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Nulliparous Women (nulliparou + woman)
Selected AbstractsAbsence of leukocyte microchimerism in oral lichen planus (OLP): an in situ hybridisation studyJOURNAL OF ORAL PATHOLOGY & MEDICINE, Issue 7 2001T. Lombardi Abstract: Oral lichen planus (OLP) is a relatively common chronic inflammatory disease. The majority of patients are between 30 and 50 years of age with a higher incidence in females. The aetiology is unknown and various hypotheses on the pathogenic mechanisms, including autoimmunity, have been proposed over the years. In the present study, we investigated whether leukocyte microchimerism, a biological situation implicated in the aetiology of some autoimmune diseases, might play a role in the pathogenesis of OLP. We used in situ hybridisation to identify Y chromosome DNA in a series of formalin-fixed paraffin-embedded oral mucosa biopsies of women with established clinical and histological disease who had given birth to a male child. The positive control, two mucosal specimens from a man with OLP, showed over 90% of keratinocytes and cells within the inflammatory infiltrate, a positive nuclear signal. The negative control, biopsies from three women having carried only female foetuses and one nulliparous woman, all with OLP, did not show any nuclear signal. In the fifteen selected cases of OLP biopsies from women who had only male offspring, nucleated cells containing the Y chromosome were not detected within the chronic inflammatory infiltrate. These results suggest that unlike some other immunologically mediated diseases, leukocyte microchimerism does not seems to be involved in the pathogenesis of OLP. [source] Impact of reproductive factors and lactation on breast carcinoma in situ riskINTERNATIONAL JOURNAL OF CANCER, Issue 1 2004Kathleen Meeske Abstract Incidence rates for breast carcinoma in situ (CIS) have increased markedly over the past 20 years. Breast CIS, detected primarily on mammography, now represents 30,45% of all screened detected breast cancers. We conducted a large population-based case-control study to evaluate the impact of reproductive factors and lactation on breast CIS risk. Case subjects were newly diagnosed with breast CIS at ages 35,64 years between March 1, 1995 and May 31, 1998 (n = 567), resided in Los Angeles County and were born in the United States. Control subjects (n = 614), identified through random digit dialing, fulfilled the same eligibility criteria and were required to have had at least one screening mammogram in the 2-year period before their interview. Women with a positive family history of breast cancer had a 2-fold increase in breast CIS risk. Parous women were at reduced risk relative to nulligravid women (odds ratio [OR] = 0.67, 95% confidence interval [CI] = 0.46,1.00). Among nulliparous women, pregnancy was unrelated to breast CIS risk. Among parous women, risk declined with each additional term pregnancy (p -trend = 0.003). No associations were found with age at first term pregnancy, induced abortion or miscarriage. Long duration of breast-feeding (,24 months) was associated with increased risk (OR = 2.00, 95% CI = 1.11,3.60). The observed effects of family history and pregnancy on breast CIS risk are consistent with those observed for invasive breast cancer. The results for breast-feeding are contrary to what has been observed in studies of invasive breast cancer. © 2004 Wiley-Liss, Inc. [source] What is the Slowest-Yet-Normal Cervical Dilation Rate Among Nulliparous Women With Spontaneous Labor Onset?JOURNAL OF OBSTETRIC, GYNECOLOGIC & NEONATAL NURSING, Issue 4 2010Jeremy L. Neal ABSTRACT Objective: To integrate research literature that has provided insights into the cervical dilation rate that may best describe the slowest-yet-normal dilation rate among nulliparous women when beginning with criteria commonly associated with active labor onset. Data Sources: A literature search from 1950 through 2008 was conducted using the Medline electronic database, reference lists from identified articles, and other key references. Study Selection: Research reports written in English with a focus on the cervical dilation and/or labor duration of low-risk, nulliparous women with spontaneous labor onset. Data Extraction: Classic and contemporary research literature was reviewed and organized under the following subheadings: Friedman Studies, Partograph Studies, Active Management of Labor Studies, Additional Studies. Data Synthesis: An integrative review of the literature approximated the slowest-yet-normal cervical dilation rate for nulliparous women when beginning with criteria commonly associated with active labor. Conclusions: The slowest-yet-normal linear dilation rate approximates 0.5 cm/hour for low-risk, nulliparous women with spontaneous labor onset when starting at dilatations traditionally associated with active labor onset. However, this linear rate must be evaluated judiciously in light of the physiological acceleration of dilation that occurs during typical labor. Given this, cervical dilation for this population is likely slower than 0.5 cm/hour in earlier active labor and faster in more advanced active labor. Faster dilation expectations (e.g., 1 cm/hour) likely contribute to an overdiagnosis of dystocia ("slow, abnormal progression of labor") in contemporary practice and, subsequently, to an overuse of interventions aimed at accelerating labor progress. [source] The Effects of Mindfulness-Based Yoga During Pregnancy on Maternal Psychological and Physical DistressJOURNAL OF OBSTETRIC, GYNECOLOGIC & NEONATAL NURSING, Issue 3 2009Amy E. Beddoe ABSTRACT Objective: To examine the feasibility and level of acceptability of a mindful yoga intervention provided during pregnancy and to gather preliminary data on the efficacy of the intervention in reducing distress. Design: Baseline and post-treatment measures examined state and trait anxiety, perceived stress, pain, and morning salivary cortisol in a single treatment group. Postintervention data also included participant evaluation of the intervention. Setting: The 7 weeks mindfulness-based yoga group intervention combined elements of Iyengar yoga and mindfulness-based stress reduction. Participants: Sixteen healthy pregnant nulliparous women with singleton pregnancies between 12 and 32 weeks gestation at the time of enrollment. Methods: Outcomes were evaluated from pre- to postintervention and between second and third trimesters with repeated measures analysis of variance and post hoc nonparametric tests. Results: Women practicing mindful yoga in their second trimester reported significant reductions in physical pain from baseline to postintervention compared with women in the third trimester whose pain increased. Women in their third trimester showed greater reductions in perceived stress and trait anxiety. Conclusions: Preliminary evidence supports yoga's potential efficacy in these areas, particularly if started early in the pregnancy. [source] Morbidity and mortality associated with pre-eclampsia at two tertiary care hospitals in Sri LankaJOURNAL OF OBSTETRICS AND GYNAECOLOGY RESEARCH (ELECTRONIC), Issue 1 2007Vajira H. W. Dissanayake Abstract Aim:, To report the occurrence of morbidity and mortality associated with carefully phenotyped pre-eclampsia in a sample of nulliparous Sinhalese women with strictly defined disease. Methods:, A phenotyping database of 180 nulliparous women with pre-eclampsia and 180 nulliparous normotensive pregnant women who were recruited for a study into genetics of pre-eclampsia was analyzed. Results:, Women who developed pre-eclampsia had significantly higher systolic blood pressure (SBP; P = 0.002) and diastolic blood pressure (DBP; P = 0.002) at booking (at approximately 13 weeks of gestation). 38.3%, 28.3% and 33.3% of women delivered at <34 weeks, at 34,36 weeks, and at term, respectively. 78% required a cesarean section. Complications included SBP , 160 mmHg (75.5%); DBP , 110 mmHg (83.8%); proteinuria ,3 + (150 mg/dL) in the urine protein heat coagulation test (87%); renal failure requiring dialysis (2%); platelet counts <100 × 109/L (13%); ,70 U/L in aspartate and/or alanine aminotransaminase (15%); placental abruption (4%); eclampsia (9%); and one maternal death. Maternal complications indicative of severe disease, apart from the incidence of SBP , 160 mmHg and DBP , 110 mmHg, were not significantly different in early and late-onset pre-eclampsia; fetal outcome was better with late-onset disease. 48% of babies were small for gestational age. Only 80 of 135 babies of women with pre-eclampsia whose condition could be confirmed at 6 weeks post-partum were alive. Conclusions:, Pre-eclampsia in Sinhalese women is associated with severe maternal morbidity and fetal morbidity and mortality, suggesting that modification of the Western diagnostic criteria and/or guidelines for medical care may be necessary. There is an urgent need to improve neonatal intensive care services in Sri Lanka. [source] Comparative study of induction of labor in nulliparous women with premature rupture of membranes at term compared to those with intact membranes: Duration of labor and mode of deliveryJOURNAL OF OBSTETRICS AND GYNAECOLOGY RESEARCH (ELECTRONIC), Issue 5 2006Kyo Hoon Park Abstract Aim:, To evaluate the effect of premature rupture of membranes (PROM) at term on the duration of labor and mode of delivery in comparison with intact membranes in nulliparous women with an unfavorable cervix whose labor was induced. Methods:, This retrospective cohort study included all term nulliparous women with an unfavorable cervix requiring labor induction over a 2-year period. Prostaglandin E2 (dinoprostone) and oxytocin were used for labor induction. Criteria for enrolment included (i) singleton pregnancy; (ii) term nulliparous women; or (iii) Bishop score below 6. Statistics were analyzed with Student's t -test, ,2 -test, Fisher's exact test, and multiple logistic regression. Results:, Our study subjects were 82 women whose labor was induced for PROM and 219 women with intact membranes whose labor was induced for social or fetal reasons. The mean durations of active phase of labor were not significantly different between women with PROM and those with intact membranes. However, the women with PROM had a significantly longer mean duration of second stage and a higher rate of cesarean delivery for failure to progress than those with intact membranes. Multiple logistic regression demonstrated that only PROM and fetal macrosomia were significantly associated with an increased risk of cesarean delivery for failure to progress after other confounding variables were adjusted. Conclusions:, Labor induction for PROM at term in nulliparous women with an unfavorable cervix is associated with longer duration of the second stage and a higher risk of cesarean delivery for failure to progress in comparison to those with intact membranes. [source] Lactational State Modifies Alcohol Pharmacokinetics in WomenALCOHOLISM, Issue 6 2007Marta Yanina Pepino Background: Given the physiological adaptations of the digestive system during lactation, the present study tested the hypothesis that lactation alters alcohol pharmacokinetics. Methods: Lactating women who were exclusively breastfeeding a 2- to 5-month-old infant and 2 control groups of nonlactating women were studied. The first control group consisted of women who were exclusively formula-feeding similarly aged infants, whereas the other consisted of women who had never given birth. A within-subjects design study was conducted such that women drank a 0.4 g/kg dose of alcohol following a 12-hour overnight fast during one test session (fasted condition) or 60 minutes after consuming a standard breakfast during the other (fed condition). Blood alcohol concentration (BAC) levels and mood states were obtained at fixed intervals before and after alcohol consumption. Results: Under both conditions, the resultant BAC levels at each time point were significantly lower and the area under the blood alcohol time curve were significantly smaller in lactating women when compared with the 2 groups of nonlactating women. That such changes were due to lactation per se and not due to recent parturient events was suggested by the finding that alcohol pharmacokinetics of nonlactating mothers, who were tested at a similar time postpartum, were no different from women who had never given birth. Despite lower BAC levels in lactating mothers, there were no significant differences among the 3 groups of women in the stimulant effects of alcohol. However, lactating women did differ in the sedative effects of alcohol when compared with nulliparous but not formula-feeding mothers. That is, both groups of parous women felt sedated for shorter periods of time when compared with nulliparous women. Conclusions: The systemic availability of alcohol was diminished during lactation. However, the reduced availability of alcohol in lactating women did not result in corresponding changes in the subjective effects of alcohol. [source] Asymmetric sphincter innervation is associated with fecal incontinence after anal sphincter trauma during childbirthNEUROUROLOGY AND URODYNAMICS, Issue 1 2007Beate M. Wietek Abstract Aims Functional asymmetry of pelvic floor innervation has been shown to exist in healthy subjects, and has been proposed to be a predictor of increased risk for fecal incontinence in case of trauma. However, this remains to be shown for different clinical conditions such as traumatic childbirth. Methods A conventional surface EMG system was used to assess the innervation of the external anal sphincter. A symmetry index was used to define the relative EMG amplitude asymmetry of the external anal sphincter between 0 (symmetric) and 1 (asymmetric). Three cohorts were studied: 40 nulliparous women in the third trimester (Study 1), 15 primiparous women within 6 months following vaginal delivery without clinically apparent anal sphincter trauma (Study 2), and 50 women after childbirth-related third or fourth degree perineal tear 6,12 months postpartum (Study 3). Furthermore, all women underwent conventional anorectal manometry. Results Sixteen or forty nulliparous women reported signs of fecal incontinence; however, relative asymmetry was not correlated to symptom severity (P,=,0.345), and not to manometric measures (Study 1). In Study 2, Women who had suffered clinically apparent anal sphincter trauma (P,=,0.07) tended to have a stronger association between incontinence and asymmetry. In Study 3, 19/50 women reported moderate to severe incontinence. Asymmetry and symptom severity were significantly correlated (P,<,0.001). Patients with incontinence had a significantly higher asymmetry score than their continent counterparts. Conclusion Functional asymmetry of anal sphincter innervation is significantly associated with incontinence symptoms, but only after childbirth-related sphincter injuries and therefore, should be regarded as an additional risk factor. Neurourol. Urodynam. © 2006 Wiley-Liss, Inc. [source] Effect of one interval vaginal delivery on the prevalence of stress urinary incontinence: A prospective cohort studyNEUROUROLOGY AND URODYNAMICS, Issue 6 2003Shing-Kai Yip Abstract Aims To analyze the effect of one interval vaginal delivery on the prevalence of stress urinary incontinence amongst a cohort of nulliparous women. Methods A cohort of 276 nulliparous women without incontinence was recruited consecutively in 1996, after they had vaginal delivery, and were followed-up for urinary incontinence in 2000. The age, obstetric variables of the 1996 delivery (mode of delivery, genital tract trauma, birth weight, epidural analgesia, episiotomy, durations of labor, postpartum urinary retention), and the presence of interval vaginal delivery during the follow-up period were recorded. The obstetric factors and the prevalence of urinary stress incontinence at follow-up were then compared between women with and without interval vaginal delivery. Logistic regression analysis was performed to test the independence of the obstetric variables in the index pregnancy and the presence of one interval vaginal delivery, with urinary stress incontinence being the dependent variable. Results A total of 148 (53.6%) women were followed-up. The prevalence of urinary incontinence was 28.6% in women without interval delivery and 21.1% in women with one interval delivery. There was no significant difference in the prevalence of urinary incontinence between the two groups (,2 test, P,=,0.31). Logistic regression showed that none of the obstetric variables or the presence of one interval vaginal delivery was significantly associated with urinary incontinence. Conclusions One interval vaginal delivery does not increase risk of urinary stress incontinence 4 years after the index vaginal delivery. Neurourol. Urodynam. 22:558,562, 2003. © 2003 Wiley-Liss, Inc. [source] The effect of the obstetrician group and epidural analgesia on the risk for cesarean delivery in nulliparous womenACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 8 2000Y. Beilin Background: The effects of regional anesthesia and of the obstetrician on the risk of cesarean delivery remain controversial. The purpose of this study was to determine whether epidural analgesia or the obstetrician group is associated with an increase in the risk for cesarean delivery in nulliparous women. Methods: Data were collected for a two-year period from the medical records of all nulliparous women who had a private obstetrician who delivered >20 babies per year, and who presented with a singleton gestation in the vertex presentation for a trial of labor. Results: Data were collected for 3699 women of whom 1832 were nulliparous. Of the 1832 nulliparous women, data were analyzed for the 1278 women who met our study criteria, representing 14 separate obstetrician groups. Excluding the 50 women whose babies were delivered for fetal distress (leaving 1228 women for analysis), the epidural rate was 93%, range 81,98%, and the cesarean delivery rate was 14%, range 8,34%. Logistic regression analyses revealed that (odds ratio, 95% confidence interval) patient age (1.7, 1.2,2.4), birth weight (1.001, 1.001,1.002), induction of labor (1.9, 1.3,2.7), non-Caucasian (1.9, 1.2,2.9) and the obstetrician group, (P=0.002), were independently associated with the risk of cesarean delivery, but epidural analgesia was not (1.6, 0.7,3.6). Conclusions: The obstetrician group is independently associated with the risk of cesarean delivery in nulliparous women, but we could not demonstrate this association with epidural analgesia. We suggest that in future studies regarding epidural analgesia and cesarean delivery, the obstetrician group should be included as a variable ( ,). [source] Independent changes in female body shape with parity and age: A life-history approach to female adiposityAMERICAN JOURNAL OF HUMAN BIOLOGY, Issue 4 2010Jonathan C.K. Wells Both aging and reproduction have been shown to influence female body shape in industrialized populations, involving redistribution of fat from lower to upper body regions. However, the extent to which effects of parity vary by age and the extent to which age affects shape independent of parity remain unclear. We studied shape variability in relation to age and parity in a cross-sectional survey of 4,130 white British women, using three-dimensional photonic scanning. In women ,40 years, bearing children was associated with increased abdominal and reduced thigh girths, independent of age and BMI. Very few such differences were statistically significant in women >40 years, suggesting the effects of parity on shape wash out over time. In nulliparous women, aging was associated with shape variability, independent of BMI, with a similar pattern of associations evident in women both ,40 and >40 years. Our data support previous findings of "covert maternal depletion" in relation to parity, but show that this is merely a more pronounced component of a general strategic shift of fat from lower to upper body with age. These findings are consistent with a life-history model of female energy stores being allocated to competing "reproduction" and "maintenance" depots, with the optimal trade-off strategy changing with age and with that strategic shift accelerated by bearing children. This model is relevant to the "grandmother hypothesis." The dual effects of age and parity on fat distribution substantially resolve by old age the profound sexual dimorphism in adiposity present at the start of adult life. Am. J. Hum. Biol. 2010. © 2009 Wiley-Liss, Inc. [source] Women's fertility and mortality in late mid life: A comparison of three contemporary populationsAMERICAN JOURNAL OF HUMAN BIOLOGY, Issue 4 2009Emily Grundy Evolutionary theory suggests a trade-off between reproduction and somatic maintenance implying a negative relationship between parity and longevity, at least in natural fertility populations. In populations in which fertility control is usual, there are also a number of mechanisms that may link reproductive careers and later mortality, but evidence of associations between women's fertility patterns and their later life health has been judged inconclusive due to varying controls for socio-economic characteristics and marital status. Here, we build on three recent studies that followed a common framework to investigate associations between women's parity and timing of first and last birth with mortality in late middle age in three contemporary developed counties, Norway, England and Wales, and the USA. Data were drawn from whole population registers (Norway); a large census-based record linkage study (England and Wales), and a nationally representative survey linked to death records (USA). Results show that teenage childbirth was associated with higher mortality risks in late middle age in all three countries. Risks of death were significantly raised among nulliparous women in Norway and England and Wales, and also raised (although not significantly so) for childless US women. However, although higher parity was associated with a slight mortality disadvantage in England and Wales and the USA, the reverse seemed the case in Norway. These finding suggest that in populations in which fertility control is usual, contextual factors influencing the relative costs and benefits of childbearing may influence associations between fertility histories and later mortality. Am. J. Hum. Biol., 2009. © 2009 Wiley-Liss, Inc. [source] Mammary Gland Architecture as a Determining Factor in the Susceptibility of the Human Breast to CancerTHE BREAST JOURNAL, Issue 5 2001Jose Russo MD The developmental pattern of the breast can be assessed by determining the composition of the breast in specific lobular structures, which are designated as lobules type 1 (Lob 1), lobules type 2 (Lob 2), and lobules type 3 (Lob 3), with Lob 1 being the less developed and Lob 3 being the most differentiated or with the highest number of ductules per lobular unit. In the present work, the patient population consisted of three groups of women who underwent surgical procedures: The first group included women who underwent reduction mammoplasty (RM) for cosmetic reasons. The second group included women who underwent prophylactic subcutaneous mastectomy after genetic counseling for either carrying the BRCA-1 gene or belonging to a pedigree with familial breast cancer (FAM), and the third group included women who underwent modified radical mastectomy (MRM) for the diagnosis of invasive carcinoma. The RM group consisted of 33 women, of whom 9 were nulliparous and 24 were parous. The FAM group consisted of 17 women, of whom 8 were nulliparous and 9 were parous. The MRM group consisted of 43 women, of whom 7 were nulliparous and 36 were parous. The analysis of the lobular composition of all of the samples from the RM group, which is considered the control group, revealed that Lob 1 represented 22%, Lob 2 represented 37%, and Lob 3 represented 38%, whereas the tissue examined from the FAM and MRM groups contained a preponderance of Lob 1 at 48% and 74%, respectively, over Lob 3, which was 10% and 3%, respectively. When the results of the analysis of breast tissue were separated according to the pregnancy history of the donor, it was found that in the control group or RM, there was a significant difference in lobular composition. Nulliparous women of the RM group showed a preponderance of Lob 1 (46%) over parous women, which contained only 17%, whereas the percentage of Lob 3 in the nulliparous group was significantly lower (7%) than the parous group (48%). In the breast tissues obtained from FAM and MRM, no significant differences in lobular composition were observed, as all of the samples contained a higher concentration of Lob 1, independent of the pregnancy history. The breast tissue of FAM and MRM of parous women had a developmental pattern that was similar to that of nulliparous women of the same group and that was less developed than the breast of parous women of the control group. An important difference between the Lob 1 of the FAM group versus the control (RM) and the MRM group was that most of these lobules had thin ductules with an increase in hyalinization of the intralobular stroma manifested in the whole-mount preparation as an alteration in the branching pattern. The data suggest that the breast tissue of women with invasive cancer, as well as those from a background of familial breast cancer, have an architectural pattern different from the control or normal tissues and that the BRCA-1 or related genes may have a functional role in the branching pattern of the breast during lobular development, mainly in the epithelial stroma interaction. [source] Does pregnancy provide vaccine-like protection against rheumatoid arthritis?ARTHRITIS & RHEUMATISM, Issue 7 2010Katherine A. Guthrie Objective Previous studies have evaluated the correlation between rheumatoid arthritis (RA) risk and pregnancy history, with conflicting results. Fetal cells acquired during pregnancy provide a potential explanation for modulation of RA risk by pregnancy. The present study was undertaken to examine the effect of parity on RA risk. Methods We examined parity and RA risk using results from a population-based prospective study in Seattle, Washington and the surrounding area and compared women who were recently diagnosed as having RA (n = 310) with controls (n = 1,418). We also evaluated the distribution of parity in cases according to HLA genotype. Results We found a significant reduction of RA risk associated with parity (relative risk [RR] 0.61 [95% confidence interval 0.43,0.86], P = 0.005). RA risk reduction in parous women was strongest among those who were younger. Most striking was that RA risk reduction correlated with the time that had elapsed since the last time a woman had given birth. RA risk was lowest among women whose last birth occurred 1,5 years previously (RR 0.29), with risk reduction lessening progressively as the time since the last birth increased (for those 5,15 years since last birth, RR 0.51; for those >15 years, RR 0.76), compared with nulliparous women (P for trend = 0.007). No correlation was observed between RA risk and either age at the time a woman first gave birth or a woman's total number of births. Among cases with the highest genetic risk of RA (i.e., those with 2 copies of RA-associated HLA alleles), a significant underrepresentation of parous women versus nulliparous women was observed (P = 0.02). Conclusion In the present study, there was a significantly lower risk of RA in parous women that was strongly correlated with the time elapsed since a woman had last given birth. While the explanation for our findings is not known, HLA-disparate fetal microchimerism can persist many years after a birth and could confer temporary protection against RA. [source] Original Article: Predicting the outcome of induction of labourAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 4 2010Ralph NADER Objective:, To test whether prediction of delivery outcome is feasible in post-term nulliparous pregnant women, using a published model and a locally produced model combining clinical and ultrasound assessment. Methods:, This is a prospective pilot study of 53 nulliparous women seen in a postdates clinic between 40 weeks four days and 41 weeks three days of gestation. They underwent a routine assessment including transabdominal ultrasound to determine amniotic fluid index, a Bishop score, and translabial ultrasound to determine the station of the fetal head at rest and bladder neck descent at rest and on valsalva. Additional information such as body weight at booking and current weight, height and a family history of caesarean section was obtained. Delivery outcome and labour details were obtained from the local obstetric database. Two models for prediction of delivery outcome were tested. Results:, Forty-nine complete datasets were analysed. Fourteen women had a normal vaginal delivery, 17 instrumental deliveries and 18 caesarean sections. A published model predicted the induction outcome in 62%. A local model using maternal age, body mass index, family history of caesarean section, station of the fetal head and bladder neck descent predicted vaginal delivery in 70% in our study. Conclusion:, Prediction of delivery outcome is of limited feasibility in post-term nulliparous pregnant women. Our locally produced model was successful in predicting vaginal delivery in 70% of women. Prediction of delivery outcome may not be sufficiently powerful to allow modification of current obstetric practice. [source] A study investigating obstetricians' and gynaecologists' management of women requesting an intrauterine deviceAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 2 2010Kirsten I. BLACK Background:, Intrauterine methods including the copper intrauterine device (Cu-IUD) and the levonorgestrel intrauterine system (LNG-IUS) provide highly effective long-term reversible contraception. The reasons for relative low use of these methods in Australia compared to many European countries are not clear, but may in part relate to provider reluctance because of outdated knowledge about their safety and efficacy. Aims:, The aim of this study was to survey Australian Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists about their knowledge of the risks, benefits and mechanisms of action of intrauterine methods. Methods:, In 2008, we undertook a cross-sectional survey of all Australian Fellows not registered as a subspecialist. The survey was mailed to 1050 practitioners and 701 were returned, comprising a response rate of 67%. Results:, Knowledge about the LNG-IUS was significantly better than for the Cu-IUD in terms of correct understanding about mechanism of action (89.3% vs. 30%; P < 0.001) and efficacy (63.2% vs. 33.5%; P < 0.001). According to the WHO, both methods are considered suitable for use in nulliparous women, yet only 39.1% of providers believed the Cu-IUD suitable compared to 69.4% for the LNG-IUS (P < 0.001). When responses were analysed according to time from graduation, many aspects of knowledge about these devices showed a linear trend, with greater accuracy in recent graduates (<10 years) compared with graduates of more than 30 years. Conclusion:, Both methods are highly effective, non-user dependent and reversible and deserve greater understanding and consideration for use by Australian practitioners and women. [source] Trends and determinants of caesarean sections births in Queensland, 1997,2006AUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 6 2009Stuart HOWELL Background:, The determinants of Queensland's rising caesarean section (CS) rate remain poorly understood because of the historical absence of standard classification methods. Aims:, We applied the Robson Ten Group Classification System (RTGCS) to population-based data to identify the main contributors to Queensland's rising CS rate. Method:, The RTGCS was applied retrospectively to the Queensland Perinatal Data Collection. CS rates were described for all ten RTGCS groups using data from 2006. Trends were evaluated using data for the years 1997,2006. Public and private sector patients were evaluated separately. Results:, In Queensland, in 2006, CS rates were 26.9 and 48.0% among public and private sector patients, respectively. Multiparous women with a previous caesarean birth (Group 5) made the greatest contribution to the CS rate in both sectors, followed by nulliparous women who had labour induced or were delivered by CS prior to the onset of labour (Group 2) and nulliparous women in spontaneous labour (Group 1). CS rates have risen in all RTGCS groups between 1997 and 2006. The trend was pronounced among multiparous women with a previous caesarean delivery (Group 5), among women with multiple pregnancies (Group 8) and among nulliparous women who had labour induced or were delivered by CS prior to the onset of labour (Group 2). Conclusions:, The CS rate in Queensland in 2006 was higher than in any other Australian state. The increase in Queensland's CS rates can be attributed to both the rising number of primary caesarean births and the rising number of repeat caesareans. [source] Can antenatal education influence how women push in labour?AUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 3 2009A Pilot Randomised Controlled Trial on Maternal Antenatal Teaching for Pushing in Second Stage of Labour (PUSH STUDY) Background:, Antenatal education on the physiology of second stage of labour and effective pushing has not been studied in the literature. Anecdotal observation seems to indicate that some nulliparous women are (at least initially) unable to push effectively. A large proportion seem to reflexly contract the levator ani muscle when asked to push which may have the effect of slowing the progress of labour. Aims:, To test the effectiveness of structured antenatal education for pushing in the second stage of labour versus normal care and its impact on delivery outcome. Methods: One hundred nulliparous women between 35 and 37 weeks gestation were randomised. Intervention: Two 15-min structured education sessions, one week apart, utilising observation of the perineum and a vaginal examination to teach correct technique for relaxing the levator ani muscle and effective pushing. Results:, In both groups, 31 of 50 women (62%) delivered vaginally. Instrumental delivery and caesarean section rates did not differ between the two groups (P = 0.78, relative risk = 1). The mean duration of active second stage for the control group was 53.96 min compared with 57.26 min for the intervention group. This difference of 3.3 min was not statistically significant (P = 0.56). Knowledge of women in the intervention group was increased and the majority of women found the educational sessions helpful. Conclusion:, Antenatal teaching to ensure effective maternal pushing in labour did not result in altered obstetric outcomes relative to the control group. However, there was a measurable qualitative effect from the intervention in that women clearly felt the education sessions to be helpful. [source] Factors associated with low immunity to rubella infection on antenatal screeningAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 5 2005Deshanie SATHANANDAN Abstract Background:, Rubella infection during the first trimester results in congenital rubella syndrome. There has been little recent published evidence identifying those at-risk of infection in the first trimester of pregnancy. This study examined the level of rubella immunity in pregnant women in a part of Sydney and risk factors for non-immunity. Methods:, We looked at data on all confinements at two maternity hospitals in Sydney in the 2-year period between July 1999 and June 2001. Variables included in our data set included mother's country of birth, mother's date of birth, hospital status (public or private patient), parity, rubella status and postpartum rubella vaccination. Results:, Of the 8096 confinements, the mother was documented as being non-immune to rubella in 567 cases (7%) of cases. Of the 567 confinements where rubella status was documented as non-immune, Asian-born women comprised of 65% (366) of non-immune women while 13% (73) were Australian-born. Country of birth remained a strong predictor of immunity, even after controlling for age, parity and hospital status. Maternal age > 35 years and nulliparity were also significant risk factors for non-immunity. Conclusion:, Programs targeting underimmunised populations for rubella vaccination should focus on overseas-born women, particularly those born in Asia, nulliparous women and also women > 35 years of age. [source] Induction of labour in nulliparous women with an unfavourable cervixBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 7 2010CE Pennell No abstract is available for this article. [source] Fear of childbirth according to parity, gestational age, and obstetric historyBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 1 2009H Rouhe Objective, To examine fear of childbirth according to parity, gestational age, and obstetric history. Design, A questionnaire study. Population and setting, 1400 unselected pregnant women in outpatient maternity clinics of a university central hospital. Methods, Visual analogue scale (VAS) and Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) and preferred mode of delivery. Main outcome measures, W-DEQ and VAS scores according to parity, gestational age, obstetric history, and preferred mode of delivery. Results, The W-DEQ and VAS scores were higher in nulliparous (W-DEQ 72.0 ± 20.0 [mean ± SD] and VAS 4.7 [median]) than parous women (65.4 ± 21.9; 3.2, P < 0.001 for both W-DEQ and VAS). Higher W-DEQ and VAS scores were found for those beyond 21 weeks of gestation compared with those before (W-DEQ 71.6 ± 23.0 versus 66.6 ± 20.0, P < 0.001; VAS 4.7 versus 3.2, P < 0.001). Caesarean section was preferred mode of delivery for 8.1% and these women scored higher on fear (W-DEQ 87.6 ± 26.5, VAS median 7.0) than those who preferred vaginal delivery (W-DEQ 61.8 ± 18.7, VAS 2.7, P < 0.001, respectively). Those with a previous caesarean scored higher on fear (W-DEQ 73.2 ± 23.5, VAS 5.1) than parous women without previous caesarean (W-DEQ 63.3 ± 20.8, VAS 2.9, P < 0.001, respectively). Those with a history of a vacuum extraction (VE) (W-DEQ 70.6 ± 19.7, VAS 5.0) had higher fear scores than those without (W-DEQ 64.8 ± 22.0, P < 0.05 and VAS 3.0, P < 0.001). Conclusion, Severe fear of childbirth was more common in nulliparous women, in later pregnancy, and in women with previous caesarean section or VE. Caesarean section as a preferred mode of childbirth was strongly associated with high score in both W-DEQ and VAS. [source] Maternal cardiac function and uterine artery Doppler at 11,14 weeks in the prediction of pre-eclampsia in nulliparous womenBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 3 2008A Khaw Objective, To assess maternal cardiac function in nulliparous women in the first trimester of pregnancy and evaluate its potential role for predicting pre-eclampsia and small for gestational age (SGA). Design, Prospective, observational, cross-sectional study. Setting, Maternity unit of a teaching hospital. Population, Nulliparous women with singleton pregnancies presenting consecutively for routine antenatal care (n= 534). Methods, Two-dimensional and M-mode echocardiography and uterine artery Dopplers were carried out at 11-14 weeks. Main outcome measures, Cardiac output (CO), stroke volume (SV), mean arterial pressure (MAP), total vascular resistance and uterine artery pulsatility index (UAPI) were compared in four outcome groups according to the development of pre-eclampsia and/or SGA. Results, Compared with the normal outcome group (n= 457), in those with pre-eclampsia but not SGA (n = 8), CO and MAP were increased; in the group with pre-eclampsia and SGA (n= 19) MAP, TRP and UAPI were increased and in the group with SGA but no pre-eclampsia (n= 50) total peripheral resistance and UAPI were increased. Independent predictors of pre-eclampsia were MAP, SV and UAPI and of SGA SV and UAPI. Conclusions, Alterations in maternal cardiac function and UAPI are observed in the first trimester of pregnancy in nulliparous women that subsequently develop pre-eclampsia and/or SGA. [source] Pelvic floor disorders 4 years after first delivery: a comparative study of restrictive versus systematic episiotomyBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 2 2008X Fritel Objective, To compare two policies for episiotomy: restrictive and systematic. Design, Quasi-randomised comparative study. Setting, Two French university hospitals with contrasting policies for episiotomy: one using episiotomy restrictively and the second routinely. Population, Seven hundred and seventy-four nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37,41 weeks. Methods, A questionnaire was mailed 4 years after delivery. Sample size was calculated to allow us to show a 10% difference in the prevalence of urinary incontinence with 80% power. Main outcome measures, Urinary incontinence, anal incontinence, perineal pain, and pain during intercourse. Results, We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, there was no difference in the prevalence of urinary incontinence (26 versus 32%), perineal pain (6 versus 8%), or pain during intercourse (18 versus 21%) between the two groups. Anal incontinence was less prevalent in the restrictive group (11 versus 16%). The difference was significant for flatus (8 versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR = 1.84, 95% CI: 1.05,3.22). Conclusions, A policy of routine episiotomy does not protect against urinary or anal incontinence 4 years after first delivery. [source] Trends in mode of delivery during 1984,2003: can they be explained by pregnancy and delivery complications?BJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 7 2007CM O'Leary Objectives, To describe trends in mode of delivery, to identify significant factors which affected mode of delivery, and to describe how these factors and their impact have changed over time. Design, Total population birth cohort. Setting, Western Australia 1984,2003. Participants, The analysis was restricted to all singleton infants delivered at 37,42 weeks of gestation with a cephalic presentation (n= 432 327). Methods, Logistic regression analyses were undertaken to estimate significant independent risk factors separately for elective and emergency caesarean sections compared with vaginal delivery (spontaneous and instrumental), adjusting for potential confounding variables. Main outcome measures, Trends in mode of delivery, demographic factors, and pregnancy and delivery complications. Estimated likelihood of elective caesarean section compared with vaginal delivery and emergency caesarean section compared with vaginal delivery. Results, Between 1984,88 and 1999,2003, the likelihood of women having an elective caesarean section increased by a factor of 2.35 times (95% CI 2.28,2.42) and the likelihood of an emergency caesarean section increased 1.89 times (95% CI 1.83,1.96). These caesarean section rate increases remained even after adjustment for their strong associations with many sociodemographic factors, obstetric risk factors, and obstetric complications. Rates of caesarean section were higher in older mothers, especially those older than 40 years of age (elective caesarean section, OR 5.42 [95% CI 4.88,6.01]; emergency caesarean section, OR 2.67 [95% CI 2.39,2.97]), and in nulliparous women (elective caesarean section, OR 1.54 [95% CI 1.47,1.61]; emergency caesarean section, OR 3.61 [95% CI 3.47,3.76]). Conclusions, Our data show significant changes in mode of delivery in Western Australia from 1984,2003, with an increasing trend in both elective and emergency caesarean section rates that do not appear to be explained by increased risk or indication. [source] The diagnostic accuracy of external pelvimetry and maternal height to predict dystocia in nulliparous women: a study in CameroonBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 5 2007AT Rozenholc Objective, In many developing countries, most women deliver at home or in facilities without operative capability. Identification before labour of women at risk of dystocia and timely referral to a district hospital for delivery is one strategy to reduce maternal and perinatal mortality and morbidity. Our objective was to assess the prediction of dystocia by the combination of maternal height with external pelvimetry, and with foot length and symphysis-fundus height. Design, A prospective cohort study. Setting, Three maternity units in Yaoundé, Cameroon. Population, A total of 807 consecutive nulliparous women at term who completed a trial of labour and delivered a single fetus in vertex presentation. Methods, Anthropometric measurements were recorded at the antenatal visit by a researcher and concealed from the staff managing labour. After delivery, the accuracy of individual and combined measurements in the prediction of dystocia was analysed. Main outcome measures, Dystocia, defined as caesarean section for dystocia; vacuum or forceps delivery after a prolonged labour (>12 hours); or spontaneous delivery after a prolonged labour associated with intrapartum death. Results, Ninety-eight women (12.1%) had dystocia. The combination of a maternal height less than or equal to the 5th percentile or a transverse diagonal of the Michaelis sacral rhomboid area less than or equal to the 10th percentile resulted in a sensitivity of 53.1% (95% CI 42.7,63.2), a specificity of 92.0% (95% CI 89.7,93.9), a positive predictive value of 47.7% (95% CI 38.0,57.5) and a positive likelihood ratio of 6.6 (95% CI 4.8,9.0), with 13.5% of all women presumed to be at risk. Other combinations resulted in inferior prediction. Conclusion, The combination of the maternal height with the transverse diagonal of the Michaelis sacral rhomboid area could identify, before labour, more than half of the cases of dystocia in nulliparous women. [source] Carbohydrate solution intake during labour just before the start of the second stage: a double-blind study on metabolic effects and clinical outcomeBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 12 2004H.C.J. Scheepers Objective To study the effects of oral carbohydrate ingestion on clinical outcome and on maternal and fetal metabolism. Design Prospective, double-blind, randomised study. Setting Leyenburg Hospital, The Hague, The Netherlands. Population Two hundred and two nulliparous women. Methods In labour, at 8 to 10 cm of cervical dilatation, the women were asked to drink a solution containing either 25 g carbohydrates or placebo. In a subgroup of 28 women, metabolic parameters were measured. Main outcome measures Number of instrumental deliveries, fetal and maternal glucose, free fatty acids, lactate, pH, Pco2, base excess/deficit and ,-hydroxybutyrate. Results Drinking a carbohydrate-enriched solution just before starting the second stage of labour did not reduce instrumental delivery rate (RR 1.1, 95% CI 0.9,1.3). Caesarean section rate was lower in the carbohydrate group, but the difference did not reach statistical significance (1%vs 7%, RR 0.2, 95% CI 0.02,1.2). In the carbohydrate group, maternal free fatty acids decreased and the lactate increased. In the umbilical cord there was a positive venous,arterial lactate difference in the carbohydrate group and a negative one in the placebo group, but the differences in pH and base deficit were comparable. Conclusion Intake of carbohydrates just before the second stage does not reduce instrumental delivery rate. The venous,arterial difference in the umbilical cord suggested lactate transport to the fetal circulation but did not result in fetal acidaemia. [source] The complex relationship between smoking in pregnancy and very preterm deliveryBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 3 2004Results of the Epipage study Objective To assess the relationship between cigarette smoking during pregnancy and very preterm births, according to the main mechanisms of preterm birth. Design Case,control study (the French Epipage study). Setting Regionally defined population of births in France. Population Eight hundred and sixty-four very preterm live-born singletons (between 27 and 32 completed weeks of gestation) and 567 unmatched full-term controls. Methods Data from the French Epipage study were analysed using a polytomous logistic regression model to control for social and demographic characteristics, pre-pregnancy body mass index and obstetric history. The main mechanisms of preterm delivery were classified as gestational hypertension, antepartum haemorrhage, premature rupture of membranes, spontaneous preterm labour and other miscellaneous mechanisms. Main outcome measures Odds ratios for very preterm birth for low to moderate (1,9 cigarettes/day) and heavy (,10 cigarettes/day) maternal smoking in pregnancy, estimated according to the main mechanisms leading to preterm birth. Results Smokers were more likely to give birth to very preterm infants than non-smokers [adjusted odds ratio (aOR) 1.7, 95% confidence interval (CI) 1.3,2.2]. Heavy smoking significantly reduced the risk of very preterm birth due to gestational hypertension (aOR 0.5, 95% CI 0.3,1.0), whereas both low to moderate and heavy smoking increased the risk of very preterm birth due to all other mechanisms (aOR between 1.6 and 2.8). Conclusion These data from the Epipage study show that maternal smoking during pregnancy is a risk factor for very preterm birth. The impact of maternal smoking on very preterm birth appears to be complex: it lowers the risk of very preterm birth due to gestational hypertension, but increases the risk of very preterm birth due to other mechanisms. These findings might explain why maternal smoking is more closely related to preterm birth among multiparous women than among nulliparous women. [source] Aspirin (100 mg) used for prevention of pre-eclampsia in nulliparous women: the Essai Régional Aspirine Mère,Enfant study (Part 1)BJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 5 2003Damien Subtil Objective To reduce the incidence of pre-eclampsia in nulliparous women, in accordance with the suggestion of a recent meta-analysis that low dose aspirin might decrease this incidence by more than half if used early enough in and at a sufficient dose during pregnancy (more than 75 mg). Design Multicentre randomised double-blinded placebo-controlled trial. Setting Twenty eight centres in Northern of France and one in Belgium. Population Three thousand and two hundred ninety-four nulliparous women recruited between 14 and 20 weeks. Methods Randomisation to either 100 mg aspirin or placebo daily from inclusion through 34 weeks. Main outcome measures Preeclampsia was defined as hypertension (,140 and or 90 mmHg) associated with proteinuria (,0.5 g/L). Results The aspirin (n= 1644) and placebo (n= 1650) groups did not differ significantly in the mothers' incidence of pre-eclampsia (28 of 1632 [1.7%] vs 26 of 1637 [1.6%]; relative risk, RR, 1.08, 95% CI 0.64,1.83), hypertension, HELLP syndrome or placental abruption, or in the children's incidence of perinatal deaths or birthweight below the 10th centile. The incidence of babies with birthweight below the third centile was significantly higher in the aspirin group, with no explanation. The incidence of maternal side effects was higher in the aspirin group, principally because of a significantly higher rate of haemorrhage. Conclusions Aspirin at a dose of 100 mg does not reduce the incidence of pre-eclampsia in nulliparous women. Aspirin (100 mg) is associated with an increase in bleeding complications. [source] Randomised comparison of uterine artery Doppler and aspirin (100 mg) with placebo in nulliparous women: the Essai Régional Aspirine Mère,Enfant study (Part 2)BJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 5 2003Damien Subtil Objective To assess the effectiveness of a pre-eclampsia prevention strategy based on routine uterine artery Doppler flow velocity waveform examination during the second trimester of pregnancy, followed by a prescription for 100 mg aspirin in the case of abnormal Doppler findings. Design Multicentre randomised controlled trial. Setting Eleven centres in the north of France and one in Belgium. Population One thousand and eight hundred and fifty-three nulliparous women recruited between 14 and 20 weeks of gestation. Methods Randomisation either to undergo a uterine Doppler examination between 22 and 24 week of gestation or to take a placebo. Women with abnormal Doppler waveforms received 100 mg of aspirin daily from Doppler examination through 36 weeks. Main outcome measures Pre-eclampsia was defined as hypertension (, 140 and/or 90 mmHg) associated with proteinuria (, 0.5 g/L). Results One thousand two hundred and fifty-three women (67%) were randomised into the systematic Doppler group and 617 (33%) into the placebo group. Of the 1175 patients in the Doppler group who underwent this examination, 239 (20.3%) had abnormal uterine artery Doppler and received a prescription for aspirin. Despite the aspirin prescription, the frequency of pre-eclampsia did not differ between the systematic Doppler group and the placebo group (28 of 1237 [2.3%] vs 9 of 616 [1.5%]; RR = 1.55, 95% CI 0.7,3.3). Furthermore, the groups did not differ in the frequency of children who were very small for their gestational age (,3rd centile) or for perinatal deaths. Compared with patients with normal Doppler findings, those with abnormal Doppler were at high risk of pre-eclampsia (RR = 5.5, 95% CI 2.5,12.2) and of giving birth to a small-for-gestational-age child (RR = 3.6, 95% CI 1.6,8.1). Conclusion Despite its sensitivity in screening for pre-eclampsia, routine uterine Doppler in the second trimester cannot be recommended for nulliparous patients. [source] A randomised clinical trial comparing the effects of delayed versus immediate pushing with epidural analgesia on mode of delivery and faecal continenceBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 12 2002Myra Fitzpatrick Objective To assess the effects of delayed vs immediate pushing in second stage of labour with epidural analgesia on delivery outcome, postpartum faecal continence and postpartum anal sphincter and pudendal nerve function. Design Prospective, randomised, controlled trial. Setting Tertiary referral maternity teaching hospital. Population One hundred and seventy nulliparous women randomised at full dilatation to immediate or delayed pushing. Methods A total of 178 nulliparous women, all with continuous epidural analgesia, were randomised at full cervical dilatation, but before the fetal head had reached the pelvic floor, to either immediate pushing or 1 hour delayed pushing. Labour outcome was analysed and all women underwent postpartum assessment of anal sphincter function, including anal manometry. Those women who had a normal delivery underwent neurophysiology studies, while those women who had an instrumental delivery underwent endoanal ultrasound. Main outcome measures Mode of delivery; altered faecal continence. Results Ninety women were randomised to immediate pushing and 88 to delayed pushing. The spontaneous delivery rate was 56% (50/90) in the immediate pushing group and 52% (46/88) in the delayed pushing group. Mean duration of labour for the immediate pushing group was 427 minutes compared with 480 minutes for the delayed pushing group (P= 0.005). Eighty-four percent (76/90) of women in the immediate pushing group received oxytocin to augment labour, 21/76 (28%) in the second stage only. Eighty-one percent (71/88) of women in the delayed pushing group received oxytocin to augment labour, 22/71 (31%) in the second stage only. Fetal outcome did not differ between the two groups. Episiotomy rates were 73% and 69% in the immediate pushing and delayed pushing groups, respectively. 26% (23/90) of the immediate pushing group and 38% (33/88) of the delayed pushing group complained of altered faecal continence after delivery (NS). Manometry, ultrasound and neurophysiology studies did not differ significantly between the two groups. Overall, 55% of women after instrumental delivery had endosonographic evidence of damage to the external anal sphincter, while 36% of women after spontaneous delivery had abnormal neurophysiology studies. Conclusions Rates of instrumental delivery were similar following immediate and delayed pushing, in association with epidural analgesia. Delayed pushing prolonged labour by 1 hour but did not result in significantly higher rates of altered continence or anal sphincter injury, when compared with immediate pushing. [source] | ||||||||||