Postdates induction with an unfavorable cervix and risk of cesarean. J Matern Fetal Neonatal Med 2019;32:2874-2878. [PMID: 29562794 PMCID: PMC6636843 DOI: 10.1080/14767058.2018.1450861]

Guideline No. 432a: Cervical Ripening and Induction of Labour - General Information

OBJECTIVE

This guideline presents evidence and recommendations for cervical ripening and induction of labour. It aims to provide information to birth attendants and pregnant individuals on optimal perinatal care while avoiding unnecessary obstetrical intervention.

TARGET POPULATION

All pregnant patients.

BENEFITS, HARMS, AND COSTS

Consistent interprofessional use of the guideline, appropriate equipment, and trained professional staff enhance safe intrapartum care. Pregnant individuals and their support person(s) should be informed of the benefits and risks of induction of labour.

EVIDENCE

Literature published to March 2022 was reviewed. PubMed, CINAHL, and the Cochrane Library were used to search for systematic reviews, randomized controlled trials, and observational studies on cervical ripening and induction of labour. Grey (unpublished) literature was identified by searching the websites of health technology assessment and health technology related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All providers of obstetrical care.

RECOMMANDATIONS

Directive clinique no 432a : Maturation cervicale et déclenchement artificiel du travail - Information générale

OBJECTIF

Présenter des données probantes et des recommandations sur la maturation cervicale et le déclenchement artificiel du travail. Fournir de l'information aux professionnels accoucheurs et aux personnes enceintes sur les soins périnataux optimaux et la prévention des interventions obstétricales inutiles.

POPULATION CIBLE

Toutes les patientes enceintes. BéNéFICES, RISQUES ET COûTS: La mise en application interprofessionnelle et cohérente de la présente directive, l'équipement adéquat et le personnel compétent améliorent la sécurité des soins per partum. Les personnes enceintes et leurs personnes de soutien doivent être informées des risques et bénéfices du déclenchement artificiel du travail. DONNéES PROBANTES: La littérature publiée jusqu'en mars 2022 a été passée en revue. Une recherche a été effectuée dans les bases de données PubMed, CINAHL et Cochrane Library pour répertorier des revues systématiques, des essais cliniques randomisés et des études observationnelles sur la maturation cervicale et le déclenchement artificiel du travail. La littérature grise (non publiée) a été obtenue à l'aide de recherches menées dans des sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, des registres d'essais cliniques et des sites Web de sociétés de spécialité médicale nationales et internationales. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Tous les fournisseurs de soins obstétricaux.

RECOMMANDATIONS

Safety and efficacy of titrated oral misoprostol solution versus vaginal dinoprostone for induction of labor: A single-center randomized control trial

Objective

To compare the efficacy and safety of the hourly administration of titrated oral misoprostol solution (OMS) and vaginal dinoprostone for induction of labor.

Methods

Titrated OMS was administrated hourly for induction of labor, starting with a dose of 20 µg and terminating at a dose of 50 µg. The safety and efficacy of OMS were compared with that of vaginal dinoprostone for induction of labor.

Results

From June 2016 to October 2019, 2280 (78.3%) and 2115 (72.9%) women who received titrated OMS and vaginal dinoprostone, respectively, had a vaginal delivery (P = 0.005). Cesarean delivery was performed in 632 (21.7%) and 783 (27.0%) women who received titrated OMS and vaginal dinoprostone, respectively (P = 0.008). Tachysystole with changes in fetal heart rate (FHR) was seen in 104 (3.6%) and 249 (8.6%) women in the OMS and dinoprostone groups, respectively (P = 0.007). The frequency of non‐reassuring FHR was lower in the OMS group compared to the dinoprostone group (P = 0.006).

Conclusion

The titrated OMS has an efficacy comparable to vaginal dinoprostone. Moreover, it causes a lower incidence of cesarean delivery, lower frequency of tachysystole with changes in FHR, and non‐reassuring FHR.

Titrated oral misoprostol has a similar efficacy to dinoprostone, but with a lower incidence of cesarean delivery and lower frequency of non‐reassuring fetal heart rate.

Oxytocin Compared to Buccal Misoprostol for Induction of Labor after Term Prelabor Rupture of Membranes

OBJECTIVE

This study was aimed to determine if admission-to-delivery times vary between term nulliparous women with prelabor rupture of membranes (PROM) who initially receive oxytocin compared with buccal misoprostol for labor induction.

STUDY DESIGN

This is a retrospective cohort of 130 term, nulliparous women with PROM and cervical dilation of ≤2 cm who underwent induction of labor with intravenous oxytocin or buccal misoprostol. The primary outcome was time from admission to delivery. Linear regressions with log transformation were used to estimate the effect of induction agent on time to delivery.

RESULTS

Women receiving oxytocin had faster admission-to-delivery times than women receiving misoprostol (16.9 vs. 19.9 hours, p = 0.013). There were no significant differences in secondary outcomes between the groups. In the adjusted model, women who received misoprostol had a 22% longer time from admission to delivery (95% CI 5.0-42.0%) compared with women receiving oxytocin.

CONCLUSION

In term nulliparous patients with PROM, intravenous oxytocin is associated with faster admission-to-delivery times than buccal misoprostol.

Induction of labour with unfavourable local conditions for suspected fetal growth restriction after 36 weeks of gestation: Factors associated with the risk of caesarean

INTRODUCTION

Induction of labour in women with an unfavourable cervix is associated with a risk of caesarean delivery. When a diagnosis of fetal growth restriction (FGR) is also involved, the risk of intrapartum fetal acidosis increases. The main objective was to identify prognostic factors for the risk of caesarean delivery after induction for suspected FGR after 36 weeks of gestation with an unripe cervix.

MATERIAL AND METHODS

This was a retrospective, single-centre (Port Royal, Paris, France) study of women with a singleton fetus in cephalic presentation, with labour induced at or after 36 weeks for suspected FGR diagnosed during second or third trimester of pregnancy with an unripe cervix (Bishop score under 6) who gave birth between 1 January 2015 and 31 December 2019. A multivariable analysis was performed to identify the factors related to an increased risk of caesarean section.

RESULTS

Of the 146 women included, 56 (38.4 %) had caesarean deliveries. After adjustment, the factors significantly associated with the risk of caesarean were maternal age greater than 39 years (ORa = 4.33 [1.22-17.2], reference: 25-39 years), nulliparity (ORa = 3.49 [1.25-11.2]), and an abnormal fetal umbilical artery Doppler velocimetry (ORa = 3.50 [1.47-8.70]). The risk of poor neonatal condition did not differ significantly between women with vaginal and caesarean deliveries (2.3 % vs 7.3 %, P = 0.21).

CONCLUSION

When FGR is suspected at 36 weeks of gestation and later, induction of labour is a reasonable option, even if the cervix is unripe, as the risk of caesarean delivery appears acceptable and neonatal status is good and similar with both modes of delivery.

Vaginal breech delivery of pregnancy before and after the estimated due date-A prospective cohort study

INTRODUCTION

3-4% of pregnant women present with a fetal breech position at term. National societies regard vaginal breech delivery as a safe option, but only for a specific and thoroughly counseled group of patients. To avoid adverse outcome, many practitioners recommend elective cesarean section once their patients go past the estimated due date. Since encompassing evidence is missing, the evaluation on this common clinical practice is needed.

OBJECTIVE

This study compares the short-term maternal and fetal outcome in intended vaginally breech deliveries before the estimated due date (until 40 0/7 weeks of gestation) to the outcome of deliveries carried out past the estimated due date (later than 40 0/7 weeks of gestation).

METHODS

This prospective cohort study includes 827 women who presented for an intended vaginal breech delivery of a singleton at our perinatal center between January 2010 and December 2016.

RESULTS

447 patients (54%) delivered before or at their estimated due date, 380 (46%) of pregnancies continued after the estimated due date. Comparing both groups, no significant difference in maternal and neonatal short-term mortality and morbidity was found. The rate of caesarian sections was increased in the group of patients, who delivered later than 40 1/7 weeks of gestation. Here, the likelihood for delivery maneuvers was also increased.

CONCLUSION

This study provides evidence, that an elective cesarean section for breech presentations at term is not obligatory when the estimated due date has passed in singleton pregnancy.

A systematic scoping review of clinical indications for induction of labour

BACKGROUND

The proportion of women undergoing induction of labour (IOL) has risen in recent decades, with significant variation within countries and between hospitals. The aim of this study was to review research supporting indications for IOL and determine which indications are supported by evidence and where knowledge gaps exist.

METHODS

A systematic scoping review of quantitative studies of common indications for IOL. For each indication, we included systematic reviews/meta-analyses, randomised controlled trials (RCTs), cohort studies and case control studies that compared maternal and neonatal outcomes for different modes or timing of birth. Studies were identified via the databases PubMed, Maternity and Infant Care, CINAHL, EMBASE, and ClinicalTrials.gov from between April 2008 and November 2019, and also from reference lists of included studies. We identified 2554 abstracts and reviewed 300 full text articles. The quality of included studies was assessed using the RoB 2.0, the ROBINS-I and the ROBIN tool.

RESULTS

68 studies were included which related to post-term pregnancy (15), hypertension/pre-eclampsia (15), diabetes (9), prelabour rupture of membranes (5), twin pregnancy (5), suspected fetal compromise (4), maternal elevated body mass index (BMI) (4), intrahepatic cholestasis of pregnancy (3), suspected macrosomia (3), fetal gastroschisis (2), maternal age (2), and maternal cardiac disease (1). Available evidence supports IOL for women with post-term pregnancy, although the evidence is weak regarding the timing (41 versus 42 weeks), and for women with hypertension/preeclampsia in terms of improved maternal outcomes. For women with preterm premature rupture of membranes (24-37 weeks), high-quality evidence supports expectant management rather than IOL/early birth. Evidence is weakly supportive for IOL in women with term rupture of membranes. For all other indications, there were conflicting findings and/or insufficient power to provide definitive evidence.

CONCLUSIONS

While for some indications, IOL is clearly recommended, a number of common indications for IOL do not have strong supporting evidence. Overall, few RCTs have evaluated the various indications for IOL. For conditions where clinical equipoise regarding timing of birth may still exist, such as suspected macrosomia and elevated BMI, researchers and funding agencies should prioritise studies of sufficient power that can provide quality evidence to guide care in these situations.