulder dystocia, listed in the National Competence Based Learning Objectives Catalog for Medicine (NKLM, Germany) can be successfully taught in medical studies using a blended learning concept (e-learning and practical application on a birth simulator)., Methods: After completing an e-learning course, final year medical students and midwife trainees demonstrated their action competence for shoulder dystocia procedure on a birth simulator. This transfer of the theoretical knowledge to the case study was assessed using an evaluation form oriented to the recommendations for action., Results: One hundred sixty medical students and 14 midwifery trainees participated in the study from April to July 2019. Overall, 95.9% of the study participants met the required standards, i.e. achieved very good to adequate performance (Ø good) in simulation training., Conclusions: E-learning with annotated high-quality learning videos is an excellent way to transfer theoretical knowledge about shoulder dystocia procedures into medical practice on a birth simulator. The learning objectives required by the NKLM for shoulder dystocia can be successfully conveyed to students via the applied blended learning concept., (© 2023. The Author(s).)

Dystocia or difficult calving in cattle is detrimental to the health of the afflicted cows and has a negative economic impact on the dairy industry. The goal of this study was to create a data-driven tool for predicting the calving difficulty of non-heifer cows using input variables that are known prior to the moment of insemination. Compared to past studies, we excluded input variables that can only be known during or after insemination, such as birth weight and gestation length. This makes the model suitable for informing mating decisions that could reduce the incidence of difficult calvings or mitigate their consequences. We used a dataset consisting of 131,527 calving records of Holstein cattle, from which we derived a total of 274 phenotypic features and estimated breeding values. The distribution of classes in the dataset was 96.7 % normal calvings, and 3.3 % difficult calvings. We used a gradient boosted trees (XGBoost) as the learning model and a bagging ensemble approach to deal with the extreme class imbalance. The model achieved an average area under the ROC curve of 0.73 on unseen test data. Using feature importance analysis, we identified a number of features that have a high discriminatory value for calving difficulty, including maternal and paternal breeding values, and past phenotypic measurements of the cow., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Routine vaginal examinations are undertaken at regular time intervals during labour to assess whether labour is progressing as expected. Unusually slow progress can be due to underlying problems, described as labour dystocia, or can be a normal variation of progress. Evidence suggests that if mother and baby are well, length of labour alone should not be used to decide whether labour is progressing normally. Other methods to assess labour progress include intrapartum ultrasound and monitoring external physical and behavioural cues. Vaginal examinations can be distressing for women, and overdiagnosis of dystocia can result in iatrogenic morbidity due to unnecessary intervention. It is important to establish whether routine vaginal examinations are effective, both as an accurate measure of physiological labour progress and to distinguish true labour dystocia, or whether other methods for assessing labour progress are more effective. This Cochrane Review is an update of a review first published in 2013., Objectives: To compare the effectiveness, acceptability, and consequences of routine vaginal examinations compared with other methods, or different timings, to assess labour progress at term., Search Methods: For this update, we searched Cochrane Pregnancy and Childbirth Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, and conference proceedings) and ClinicalTrials.gov (28 February 2021). We also searched the reference lists of retrieved studies., Selection Criteria: We included randomised controlled trials (RCTs) of vaginal examinations compared with other methods of assessing labour progress and studies assessing different timings of vaginal examinations. Quasi-RCTs and cluster-RCTs were eligible for inclusion. We excluded cross-over trials and conference abstracts., Data Collection and Analysis: Two review authors independently assessed all studies identified by the search for inclusion in the review. Four review authors independently extracted data. Two review authors assessed risk of bias and certainty of the evidence using GRADE., Main Results: We included four studies that randomised a total of 755 women, with data analysed for 744 women and their babies. Interventions used to assess labour progress were routine vaginal examinations, routine ultrasound assessments, routine rectal examinations, routine vaginal examinations at different frequencies, and vaginal examinations as indicated. We were unable to conduct meta-analysis as there was only one study for each comparison.  All studies were at high risk of performance bias due to difficulties with blinding. We assessed two studies as high risk of bias and two as low or unclear risk of bias for other domains. The overall certainty of the evidence assessed using GRADE was low or very low.  Routine vaginal examinations versus routine ultrasound to assess labour progress (one study, 83 women and babies) Study in Turkey involving multiparous women with spontaneous onset of labour. Routine vaginal examinations may result in a slight increase in pain compared to routine ultrasound (mean difference -1.29, 95% confidence interval (CI) -2.10 to -0.48; one study, 83 women, low certainty evidence) (pain measured using a visual analogue scale (VAS) in reverse: zero indicating 'worst pain', 10 indicating no pain). The study did not assess our other primary outcomes: positive birth experience; augmentation of labour; spontaneous vaginal birth; chorioamnionitis; neonatal infection; admission to neonatal intensive care unit (NICU). Routine vaginal examinations versus routine rectal examinations to assess labour progress (one study, 307 women and babies) Study in Ireland involving women in labour at term. We assessed the certainty of the evidence as very low. Compared with routine rectal examinations, routine vaginal examinations may have little or no effect on: augmentation of labour (risk ratio (RR) 1.03, 95% CI 0.63 to 1.68; one study, 307 women); and spontaneous vaginal birth (RR 0.98, 95% CI 0.90 to 1.06; one study, 307 women). We found insufficient data to fully assess: neonatal infections (RR 0.33, 95% CI 0.01 to 8.07; one study, 307 babies); and admission to NICU (RR 1.32, 95% CI 0.47 to 3.73; one study, 307 babies). The study did not assess our other primary outcomes: positive birth experience; chorioamnionitis; maternal pain. Routine four-hourly vaginal examinations versus routine two-hourly examinations (one study, 150 women and babies) UK study involving primiparous women in labour at term. We assessed the certainty of the evidence as very low. Compared with routine two-hourly vaginal examinations, routine four-hourly vaginal examinations may have little or no effect, with data compatible with both benefit and harm, on: augmentation of labour (RR 0.97, 95% CI 0.60 to 1.57; one study, 109 women); and spontaneous vaginal birth (RR 1.02, 95% CI 0.83 to 1.26; one study, 150 women). The study did not assess our other primary outcomes: positive birth experience; chorioamnionitis; neonatal infection; admission to NICU; maternal pain. Routine vaginal examinations versus vaginal examinations as indicated (one study, 204 women and babies)  Study in Malaysia involving primiparous women being induced at term. We assessed the certainty of the evidence as low. Compared with vaginal examinations as indicated, routine four-hourly vaginal examinations may result in more women having their labour augmented (RR 2.55, 95% CI 1.03 to 6.31; one study, 204 women). There may be little or no effect on: • spontaneous vaginal birth (RR 1.08, 95% CI 0.73 to 1.59; one study, 204 women); • chorioamnionitis (RR 3.06, 95% CI 0.13 to 74.21; one study, 204 women); • neonatal infection (RR 4.08, 95% CI 0.46 to 35.87; one study, 204 babies); • admission to NICU (RR 2.04, 95% CI 0.63 to 6.56; one study, 204 babies). The study did not assess our other primary outcomes of positive birth experience or maternal pain., Authors' Conclusions: Based on these findings, we cannot be certain which method is most effective or acceptable for assessing labour progress. Further large-scale RCT trials are required. These should include essential clinical and experiential outcomes. This may be facilitated through the development of a tool to measure positive birth experiences. Data from qualitative studies are also needed to fully assess whether methods to evaluate labour progress meet women's needs for a safe and positive labour and birth, and if not, to develop an approach that does., (Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Objectives: The aim of the study was to compare the perinatal outcome between the normal weight, overweight and obese pregnant women who delivered in the third-level center of reference. Moreover, the objective was to analyze the usefulness of predelivery body mass index (BMI) in prediction of preterm delivery, prolonged second stage of labor, instrumental vaginal delivery, cesarean section, fetal macrosomia, dystocia and newborn acidosis., Material and Methods: The retrospective study included 2104 patients, divided into three groups, with BMI between 18.5 and 24.9; 25.0 and 29.9; higher than or equal 30.0 kg/m2, respectively. The data were assessed from the medical history., Results: The predelivery obesity increases the risk of cesarean section (aOR 1.63), macrosomia (aOR 8.89) and dystocia (aOR 3.40) in comparison to normal weight women. Moreover, the obese females had three times greater risk of having a macrosomic child (aOR 3.57) and 1.5 times greater risk of cesarean section (aOR 1.52) than overweight group. The role of predelivery BMI in the prediction of cesarean delivery (AUC 0.550; sensitivity 0.39; specificity 0.71, p < 0.001, cut-off value 28.7 kg/m2), macrosomia (AUC 0.714; sensitivity 0.66; specificity 0.70; p < 0.001, cut-off value 29.0 kg/m2) and dystocia (AUC 0.658; sensitivity 0.77; specificity 0.53, p < 0.001, cut-off value 27.0 kg/m2) was significant., Conclusions: The predelivery obesity increases the risk of cesarean section, macrosomia and shoulder dystocia and is a useful parameter in the prediction of perinatal outcomes. The establishing cut-off value for predelivery BMI was the lowest in prediction of shoulder dystocia.

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.

Efficient calving surveillance is essential for avoiding stillbirth due to unattended dystocia. Calving sensors can help detect the onset of parturition and thus ensure timely calving assistance if necessary. Tail-raising is an indicator of imminent calving. The objective of this study was to evaluate a tail-mounted inclinometer sensor (Moocall Ltd., Dublin, Ireland) and to monitor skin integrity after sensor attachment. Cows (n = 157) and heifers (n = 23) were enrolled at 275 d post insemination, and a sensor was attached to each cow's tail. Investigators checked for signs indicating the onset of stage II of parturition, verified the position of the sensor, and evaluated the skin integrity of the tail above and below the sensor hourly for 24 h/d. We used 5 different intervals (i.e., 1, 2, 4, 12, and 24 h until calving) to calculate sensitivity and specificity. Sensors continuously remained on the tail (i.e., within 3 cm of the initial attachment position) after initial attachment until the onset of calving in only 13.9% of animals (n = 25). Sensors were reattached until a calving event occurred (51.6%) or the animal was excluded for other reasons (34.4%). In 31 animals the sensor was removed because the tail was swollen or painful. Heifers were significantly less likely than cows to lose a sensor but more likely to experience tail swelling or pain. Depending on the interval preceding the onset of parturition, sensitivity varied from 19 to 75% and specificity from 63 to 96%., (Copyright © 2021 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Dystocia (abnormally slow or protracted labor) accounts for 25% to 55% of primary cesarean deliveries. The latent phase of labor begins with onset of regular, painful contractions and continues until 6 cm of cervical dilation. Current recommendations are to avoid admission to labor and delivery during the latent phase, assuming maternal/fetal status is reassuring. The active phase begins at 6 cm. An arrested active phase is defined as more than four hours without cervical change despite rupture of membranes and adequate contractions and more than six hours of no cervical change without adequate contractions. Managing a protracted active phase includes oxytocin augmentation with or without amniotomy. The second stage of labor begins at complete cervical dilation and continues to delivery. This stage is considered protracted if it lasts three hours or more in nulliparous patients without an epidural or four hours or more in nulliparous patients with an epidural. Primary interventions for a protracted second stage include use of oxytocin and manual rotation if the fetus is in the occiput posterior position. When contractions or pushing is inadequate, vacuum or forceps delivery may be needed. Effective measures for preventing dystocia and subsequent cesarean delivery include avoiding admission during latent labor, providing cervical ripening agents for induction in patients with an unfavorable cervix, encouraging the use of continuous labor support (e.g., a doula), walking or upright positioning in the first stage, and not diagnosing failed induction during the latent phase until oxytocin has been given for 12 to 18 hours after membrane rupture. Elective induction at 39 weeks' gestation in low-risk nulliparous patients may reduce the risk of cesarean delivery.

Fetal shoulder dystocia (FSD) is an unpredictable and critical obstetric intrapartum emergency, where an objective problem is the relationship between the mother's pelvis and the child, i. e., an anthropometric disorder of delivery mechanics and dynamics. It is evident that the need to perform other maneuvers indicates the severity of FSD, which in turn correlates with the consequent iatrogenic injury of the fetus and/or mother. FSD is certainly the most controversial forensic obstetric problem, with the most disputes, compensation for damages due to peripartum injury to the child and/or mother, pain suffered, the need for someone else's care, and permanent disability. Suboptimal procedures and inadequate documentation are factors of forensic risk and subsequent litigations. Prevention of FSD is generally not possible, although good antenatal care can sometimes exclude risky cases of FSD, and some rare, chronic intrauterine disorders can result in orthopedic and neurological sequelae, which is especially important in forensic analysis. Because FSD is largely impossible to predict, it must be viewed as an intrapartum acceptable risk. During childbirth, FSD may compromise the safety of the mother and unborn child, therefore education and skills acquisition are necessary for obstetric work. Risk control, proper procedures, and proper documentation, along with good communication with the pregnant women and their families, significantly reduce litigation procedures., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Introduction: Fetal overgrowth is an acknowledged risk factor for abnormal labor course and maternal and perinatal complications. The objective of this study was to evaluate whether the use of antenatal ultrasound-based customized fetal growth charts in fetuses at risk for large-for-gestational age (LGA) allows a better identification of cases undergoing caesarean section due to intrapartum dystocia., Material and Methods: An observational study involving four Italian tertiary centers was carried out. Women referred to a dedicated antenatal clinic between 35 and 38 weeks due to an increased risk of having an LGA fetus at birth were prospectively selected for the study purpose. The fetal measurements obtained and used for the estimation of the fetal size were biparietal diameter, head circumference, abdominal circumference and femur length, were prospectively collected. LGA fetuses were defined by estimated fetal weight (EFW) >95th centile either using the standard charts implemented by the World Health Organization (WHO) or the customized fetal growth charts previously published by our group. Patients scheduled for elective caesarean section (CS) or for elective induction for suspected fetal macrosomia or submitted to CS or vacuum extraction (VE) purely due to suspected intrapartum distress were excluded. The incidence of CS due to labor dystocia was compared between fetuses with EFW >95th centile according WHO or customized antenatal growth charts., Results: Overall, 814 women were eligible, however 562 were considered for the data analysis following the evaluation of the exclusion criteria. Vaginal delivery occurred in 466 (82.9 %) women (435 (77.4 %) spontaneous vaginal delivery and 31 (5.5 %) VE) while 96 had CS. The EFW was >95th centile in 194 (34.5 %) fetuses according to WHO growth charts and in 190 (33.8 %) by customized growth charts, respectively. CS due to dystocia occurred in 43 (22.2 %) women with LGA fetuses defined by WHO curves and in 39 (20.5 %) women with LGA defined by customized growth charts (p 0.70). WHO curves showed 57 % sensitivity, 72 % specificity, 24 % PPV and 91 % NPV, while customized curves showed 52 % sensitivity, 73 % specificity, 23 % PPV and 91 % NPV for CS due to labor dystocia., Conclusions: The use of antenatal ultrasound-based customized growth charts does not allow a better identification of fetuses at risk of CS due to intrapartum dystocia., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: Labor dystocia is the most common cause of cesarean birth in the United States, yet how dystocia develops during labor remains elusive. Uterine activity monitoring has significant potential for advancing our understanding of labor dystocia. While evaluating contraction frequency and amplitude is a common component of labor dystocia management, the literature describing the relationship between measures of uterine activity and labor dystocia is heterogeneous and has not been synthesized to identify the best methods for use in clinical investigation., Methods: We conducted a literature search for original research exploring the relationship between uterine activity and labor dystocia published between 2000 and 2019. Included articles were critically reviewed and synthesized., Results: Across 11 identified studies, investigators employed 3 different techniques for monitoring uterine activity and 9 different measures were employed. Uterine activity measures, including Montevideo units, uterine electromyography power density spectrum and sample entropy, and the fall-to-rise ratio of contraction shape, detected patterns associated with labor dystocia or cesarean birth., Discussion: The use of multiple regression with clinical covariates and a uterine activity measure increased the accuracy of predicting cesarean delivery. Uterine electromyography may be especially useful to evaluate labor dystocia phenotypes to differentiate uterine muscle fatigue from understimulation and lead to algorithms for increased precision in the diagnosis of labor dystocia and innovative approaches to treatment., (© 2020 The Authors. Journal of Midwifery & Women's Health published by Wiley Periodicals, Inc. on behalf of American College of Nurse Midwives (ACNM).)

The ongoing debate about what models of cervical dilatation and fetal descent should guide clinical decision-making has sown uncertainty among obstetric practitioners. We previously argued that the adoption of recently published labor assessment guidelines promoted by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine may have been premature. Before accepting any new clinical approaches as the standard of care, their underlying hypotheses should be thoroughly tested to ensure they are at least equivalent (or, preferably, superior) to existing management paradigms. Some of the apparent urgency to subscribe to new clinical tactics has been fueled by legitimate concerns about the rise in the cesarean delivery rate over the past several decades. A major contributor to this change in practice patterns is that more cesarean deliveries are being done for diagnoses that fall under the rubric of dystocia than ever before. As a consequence, traditional labor curves-fundamental for assessing labor progress-and the practice paradigms associated with them have received intense scrutiny as a possible contributor to this delivery trend. Moreover, the recent proposal of new labor curves and accompanying management guidelines has, understandably, fed the appetite to correct a perceived problem. However, the cesarean delivery rate rose most rapidly during decades when there was no major change in traditional labor curves or in the guidelines for their interpretation. Also, during the years since the new guidelines were first published, there has been no major fall in cesarean delivery frequency. This raises the question of whether there was truly a fundamental flaw in the traditional labor management paradigms or whether their proper interpretation and use had been somehow forgotten, ignored, or corrupted. More important, existing studies have shown that application of the new guidelines often (but not always) results in a modest fall in the cesarean delivery rate, but that this change may be accompanied by significant increases in maternal and neonatal morbidity. These results strongly suggest more caution in the adoption of the American College of Obstetricians and Gynecologists / Society for Maternal-Fetal Medicine labor assessment recommendations. They are based on a hypothesis that has yet to undergo thorough evaluation of its risks and benefits., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Assessment of pelvic configuration is an important factor in the prediction of a successful vaginal birth. However, manual evaluation of the pelvis is practically a vanishing art, and imaging techniques are not available as a real-time bed-side tool. Unlike the obstetrical conjugate diameter (OC) and inter spinous diameter (ISD), the pubic arch angle (PAA) can be easily measured by transperineal ultrasound. Objectives: Three-dimensional computed tomography bone reconstructions were used to measure the three main birth canal diameters, evaluate the correlation between them, and establish the normal reference range for the inlet, mid-, and pelvic outlet. Study design: Measurements of the PAA, obstetric conjugate (OC), and ISD were performed offline using three-dimensional post processing reconstruction in bone algorithm application of the pelvis on examinations performed for suspected renal colic in nonpregnant reproductive age woman. The mean of two measurements was used for statistical analysis which included reproducibility of measurements, regression curve estimation between PAA, OC, and ISD, and calculation of the respective reference range centiles for each PAA degree. Results: Two hundred ninety-eight women comprised the study group. The mean ± SD of the PAA, ISD, and OC were 104.9° (±7.4), 103.8 mm (±7.3), and 129.9 mm (±8.3), respectively. The intra- and interobserver agreement defined by the intraclass correlation coefficient (ICC) was excellent for all parameters (range 0.905-0.993). A significant positive correlation was found between PAA and ISD and between PAA and OCD (Pearson's correlation = 0.373 ( p  < .001), and 0.163 ( p  = .022), respectively). The best regression formula was found with quadratic regression for inter spinous diameter (ISD): 34.122778 + (0.962182*PAA - 0.002830*PAA 2 ), and linear regression for obstetric conjugate (OC): 110.638397 + 0.183156*PAA. Modeled mean, SD, and reference centiles of the ISD and OCD were calculated using the above regression models as function of the PAA. Conclusions: We report significant correlation between the three pelvic landmarks with greatest impact on the prediction of a successful vaginal delivery: the PAA which is easily measured sonographically and the ISD and OC which are not measurable by ultrasound. This correlation may serve as a basis for future studies to assess its utility and prognostic value for a safe vaginal delivery.

Reducing neonatal mortality is one of the targets of Sustainable Development Goal 3 on good health and well-being. The highest rates of neonatal death occur in sub-Saharan Africa. Birth asphyxia is one of the major preventable causes. Early detection and timely management of abnormal labour progress and fetal compromise are critical to reduce the global burden of birth asphyxia. Labour progress, maternal and fetal well-being are assessed using the WHO partograph and intermittent fetal heart rate monitoring. However, in low-resource settings adherence to labour guidelines and timely response to arising labour complications is generally poor. Reasons for this are multifactorial and include lack of resources and skilled health care staff. This case study in a Malawian hospital illustrates how delayed recognition of abnormal labour and prolonged decision-to-delivery interval contributed to birth asphyxia, as an example of many delivery rooms in low-income country settings., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The current study aims to evaluate a simple method for sonographic measurement of the fetal biacromial diameter for prediction of fetal macrosomia in term pregnancy., Materials and Methods: The current study was a single center prospective observational study conducted in a tertiary University Hospital from January 2015 to May 2017. We included all consecutive term (37-42 weeks) pregnant women presented to the labor ward for delivery. Ultrasound parameters were measured as biparietal diameter, head circumference, transverse thoracic diameter, mid arm diameter, abdominal circumference, femur length, estimated fetal weight, and amniotic fluid index. The proposed ultrasound formula "Youssef's formula" to measure the fetal biacromial diameter is: [Transverse thoracic diameter +2 × midarm diameter]. The accuracy of proposed formula was compared to the actual biacromial diameter of the newborn after delivery. The primary outcome of the study was accuracy of sonographic measurement of fetal biacromial diameter in prediction of fetal macrosomia in terms of sensitivity and specificity Results: The study included 600 participants; 49 (8.2%) of them delivered a macrosomic neonates and 551 (91.8%) delivered average weight neonates. There was no statistical significant difference between the proposed fetal biacromial diameter measured by ultrasound and the actual neonatal biacromial diameter measured after birth (p = .192). The area under the curve (AUC) for prediction of macrosomia at birth based on the fetal biacromial diameter and the abdominal circumference was 0.987 and 0.989, respectively, on receiver operating characteristic (ROC) curve analysis. Using the biacromial diameter cutoff of 15.4 cm has a PPV for prediction of macrosomia (88.4%) and 96.4% sensitivity with overall accuracy of 97%. Similarly, with the abdominal circumference (AC) cutoff of 35.5 cm, the PPV for prediction of macrosomia (87.7%) and 96.4% sensitivity with overall accuracy of 96.83%. No statistical significant difference between both of them was observed for prediction of fetal macrosomia (p = .841) Conclusions: The sonographic measurement of fetal biacromial diameter seems to be a new simple and accurate method for prediction of fetal macrosomia and shoulder dystocia at birth.

A precipitous delivery can be among the most stressful events an emergency physician encounters. The physician must assess 2 patients (mother and fetus) and be prepared to manage a variety of complications that may arise during delivery. A majority of precipitous deliveries result in good outcomes for both mother and baby, but emergency physicians must be prepared to manage feared complications, such as tight nuchal cords, shoulder dystocia, and breech presentation. An understanding of the labor process as well as advanced planning can help decrease the stress and chaos inherent to any precipitous delivery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Previous studies have shown that risk of cesarean section increases among multiparous women as interbirth interval increases. One possibility is that progress of labor may vary with interbirth interval, such that with longer intervals, labor curves of multiparas more closely resemble those of nulliparas. We sought to define labor curves among a cohort of multiparas with varying interbirth intervals., Study Design: This was a retrospective cohort study of term multiparas with known interval from last delivery and only vaginal deliveries. Subjects were grouped by interval between the studied pregnancy and the most recent birth: 0 to 59, 60 to 119, and ≥120 months. Statistical analysis was performed using linear mixed effects model. Group slopes and intercepts were compared using model t -tests for individual effects. Length of second stage was compared using a Wilcoxon's rank-sum test., Results: Groups did not differ significantly in demographic or obstetrical characteristics. Rate of dilation was similar between the 0 to 59 and 60 to 119 month groups ( p  = 0.38), but faster in the ≥120 month group compared with the 60 to 119 month group ( p  = 0.037). Median duration of second stage increased slightly with increased interbirth interval ( p  = 0.003)., Conclusion: Prolonged interbirth interval is not associated with slower active phase of labor., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Context: There is increasing evidence for Müllerian-inhibiting substance (MIS)/anti-Müllerian hormone (AMH) physiologic activity in the human uterus, so it is relevant to study how MIS/AMH levels impact pregnancy., Objective: To investigate the association of MIS/AMH levels with the risk of adverse obstetric outcomes., Design: Retrospective cohort study., Setting: Academic fertility center., Patients: Women who became pregnant through in vitro fertilization between January 2012 and October 2016. Exclusion criteria were: oocyte donation, gestational carrier, multiple gestations, miscarriage before 20 weeks, or medically indicated preterm deliveries., Interventions: None., Main Outcome Measures: There were two primary outcomes, preterm birth and cesarean delivery for arrest of labor. Because MIS/AMH level is highly skewed by certain infertility diagnoses, the preterm birth analysis was stratified by polycystic ovary syndrome (PCOS) diagnosis, and the cesarean delivery for arrest of labor analysis was stratified by diminished ovarian reserve diagnosis. χ2, Mann-Whitney, and t tests were used as appropriate. A P value of <0.05 was considered statistically significant., Results: Among women with PCOS, those who delivered prematurely had substantially higher MIS/AMH levels (18 vs 6.4 ng/mL, P = 0.003) than did those who delivered at term. At the highest MIS/AMH values, preterm deliveries predominated; above the 90th percentile in women with PCOS, all deliveries were premature. No effect of MIS/AMH level was observed in women without PCOS. We found no association between MIS/AMH values and cesarean delivery for labor arrest., Conclusion: In women with PCOS, substantially elevated MIS/AMH levels are significantly associated with preterm birth, suggesting closer follow-up and further studies to elucidate the underlying mechanisms.

Placental steroid sulphatase deficiency (SSD) is an X-linked inborn error of metabolism. Congenital X-linked ichthyosis (XLI) is a genetic disorder of keratinisation caused by steroid sulphatase (STS) deficiency, which results in a scaling skin condition in male infants shortly after birth. It may be associated with failed induction of labor and prolonged labor leading to cesarean delivery due to 'cervical dystocia'. We present two cases of congenital ichthyosis. Thorough counselling of women with a previously affected pregnancy during the antenatal period should include discussion about mode of delivery and a critical review of the complexities of prenatal diagnosis in this condition. We propose a clinical management pathway to offer women with a previous pregnancy affected by this rare condition. SIMILAR CASES PUBLISHED: Less than 50 cases reported.

Background: Purpose of this study was to investigate differences between primiparous term pregnancies, one leading to vaginal delivery (VD) and the other to acute cesarean section (CS) due to labor dystocia in the first stage of labor. We particularly wanted to assess the influence of body mass index (BMI) on CS risk., Methods: A retrospective case-control study in a tertiary delivery unit with 5200 deliveries annually. Cases were 296 term primiparous women whose intended vaginal labor ended in acute CS because of dystocia. Controls were primiparas with successful vaginal delivery VD (n = 302). The data were retrieved from medical records. Multiple logistic regression analyses were used to assess the associations between BMI and covariates on labor dystocia., Results: In the cases ending with acute CS, women were older (OR 1.06 [1.03-1.10]), shorter (OR 0.94 [0.91-0.96]) and more often had a chronic disease (OR 1.60 [1.1-2.29]). In this group fetal malposition (OR 42.0 [19.2-91.9]) and chorioamnionitis (OR 10.9 [5.01-23.6]) were more common, labor was less often in an active phase (OR 3.37 [2.38-4.76]) and the cervix was not as well ripened (1.5 vs. 2.5 cm, OR 0.57 [0.48-0.67] on arrival at the birth unit. BMI was higher in the dystocia group (24.1 vs. 22.6 kg/m 2 , p < 0.001), and rising maternal pre-pregnancy BMI had a strong association with dystocia risk. If BMI increased by 1 kg/m 2 , the risk of CS was 10% elevated. Among obese primiparas, premature rupture of membranes, chorioamnionitis and induction of labor were more common. Their labors were less often in an active phase at hospital admission. Severely obese primiparas (BMI ≥ 35 kg/m 2 ) had 4 hours longer labor than normal-weight parturients., Conclusions: Labor dystocia is a multifactorial phenomenon in which the possibility to ameliorate the condition via medical treatment is limited. Hospital admission at an advanced stage of labor is recommended. Pre-pregnancy weight control in the population at reproductive age is essential, as a high BMI is strongly associated with labor dystocia.

Backgound Partographs are used in many labour settings to provide a pictorial overview of a woman's cervical dilation pattern in the first stage of labor and to alert clinicians to slow progress possibly requiring intervention. Recent reviews called for large trials to establish the efficacy of partographs to improve birth outcomes whilst highlighting issues of clinician compliance with use. Previous studies have also reported issues with participant recruitment related to concerns regarding the possibility of a longer labour. Objectives We sought to compare a standard partograph with an action line, to a newly designed partograph with a stepped line, to determine the feasibility of recruitment to a larger clinical trial. Methods A pragmatic, single-blind randomised trial wherein low-risk, nulliparous women in spontaneous labour at term were randomized to an action-line or stepped-line partograph. First stage labour management was guided by the allocated partograph. Primary outcomes included the proportion of eligible women recruited, reasons for failed recruitment and compliance with partograph use. Secondary outcomes included rates of intervention, mode of birth, maternal and neonatal outcomes. Results Of the 384 potentially eligible participants, 38% (149/384) were approached. Of these 77% (116/149) consented, with 85% (99/116) randomized, only nine women approached (6%) declined to participate. A further 9% (14/149) who were consented antenatally were not eligible at onset of labor and 7% (10/149) of women approached in the birth suite but did not meet the inclusion criteria. Compliance with partograph completion was 65% (action) versus 84% (dystocia line). Conclusions for Practice Participant recruitment to a larger randomized controlled trial comparing new labour management guidelines to standard care is feasible. Effective strategies to improve partograph completion compliance would be required to maintain trial fidelity.

Dystocia can be defined broadly as "difficult birth" or more specifically as difficulty in the bitch expelling the pups through the cervix, vagina, and vestibule. It is a fairly common emergency presented to the small animal practitioner with an incidence rate of approximately 5%. The incidence of dystocia is highest in toy and brachycephalic breeds, and occurs frequently in small litters (<3 pups) due to fetal oversize and delayed onset of labor. As duration of labor progresses, the mortality of the pups and even the bitch increases, with the highest number of stillborn pups occurring after 6 hours from the time of active parturition. Practitioners should understand the mechanism of normal parturition so that abnormalities can be readily identified and medical or surgical intervention performed in a safe and timely manner., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Gestational diabetes mellitus (GDM) is independently associated with an increased risk of maternal-fetal complications. Improved glycemic control allows reducing perinatal morbidity and mortality and, specifically, the risk of macrosomia and shoulder dystocia which are the most common complications associated with GDM. Nonetheless, a need for early antenatal predictor of neonatal morbidity in women suffering from GDM is required. The objective of the study was to evaluate the efficacy of different maternal, biological, and antenatal parameters at the time of diagnosis of GDM or perinatal variables as predictors of neonatal morbidity., Study Design: This was a prospective observational study recruited all pregnant women with diagnosis of GDM at first- or second-trimester in a tertiary care hospital from July 2014 to October 2015. Different antenatal parameters (maternal weight, weight gain during pregnancy, history of GDM, history of macrosomia, serum fructosamine, HbA1c) were obtained at the time of diagnosis of GDM. Mode of delivery was also analyzed. Neonatal morbidity was defined by at least one of the following criteria: preterm birth <37 weeks, macrosomia, shoulder dystocia, respiratory distress syndrome, 5-min Apgar score <7, pH < 7.10 and admission to the NICU (neonatal intensive care unit) for 24 h. Univariate and logistic regression analyses were performed to determine independent antenatal predictors of neonatal morbidity., Results: Two hundred pregnant women with diagnosis of GDM were included. The mean gestational age at the time of diagnosis of GDM was 22 ± 6 weeks. Insulin was required in 72/200 (36%) women for glycemic control during pregnancy. Neonatal morbidity occurred in 21% (n = 42). In the univariate analysis, neonatal morbidity was associated with nulliparity (50% compared to 32%, p = 0.03), induction of labor (36% compared to 27%, p = 0.03) and cesarean section (36% compared to 12%, p < 0.01). Multivariable logistic regression analysis found a significant association between nulliparity and neonatal morbidity (adjusted odds ratio [OR] 2.3, 95% confidence interval [CI] 1.1-4.7). Cesarean delivery was also significantly associated with neonatal morbidity (aOR 7.6, 95% CI 2.9-20)., Conclusion: This suggests that nulliparity was an efficient antenatal predictor of neonatal morbidity at the time of diagnosis of GDM. Cesarean section was also associated with neonatal morbidity in women with GDM., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: We aimed to compare maternal and neonatal outcomes of spontaneous term labor among primigravidae who were monitored by the novel labor scale versus the World Health Organization (WHO) partograph., Study Design: A single center, double-blinded randomized trial had been conducted between July 2015 and June 2016. Nulliparous women in spontaneous labor with singleton term pregnancies were randomized to either labor scale or the WHO partograph for management of labor. Primary outcome was successful vaginal delivery. Secondary outcome included low APGAR scores, birth injuries, postpartum hemorrhage, and infection., Results: One hundred ten patients were randomized (55 in each arm). Women managed with labor scale had significantly lower rate of cesarean deliveries than women managed with the partograph arm (3.6% versus 18.2%, P =0.03). There was a significant reduction in the rate and duration of oxytocin administration for augmentation of labor (21.8% versus 69.1%, P < 0.0001) and a significant increase in average 1-minute APGAR score in the labor scale group., Conclusion: Labor monitoring with the labor scale is associated with lower rate of cesarean section, less and shorter use of oxytocin for augmentation of labor. Monitoring of labor progress starting at 5 cm or more is also associated with lower rate of cesarean delivery., Competing Interests: Conflict of Interest: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: In 2010 the Consortium on Safe Labor published labor curves. It was proposed that the rate of cesarean delivery could be lowered by avoiding the diagnosis of arrest of dilation before 6 cm. However, there is little information on the uptake of the guidelines and on changes in cesarean delivery rates that may have occurred., Objective: The objective of the study was to test the following hypotheses: (1) among patients laboring at term, rates of arrest of dilation disorders have decreased, leading to a decrease in the rate of cesarean delivery; (2) in the second stage, pushing duration prior to diagnosis of arrest of descent has increased, also leading to a reduction in the rate of cesarean delivery for this indication. As a secondary aim, we investigated changes in maternal and neonatal morbidity., Study Design: This was a secondary analysis of a prospective cohort study of all patients presenting at ≥37 weeks' gestation from 2010 through 2014 with a nonanomalous vertex singleton and no prior history of cesarean delivery. Rates of cesarean delivery, arrest of dilation, and changes in rates of maternal and neonatal morbidity were calculated in crude and adjusted models. Cervical dilation at diagnosis of the arrest of dilation, time spent at the maximal dilation prior to diagnosis of arrest of dilation, and time in the second stage prior to the diagnosis of arrest of descent were compared over the study period., Results: There were 7845 eligible patients. The cesarean delivery rate in 2010 was 15.8% and, in 2014, 17.7% (P trend = .51). In patients undergoing cesarean delivery for the arrest of dilation, the median cervical dilation at the time of cesarean delivery was at 5.5 cm in 2010 and 6.0 cm in 2014 (P trend = .94). In these patients, there was an increase in the time spent at last dilation: 3.8 hours in 2010 to 5.2 hours in 2014 (P trend = .02). There was no change in the frequency of patients diagnosed with the arrest of dilation at <6 cm: 51.4% in 2010 and 48.6% in 2014 (P trend = .56). However, in these patients, the median time spent at the last cervical dilation was 4.0 hours in 2010 and 6.7 hours in 2014 (P trend = .046). There were 206 cesarean deliveries for the arrest of descent. The median pushing time in these patients increased in multiparous patients from 1.1 hours in 2010 to 3.4 hours in 2014 (P trend = .009); in nulliparous patients these times were 2.7 hours in 2010 and 3.8 hours in 2014 (P trend = .09). There was a significant trend toward increasing adverse neonatal and maternal outcomes (P < .001 for each). The adjusted odds ratio for adverse maternal outcome for 2014 compared with 2010 was 1.66 (95% confidence interval, 1.27-2.17); however, considering only transfusion, hemorrhage, or infection, there was no difference (P trend = .96). The adjusted odds ratio of adverse neonatal outcome in 2014 compared with 2010 was 1.80 (95% confidence interval, 1.36-2.36)., Conclusion: Despite significant changes in labor management that have occurred over the initial years since publication of the new labor curves and associated guidelines, the primary cesarean delivery rate was not reduced and there has been an increase in maternal and neonatal morbidity in our institution. A randomized controlled trial is needed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

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., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Fetal ascites has been diagnosed more frequently these days because of routine ultrasound scanning in pregnancy. However as a cause of dystocia in labour, it is very rare. Twenty four years second gravida of 28 weeks 6 days of gestation presented to labour room with preterm obstructed labour. Abdominal examination revealed less readily palpable fetal parts and distantly localized fetal heart sounds. An urgent ultrasound showed huge maternal ovarian cyst. She then underwent emergency cesarean section; delivered a male baby with grossly distended abdomen. However, the ovaries were normal looking. Routine antenatal ultrasounds help in identifying maternal and congenital fetal anomalies. They also guide in planning the most appropriate management. Whenever fetal ascites is diagnosed antenatally, possibility of dystocia in labour should be kept in mind.

Shoulder dystocia and postpartum hemorrhage represent two of the most common emergencies faced in obstetric clinical practice, both requiring prompt recognition and management to avoid significant morbidity or mortality. Shoulder dystocia is an uncommon, unpredictable, and unpreventable obstetric emergency and can be managed with appropriate intervention. Postpartum hemorrhage occurs more commonly and carries significant risk of maternal morbidity. Institutional protocols and algorithms for the prevention and management of shoulder dystocia and postpartum hemorrhage have become mainstays for clinicians. The goal of this review is to summarize the diagnosis, incidence, risk factors, and management of shoulder dystocia and postpartum hemorrhage., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aims: To report on the opinions and reported practices of Australian obstetricians and general practice (GP) obstetricians, in the definition and management of spontaneous first stage of labour, in low-risk nulliparous women., Materials and Methods: Cross-sectional survey sent electronically to all Australian Specialist obstetricians (FRANZCOG) and Diplomates. Respondents answered questions regarding care of nulliparous women in spontaneous labour at term across three domains: (i) practitioners' characteristics; (ii) current practice; (iii) opinion regarding joint statement by ACOG/SMFM (Society of Maternal Fetal Medicine) 'Safe prevention of primary caesarean section'., Results: The dataset included responses from 664 participants, representing 29% of Specialists and 11% of Diplomates. Responses varied in the criteria used to define normal labour, and the diagnosis and management of prolonged labour. Clinicians with more post-qualification experience considered the minimal acceptable progress to be faster than those with fewer years of experience (P = 0.02). Clinicians working in higher acuity hospitals were more likely to augment labour for longer prior to recommending a caesarean section for active phase arrest, compared to those in lower acuity hospitals (P = 0.025). The majority of respondents (58.2%) already based their practice on the ACOG/SMFM 'Safe prevention of primary caesarean section' statement, or would now consider changing their practice., Conclusion: There is a lack of consensus among Australian obstetricians and GP obstetricians regarding definition of normal progress in first stage of labour and how to manage abnormal progress; however, many are open to new recommendations for practice., (© 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Professional maternity care organizations within the United States are aligned in the goal to prevent the first cesarean birth in nulliparous women with a term, singleton, vertex fetus. Currently, one in 3 women are at risk for having a cesarean birth. The most common reason for cesarean in the United States is labor dystocia. The evidence supports delaying admission to the birthing unit until active labor is established, thereby minimizing the inadvertent diagnosis of labor dystocia. Providers are familiar with the rationale supporting delayed admission to the birthing unit until active labor is established; however, there is very little evidence on how to effectively promote this delay. Provider apprehension and the lack of early labor support are challenges to sending women home to await the onset of active labor. Maternal anxiety, fear, pain, and unpreparedness also play a part in this reluctance. To address these obstacles, South Shore Hospital created an early labor lounge with stations aimed at instilling confidence in the birth team, promoting teamwork, facilitating relaxation, and reducing anxiety for laboring women. A literature review focusing on women's perceptions of promoting admission in active labor, maternal anxiety, and nonpharmacologic strategies for managing early labor are discussed within the context of the creation, implementation, and evaluation of an early labor lounge., (© 2017 by the American College of Nurse-Midwives.)

The objectives of this study were to explore changes of rumination time and reticuloruminal pH and temperature of dairy cows and heifers (means ± standard deviation; age = 5.8 ± 1.9; parity = 2.7 ± 1.4; body condition score = 3.2 ± 0.2) with eutocic (EUT, n = 10) and dystocic calving (DYS, n = 8). The recording period lasted from 3 d before calving until 7 d in milk. For the comparison of rumination time and reticuloruminal characteristics between groups, time to return to baseline (the time interval required to return to baseline from the delivery of the calf) and area under the curve (AUC; both for prepartum and postpartum periods) were calculated for each parameter. Rumination time decreased from baseline 28 h before calving both for EUT and DYS cows; after 20 h before calving, it decreased to 32.4 ± 2.3 and 13.2 ± 2.0 min/4 h between 8 and 4 h before delivery in EUT and DYS cows, respectively, and then it decreased below 10 and 5 min during the last 4 h before calving. Until 12 h after delivery, rumination time reached 42.6 ± 2.7 and 51.0 ± 3.1 min/4 h in DYS and EUT dams, respectively; however, AUC and time to return to baseline suggested lower rumination activity in DYS cows than in EUT dams for the 168-h postpartum observational period. Reticuloruminal pH decreased from baseline 56 h before calving both for EUT and DYS cows, but did not differ between groups before delivery. Reticuloruminal pH showed a decreasing tendency and clear diurnal variation after calving for both EUT and DYS cows, with slightly higher AUC values in DYS cows. In DYS cows, reticuloruminal temperature decreased from baseline 32 h before calving by 0.23 ± 0.02°C, whereas in EUT cows such a decrease was found only 20 h before delivery (0.48 ± 0.05°C). The AUC of reticuloruminal temperature calculated for the prepartum period was greater in EUT cows than in DYS cows. During the first 4 h after calving, reticuloruminal temperature decreased from 39.68 ± 0.09 to 38.96 ± 0.10°C and from 39.80 ± 0.06 to 38.81 ± 0.08°C in EUT and DYS cows, respectively, and reached baseline levels after 35.4 ± 3.4 and 37.8 ± 4.2 h after calving in EUT and DYS cows, respectively. Based on our results, continuous monitoring of changes in rumination time and reticuloruminal temperature seems to be promising in the early detection of cows with a higher risk of dystocia. Depressed rumination activity of DYS cows after calving highlights the importance of the postpartum monitoring of cows experiencing difficulties at calving. The effect of dystocia on postpartum reticuloruminal pH was not pronounced., (Copyright © 2017 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Objectives The aim of this study was to describe the incidence of feline dystocia with respect to breed. Methods The data used were reimbursed claims for veterinary care insurance and/or life insurance claims in cats registered in a Swedish insurance database from 1999-2006. Results The incidence rates for dystocia were about 22 cats per 10,000 cat-years at risk, 67 per 10,000 for purebred cats and seven per 10,000 for domestic shorthair cats. The median age was 2.5 years. A significant effect of breed was seen. An incidence rate ratio (IRR) that was significantly higher compared with other purebred cats was seen in the British Shorthair (IRR 2.5), the Oriental group (IRR 2.2), Birman (IRR 1.7), Ragdoll (IRR 1.5) and the Abyssinian group (IRR 1.5). A significantly lower IRR was seen in the Norwegian Forest Cat (IRR 0.38), the Maine Coon (IRR 0.48), the Persian/Exotic group (IRR 0.49) and the Cornish Rex (IRR 0.50). No common factor among the high-risk breeds explained their high risk for dystocia. There was no effect of location; that is, the incidence rate did not differ depending on whether the cat lived in an urban or rural area. Caesarean section was performed in 56% of the cats with dystocia, and the case fatality was 2%. Conclusions and relevance The incidence rate for dystocia was of a similar magnitude in purebred cats as in dogs. The IRR varied significantly among breeds, and the main cause for dystocia should be identified separately for each breed. A selection for easy parturitions in breeding programmes is suggested.

Background and Objectives: There are only few training programs in obstetric emergencies currently in use and only some of them were evaluated with an adequate sample of participants. Therefore, we present the evaluation of the novel Standardized Trainings in Obstetrical Emergencies (STrObE), conducted in Lithuania. The aim of this study was to analyze whether participants' self-reported knowledge and confidence increased after the trainings, and whether the impact of the trainings was long-lasting., Materials and Methods: Data was collected across the majority of hospitals providing secondary and tertiary obstetrical care in Lithuania in 2015. A total of 650 obstetricians-gynecologists and midwives attended the trainings; 388 (response rate 59.7%) of them filled in the initial questionnaire before the trainings, 252 (64.9%) immediately after, 160 (41.2%) 6 weeks after, and 160 (41.2%) 6 months after the trainings, which was the final sample for the analyses. Participants used a Likert-type scale to evaluate their knowledge and confidence about management of urgent obstetrical situations: vacuum-assisted vaginal delivery, shoulder dystocia, postpartum hemorrhage, preeclampsia/eclampsia, early preterm labor, and dystocia. We assessed how participants' self-reported knowledge and confidence changed after the trainings (compared to before the trainings) and how long the effect was retained for., Results: The mean score of self-reported knowledge in obstetrical emergencies increased immediately after the trainings comparing to the scores before the trainings (P<0.001) and it did not differ further between the three time points after the trainings (i.e. immediately, 6 weeks, and 6 months; P>0.05). The same pattern was observed for self-reported confidence scores. The increase in self-reported knowledge and confidence after the trainings was stable. Moreover, the self-reported knowledge and confidence gains were greater for those participants with lower work experience, although benefit was seen across all experience levels., Conclusions: STrObE improved participants' self-reported knowledge and confidence and lasting positive effects were observed for at least 6 months after the initial trainings. Moreover, the trainings were more beneficial for those with lower work experience, although they benefited all the participants., (Copyright © 2018 The Lithuanian University of Health Sciences. Production and hosting by Elsevier Sp. z o.o. All rights reserved.)

Objectives: To evaluate the effect of the occiput posterior (OP) position on dystocia and perinatal outcomes., Methods: This was a prospective cohort study of 162 primiparous women. We performed intrapartum sonography, and fetal occiput positions were recorded. The relationships between the position of the occiput and the course of labor and perinatal outcomes were investigated. Statistical analysis was performed using SAS 9.2., Results: Fifty-six of 162 fetuses were found to be in the OP position during the first stage of labor. Eight (80.0%) of 10 fetuses in the OP position during the second stage were among the 56 that were in OP position during the first stage. The rate of cesarean sections performed in the OP position group during the first stage was significantly higher than the rate in the non-OP position group (37.5% versus 8.5%, p < 0.0001). The duration of the second stage of labor was longer and neonatal complications occurred more frequently in the OP position group during the second stage than in the non-OP position group (77.9  ±  33.4 min versus 52.2  ± 26.6 min, p = 0.0104; 50.0% versus 17.2%, p = 0.0118)., Conclusions: The OP position may be a useful predicator for labor dystocia that can lead to poor neonatal outcomes.

A prior history of delivery complicated by shoulder dystocia confers a 6-fold to nearly 30-fold increased risk of shoulder dystocia recurrence in a subsequent vaginal delivery, with most reported rates between 12% and 17%. Whereas prevention of shoulder dystocia in the general population is neither feasible nor cost-effective, directing intervention efforts at the particular subgroup of women with a prior history of shoulder dystocia has merit. Potentially modifiable risk factors and individualized management strategies that may reduce shoulder dystocia recurrence and its associated significant morbidities are reviewed.

Objective: To examine the course and outcome of deliveries occurring in women who previously experienced shoulder dystocia. In addition, recurrent shoulder dystocia risk factors were assessed., Methods: A retrospective cohort analysis comparing all singleton deliveries with and without shoulder dystocia in their preceding delivery was conducted. Independent predictors of recurrent shoulder dystocia were investigated using a multiple logistic regression model., Results: Of the 201,422 deliveries included in the analysis, 307 occurred in women with a previous shoulder dystocia (0.015 %). Women with a history of shoulder dystocia were more likely to be older, experienced higher rates of gestational diabetes mellitus, polyhydramnios, prolonged second stage, operative delivery and macrosomia (>4000 g) in the following delivery. Previous shoulder dystocia was found to be an independent risk factor for recurrent shoulder dystocia (OR = 6.1, 95 % CI 3.2-11.8, p value <0.001) in the multivariable regression analysis., Conclusions: Shoulder dystocia is an independent risk factor for recurrent shoulder dystocia. Deliveries in women with a history of shoulder dystocia are characterized by higher rates of operative delivery, prolonged second stage of labor and macrosomia.

Background: It remains uncertain whether clinical factors known prior to delivery can predict which women are more likely to experience shoulder dystocia in the setting of operative vaginal delivery., Objective: We sought to identify whether shoulder dystocia can be accurately predicted among women undergoing an operative vaginal delivery., Study Design: This was a case-control study of women undergoing a low or outlet operative vaginal delivery from 2005 through 2014 in a single tertiary care center. Cases were defined as women who experienced a shoulder dystocia at the time of operative vaginal delivery. Controls consisted of women without a shoulder dystocia at the time of operative vaginal delivery. Variables previously identified to be associated with shoulder dystocia that could be known prior to delivery were abstracted from the medical records. Bivariable analyses and multivariable logistic regression were used to identify factors independently associated with shoulder dystocia. A receiver operating characteristic curve was created to evaluate the predictive value of the model for shoulder dystocia., Results: Of the 4080 women who met inclusion criteria, shoulder dystocia occurred in 162 (4.0%) women. In bivariable analysis, maternal age, parity, body mass index, diabetes, chorioamnionitis, arrest disorder as an indication for an operative vaginal delivery, vacuum use, and estimated fetal weight >4 kg were significantly associated with shoulder dystocia. In multivariable analysis, parity, diabetes, chorioamnionitis, arrest disorder as an indication for operative vaginal delivery, vacuum use, and estimated fetal weight >4 kg remained independently associated with shoulder dystocia. The area under the curve for the generated receiver operating characteristic curve was 0.73 (95% confidence interval, 0.69-0.77), demonstrating only a modest ability to predict shoulder dystocia before performing an operative vaginal delivery., Conclusion: While risk factors for shoulder dystocia at the time of operative vaginal delivery can be identified, reliable prediction of shoulder dystocia in this setting cannot be attained., (Copyright © 2016 Elsevier Inc. All rights reserved.)