1
306 SPO Abstracts 217 FHEr:::T (F RruI'INE WEl'XLY QRVICAL EXAt£ AT 'Im1 CN ffifMATIlRE RUPIURE (F 'llIE MEMffiANES: A RANrrMIZED CINI1UlBJ 1RIAL R.M::Mfie x , L.Osoorne x , G.Nelson x , C. Parke x , S.Crawrer x , M.Orleans x , A. lbverkaiqJ University of Colorado Iffilth SciEnCeS Center and Kaiser-PermnaJ.te, fewer, Colorado PraIBture rupture of tre OBllbranes (mN) cootinues to contrioote to increased mternal and neonatal IIDrbidity. \Ie coo:locted a rand<JIIized cootrolled trial to determine wrether routine weekly antepartun cervical exanE begun at Tlloeeks loere associated with mN. mN was defined as rupture of tre OBllbranes at any tine before tre onset of laoor. Sample size calculations loere based 00 an incideoce of I'5%" Of..=.OS,p Exclusions included history of mN, pretenD laoor, and antep:utUll bleeding. 282 patients loere rand<JIIized to no exanE while 2ffi loere rand<JIIized to weekly exaIB. mN and other ootcare variables are listed below. OJtcare No emn Exan -E..... - mN 17.4% 16.& Indoction 16.OZ Xl.OZ 18.9% 14.1% tE Cesarean 11.7% 9.4% tE O1ori<mniooitis 4.3% 3.2% tE fularetritis 1.1% 1.4% aNlIEICN: In oor poJX.1lation, there is no associatioo beo.een routine weekly antepartU1l cervical exaIB at tenD and mN or other stilly endpoints. 218 EXPRESSION OF PARATHYROID HORMONE-RELATED PEPTIDE (PTHrp) mRNA IN MURINE PLACENTA AND PREGNANT UTERUS. Ferguson II JE, Saunders TJX, Gorman JX, Martin TJX,+, Bruns DEX, Bruns MEHX. Departments of Obstetrics and Gynecology and Pathology, University of Virginia School of Medicine, Charlottesville, VA and +St. Vincent's Inst. of Med. Res., Melbourne, Australia. PTHrp was first isolated from tumors associated with humoral hypercalcemia of malignancy. and iIl..Yi!N, PTHr peptides produce the same biological effects as PTH in bone and in kidney. The role of PTHrp in normal tissues is unknown. Recent reports have identified expression of PTHrp mRNA in rat term uterus and rat mammary gland. Our Interest in maternal-fetal calcium endocrinology led us to perform studies on the expression of PTHrp mRNA (with cDNA from T.J. Martin) in the mouse uteroplacental unit (uterus, yolk sac and placenta) throughout pregnancy. Using RNA Northern gel blot analysis (32p-cDNA hybridization to total RNA) we have found evidence of PTHrp mRNA expression on days 12-19 of gestation in mouse pregnant uterus and in early-to-mid gestation placenta. The PTHrp is -2.0 kb size, identical to that in mammary gland. The expression of PTHrp mRNA is temporally associated with the expression of vitamin D receptor mRNA (-4.0 kb) and calbindin-D9k mRNA (0.6 kb). In summary the mRNA of a new calcium regulatory hormone, f.I.I::I..rJL, is expressed throughout pregnancy in mouse placenta and uterus suggesting that local hormonal regulation of calcium physiology is important to maintain pregnancy. It will be important to apply these new insights to human pregnancy. January 1991 Am J Obstet Gynewl 219 THE SECOND STAGE OF LABOR: FACTORS INFLUENCING DURATION. 'Pifer, J , Newton, E , Dept of Ob/Gyn, The University of Texas Healt Science Center at San AntoniO, San Antonio, TX Management of the second stage of labor is controversial, particularly when prolonged. There is a lack of understanding of the factors influencing the duration of this portion of labor. This study was undertaken to identify those factors and determ ine their relative contribution. A group of 403 primiparas and 336 multiparas with spontaneous vaginal deliveries were extensively analyzed with a history, a physical exam (including clinical pelvimetry). labor Ide livery data and multiple neonatal measurements Stepwise multiple linear regression identified the following factors as independent predictors in primiparas, multiparas and the combined group The table below illustrates the percentage of relative contribution to the R2 by each of those factors Primiparas Multiparas Total Group R2=.173 R2=.143 R2=.242 Epidural analgesia 43% 53% 28% Length of active phase 14% 16% 12% Low parity 23% 51% Weight gain 5% 8% NS Blrthweight 27% NS 7% Smaller maternal shoe size 6% NS 2% Station at complete dilation 5% NS NS Epidural analgesia and length of the active phase were aSSOCiated With duration of the second stage in all three groups. In primiparas, birthweight, maternal shoe size and station at complete dilation predicted length of second stage while parity was Important In multiparas and the total group In summary, parity, preceding labor dynamics and epidural analgesia contribute 91 % of the predictable variation In the duration of the second stage. However, 75% of the variance in the length of the second stage remains unexplained. 220 ACTIVE MANAGEMENT OF LABOR (AMOL) - AN EVALUATION OF ITS EFFICACY. JA Lopez-Zeno', AM Peaceman' and ML Socol. Northwestern Univ. Med. Sch., Chicago, IL. AMOL has been proposed as a means to lower the rate of cesarean section for nulliparous term patients, but has never been studied in a randomized trial. We have initiated an ongoing study, whereby, at the time of diagnosis of labor (painful regular uterine contractions with complete cervical effacement or spontaneous rupture of the membranes) patients are randomly assigned to either AMOL or control. AMOL patients have immediate amniotomy followed by institution of oxy1ocin whenever cervical dilation is <1 cm/hr. Oxytocin is begun at 6mU/min and increased by 6mUimin every 15min to achieve a uterine contraction frequency of 7 per 15min. Control patients are managed with amniotomy and augmentation of labor at the discretion of the attending physician. Oxy1ocin is begun at 1mUimin and increased by 1 or 2mUimin every 15min to achieve a uterine contraction frequency of 6 to 8 per 20m in. Results: the groups did not differ in dilation at diagnOSIs of labor, need for oxytocin administration, or use of epidural anesthesia. Pertinent outcome variables are listed below: AMOL(n=161) Ctrl(n=165) p value SVD 98 91 NS CIS 21 26 NS Forceps 42 48 NS Length 1 st stage (hr) 5.42 6.70 <.001 Length 2nd stage (hr) 1.46 1.57 NS Length of Labor (hr) 6.88 8.27 <.001 Conclusion: AMOL was associated with a statistically significant decrease in the length of the first stage and the overall length of labor. There was a modest decrease in the incidence of CIS and forceps deliveries in the AMOL group, but at this point in the study these differences are not statistically significant.

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Page 1: 220 Active management of labor (AMOL) ? An evaluation of its efficacy

306 SPO Abstracts

217 FHEr:::T (F RruI'INE WEl'XLY QRVICAL EXAt£ AT 'Im1 CN ffifMATIlRE RUPIURE (F 'llIE MEMffiANES: A RANrrMIZED CINI1UlBJ 1RIAL R.M::Mfie

x, L.Osoorne

x, G.Nelson

x, C. Parke

x,

S.Crawrerx

, M.Orleansx

, A. lbverkaiqJ University of Colorado Iffilth SciEnCeS Center and Kaiser-PermnaJ.te, fewer, Colorado

PraIBture rupture of tre OBllbranes (mN) cootinues to contrioote to increased mternal and neonatal IIDrbidity. \Ie coo:locted a rand<JIIized cootrolled trial to determine wrether routine weekly antepartun cervical exanE begun at Tlloeeks loere associated with mN. mN was defined as rupture of tre OBllbranes at any tine before tre onset of laoor. Sample size calculations loere based 00 an incideoce of I'5%" Of..=.OS,p =.2,~P=.1. Exclusions included history of mN, pretenD laoor, and antep:utUll bleeding. 282 patients loere rand<JIIized to no exanE while 2ffi loere rand<JIIized to weekly exaIB. mN and other ootcare variables are listed below. OJtcare No emn Exan -E.....-mN 17.4% 16.& ~ Indoction 16.OZ Xl.OZ ~ ~tatioo 18.9% 14.1% tE Cesarean 11.7% 9.4% tE O1ori<mniooitis 4.3% 3.2% tE fularetritis 1.1% 1.4% ~ aNlIEICN: In oor poJX.1lation, there is no associatioo beo.een routine weekly antepartU1l cervical exaIB at tenD and mN or other stilly endpoints.

218 EXPRESSION OF PARATHYROID HORMONE-RELATED PEPTIDE (PTHrp) mRNA IN MURINE PLACENTA AND PREGNANT UTERUS. Ferguson II JE, Saunders T JX, Gorman JX, Martin TJX,+, Bruns DEX, Bruns MEHX. Departments of Obstetrics and Gynecology and Pathology, University of Virginia School of Medicine, Charlottesville, VA and +St. Vincent's Inst. of Med. Res., Melbourne, Australia.

PTHrp was first isolated from tumors associated with humoral hypercalcemia of malignancy. ~ and iIl..Yi!N, PTHr peptides produce the same biological effects as PTH in bone and in kidney. The role of PTHrp in normal tissues is unknown. Recent reports have identified expression of PTHrp mRNA in rat term uterus and rat mammary gland. Our Interest in maternal-fetal calcium endocrinology led us to perform studies on the expression of PTHrp mRNA (with cDNA from T.J. Martin) in the mouse uteroplacental unit (uterus, yolk sac and placenta) throughout pregnancy. Using RNA Northern gel blot analysis (32p-cDNA hybridization to total RNA) we have found evidence of PTHrp mRNA expression on days 12-19 of gestation in mouse pregnant uterus and in early-to-mid gestation placenta. The PTHrp is -2.0 kb size, identical to that in mammary gland. The expression of PTHrp mRNA is temporally associated with the expression of vitamin D receptor mRNA (-4.0 kb) and calbindin-D9k mRNA (0.6 kb). In summary the mRNA of a new calcium regulatory hormone, f.I.I::I..rJL, is expressed throughout pregnancy in mouse placenta and uterus suggesting that local hormonal regulation of calcium physiology is important to maintain pregnancy. It will be important to apply these new insights to human pregnancy.

January 1991 Am J Obstet Gynewl

219 THE SECOND STAGE OF LABOR: FACTORS INFLUENCING DURATION. 'Pifer, J , Newton, E , Dept of Ob/Gyn, The University of Texas Healt Science Center at San AntoniO, San Antonio, TX

Management of the second stage of labor is controversial, particularly when prolonged. There is a lack of understanding of the factors influencing the duration of this portion of labor. This study was undertaken to identify those factors and determ ine their relative contribution. A group of 403 primiparas and 336 multiparas with spontaneous vaginal deliveries were extensively analyzed with a history, a physical exam (including clinical pelvimetry). labor Ide livery data and multiple neonatal measurements Stepwise multiple linear regression identified the following factors as independent predictors in primiparas, multiparas and the combined group The table below illustrates the percentage of relative contribution to the R2 by each of those factors

Primiparas Multiparas Total Group R2=.173 R2=.143 R2=.242

Epidural analgesia 43% 53% 28% Length of active phase 14% 16% 12% Low parity 23% 51% Weight gain 5% 8% NS Blrthweight 27% NS 7% Smaller maternal shoe size 6% NS 2% Station at complete dilation 5% NS NS Epidural analgesia and length of the active phase were aSSOCiated With duration of the second stage in all three groups. In primiparas, birthweight, maternal shoe size and station at complete dilation predicted length of second stage while parity was Important In multiparas and the total group In summary, parity, preceding labor dynamics and epidural analgesia contribute 91 % of the predictable variation In the duration of the second stage. However, 75% of the variance in the length of the second stage remains unexplained.

220 ACTIVE MANAGEMENT OF LABOR (AMOL) - AN EVALUATION OF ITS EFFICACY. JA Lopez-Zeno', AM Peaceman' and ML Socol. Northwestern Univ. Med. Sch., Chicago, IL.

AMOL has been proposed as a means to lower the rate of cesarean section for nulliparous term patients, but has never been studied in a randomized trial. We have initiated an ongoing study, whereby, at the time of diagnosis of labor (painful regular uterine contractions with e~her complete cervical effacement or spontaneous rupture of the membranes) patients are randomly assigned to either AMOL or control. AMOL patients have immediate amniotomy followed by institution of oxy1ocin whenever cervical dilation is <1 cm/hr. Oxytocin is begun at 6mU/min and increased by 6mUimin every 15min to achieve a uterine contraction frequency of 7 per 15min. Control patients are managed with amniotomy and augmentation of labor at the discretion of the attending physician. Oxy1ocin is begun at 1 mUimin and increased by 1 or 2mUimin every 15min to achieve a uterine contraction frequency of 6 to 8 per 20m in. Results: the groups did not differ in dilation at diagnOSIs of labor, need for oxytocin administration, or use of epidural anesthesia. Pertinent outcome variables are listed below:

AMOL(n=161) Ctrl(n=165) p value SVD 98 91 NS CIS 21 26 NS Forceps 42 48 NS Length 1 st stage (hr) 5.42 6.70 <.001 Length 2nd stage (hr) 1.46 1.57 NS Length of Labor (hr) 6.88 8.27 <.001

Conclusion: AMOL was associated with a statistically significant decrease in the length of the first stage and the overall length of labor. There was a modest decrease in the incidence of CIS and forceps deliveries in the AMOL group, but at this point in the study these differences are not statistically significant.