Amanda C. Zofkie’s research while affiliated with Washington University in St. Louis and other places

Objective The American College of Obstetricians and Gynecologists recommends speculum exams, rather than digital exams, for evaluation of the cervix after preterm prelabor rupture of membranes (PPROM). However, in clinical practice, digital exams may be necessary. We examined whether increasing numbers of digital exams were associated with adverse outcomes in PPROM. Study Design This was a single-center retrospective cohort study of patients admitted between 2019 and 2021 with PPROM at 24 to 34 weeks of gestation. The primary outcome was intra-amniotic infection and inflammation (triple I), compared between patients who had ≤1 or ≥2 digital exams during expectant management of PPROM. Secondary outcomes included latency, antepartum events, and other maternal and neonatal morbidities. Groups were compared using univariate analysis and Cox proportional hazards model to account for time between admission and delivery and potential confounders. Results Of 125 patients included in the analysis, 46 (36.8%) had ≤ 1 and 79 (63.2%) had ≥2 digital exams. There was no significant difference in triple I between groups (adjusted hazard ratio [aHR]: 1.03, 95% confidence interval [CI]: 0.47, 2.26). There were no significant differences in composite maternal or neonatal morbidities or latency from admission to delivery between groups (8 days [interquartile range (IQR): 3, 14] vs. 6 days [IQR: 3, 12]). There was a higher rate of spontaneous labor as the indication for delivery in the group with ≥2 exams (aHR: 2.07, 95% CI: 1.04, 4.11). Conclusion In this retrospective cohort study, ≥2 digital exams during expectant management of PPROM was not associated with change in infectious morbidity or pregnancy latency. There was an increase in spontaneous labor in the group with more digital exams; this may be due to confounding by indication, as patients who are in prodromal labor are more likely to receive digital exams. These results suggest equipoise in exam type in the management of PPROM. Key Points

INTRODUCTION Second-trimester transvaginal cervical length (TVCL) under 2.5 cm is a well-established risk factor for preterm birth, although few studies have evaluated delivery outcomes in “normal” cervical length groups. We aimed to evaluate the association of normal TVCL (2.5 cm or greater) tertiles on gestational age (GA) at delivery. METHODS This is a retrospective cohort study of patients eligible for vaginal birth with singleton term gestations and normal TVCL (at 16–24 weeks of gestation) delivering at a tertiary care center June 2022 to June 2023. Mean GA at delivery and rates of term deliveries were compared by TVCL tertiles (T1: 2.5–3.49 cm, T2: 3.5–4.49 cm, and T3: 4.5 cm or greater). Multivariable logistic regression was used to control for potential confounders. Institutional review board approval was obtained. RESULTS Of 1,034 eligible deliveries, 984 (95.2%) were term (37 0/7 weeks or greater). Patients with TVCLs in T2 and T3 were significantly more likely to have a term delivery than patients with TVCL in T1 (T2 96.0% versus T1 90.9%, P =.007; T3 96.2%, P =.03). Compared to T1, those with TVCLs in T2 and T3 also had increased odds ratio (OR) of a term birth (OR 2.4 [CI, 1.2–4.8] and OR 2.55 [CI, 1.03–6.7], respectively). After adjusting for confounders, this relationship remained statistically significant (T2 adjusted OR 3.05 [CI, 1.4–6.6]; T3 3.91 [CI, 1.3–11.4]). CONCLUSION Patients with longer TVCL measured at anatomy ultrasound are significantly more likely to have a term delivery, even after adjusting for confounders. These results can be used to guide patient counseling and expectations for labor and delivery outcomes.

INTRODUCTION Second-trimester transvaginal cervical length (TVCL) under 2.5 cm is associated with increased rates of spontaneous preterm birth; however, little is known about the effect of increasing TVCLs on spontaneous labor rates. We aimed to determine if longer TVCL is associated with increased risk of induction of labor (IOL). METHODS This is a retrospective cohort study of patients eligible for vaginal birth with singleton term gestations and normal TVCL (at 16–24 weeks of gestation) delivering at a tertiary care center June 2022 to June 2023. Rates of IOL were compared by TVCL tertiles (T1: 2.5–3.49 cm; T2: 3.5–4.49 cm; and T3: 4.5 cm or greater). Multivariable logistic regression controlled for potential confounders. Institutional review board approval was obtained. RESULTS Of 1,027 eligible deliveries, 594 (58%) underwent IOL. Patients with TVCLs in T2 and T3 were significantly more likely to undergo IOL than patients with TVCL in T1 (T2 59.6% versus T1 49.4%, P =.02; T3 56.5%, P =.04). Patients in T2 had increased odds of IOL compared to those in T1 (OR 1.5 [CI, 1.1–2.1]). This relationship did not remain significant after adjusting for potential confounders including term delivery, delivery mode, race/ethnicity, age, and body mass index. The odds of IOL with TVCL in T3 were not significantly different than for those in T1, before and after adjusting for confounders. CONCLUSION Within a cohort of patients with normal mid-trimester TVCL, increasing TVCLs were not associated with higher rates of IOL after adjusting for confounding variables. These results can be used to guide patient counseling surrounding birth plans and expectations for labor and delivery.

INTRODUCTION Second-trimester transvaginal cervical length (TVCL) under 2.5 cm is a well-established risk factor for preterm birth and mid-trimester loss. However, few studies have investigated birth outcomes associated with increasing lengths of “normal” TVCL (2.5 cm or greater). We aimed to evaluate the association of normal TVCL tertiles with mode of delivery. METHODS This is a retrospective cohort study of patients eligible for vaginal birth with singleton term gestations and normal TVCL (at 16–24 weeks of gestation) delivering at a tertiary care center from June 2022 to June 2023. Mode of delivery was compared by TVCL tertiles: T1, 2.5–3.49 cm; T2, 3.5–4.49 cm; and T3, 4.5 cm or greater. Multivariable logistic regression controlled for potential confounders. Institutional review board approval was obtained. RESULTS Of 1,033 eligible deliveries, 175 (16.9%), 621 (60.1%), and 237 (22.9%) had TVCL in T1, T2, and T3, respectively. Compared to patients with TVCL in T1, those in T2 and T3 were significantly more likely to have an intrapartum cesarean delivery (CD) (T1 3.4% versus T2 8.5%, P =.02; T3 11.8%, P =.002), with odds ratios (ORs) of 2.63 (CI, 1.1–7.6) and 3.77 (CI, 1.5–11.4), respectively. After adjusting for confounders, those with TVCL in T3 remained statistically more likely to undergo CD than those in T1, adjusted OR 6.7 (CI, 2.3–19.2). Of note, no patients with TVCL in T1 had CD for Stage 1 arrest. CONCLUSION Patients with longer TVCL at 16–24 weeks are significantly more likely to undergo an intrapartum CD. This association can be considered during patient counseling on delivery outcome expectations.

Objective Maternal pushing can yield lactate levels that are above the normal range for nonpregnant individuals. Many hospitals require lactate levels as part of sepsis bundles, and this can confuse the clinicians when measured during labor. The objective of this study was to observe lactate levels in uncomplicated labor. Study Design This was a prospective study of patients presenting to Labor and Delivery in early labor. Patients met inclusion criteria if they presented at 37 weeks' gestation or greater and were either 3 to 4 cm dilated, in early labor with rupture of membranes less than 12 hours, or were being induced for oligohydramnios or postdates gestation. A baseline maternal lactate level was collected at enrollment. Further levels were collected at complete cervical dilation and every 30 minutes during the second stage of labor up to 3 hours or until delivery. Results From January 7, 2021, through December 30, 2021, a total of 148 screened patients met the inclusion criteria and 38 were enrolled. Eight (21%) patients withdrew after baseline lactate level was drawn. Twenty-three (61%) patients had a level drawn at complete dilation. Of the 12 (32%) patients with a lactate level drawn at complete and after 30 minutes of pushing, the mean change in lactate level was 2.0 ± 1.8 mmol/L or 0.07 ± 0.06 mmol/L/min (p < 0.01). This change is more pronounced in the second stage of labor for patients with chorioamnionitis (2.6 mmol/L), although this difference is not statistically significant (p = 0.41). Conclusion Lactate levels increase significantly once a patient reaches complete cervical dilation within 30 minutes of pushing. This increase is more pronounced, although significantly, in patients with chorioamnionitis. As sepsis is one of the leading causes of maternal morbidity and mortality, this pilot study is relevant for providers to see the natural course of lactate levels in labor. Key Points

Objective This study aimed to examine the relationship of fetal station in the first stage of labor to labor curves and cesarean delivery rates among women presenting in spontaneous labor. Study Design Labor curves for patients with nonanomalous singletons who presented in spontaneous labor to our hospital's Obstetric Triage Unit with intact membranes from January 1, 2012, to August 31, 2016 were reviewed. Cervical exams and time of exam were obtained for each patient from presentation to triage until delivery. Station for each presentation and cervical dilation was estimated using a random effects model and the slope of cervical station change was calculated to estimate the change in dilation by hour. Perinatal outcomes, including cesarean delivery rates, were examined according to fetal station at initial presentation. Factors known to affect labor curves—epidural analgesia, infant birthweight, maternal habitus, and parity—were also examined. Results There were 8,123 patients presented in spontaneous labor with intact membranes. For patients presenting at 6-cm dilation, the rate of change of labor was significantly different when identified to have a station greater than 0 (+1 and more caudad) when compared with those with −1 and more cephalad station (both p < 0.001). This relationship persisted when analyzed according to epidural analgesia, birthweight, maternal habitus, and parity. The frequency of cesarean delivery was significantly higher for women presenting in spontaneous labor with negative fetal station (p < 0.05). When stratified across all dilation (3–9 cm), this trend remained significant (p < 0.001). Conclusion In the first stage of labor, advanced fetal station was significantly associated with differing rates of labor progression, and positive fetal station was significantly less likely to result in cesarean delivery. Physical examination, including station, remains a critical element in labor management. Key Points