Membrane stripping to prevent post-term pregnancy in Enugu, Nigeria: a randomized controlled trial

Membrane sweeping at term to promote spontaneous labor and reduce the likelihood of formal labor induction for prolonged pregnancy, in South Asia and the world: A meta-analysis

BACKGROUND

Membrane sweeping promotes the spontaneous onset of labor, reducing the need for formal labor induction. In addition to the safety profile, membrane sweep is a cost-effective measure in a low-resource setting like South Asia.

OBJECTIVES

To the best of our knowledge, previous reviews and meta-analyses have not explored the timing and frequency of membrane sweeping or its association with the period of gestation (POG) and parity. Additionally, the results should be interpreted with caution due to the inclusion of older studies and the analyses conducted regardless of ethnicity in previous literature. We addressed these gray areas in the current study to fill the research gap.

SEARCH STRATEGY

We searched PubMed, Google Scholar, Science Direct, and Cochrane Reviews. Study selection was performed using the semi-automated tool Rayyan.

SELECTION CRITERIA

The selection criteria for this study encompassed the inclusion of randomized controlled trials (RCTs) published in English between January 2010 and May 2023, with accessible full-text articles. The focus was on low-risk pregnant women carrying a single fetus in a cephalic presentation at term (37-42 weeks) gestation, confirmed by reliable methods. Essential data for relative risk (RR) and 95% confidence interval (CI) calculation must be present.

DATA COLLECTION AND ANALYSIS

The Cochrane risk-of-bias (RoB2) tool and funnel plots were used to assess bias. Review Manager (RevMan) 5.4 version was used for analysis. The Mantel-Haenszel statistics and random effects were used to calculate the overall effect of risk ratio with a 95% confidence interval. Study heterogeneity was calculated using the I2 statistic. Two subgroups were used in the analysis: South Asia and the rest of the world.

MAIN RESULTS

A total of 13 RCTs with 2599 participants were analyzed. Overall, membrane sweep effectively reduced formal IOL with an effect size of 2.43 (95% CI: 1.51-3.91). It also promoted spontaneous labor with an effect size of 1.71 (95% CI: 1.15-2.55). In the South Asian subgroup, membrane sweeping significantly promoted the spontaneous onset of labor with an overall effect of 1.85 (95% CI: 1.37-2.51), and in the rest of the world subgroup, membrane sweeping significantly reduced formal labor induction with an overall effect of 1.93 (95% CI: 1.33-2.82). The pooled effects were significant in mulipara with a POG ≥40 W in the South Asian subgroup.

CONCLUSIONS

Membrane sweeping effectively reduces the need for formal labor induction and promotes spontaneous labor. This may be particularly relevant in South Asian populations where a disproportionate ethnic contribution to stillbirth rates is noted. Due to the limited number of RCTs addressing the factors and study methodology heterogeneity, we had limited data in some subgroup analyses. Therefore, we encourage more RCTs and meta-analyses on POG, parity, timing and frequency of membrane sweeping, and ethnic differences.

A randomized comparative study of serial membrane sweeping at term for vaginal birth after caesarean section in two tertiary hospitals in Delta State

Introduction

postdate pregnant women with one previous caesarean section that are planned for vaginal birth after caesarean sections are faced with adverse pregnancy outcomes. This trial was conducted to determine the effect of serial membrane sweeping from 38 weeks gestation in pregnant women planned for vaginal birth after caesarean section.

Methods

this randomized controlled trial (RCT) was conducted on 90 women at 38 weeks with one previous caesarean section. In the study group, membranes sweeping commenced at 38 weeks and repeated weekly till labour onset. If no labour onset at 41 weeks and 3 days, elective caesarean section was done. In the control group, patients awaited labour onset till 41 weeks and 3 days, after which elective caesarean section was done. Data collected were analyzed using the Statistical Package for Social Sciences (SPSS ver. 22). All analyses were done at p<0.05.

Results

labour onset before 41 weeks and 3 days was statistically significantly higher in the study group compared to the control group (RR= 1.5; 95% CI: 1.1 - 2.0; P=0.006). Likewise, successful vaginal birth after caesarean section was statistically significantly higher in the study group (RR=1.7; 95% CI: 1.2-2.5; P = 0.001).

Conclusion

serial membrane sweeping from 38 weeks gestation has significant beneficial effect on labour onset and successful vaginal delivery in women with one previous caesarean section.

Effectiveness of Single Fetal Membrane Sweeping in Reducing Elective Labor Induction for Postdate Pregnancies (38+0 to 40+6 Weeks): A Randomized Controlled Trial

BACKGROUND

 Postdate pregnancy is characterized by a heightened risk for both maternal and perinatal complications. Owing to the risks, clinicians frequently turn to elective labor induction as a management strategy for postdate pregnancies. However, patients are increasingly informed and apprehensive about this approach and its associated risks. This has prompted a search for alternative management methods that may encourage spontaneous labor in pregnant women. One such approach is the use of fetal membrane sweeping, a method known to increase the likelihood of spontaneous labor onset. Yet, it remains unclear whether a single fetal membrane sweeping procedure can effectively reduce the need for elective labor induction in postdate pregnancies while minimizing risks to both the mother and fetus.

OBJECTIVES

The primary objective of this study was to assess the efficacy of a single fetal membrane sweeping procedure conducted between 38+0 and 40+6 weeks of gestation in reducing the rate of elective labor induction among postdate pregnancies at Central Hospital Benin City, Nigeria. Secondary objectives included evaluating the impact of membrane sweeping on maternal and perinatal outcomes.

METHODOLOGY

This open-label superiority randomized controlled study was carried out from June 2020 to March 2021, following ethical approval from the Hospital Management Board (HMB). One hundred and forty eligible participants, without contraindications to vaginal delivery, were randomly assigned to one of two groups. The first group received a single fetal membrane sweeping procedure between 38+0 and 40+6 weeks of gestation, while the control group underwent vaginal examination only to assess the Bishop score. Participants were monitored until delivery. Data analysis was performed. Results were considered statistically significant at p < 0.05.

RESULTS

The implementation of a single fetal membrane sweeping procedure effectively reduced the incidence of elective labor induction. Specifically, the membrane sweep group exhibited a significantly lower rate of elective labor induction compared to the control group (9.0% vs. 27.1%; p=0.0083). Moreover, a substantial proportion of the treatment group (91.4%) experienced spontaneous labor, while the control group reported a rate of 72.9%. The difference was statistically significant (p=0.0054). Notably, the control group exhibited a significantly longer mean time interval from recruitment to delivery (10.67±3.51 days) than the membrane sweeping group (3.64±4.123 days; p<0.05). Also, postdate women in the membrane sweep group were less likely to require cervical ripening with Foley's catheter than those in the control group (33.3% vs. 100%; RR: 0.33 (0.11-1.03); p=0.0057). Still, maternal satisfaction was significantly higher in the membrane-sweeping group (p<0.01). No significant differences were noted across the groups in maternal and neonatal outcomes.

CONCLUSION

In low-risk term pregnancies, a single fetal membrane sweeping procedure is a superior alternative to no membrane sweeping in reducing the rate of elective labor induction for postdate pregnancies and in shortening the duration of term pregnancy.

Twice-Weekly Versus Once-Weekly Membrane Sweeping in the Prevention of Post-Term Pregnancy: a Systematic Review and Meta-Analysis of Randomized Controlled Trials

Membrane sweeping is considered a simple and effective method for initiating spontaneous onset of labor. Despite the widely accepted membrane sweeping use to prevent post-term birth, the optimal frequency has not been estimated. We aimed to assess the effectiveness and safety of twice-weekly versus once-weekly membrane sweeping in post-term pregnancy prevention. Four different databases were searched for available clinical trials from inception to October 2022. We selected randomized controlled trials (RCTs) that compared twice-weekly membrane sweeping in intervention group versus once-weekly membrane sweeping in control group among pregnant women with singleton pregnancy at ≥ 39 gestational weeks. Our primary outcomes were the rate of spontaneous onset of labor and the requirement for formal methods of labor induction. Our secondary outcomes were sweeping to delivery interval in days, gestational age at delivery in weeks, Bishop score at admission, chorioamnionitis, and premature rupture of membranes. Three RCTs (596 patients) were included. Twice-weekly membrane sweeping was associated with significant increase in the rate of spontaneous onset of labor and significant decline in labor induction rate in comparison with once-weekly group. Duration from sweeping to delivery was significantly shorter among the twice-weekly group (p<0.001). Furthermore, gestational age at delivery was significantly earlier in the twice-weekly group. A significantly higher Bishop score at admission was observed in the twice-weekly group (p=0.02). There were no significant differences across both groups in chorioamnionitis and premature rupture of membranes. In conclusion, twice-weekly membrane sweeping is more effective in preventing post-maturity pregnancy than once-weekly sweeping without added adverse events.

Perinatal and maternal outcomes according to timing of induction of labour: A systematic review and meta-analysis

The risk of adverse perinatal and maternal outcomes increases with gestational age, and although induction of labour may reduce these risks, the optimal timing of induction remains unknown. We carried out a systematic review and meta-analysis, to determine the gestational age at which induction should be offered. We searched Cochrane Central Register of Controlled Trials, Medline, and Embase databases from inception to July 2022, to identify randomised trials comparing induction of labour at or beyond 37' weeks gestation with expectant management or delayed induction, and according to the gestational age at planned induction. We undertook random effects meta-analysis and pooled estimates as odds ratios with 95% confidence intervals. We assessed risk of bias of studies using the Cochrane Risk of Bias tool 2.0. We included 44 trials (23,960 women and 22,191 offspring) from 1,839 citations in our meta-analysis. The odds of perinatal death (odds ratio 0.42, 95% confidence interval 0.22 to 0.81; 26 studies, 20,154 offspring), stillbirth (0.40, 0.16 to 0.98; 25 studies, 19,412 offspring), admission to neonatal intensive care unit (0.86, 0.78 to 0.96; 23 studies, 18,846 offspring), and caesarean section (0.90, 0.83 to 0.98; 40 studies, 23,616 women) were reduced in the induction of labour group compared to expectant management or delayed induction. The odds of admission to neonatal intensive care unit (0.82, 0.70 to 0.96; 6 studies, 9,316 offspring) were lower with induction of labour at 41 weeks compared to induction at or after 42 weeks' gestation, and the odds of caesarean section were reduced with labour induction at 39 weeks' compared to induction at or after 40 weeks' (0.83, 0.74 to 0.93; 8 studies, 7,677 women). There were no significant differences in pregnancy outcomes by method of induction of labour. Induction of labour compared to expectant management or delayed induction reduces the risk of adverse pregnancy outcomes, and the optimal timing may depend on the specific outcome of interest.

Effectiveness and safety of membrane sweeping in the prevention of post-term pregnancy: a randomised controlled trial

There is a rising concern with increasing rates of pharmacologically induced labour and its complications. Membrane sweeping is a simple and less invasive means of initiating spontaneous labour onset. We compared the safety and efficacy of membrane sweeping. A total of 186 women (62 in each arm) were recruited at the antenatal clinic at 39 weeks. The intervention groups had membrane sweeping once and twice weekly respectively while the control arm had no membrane sweeping. They were all monitored and followed up till delivery. The trial was registered with the South Africa registry www.pactr.org (PACTR202112841108933) The incidence of prolonged pregnancy was 32.3%, 19.4% and 11.7% among the control, once-weekly, and twice-weekly groups respectively. The sweeping to the delivery interval was significantly shorter for the twice-weekly group (7.4 days) compared to once weekly (8.8 days) and the control group (10.6 days). There were significantly higher odds of spontaneous labour onset in the twice-weekly group (HR 1.53, p = .029) compared to the control group (HR 0.65, p = .033) and the once-weekly group using once weekly as reference. Membrane sweeping is a safe and effective means of preventing prolonged pregnancy. Twice-weekly sweeping of foetal membranes is more effective than once-weekly or no sweeping without added adverse feto-maternal outcomes.IMPACT STATEMENTWhat is already known about the subject? There is no evidence supporting any increase in maternal or foetal morbidity suggesting that membrane sweeping is a safe procedure to offer to all low-risk pregnant women so as to initiate spontaneous labour onset.What do the results of the study add? Membrane sweeping twice weekly after 39weeks for low-risk pregnant women is more effective than once weekly or no sweep with no added adverse maternal or perinatal risks.What are the implications of these findings for clinical practice and or further research? Twice-weekly membrane sweeping is encouraged in selected patients to reduce the risks associated with post-term pregnancy.

Membrane sweeping for induction of labour

BACKGROUND

Induction of labour involves stimulating uterine contractions artificially to promote the onset of labour. There are several pharmacological, surgical and mechanical methods used to induce labour. Membrane sweeping is a mechanical technique whereby a clinician inserts one or two fingers into the cervix and using a continuous circular sweeping motion detaches the inferior pole of the membranes from the lower uterine segment. This produces hormones that encourage effacement and dilatation potentially promoting labour. This review is an update to a review first published in 2005.

OBJECTIVES

To assess the effects and safety of membrane sweeping for induction of labour in women at or near term (≥ 36 weeks' gestation).

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (25 February 2019), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (25 February 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing membrane sweeping used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed on a predefined list of labour induction methods. Cluster-randomised trials were eligible, but none were identified.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, risk of bias and extracted data. Data were checked for accuracy. Disagreements were resolved by discussion, or by including a third review author. The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included 44 studies (20 new to this update), reporting data for 6940 women and their infants. We used random-effects throughout. Overall, the risk of bias was assessed as low or unclear risk in most domains across studies. Evidence certainty, assessed using GRADE, was found to be generally low, mainly due to study design, inconsistency and imprecision. Six studies (n = 1284) compared membrane sweeping with more than one intervention and were thus included in more than one comparison. No trials reported on the outcomes uterine hyperstimulation with/without fetal heart rate (FHR) change, uterine rupture or neonatal encephalopathy. Forty studies (6548 participants) compared membrane sweeping with no treatment/sham Women randomised to membrane sweeping may be more likely to experience: · spontaneous onset of labour (average risk ratio (aRR) 1.21, 95% confidence interval (CI) 1.08 to 1.34, 17 studies, 3170 participants, low-certainty evidence). but less likely to experience: · induction (aRR 0.73, 95% CI 0.56 to 0.94, 16 studies, 3224 participants, low-certainty evidence); There may be little to no difference between groups for: · caesareans (aRR 0.94, 95% CI 0.85 to 1.04, 32 studies, 5499 participants, moderate-certainty evidence); · spontaneous vaginal birth (aRR 1.03, 95% CI 0.99 to 1.07, 26 studies, 4538 participants, moderate-certainty evidence); · maternal death or serious morbidity (aRR 0.83, 95% CI 0.57 to 1.20, 17 studies, 2749 participants, low-certainty evidence); · neonatal perinatal death or serious morbidity (aRR 0.83, 95% CI 0.59 to 1.17, 18 studies, 3696 participants, low-certainty evidence). Four studies reported data for 480 women comparing membrane sweeping with vaginal/intracervical prostaglandins There may be little to no difference between groups for the outcomes: · spontaneous onset of labour (aRR, 1.24, 95% CI 0.98 to 1.57, 3 studies, 339 participants, low-certainty evidence); · induction (aRR 0.90, 95% CI 0.56 to 1.45, 2 studies, 157 participants, low-certainty evidence); · caesarean (aRR 0.69, 95% CI 0.44 to 1.09, 3 studies, 339 participants, low-certainty evidence); · spontaneous vaginal birth (aRR 1.12, 95% CI 0.95 to 1.32, 2 studies, 252 participants, low-certainty evidence); · maternal death or serious morbidity (aRR 0.93, 95% CI 0.27 to 3.21, 1 study, 87 participants, low-certainty evidence); · neonatal perinatal death or serious morbidity (aRR 0.40, 95% CI 0.12 to 1.33, 2 studies, 269 participants, low-certainty evidence). One study, reported data for 104 women, comparing membrane sweeping with intravenous oxytocin +/- amniotomy There may be little to no difference between groups for: · spontaneous onset of labour (aRR 1.32, 95% CI 88 to 1.96, 1 study, 69 participants, low-certainty evidence); · induction (aRR 0.51, 95% CI 0.05 to 5.42, 1 study, 69 participants, low-certainty evidence); · caesarean (aRR 0.69, 95% CI 0.12 to 3.85, 1 study, 69 participants, low-certainty evidence); · maternal death or serious morbidity was reported on, but there were no events. Two studies providing data for 160 women compared membrane sweeping with vaginal/oral misoprostol There may be little to no difference between groups for: · caesareans (RR 0.82, 95% CI 0.31 to 2.17, 1 study, 96 participants, low-certainty evidence). One study providing data for 355 women which compared once weekly membrane sweep with twice-weekly membrane sweep and a sham procedure There may be little to no difference between groups for: · induction (RR 1.19, 95% CI 0.76 to 1.85, 1 study, 234 participants, low-certainty); · caesareans (RR 0.93, 95% CI 0.60 to 1.46, 1 study, 234 participants, low-certainty evidence); · spontaneous vaginal birth (RR 1.00, 95% CI 0.86 to 1.17, 1 study, 234 participants, moderate-certainty evidence); · maternal death or serious maternal morbidity (RR 0.78, 95% CI 0.30 to 2.02, 1 study, 234 participants, low-certainty evidence); · neonatal death or serious neonatal perinatal morbidity (RR 2.00, 95% CI 0.18 to 21.76, 1 study, 234 participants, low-certainty evidence); We found no studies that compared membrane sweeping with amniotomy only or mechanical methods. Three studies, providing data for 675 women, reported that women indicated favourably on their experience of membrane sweeping with one study reporting that 88% (n = 312) of women questioned in the postnatal period would choose membrane sweeping in the next pregnancy. Two studies reporting data for 290 women reported that membrane sweeping is more cost-effective than using prostaglandins, although more research should be undertaken in this area.

AUTHORS' CONCLUSIONS

Membrane sweeping may be effective in achieving a spontaneous onset of labour, but the evidence for this was of low certainty. When compared to expectant management, it potentially reduces the incidence of formal induction of labour. Questions remain as to whether there is an optimal number of membrane sweeps and timings and gestation of these to facilitate induction of labour.

Effectiveness of antenatal perineal massage in reducing perineal trauma and post-partum morbidities: A randomized controlled trial

AIM

The study aimed to evaluate the effectiveness of antenatal perineal massage (APM) in reducing perineal trauma and post-partum morbidities.

METHODS

A randomized controlled trial of 108 primigravidae at the University of Nigeria Teaching Hospital, Enugu, Nigeria, was conducted from January 2013 to May 2014. The intervention group received APM, while the control group did not receive APM.

RESULTS

Women who received APM were significantly more likely to have an intact perineum after childbirth [27/53 (50.9%) vs 16/55 (29.1%); RR: 1.75; 95% CI: 1.07-2.86; P = 0.02]. The incidence of episiotomy was lower in the intervention group [20/53 (37.7%) vs 32/55 (58.2%); RR: 0.65; 95% CI: 0.43-0.98; P = 0.03; NNT = 5]. Women who received APM were significantly less likely to develop flatus incontinence [4/53 (8.3%) vs 13/55 (26.0%); RR: 0.32; 95% CI: 0.11-0.91; P = 0.03]. However, the incidences of premature rupture of membranes, preterm labor and birth asphyxia were similar between the two groups (P > 0.05).

CONCLUSION

APM reduces the incidence of episiotomy and increases the incidence of women with an intact perineum after vaginal delivery. It also reduces the risk of flatus incontinence after childbirth without increased maternal or neonatal complications. Women should therefore be counseled on the likely benefits of APM and the information provided during antenatal care. Obstetricians should consider the technique as routine prenatal care for nulliparous women so as to reduce the incidence of perineal trauma during vaginal birth.

Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

More than 150,000 pregnant women in England and Wales have their labour induced each year. Multiple pharmacological, mechanical and complementary methods are available to induce labour.

OBJECTIVE

To assess the relative effectiveness, safety and cost-effectiveness of labour induction methods and, data permitting, effects in different clinical subgroups.

METHODS

We carried out a systematic review using Cochrane methods. The Cochrane Pregnancy and Childbirth Group's Trials Register was searched (March 2014). This contains over 22,000 reports of controlled trials (published from 1923 onwards) retrieved from weekly searches of OVID MEDLINE (1966 to current); Cochrane Central Register of Controlled Trials (The Cochrane Library); EMBASE (1982 to current); Cumulative Index to Nursing and Allied Health Literature (1984 to current); ClinicalTrials.gov; the World Health Organization International Clinical Trials Registry Portal; and hand-searching of relevant conference proceedings and journals. We included randomised controlled trials examining interventions to induce labour compared with placebo, no treatment or other interventions in women eligible for third-trimester induction. We included outcomes relating to efficacy, safety and acceptability to women. In addition, for the economic analysis we searched the Database of Abstracts of Reviews of Effects, and Economic Evaluations Databases, NHS Economic Evaluation Database and the Health Technology Assessment database. We carried out a network meta-analysis (NMA) using all of the available evidence, both direct and indirect, to produce estimates of the relative effects of each treatment compared with others in a network. We developed a de novo decision tree model to estimate the cost-effectiveness of various methods. The costs included were the intervention and other hospital costs incurred (price year 2012-13). We reviewed the literature to identify preference-based utilities for the health-related outcomes in the model. We calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit. We represent uncertainty in the optimal intervention using cost-effectiveness acceptability curves.

RESULTS

We identified 1190 studies; 611 were eligible for inclusion. The interventions most likely to achieve vaginal delivery (VD) within 24 hours were intravenous oxytocin with amniotomy [posterior rank 2; 95% credible intervals (CrIs) 1 to 9] and higher-dose (≥ 50 µg) vaginal misoprostol (rank 3; 95% CrI 1 to 6). Compared with placebo, several treatments reduced the odds of caesarean section, but we observed considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 µg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed 'best'. Few studies collected information on women's views. Owing to incomplete reporting of the VD within 24 hours outcome, the cost-effectiveness analysis could compare only 20 interventions. The analysis suggested that most interventions have similar utility and differ mainly in cost. With a caveat of considerable uncertainty, titrated (low-dose) misoprostol solution and buccal/sublingual misoprostol had the highest likelihood of being cost-effective.

LIMITATIONS

There was considerable uncertainty in findings and there were insufficient data for some planned subgroup analyses.

CONCLUSIONS

Overall, misoprostol and oxytocin with amniotomy (for women with favourable cervix) is more successful than other agents in achieving VD within 24 hours. The ranking according to safety of different methods was less clear. The cost-effectiveness analysis suggested that titrated (low-dose) oral misoprostol solution resulted in the highest utility, whereas buccal/sublingual misoprostol had the lowest cost. There was a high degree of uncertainty as to the most cost-effective intervention.

FUTURE WORK

Future trials should be powered to detect a method that is more cost-effective than misoprostol solution and report outcomes included in this NMA.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013005116.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Membrane sweeping added to formal induction method to increase the spontaneous vaginal delivery: a meta-analysis

BACKGROUND

Membrane sweeping (MS) could increase the likelihood of spontaneous labor within 48 h. However, the rationale for performing routinely an intervention with the potential to induce labor in women with an uneventful pregnancy at 38 weeks of gestation is, at least, questionable. We conducted a meta-analysis of randomized controlled trial (RCT) studies to assess evaluated the effect of MS added to formal induction method on the spontaneous vaginal delivery, compared with formal induction alone.

METHODS

PubMed, Embase, Cochrane Library databases, Web of Science, and Clinical Trials were searched from their inception to March 8, 2017. We estimate summarized relative risk (RR) and 95% confidence intervals (CIs) for dichotomous outcomes. The primary outcome was vaginal delivery, and second outcomes (side effects of MS) included meconium-stained liquor, admission to the neonatal unit, instrumental delivery.

RESULTS

Four RCTs with a total of 1377 participants were identified. The summary RR in the overall group was 1.12 (95% CI 1.05-1.18), with moderate heterogeneity (P = 0.22, I² = 33%). The summary RR in the nulliparas' subgroup was 1.32 (95% CI 1.18-1.48), with no heterogeneity (P = 0.79, I² = 0%). MS did not increase the risk of side effects.

CONCLUSIONS

MS added to formal induction significantly increased vaginal delivery rates, especially in nulliparas compared with formal induction alone. Notably, there are no obvious side effects of MS. Meanwhile, more RCTs studies are needed to investigate the side effects of MS on instrumental delivery, postpartum hemorrhage, and cervical laceration.

Oral versus vaginal misoprostol for induction of labor in Enugu, Nigeria: a randomized controlled trial

OBJECTIVE

The study aimed at comparing the effectiveness and maternal satisfaction of oral misoprostol with vaginal misoprostol for induction of labor at term.

MATERIALS AND METHODS

A randomized controlled trial of 140 term pregnant women at the University of Nigeria Teaching Hospital Enugu, Nigeria, was conducted from April 2011 to May 2012. The women were equally randomized into two groups (A and B) to receive oral and vaginal misoprostol, respectively.

RESULTS

The vaginal route reduced the mean induction-vaginal delivery interval by four-and-half hours (20.7 ± 12.1 vs. 16.2 ± 10.4; mean difference: 4.50, 95% CI 0.63-0.82; p = 0.02). Furthermore, the mean dose of misoprostol required to achieve induction of labor and the mean duration of oxytocin augmentation when indicated were significantly less in the vaginal group than in the oral group (2.5 ± 1.3 vs. 2.0 ± 1.1; mean difference: 0.50, 95% CI 0.10-0.90; p = 0.02 and 4.6 ± 3.2 vs. 3.4 ± 3.1; mean difference: 1.20, 95% CI 0.15-0.23; p = 0.03 respectively). However, neonatal complications and maternal satisfaction were similar between the two groups.

CONCLUSION

Both routes of administration are effective in the induction of labor at term and have comparable maternal satisfaction. However, the vaginal route has the added advantage of shorter induction-delivery interval among others, and thus should be highly considered when induction of labor is indicated at term.

Women's perception of accuracy of ultrasound dating in late pregnancy: a challenge to prevention of prolonged pregnancy in a resource-poor Nigerian setting

Background

Expected date of delivery (EDD) is estimated from the last menstrual period (LMP) or ultrasound scan. Conflicts between these estimates especially on the part of the physician and his/her patient could pose a challenge to prevention of prolonged pregnancy. The objective of this study was to determine the perception and acceptability of menstrual dating (EDD derived from LMP) with regard to timing of labor induction for postdatism by pregnant women who have a late pregnancy (≥23 weeks’ gestation) ultrasound scan.

Methods

This cross-sectional study included 443 consecutive pregnant women receiving antenatal care at two tertiary health institutions in Enugu, Nigeria, from January 1, 2013 to March 31, 2013.

Results

The mean age of the women was 27.9±2.41 (range 17–45) years. Most ultrasound scans (90.8%, 357/389) were carried out in late pregnancy, and 41.9% (167/389) were self-referred. The majority of the respondents (51.7%, 229/443) did not accept induction of labor for postdatism at a certain menstrual dating-derived gestational age of 40 weeks plus 10 days if the late pregnancy ultrasound scan dating was less. Predictors of this poor attitude to timing of induction of labor for postdatism included low educational level, low social class, and poor knowledge of the limitations of ultrasound scan dating in late pregnancy (P<0.05).

Conclusion

The worrisome confidence in ultrasound scan dating is a challenge to the prevention of prolonged pregnancy and its complications in our environment. Antenatal health education should discourage self-referral for ultrasound scan dating and emphasize its limitations in late pregnancy as well as the perinatal effects of prolonged pregnancy.