Labor Induction at 39 Weeks Compared with Expectant Management in Low-Risk Parous Women

Effect of Vaginal Washing before Intravaginal Prostaglandin Insertion on Induction of Labor: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

Saline vaginal douching prior to intravaginal prostaglandin application might increase the vaginal pH, leading to improvement of prostaglandin bioavailability, by which the outcomes of labor induction can be greatly improved. Thus, we aimed to evaluate the effect of vaginal washing with normal saline before insertion of vaginal prostaglandin for labor induction.

STUDY DESIGN

A systematic search was done in PubMed, Cochrane Library, Scopus, and ISI Web of Science from inception to March 2022. We selected randomized controlled trials (RCTs) that compared vaginal washing using normal saline versus no vaginal washing in the control group before intravaginal prostaglandin insertion during labor induction. We used RevMan software for our meta-analysis. Our main outcomes were the duration of intravaginal prostaglandin application, duration from intravaginal prostaglandin insertion to active phase of labor, duration from intravaginal prostaglandin insertion till total cervical dilatation, labor induction failure rate, incidence of cesarean section (CS), and rates of neonatal intensive care unit (NICU) admission and fetal infection postdelivery.

RESULTS

Five RCTs were retrieved with a total number of 842 patients. Duration of prostaglandin application, duration from prostaglandin insertion to active phase of labor, and time interval from prostaglandin insertion to total cervical dilatation were significantly shorter among vaginal washing group (p < 0.05). Vaginal douching prior to prostaglandin insertion significantly decreased the incidence of failed labor induction (p < 0.001). After the removal of reported heterogeneity, vaginal washing was linked to a significant decline in CS incidence (p = 0.04). In addition, the rates of NICU admission and fetal infection were significantly lower in the vaginal washing group (p < 0.001).

CONCLUSION

Vaginal washing with normal saline before intravaginal prostaglandin insertion is a useful and easily applicable method for labor induction with good outcomes.

KEY POINTS

· Induction of labor is frequently used in the obstetrics field.. · We assessed vaginal washing impact before prostaglandin insertion for labor induction.. · Vaginal washing is an easily applicable method for labor induction with good outcomes..

Outcomes among Nulliparous Women Undergoing Nonmedically Indicated Induction of Labor at 39 Weeks Compared with Expectant Management Differ by Maternal Age

OBJECTIVE

Prior studies have demonstrated the potential benefit of nonmedically indicated induction of labor for nulliparous women at 39 weeks of gestation, yet few have studied the impact of this management strategy in different maternal age groups on obstetric outcomes. We sought to assess whether obstetric outcomes among women undergoing nonmedically indicated induction of labor at 39 weeks of gestation as compared with expectant management vary based on maternal age.

STUDY DESIGN

This was a retrospective cohort study of singleton, nonanomalous, deliveries between 2007 and 2012 in California. We defined nonmedically indicated induction of labor as induction of labor without a specific medical indication, and women with planned cesarean sections were excluded. We compared induction of labor with expectant management beyond the gestational age of induction and examined this comparison in different maternal age groups. Numerous maternal and neonatal outcomes were examined. Chi-squared and multivariable logistic regression analyses were used for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance.

RESULTS

A total of 630,485 women-infant dyads met our inclusion criteria and were included in this study. At 39 weeks' gestation, 6% of women underwent nonmedically indicated induction of labor and 94% underwent expectant management. Women 20 to 34 and ≥35 years old had lower odds of cesarean delivery if they underwent induction of labor. Women of all ages undergoing nonmedically indicated induction of labor had higher odds of operative vaginal delivery. Neonatal outcomes were better with nonmedically indicated induction of labor, including lower odds of neonatal intensive care unit admission and neonatal respiratory distress.

CONCLUSION

Our study demonstrated that obstetric outcomes vary among women undergoing nonmedically indicated induction of labor compared with expectant management when stratified by maternal age. These findings illustrate the importance of understanding age-related differences in outcomes associated with nonmedically indicated induction of labor.

KEY POINTS

· Outcomes are different by age with nonmedically indicated induction of labor (IOL).. · The odds of cesarean delivery with IOL decreases with increasing maternal age compared with expectant management.. · Neonatal outcomes were improved with IOL compared with expectant management..

Maternal and neonatal adverse outcomes in individuals with a prior cesarean birth who undergo induction at 39 weeks

OBJECTIVE

To compare the maternal and neonatal adverse outcomes among individuals with one or two prior cesarean deliveries who are induced at 39 weeks gestational age versus those that are expectantly managed.

METHODS

This was a population-based cross-sectional study using U.S. National Vital Statistics 2014-2018 period linked birth and infant death data. Cohorts were individuals with one or two prior cesarean deliveries who were induced at 39.0 to 39.6 weeks gestation or underwent delivery from 40.0 to 41.6 weeks gestational age from either spontaneous labor or induction. The primary outcome was a composite of maternal adverse outcomes: admission to the intensive care unit, transfusion, uterine rupture, or unplanned hysterectomy. The secondary outcome was a composite of neonatal adverse outcomes, including: 5-minute Apgar score <5, assisted ventilation for >6 h, neonatal seizures, or neonatal mortality (death within 27 days of birth).

RESULTS

Of 263,489 women who met the inclusion criteria 21,951 (8.3%) underwent induction at 39 weeks. The composite maternal adverse outcome was significantly higher in women who delivered at 40-41 weeks gestation when compared to the 39 week gestation induction of labor cohort (8.1 versus 9.4 per 1,000 births; aRR 1.18; 95% CI 1.01-1.39). The overall rate of composite neonatal adverse outcome was 10.4 per 1,000 live births. The composite neonatal adverse outcome was also significantly elevated among deliveries at 40-41 weeks gestation as well (8.6 vs. 10.8 per 1,000 live births; aRR 1.31; 95%CI 1.12-1.53).

CONCLUSION

In women undergoing trial of labor after cesarean, induction of labor at 39 weeks gestation was associated with fewer maternal and neonatal adverse outcomes when compared to delivery at 40-41 weeks gestation.

Out-of-Hospital Cervical Ripening With a Synthetic Hygroscopic Cervical Dilator May Reduce Hospital Costs and Cesarean Sections in the United States-A Cost-Consequence Analysis

Objective: Out-of-hospital (outpatient) cervical ripening prior to induction of labor (IOL) is discussed for its potential to decrease the burden on hospital resources. We assessed the cost and clinical outcomes of adopting an outpatient strategy with a synthetic hygroscopic cervical dilator, which is indicated for use in preinduction cervical ripening.

Methods: We developed a cost-consequence model from the hospital perspective with a time period from IOL to post-delivery discharge. A hypothetical cohort of women to undergo IOL at term with an unfavorable cervix (all risk levels) were assessed. As the standard of care (referred to as IP-only) all women were ripened as inpatients using the vaginal PGE2 insert or the single-balloon catheter. In the comparison (OP-select), 50.9% of low-risk women (41.4% of the study population) received outpatient cervical ripening using a synthetic hygroscopic cervical dilator and the remaining women were ripened as inpatients as in the standard of care. Model inputs were sourced from a structured literature review of peer-reviewed articles in PubMed. Testing of 2,000 feasible scenarios (probabilistic multivariate sensitivity analysis) ascertained the robustness of results. Outcomes are reported as the average over all women assessed, comparing OP-select to IP-only.

Results: Implementing OP-select resulted in hospital savings of US$689 per delivery, with women spending 1.48 h less time in the labor and delivery unit and 0.91 h less in the postpartum recovery unit. The cesarean-section rate was decreased by 3.78 percentage points (23.28% decreased to 19.50%). In sensitivity testing, hospital costs and cesarean-section rate were reduced in 91% of all instances.

Conclusion: Our model analysis projects that outpatient cervical ripening has the potential to reduce hospital costs, hospital stay, and the cesarean section rate. It may potentially allow for better infection-prevention control during the ongoing COVID-19 pandemic and to free up resources such that more women might be offered elective IOL at 39 weeks.