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Fulltext Routine vaginal examinations compared to other methods for assessing progress of labour to improve outcomes for women and babies at term

Moncrieff G, Gyte GM, Dahlen HG, Thomson G, Singata-Madliki M, Clegg A, et al.

Cochrane Database Syst Rev, 2022 Mar 04;3(3):CD010088.
PMID: 35244935 DOI: 10.1002/14651858.CD010088.pub3

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.

Matched MeSH terms: Chorioamnionitis*
Successful delayed-interval delivery in the presence of clinical chorioamnionitis in the leading twin: A report of two cases

Sukumaran S, Kanagalingam D

Med J Malaysia, 2019 02;74(1):85-86.
PMID: 30846669

We present two cases of diamniotic, dichorionic twin pregnancies in which after the loss of the first foetus in the setting of clinical chorioamnionitis, both pregnancies were successfully managed by delayed-interval delivery. A fourstage protocol including aspects of management in this specific setting is proposed. We consider the importance of a selection process when managing conservatively, measures to promote latency and decisions regarding delivery of the foetuses. Whilst we report successful case studies of conservative management with delayed-interval delivery, we support a cautious approach and understand that in the setting of clinical chorioamnionitis of the remaining foetus, delivery is necessary.

Matched MeSH terms: Chorioamnionitis/diagnosis*
Fulltext Candida Chorioamnionitis in Mothers with Gestational Diabetes Mellitus: A Report of Two Cases

Shazniza Shaaya E, Halim SAA, Leong KW, Ku KBP, Lim PS, Tan GC, et al.

Int J Environ Res Public Health, 2021 07 13;18(14).
PMID: 34299901 DOI: 10.3390/ijerph18147450

Background:Candida chorioamnionitis is rarely encountered, even though vulvovaginal candidiasis incidence is about 15%. Interestingly, it has characteristic gross and histological findings on the umbilical cord that are not to be missed. Case Report: We report two cases of Candida chorioamnionitis with presence of multiple yellowish and red spots of the surface of the umbilical cord. Microscopically, these consist of microabscesses with evidence of fungal yeasts and pseudohyphae. The yeasts and pseudohyphae were highlighted by periodic acid- Schiff and Grocott methenamine silver histochemical stains. Both cases were associated with a history of gestational diabetes mellitus. Discussion: Peripheral funisitis is a characteristic feature of Candida chorioamnionitis. It is associated with high risk of adverse perinatal and neonatal outcomes, such as preterm delivery, stillbirth and neonatal death. We recommend careful examination of the umbilical cord of mothers with gestational diabetes mellitus.

Matched MeSH terms: Chorioamnionitis*
Fulltext GIFT triplets and management problems--a case report

Wong KK, Lim CT

Med J Malaysia, 1991 Sep;46(3):294-6.
PMID: 1839929

Pregnancies conceived through assisted reproduction can present considerable management problems to the obstetric and paediatric staff. Multiple pregnancies are common. The complication of prematurity increases the morbidity and mortality rates of the neonates.

Matched MeSH terms: Chorioamnionitis/etiology
Fulltext An immunohistochemical study of Toll-like receptors 2 and 4 in placenta with and without infection

Hayati AR, Mohamed AE, Tan GC

Malays J Pathol, 2010 Jun;32(1):13-9.
PMID: 20614721 MyJurnal

The placenta constitutes a physical and immunological barrier against infectious agents. Toll-like receptors (TLRs) are essential components for the induction of innate immunity responses in different human tissues including the placenta. We investigated the expressions of TLR2 and TLR4 in the decidua and amniotic cells in non-inflamed placenta and placenta with infection.

Matched MeSH terms: Chorioamnionitis/immunology*; Chorioamnionitis/metabolism; Chorioamnionitis/pathology
Fulltext Gestational age at time of in utero lipopolysaccharide exposure influences the severity of inflammation-induced diaphragm weakness in lambs

Karisnan K, Mahzabin T, Bakker AJ, Song Y, Noble PB, Pillow JJ, et al.

Am J Physiol Regul Integr Comp Physiol, 2018 04 01;314(4):R523-R532.
PMID: 29212808 DOI: 10.1152/ajpregu.00150.2017

The preterm diaphragm is functionally immature compared with its term counterpart. In utero inflammation further exacerbates preterm diaphragm dysfunction. We hypothesized that preterm lambs are more vulnerable to in utero inflammation-induced diaphragm dysfunction compared with term lambs. Pregnant ewes received intra-amniotic (IA) injections of saline or 10 mg lipopolysaccharide (LPS) 2 or 7 days before delivery at 121 days (preterm) or ∼145 days (term) of gestation. Diaphragm contractile function was assessed in vitro. Plasma cytokines, diaphragm myosin heavy chain (MHC) isoforms, and oxidative stress were evaluated. Maximum diaphragm force in preterm control lambs was significantly lower (22%) than in term control lambs ( P < 0.001). Despite similar inflammatory cytokine responses to in utero LPS exposure, diaphragm function in preterm and term lambs was affected differentially. In term lambs, maximum force after a 2-day LPS exposure was significantly lower than in controls (by ~20%, P < 0.05). In preterm lambs, maximum forces after 2-day and 7-day LPS exposures were significantly lower than in controls (by ~30%, P < 0.05). Peak twitch force after LPS exposure was significantly lower in preterm than in controls, but not in term lambs. In term lambs, LPS exposure increased the proportion of MHC-I fibers, increased twitch contraction times, and increased fatigue resistance relative to controls. In preterm diaphragm, the cross-sectional area of embryonic MHC fibers was significantly lower after 7-day versus 2-day LPS exposures. We conclude that preterm lambs are more vulnerable to IA LPS-induced diaphragm dysfunction than term lambs. In utero inflammation exacerbates diaphragm dysfunction and may increase susceptibility to postnatal respiratory failure.

Matched MeSH terms: Chorioamnionitis/blood; Chorioamnionitis/chemically induced; Chorioamnionitis/physiopathology*
Fulltext Placental histopathological examination in foetal sepsis

Haza Syakirin Mohamad Zin, Salmi Abdullah, Norazlah Bahari, Thandayathany, Vijayaletchumi, Hayati Abd Rahman, Nur Syahrina Rahim

Borneo Journal of Medical Sciences, 2018;12(2):35-40.
MyJurnal

Intrauterine infection has emerged to be the main and frequent cause of premature delivery and foetal demise. Microorganisms gain entry into the amniotic cavity via ascending route, haematogenous dissemination, retrograde seeding from peritoneal cavity and accidental introduction during invasive procedures. This is a case of foetal loss in utero from a twin pregnancy due to intrauterine sepsis diagnosed through placenta examination. Both maternal and foetal evidences of inflammatory response were demonstrated in the placenta on histology. Microscopically, there were acute chorioamnionitis and villitis as well as abundant gram positive cocci in the foetal blood within placental villous capillaries. The presence of intravascular bacterial organism provides evidence for a conclusive diagnosis of intrauterine sepsis, particularly where the placenta or foetal blood microbiological cultures results are not available or equivocal. More attention should therefore be given when sampling, as pathological evidences of underlying foetal compromise or death could be provided by well-represented placental tissue samples.

Matched MeSH terms: Chorioamnionitis
Fulltext Post-partum invasive group b Streptococcus infection with fatal outcome: a case report

Siti Zulaikha Zakariah, Syafinaz Amin Nordin, Khairul Anuar Zainun, Asyraff Md Najib

Malaysian Journal of Medicine and Health Sciences, 2018;14(3):57-59.
MyJurnal

Group B streptococcus (GBS) is generally known to cause severe disease in the neonate and immunocompromised adults. GBS in the pregnant mother is rare and can potentially be fatal. Clinical presentation can be as mild as an uncomplicated urinary tract infection or serious invasive disease in the form of bacteremia, chorioamnionitis, endometritis and septic abortion. We report a case of a 46-year-old Para 3 lady, post-partum day 12, whom was found dead at home. Prior to her death, she had intermittent fever and abnormal lochia. Autopsy findings indicate GBS endometritis and bacteraemia. She was never screened for GBS. The cost-effectiveness of universal GBS screening needs to be explored to reduce maternal and neonatal morbidity due to GBS.

Matched MeSH terms: Chorioamnionitis