Epidurals and the Modern Labor Curve: How Epidural Timing Impacts Fetal Station during Active Labor

2017 ◽  
Vol 35 (05) ◽  
pp. 421-426
Author(s):  
Methodius Tuuli ◽  
Molly Stout ◽  
Candice Woolfolk ◽  
Kimberly Roehl ◽  
George Macones ◽  
...  
Keyword(s):  
Odds Ratio ◽  
Primary Outcome ◽  
Secondary Analysis ◽  
Single Institution ◽  
Second Stage Of Labor ◽  
Second Stage ◽  
Increased Risk ◽  
Active Labor ◽  
Secondary Outcomes ◽  
Singleton Pregnancies

Objective The objective of this study was to estimate epidural timing's impact on fetal station during active labor. Study Design This secondary analysis of a single-institution prospective cohort study included all term singleton pregnancies, stratified by parity. Those with early epidurals (placed at <6 cm) were compared with those with late epidurals (placed at ≥6 cm). The primary outcome was median fetal station from 6 to 10 cm. Secondary outcomes included rate of prolonged first or second stage of labor (>95%). Multivariable logistic regression adjusted for labor type. Results Among 7,647 women, 3,434 were nulliparous (2,983 with early epidurals and 451 with late epidurals) and 4,213 multiparous (3,141 with early epidurals and 1,072 with late epidurals). Interquartile ranges (IQRs) suggested fetal station at 6 cm was likely lower among those with early epidurals (nulliparous: median head station −1 [IQR: −1 to 0] for early epidural vs. −1 [IQR: −2 to 0] for late epidural, p < 0.01; multiparous: −1 (IQR: −2 to 0] for early epidural vs. −1 [IQR: −3 to −1] for late epidural, p < 0.01). Early epidurals were not associated with increased risk of prolonged first stage, but among nulliparous were associated with decreased risk of prolonged second stage (adjusted odds ratio: 0.66 [95% confidence interval: 0.44–0.99]). Conclusion Early epidurals were associated with lower fetal station in active labor but not prolonged first stage.

Effect of Trial of Labor before Cesarean and Risk of Subsequent Placenta Accreta Spectrum Disorders

2019 ◽  
Vol 37 (06) ◽  
pp. 633-637
Author(s):  
Katharine N. O'Malley ◽  
Mary E. Norton ◽  
Sarah S. Osmundson
Keyword(s):  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Primary Outcome ◽  
Placenta Accreta ◽  
Secondary Analysis ◽  
Subsequent Pregnancy ◽  
Trial Of Labor ◽  
Increased Risk ◽  
Placenta Accreta Spectrum ◽  
Spectrum Disorders

Abstract Objective This study aimed to examine whether labor before cesarean affects the risk of placenta accreta spectrum (PAS) disorders in a subsequent pregnancy. Study Design This is a secondary analysis of the Cesarean Registry, a prospective cohort study of women undergoing cesarean between 1999 and 2002. Women with one prior cesarean with known indications, which were categorized as likely associated with labor (labored cesarean) versus likely not associated with labor (unlabored cesarean), were included. Primary outcome was PAS disorder. Results Of 34,224 women, 60% had a “labored cesarean” and 40% had an “unlabored cesarean.” Women with prior unlabored cesarean were more likely to have subsequent PAS disorder compared with women with a prior labored cesarean after adjusting for confounders (0.28 vs. 0.13%; adjusted odds ratio: 2.03; 95% confidence interval: 1.22–3.38). Conclusion Prior unlabored cesarean is associated with an increased risk of PAS disorders in a subsequent pregnancy. This association may aid in risk stratification in women with suspected PAS disorders and help counsel about risks associated with cesarean on maternal request.

Risk of Neonatal Neurologic Morbidity in Advancing Term Gestations

2017 ◽  
Vol 35 (07) ◽  
pp. 599-604 ◽  
Author(s):  
Molly Stout ◽  
Methodius Tuuli ◽  
Julia López ◽  
George Macones ◽  
Alison Cahill ◽  
...  
Keyword(s):  
Primary Outcome ◽  
Secondary Analysis ◽  
Neonatal Morbidity ◽  
Meconium Aspiration Syndrome ◽  
Delivery Mode ◽  
Single Institution ◽  
Term Infants ◽  
Increased Risk ◽  
Adverse Neonatal Outcomes ◽  
Ischemic Encephalopathy

Objective Placental insufficiency is associated with neonatal neurologic morbidity and late-term gestations (410/7–416/7 weeks). Whether late-term infants are at increased risk of neurologic morbidity compared with term infants (390/7–406/7 weeks) remains unclear. We aim to compare risk of neurologic morbidity among late-term and term infants. Study Design This secondary analysis of a single-institution prospective cohort study included all liveborn, nonanomalous singleton term and late-term infants, with data on adverse neonatal outcomes up until 28 days of life. The primary outcome was a neonatal neurologic morbidity composite, defined by having one of these conditions: neonatal seizures, intraventricular hemorrhage, hypoxic-ischemic encephalopathy, and neonatal hypothermic therapy. Secondary outcomes were the composite's individual components and nonneurologic neonatal morbidity. Multivariable logistic regression adjusted for delivery mode, nulliparity, and labor type. Results Of 5,529 infants included, 747 were late term and 4,782 were term. The risk of composite neurologic morbidity was not significantly different among late-term or term infants (0.5 vs. 0.6%; adjusted odds ratio: 0.59, 95% confidence interval: 0.21–1.71). Overall neonatal morbidity was not significantly different in the two groups, though late-term infants had a nonsignificantly higher prevalence of respiratory distress syndrome (5.5 vs. 3.3%) and meconium aspiration syndrome (0.7 vs. 0.2%). Conclusion Neonatal neurologic morbidity is uncommon after 39 weeks. Risk does not increase after 41 weeks.

Galectin-3 predicts cardiovascular events in patients with type-2 diabetes

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Lorenzo-Almoros ◽  
A Pello ◽  
A Acena ◽  
J Martinez-Milla ◽  
N Tarin ◽  
...  
Keyword(s):  
Heart Failure ◽  
Type 2 Diabetes ◽  
Plasma Levels ◽  
Cardiovascular Events ◽  
Primary Outcome ◽  
Funding Source ◽  
Increased Risk ◽  
Galectin 3 ◽  
Secondary Outcomes

Abstract Introduction Type-2 diabetes mellitus (T2DM) is associated with early and severe atherosclerosis. However, few biomarkers can predict cardiovascular events in this population. Methods We followed 964 patients with coronary artery disease (CAD), assessing at baseline galectin-3, monocyte chemoattractant protein-1 (MCP-1) and N-terminal fragment of brain natriuretic peptide (NT-proBNP) plasma levels. Secondary outcomes were acute ischemia and heart failure or death. Primary outcome was the combination of the secondary outcomes. Results Male patients were 75.0% in T2DM and 76.6% in the non-T2DM subgroup (p=0.609). Age was 61.0 (54–72) and 60.0 (51–71) years, respectively (p=0.092). 232 patients had T2DM. Patients with T2DM showed higher MCP-1 [144 (113–195) vs. 133 (105–173) pg/ml, p=0.006] and galectin-3 [8.3 (6.5–10.5) vs. 7.8 (5.9–9.8) ng/ml, p=0.049] levels. Median follow-up was 5.39 years (2.81- 6.92). Galectin-3 levels were associated with increased risk of the primary outcome in T2DM patients [HR 1.57 (1.07–2.30); p=0.022], along with a history of cerebrovascular events. Treatment with clopidogrel was associated with lower risk. In contrast, NT-proBNP and MCP-1, but not galectin-3, were related to increased risk of the event in non-diabetic patients [HR 1.21 (1.04–1.42); p=0.017 and HR 1.23 (1.05–1.44); p=0.012, respectively], along with male sex and age. Galectin-3 was also the only biomarker that predicted the development of acute ischemic events and heart failure or death in T2DM patients, while in non-diabetics MCP-1 and NT-proBNP, respectively, predicted these events. Conclusion In CAD patients, cardiovascular events are predicted by galectin-3 plasma levels in patients with T2DM, and by MCP-1 and NT-proBNP in those without T2DM. Effect of Gal-3 on the primary endpoint Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Insituto de Salud Carlos III

Impact of obesity on the clinical outcomes of patients undergoing pacemaker insertion during hospitalization: An analysis of the United States National Inpatient Sample

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
M Almani ◽  
M Usman ◽  
M Qudrat Ullah ◽  
N Fatima ◽  
M Yousuf ◽  
...  
Keyword(s):  
Heart Failure ◽  
Odds Ratio ◽  
Primary Outcome ◽  
Decompensated Heart Failure ◽  
Obesity Paradox ◽  
Obese Patients ◽  
National Inpatient Sample ◽  
Inpatient Mortality ◽  
Secondary Outcomes ◽  
Pacemaker Insertion

Abstract Funding Acknowledgements Type of funding sources: None. 1. Introduction Obesity causes significant cardiovascular morbidity. Nonetheless, there is also evidence supporting obesity paradox particularly in heart failure patients. The impact of obesity on the outcomes of patients undergoing pacemaker insertion is not well studied. 2. Purpose The purpose of this study is to determine if obesity paradox exists for the patients who undergo pacemaker insertion. 3. Methods Data were extracted from the National Inpatient Sample (NIS) 2016 - 2018 Database. The NIS was searched for patients who underwent pacemaker insertion while hospitalized. The patients were divided into two groups based on presence or absence of obesity as secondary diagnosis using ICD-10 codes. The primary outcome was inpatient mortality. Multivariate logistic and linear regression analysis was used accordingly to adjust for confounders. STATA software was used to for analysis. 4. Results Of 408,040 patients who underwent pacemaker insertion, 64185 (15.7%) were obese. The adjusted odds ratio for inpatient mortality for obese patient undergoing pacemaker insertion compared to non-obese patients was 0.65 (95% CI 0.516 – 0.821, p &lt; 0.001). Secondary outcomes are listed in table 1. 5. Conclusion Obese patients who underwent pacemaker insertion had lower inpatient mortality compared to non-obese patients. Also, obese patients undergoing pacemaker insertion were less likely to have cardiac arrest but they were more likely to develop decompensated heart failure and acute renal failure compared to non-obese patients. Outcome Without Obesity, % With Obesity, % aOR (95% CI) p-value* Primary outcome In hospital mortality 10.8 7.0 0.65 (0.516 - 0.821) &lt;0.001* Secondary outcomes Length of stay (days), mean 5.7 6.3 0.031 (-0.105 - 0.168) # 0.654 Total hospital charges (US$), mean 121250 134757 720 (-2307 - 3747) # 0.641 Decompensated heart failure 13.3 19.2 1.53 (1.451 - 1.629) &lt;0.001* Cardiogenic shock 2.3 2.7 1.00 (0.883 - 1.141) 0.954 IABP placement 0.5 0.6 0.98 (0.746 - 1.294) 0.898 Cardiac arrest 4.27 4.30 0.83 (0.753 - 0.920) &lt;0.001* Acute renal failure 20.7 25.4 1.17 (1.112 - 1.231) &lt;0.001* Abbreviations: *; statistically significant, #; adjusted mean difference, aOR: adjusted odds ratio, CI: confidence interval, IABP: Intra-aortic balloon pump.Adjusting factors: Age, race, Charlson comorbidity index, primary insurance, median household income for patient’s zip code, location and teaching status of the admitting hospital, dyslipidemia, chronic obstructive pulmonary disease, hypertension, peripheral vascular disease, diabetes mellitus, chronic kidney disease, liver disease and smoking status. Table 1: Clinical outcomes of hospitalizations for pacemaker insertion based on presence or absence of obesity, analysis of United States National Inpatient Sample from 2016 through 2018.

Abstract 154: Diabetic Retinopathy and Risk of Stroke: A Secondary Analysis of Accord

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ka-ho Wong ◽  
Cecilia Peterson ◽  
Rock Theodore ◽  
Kinga aitken ◽  
Michael Dela Cruz ◽  
...  
Keyword(s):  
Diabetic Retinopathy ◽  
Primary Outcome ◽  
Cox Model ◽  
Secondary Analysis ◽  
Cox Models ◽  
Interaction Terms ◽  
Increased Risk ◽  
Microvascular Pathology ◽  
Fundus Photographs

Background: Diabetic retinopathy is a common microvascular complication of diabetes. Previous research has shown that the macrovascular complications of diabetes, including stroke, are often comorbid with shared and, possibly, synergistic pathology. Methods: This is a secondary analysis of the subgroup of patients who enrolled in the ACCORD Eye study of ACCORD. The primary outcome is stroke during follow-up. The primary predictor was presence of diabetic retinopathy on the Early Treatment Diabetic Retinopathy Study Severity Scale as assessed from seven-field stereoscopic fundus photographs at study baseline. We fit adjusted Cox models to the primary outcome to provide hazard ratios for stroke and included interaction terms with the ACCORD randomization arms. Results: We included 2,828 patients with a mean (SD) age of 62.1 years and 61.8% were male. The primary outcome of stroke was met by 117 patients during a mean (SD) of 5.4 (1.8) years of follow-up. Diabetic retinopathy was present in 874/2,828 (30.9%) of patients at baseline, and was more common in patients with stroke versus without stroke (41.0 vs 30.5%, p=0.016). In the Cox model, adjusted for baseline patient age, gender, race, total cholesterol, Hgb A1c, smoking, and randomization arm, we found that diabetic retinopathy remained associated with incident stroke (HR 1.60, 95% CI 1.10-2.32, p=0.015) (Figure 1). This association was not affected by randomization to the ACCORD glucose intervention (p=0.305), lipid intervention (p=0.546), or blood pressure intervention (p=0.422). Conclusion: Diabetic retinopathy is associated with an increased risk of stroke, which suggests that the microvascular pathology inherent to diabetic retinopathy has larger cardiovascular implications.

Abstract TMP5: Secondary Analysis of Eptifibatide Plus Full Dose rt-PA in Ischemic Stroke

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Opeolu Adeoye ◽  
Heidi Sucharew ◽  
Jane Khoury ◽  
Pamela Schmit ◽  
Joseph Broderick ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Propensity Score ◽  
Logistic Model ◽  
Primary Outcome ◽  
Secondary Analysis ◽  
Full Dose ◽  
Control Subjects ◽  
Secondary Outcomes ◽  
And Control ◽  
Consistent Direction

Background: The Phase 2 Combined approach to Lysis utilizing Eptifibatide And Rt-PA in Acute Ischemic Stroke - Full Dose Regimen (CLEAR-FDR) trial was a single arm trial that demonstrated the safety of full dose (0.9mg/kg) rt-PA plus eptifibatide in AIS patients treated with rt-PA within three hours of symptom onset. Interventional Management of Stroke (IMS) III randomized AIS patients to rt-PA plus endovascular therapy versus standard r-tPA. Albumin in Acute Stroke (ALIAS) Part 2 randomized patients to albumin±rt-PA versus saline±rt-PA. We compared outcomes in CLEAR-FDR patients to propensity score-matched rt-PA only subjects in ALIAS Part 2 and IMS. Methods: All datasets were restricted to subjects with baseline modified Rankin score (mRS) of 0 or 1. Controls were selected using propensity score matching of CLEAR-FDR subjects and rt-PA only subjects from both IMS III and ALIAS. Age, gender, race, baseline mRS, baseline NIHSS score, and time from stroke onset to rt-PA were included in the logistic model used to generate a propensity score for each subject. The greedy matching algorithm was then used to match 1:3. The primary outcome was 90-day severity-adjusted mRS dichotomization based on baseline NIHSS. Secondary outcomes were 90-day mRS dichotomized as excellent (mRS 0-1); favorable (mRS 0-2); and, nonparametric analysis of the ordinal mRS. Results: Eighteen CLEAR-FDR subjects were matched with 52 controls. Median age in CLEAR-FDR and control subjects was 67 and 68 years respectively. Median NIHSS in both CLEAR-FDR and control subjects was 11. At 90 days, CLEAR-FDR subjects had a nonsignificant greater proportion of patients with a favorable primary outcome (61% versus 38%; unadjusted RR 1.59; 95%CI 0.96-2.63; P=0.10). Secondary outcomes also favored CLEAR-FDR subjects: excellent outcomes - 67% versus 38% (RR 1.73; 95%CI 1.08-2.79; P=0.04); favorable outcomes - 67% versus 58% (RR 1.16; 95%CI 0.77-1.73; P=0.50); and ordinal Cochran-Mantel-Haenszel, P=0.13. Conclusion: The outcomes for combination of full dose rt-PA plus eptifibatide showed a consistent direction of effect in favor of the combination over rt-PA alone. A trial to establish the efficacy of rt-PA plus eptifibatide for improving AIS outcomes is warranted and in the planning stages.

scholarly journals Acute Kidney Injury and Bronchopulmonary Dysplasia in Premature Neonates Born Less than 32 Weeks' Gestation

2019 ◽  
Vol 37 (03) ◽  
pp. 341-348 ◽  
Author(s):  
Michelle C. Starr ◽  
Louis Boohaker ◽  
Laurie C. Eldredge ◽  
Shina Menon ◽  
Russell Griffin ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Bronchopulmonary Dysplasia ◽  
Premature Infants ◽  
Gestational Age ◽  
Odds Ratio ◽  
Retrospective Cohort ◽  
Primary Outcome ◽  
Secondary Analysis ◽  
Kidney Injury ◽  
Multiple Factors

Abstract Objective This study aimed to evaluate the association between acute kidney injury (AKI) and bronchopulmonary dysplasia (BPD) in infants born <32 weeks of gestational age (GA). Study Design Present study is a secondary analysis of premature infants born at <32 weeks of GA in the Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) retrospective cohort (n = 546). We stratified by gestational age and used logistic regression to determine association between AKI and moderate or severe BPD/mortality. Results Moderate or severe BPD occurred in 214 of 546 (39%) infants, while death occurred in 32 of 546 (6%); the composite of moderate or severe BPD/death occurred in 246 of 546 (45%). For infants born ≤29 weeks of gestation, the adjusted odds ratio (OR) of AKI and the primary outcome was 1.15 (95% confidence interval [CI] = 0.47–2.86; p = 0.76). Infants born between 29 and 32 weeks of gestation with AKI had four-fold higher odds of moderate or severe BPD/death that remained after controlling for multiple factors (adjusted OR = 4.21, 95% CI: 2.07–8.61; p < 0.001). Conclusion Neonates born between 29 and 32 weeks who develop AKI had a higher likelihood of moderate or severe BPD/death than those without AKI. Further studies are needed to validate our findings and evaluate mechanisms of multiorgan injury.

scholarly journals Obesity, Second Stage Duration, and Labor Outcomes in Nulliparous Women

2019 ◽  
Author(s):  
Antonina I. Frolova ◽  
Nandini Raghuraman ◽  
Molly J. Stout ◽  
Methodius G. Tuuli ◽  
George A. Macones ◽  
...  
Keyword(s):  
Maternal Morbidity ◽  
Secondary Analysis ◽  
Neonatal Morbidity ◽  
Fetal Distress ◽  
Obese Women ◽  
Stage Duration ◽  
Second Stage ◽  
Nulliparous Women ◽  
Increased Risk ◽  
Labor Outcomes

Abstract Objective To estimate second stage duration and its effects on labor outcomes in obese versus nonobese nulliparous women. Study Design This was a secondary analysis of a cohort of nulliparous women who presented for labor at term and reached complete cervical dilation. Adjusted relative risks (aRR) were used to estimate the association between obesity and second stage characteristics, composite neonatal morbidity, and composite maternal morbidity. Effect modification of prolonged second stage on the association between obesity and morbidity was assessed by including an interaction term in the regression model. Results Compared with nonobese, obese women were more likely to have a prolonged second stage (aRR: 1.48, 95% CI: 1.18–1.85 for ≥3 hours; aRR: 1.65, 95% CI: 1.18–2.30 for ≥4 hours). Obesity was associated with a higher rate of second stage cesarean (aRR: 1.78, 95% CI: 1.34–2.34) and cesarean delivery for fetal distress (aRR: 2.67, 95% CI: 1.18–3.58). Obesity was also associated with increased rates of neonatal (aRR: 1.38, 95% CI: 1.05–1.80), but not maternal morbidity (aRR: 1.06, 95% CI: 0.90–1.25). Neonatal morbidity risk was not modified by prolonged second stage. Conclusion Obesity is associated with increased risk of neonatal morbidity, which is not modified by prolonged second stage of labor.

Seasonality of Hypoosmolar Hyponatremia in Medical Inpatients – Data from a Nationwide Cohort Study

2020 ◽  
Vol 105 (4) ◽  
pp. e947-e954
Author(s):  
Alexander Kutz ◽  
Fahim Ebrahimi ◽  
Clara O Sailer ◽  
Ulrich Wagner ◽  
Philipp Schuetz ◽  
...  
Keyword(s):  
Cohort Study ◽  
Odds Ratio ◽  
Primary Outcome ◽  
Age Groups ◽  
Outdoor Temperature ◽  
Specific Difference ◽  
Electrolyte Disturbance ◽  
Elderly Female ◽  
Medical Inpatients ◽  
Secondary Outcomes

Abstract Context Hyponatremia is the most prevalent electrolyte disturbance in hospitalized patients. Previous studies have shown a seasonal variation of profound hyponatremia with higher prevalence during warmer months. Objective This study aimed at analyzing the seasonal prevalence and sex- and age-specific differences of hyponatremia in medical inpatients. Design Nationwide cohort study from January 2009 and December 2015 using prospective administrative data. Setting Medical inpatients. Patients Diagnosis of hypoosmolar hyponatremia. Main outcome measures The primary outcome was the monthly alteration in hyponatremia prevalence. Secondary outcomes were the association of outdoor temperature with hyponatremia prevalence and differences among sex and age groups. Results Of 2 426 722 medical inpatients, 84 210 were diagnosed with hypoosmolar hyponatremia, of whom 61% (n = 51 262) were female. The highest overall prevalence of hyponatremia was observed in July (4.5%, n = 8976); the lowest in December (2.7%, n = 6530). The overall prevalence of hyponatremia in women compared with men was higher by 58% (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.56-1.60). The sex-specific difference was most pronounced in the warmest month of July (mean temperature 20.1°C (OR, 1.76; 95% CI, 1.68-1.84). We observed the strongest association between seasonality and hyponatremia in elderly (&gt;80 years) female inpatients admitted during the month of July (OR, 2.40; 95% CI, 2.20-2.62]). Conclusion The prevalence of diagnosed hypoosmolar hyponatremia in medical inpatients increases during summer months with higher outdoor temperature. Elderly female inpatients were most susceptible to the seasonal rise in hyponatremia prevalence.

The Effects of an External Nasal Dilator on Labor

2005 ◽  
Vol 19 (2) ◽  
pp. 221-224 ◽  
Author(s):  
Oscar Sadan ◽  
Sagit Shushan ◽  
Ido Eldar ◽  
Shmuel Evron ◽  
Samuel Lurie ◽  
...  
Keyword(s):  
Active Phase ◽  
Well Being ◽  
Control Group ◽  
Second Stage Of Labor ◽  
Second Stage ◽  
Satisfaction Rate ◽  
Several Variables ◽  
Active Labor ◽  
Meconium Stained Amniotic Fluid

Background The aim of this study was to assess the effect of an external nasal dilator on several variables characterizing labor in both mother and fetus. Methods One hundred and fifty primigravida women in active labor were randomized to wear, throughout labor, either a dilator spring-loaded nasal strip or a placebo device. Data were obtained during labor and compared between the groups. After delivery, the satisfaction rate was assessed. Results No differences were found between the study and the control group regarding rate of induction or augmentation of labor as well as Montevideo units reached, frequency of rupture of membranes, duration of the active phase and second stage of labor, usage of epidural analgesia, normal fetal heart pattern, meconium-stained amniotic fluid, and neonatal well being. Length of maternal and neonatal hospitalization also did not differ between the groups. Satisfaction rate was significantly higher in parturient women wearing nasal strips with a dilator spring than in parturient women wearing a placebo spring (P < 0.0001). Conclusion Nasal strips do not change the course but ameliorate the quality of labor by improving the ease of breathing. Nasal dilators sustain the respiratory effort associated with the long process of labor and may control the switch from nasal to oronasal breathing during delivery.

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