Immediate Compared With Delayed Oxytocin After Amniotomy Labor Induction in Parous Women: A Randomized Controlled Trial

Tugging the Foley catheter balloon every three hours in induction of labor after one previous cesarean: a randomized controlled trial

BACKGROUND

Induction of labor after 1 previous cesarean delivery with an unripe cervix have an especially high risk for unplanned cesarean delivery and uterine rupture. Mechanical balloon ripening is often preferred over prostaglandin-based ripening during induction of labor after 1 previous cesarean delivery, because uterine rupture has been associated with prostaglandin use. The transcervical Foley balloon can be dislodged past the ripened cervix and be retained comfortably in the vagina during passive placement. Tugging of the Foley catheter can be a noninvasive and tolerated method for timelier retrieval of the retained balloon; expediting discovery of a ripened cervix would permit an earlier follow-on amniotomy and oxytocin infusion, thereby hastening birth.

OBJECTIVE

This study aimed to evaluate the effect of tugging of the Foley balloon for 30 seconds every 3 hours during 12 hours of scheduled placement in comparison with standard care (no tugging) on the induction to birth interval and patient satisfaction.

STUDY DESIGN

This randomized controlled trial, conducted at a university hospital in Malaysia, recruited participants from April 2023 to March 2024. Eligible participants admitted for Foley balloon induction of labor who had 1 previous cesarean were recruited. After balloon insertion, participants were randomized to tugging or standard care. Following balloon displacement, a vaginal examination was performed to check the cervix. The examination findings then dictated the follow-on management of induction of labor after 1 previous cesarean according to standard practice. The primary outcomes were the induction (Foley insertion) to delivery interval and participants' satisfaction with the birthing process. Secondary outcomes were largely derived from the core outcome set for trials on induction of labor. Based on a superiority hypothesis, it was calculated that a sample size of 126 would be required to detect a 4-hour reduction in the induction-to-delivery interval and a 1.5 point increase in the satisfaction score based on a 0 to 10 numerical rating scale with the level of significance set at 0.05, power at 80%, and a 10% drop out rate. Comparative analyses using an intention-to-treat approach were conducted using t tests, Mann-Whitney U tests, chi square tests, and Fisher exact tests as appropriate.

RESULTS

A total of 126 participants were randomized with 63 in each trial arm. The induction to birth interval was (mean ± standard deviation) 29.7±9.6 hours for those in the 3-hourly tugging group and 29.8±9.1 hours for those under standard care (P=.950), and maternal satisfaction with the induction of labor after 1 previous cesarean delivery birth process, assessed using a 0 to 10 numerical rating scale, was (median [interquartile range]) 8 [7-9] and 8 [7-9] (P=.936), respectively. The cesarean delivery rate was 37 of 63 (59%) vs 41 of 63 (65%) (P=.238) for those in the tugging group vs standard care, and the main indication for unplanned cesarean delivery was failure to progress with an incidence of 24 of 37 (65%) and 24 of 41 (59%) (P=.914) for tugging vs standard care arms, respectively. Three-hourly tugging also did not shorten the interval from induction to balloon displacement, amniotomy, the start of oxytocin infusion, or the second stage of labor.

CONCLUSION

Tugging the catheter every 3 hours during scheduled 12-hour Foley balloon placement for induction of labor after 1 previous cesarean delivery did not hasten birth or improve patient satisfaction when compared with standard care.

Induction of labor in late-term pregnancy: amniotomy plus early oxytocin perfusion versus amniotomy plus oxytocin perfusion delayed by 24 h

OBJECTIVE

To assess the maternal and fetal benefits of delaying oxytocin perfusion by 24 h following labor induction by amniotomy after 41 weeks of gestation (WG).

METHODS

We performed a retrospective review including all women with a vertex presentation fetus who had an indication for labor induction by amniotomy with or without oxytocin after 41 WG between 2015 and 2022. Patients who underwent an IOL by amniotomy followed by oxytocin perfusion within 0 to 4 hours (early oxytocin group: EO group) were compared with patients who underwent an IOL by amniotomy alone or followed by an oxytocin perfusion after an expectant period for up to 24 hours in the absence of a spontaneous onset of labor (delayed oxytocin group: DO group). The primary outcome was the rate of vaginal delivery (natural or operative). The secondary outcomes were maternal and neonatal complications.

RESULTS

We included 363 patients: 103 patients in the EO group and 260 in the DO group. Only 47 of the women in the DO group (18 %) required oxytocin. The proportion of vaginal deliveries was significantly higher in the DO group (248 patients, 95.4 %) than in the EO group (85 patients, 82.55 %) (p<0.01). Maternal morbidity did not differ significantly between groups. Fewer babies displayed severe newborn acidemia or required transfer to the neonatal intensive care unit in the DO group (p<0.05).

CONCLUSION

Delaying oxytocin administration by 24 hours after amniotomy was associated with a significantly higher rate of vaginal delivery. These results required confirmation in prospective randomized studies.

Routine vaginal examination to assess labor progress at 8 compared to 4 hours after early amniotomy following Foley balloon ripening in the labor induction of multiparas: a randomized trial

BACKGROUND

Vaginal examination to monitor labor progress is recommended at least every 4 hours, but it can cause pain and embarrassment to women. Trial data are limited on the best intensity for vaginal examination. Vaginal examination is not needed for oxytocin dose titration after an amniotomy has been performed and oxytocin infusion started. The Foley balloon commonly ripens the cervix without strong contractions. Amniotomy and oxytocin infusion are usually required to drive labor.

OBJECTIVE

This study aimed to evaluate the first vaginal examination at 8 vs 4 hours after amniotomy-oxytocin after Foley ripening in multiparous labor induction.

STUDY DESIGN

A randomized controlled trial was conducted from October 2021 to September 2022 at the University Malaya Medical Center, Kuala Lumpur, Malaysia. Multiparas at term were recruited at admission for labor induction. Participants were randomized to a first routine vaginal examination at 8 or 4 hours after Foley balloon ripening and amniotomy. Titrated oxytocin infusion was routinely commenced after amniotomy to initiate contractions. The 2 primary outcomes were the time from amniotomy to delivery (noninferiority hypothesis) and maternal satisfaction (superiority hypothesis). Data were analyzed using the Student t test, Mann-Whitney U test, and chi-square test (or Fisher exact test), as suitable for the data.

RESULTS

A total of 204 women were randomized, 102 to each arm. Amniotomy to birth intervals were 4.97±2.47 hours in the 8-hour arm and 5.79±3.17 hours in the 4-hour arm (mean difference, -0.82; 97.5% confidence interval, -1.72 to 0.08; P=.041; Bonferroni correction), which were noninferior within the prespecified 2-hour upper margin, and the maternal satisfaction scores (11-point 0-10 numerical rating scale) with allocated labor care were 9 (interquartile range, 8-9) in the 8-hour arm and 8 (interquartile range, 7-9) in the 4-hour arm (P=.814). In addition, oxytocin infusion to birth interval difference was noninferior within the 97.5% confidence interval (-1.59 to 0.23) margin of 1.3 hours. Of the maternal outcomes, the amniotomy to first vaginal examination intervals were 3.9±1.8 hours in the 8-hour arm and 3.4±1.3 hours in the 4-hour arm (P=.026), and the numbers of vaginal examinations were 2.00 (interquartile range, 2.00-3.00) in the 8-hour arm and 3.00 (interquratile range, 2.00-3.25) in the 4-hour arm (P<.001). For the 8-hour arm, the first vaginal examination was less likely to be as scheduled and more likely to be indicated by sensation to bear down (P<.001), and the epidural analgesia rates were lower (13/102 participants [12.7%] in the 8-hour arm vs 28/102 participants [27.5%] in the 4-hour arm; relative risk, 0.46; 95% confidence interval, 0.26-0.84; P=.009). Other outcomes of the mode of delivery, indications for cesarean delivery, and delivery blood loss were not different. Neonatal outcomes were not different.

CONCLUSION

Routine first vaginal examination at 8 hours compared with that at 4 hours was noninferior for the time to birth but did not improve maternal satisfaction.

Early versus delayed amniotomy with immediate oxytocin after Foley catheter cervical ripening in multiparous women with labor induction: A randomized controlled trial

OBJECTIVE

To evaluate immediate oxytocin and early amniotomy compared with delayed amniotomy after Foley catheter cervical ripening in multiparous women on intervention-to-delivery interval.

METHODS

This randomized trial was conducted in Malaysia in 232 term multiparous women with balloon catheter-ripened cervixes (dilatation ≥3 cm), singleton fetus, cephalic presentation with intact membranes, and reassuring fetal heart rate tracing. They were randomized to immediate titrated intravenous oxytocin infusion and early amniotomy (116) or delayed amniotomy after 4 h of oxytocin (116). Primary outcome was intervention (oxytocin initiation)-to-delivery interval.

RESULTS

Oxytocin-to-delivery intervals were a median of 4.99 h (interquartile range [IQR], 3.21-7.82 h) versus 6.23 h (IQR, 4.50-8.45 h) (P < 0.001) for the early versus delayed amniotomy arms, respectively. Delivery rate at 4 h and 6 h after oxytocin infusion were 40 of 116 (35%) versus 22 of 116 (19%) (relative risk [RR], 1.82 [95% confidence interval (CI), 1.16-2.86], P = 0.011) and 77 of 116 (66%) versus 54 of 116 (47%) (RR, 1.43 [95% CI, 1.13-1.80], P = 0.003) for the early versus delayed amniotomy arms, respectively. Maternal satisfaction on birth process were 7 (IQR, 6-8) versus 7 (IQR, 7-8) (P = 0.006), uterine hyperstimulation rates were 10 of 116 (9%) versus 14 of 116 (12%) (RR, 0.71 [95% CI, 0.33-1.54]) (P = 0.519), and Cesarean delivery rates were 17 of 116 (15%) versus 19 of 116 (16%) (RR, 0.90 [95% CI, 0.49-1.63], P = 0.856) for the early versus delayed amniotomy arms, respectively.

CONCLUSION

In multiparas at term following cervical ripening by Foley catheter, immediate oxytocin and early amniotomy compared with a scheduled 4-h delay to amniotomy shortens the interval to birth and decreases uterine hyperactivity in labor but lowers maternal satisfaction. The cesarean delivery rate is not significantly reduced.

CLINICAL TRIAL REGISTRATION

This study was registered with the International Standard Randomised Controlled Trial Number (ISRCTN) on September 29, 2020, with trial identification number: ISRCTN87066007 (https://doi.org/10.1186/ISRCTN87066007). The first participant was recruited on September 29, 2020, after ISRCTN registry confirmation was received.

Early versus Delayed Amniotomy with Immediate Oxytocin After Foley Catheter Cervical Ripening in Nulliparous Labor Induction: A Randomized Trial

OBJECTIVE

To evaluate immediate oxytocin and early amniotomy compared to delayed amniotomy after Foley catheter cervical ripening in nulliparous women on intervention to delivery interval.

METHODS

A randomized trial was conducted from September 2020-March 2021. 140 term nulliparas (70 early amniotomy, 70 delayed amniotomy) with Foley catheter ripened cervices (dilatation ≥3cm achieved), singleton fetus, cephalic presentation with intact membranes and reassuring fetal heart rate tracing were recruited. Women were randomized to immediate titrated intravenous oxytocin infusion and early amniotomy or delayed amniotomy (after 4 hours of oxytocin). Primary outcome was intervention (oxytocin) to delivery interval (hours).

RESULTS

Intervention to delivery intervals(hours) were mean±standard deviation 9.0±3.6 vs.10.6±3.5 hours (mean difference of 1.4 hours), P=0.004 for early vs.delayed amniotomy arms respectively. Birth rate at 6 hours after oxytocin infusion were 19/70(27.1%) vs.8/70(11.4%) RR 2.38(1.11-5.06) NNTb 7(3.5-34.4), P=0.03, Cesarean delivery rate 29/70(41.4%) vs.33/70(47.1%) RR 0.88(0.61-1.28), P=0.50, and maternal satisfaction on birth process were median [interquartile range] 7[7-8] vs.7[7-8], P=0.40 for early vs.delayed amniotomy arms respectively.

CONCLUSION

In term nulliparas with cervices ripened by Foley catheter, immediate oxytocin and early amniotomy compared to a planned 4-hour delay to amniotomy shortens the intervention to delivery interval but did not significantly reduce the Cesarean delivery rate.

Induction of labour involving an amniotomy: Waiting compared to immediate oxytocin

During induction of labour (IOL), the optimal timing of oxytocin following amniotomy is unknown, with limited data to guide decision-making. This study aimed to see whether a 2-h delay after amniotomy before starting oxytocin during IOL reduced the use of oxytocin as well as other positive or negative impact. A propensity-score-matched cohort study assessed the maternal, neonatal and process outcomes of 1168 women (584 per group) comparing immediate oxytocin to a 2-h delay ('wait') after amniotomy. Women who waited were significantly less likely to receive oxytocin (61.2 vs 100%, P < 0.001) but more likely to receive antibiotics (14.7 vs 10.3%, P = 0.021), to be delivered by caesarean section (20.0 vs 14.6%, P = 0.013) and to be exclusively breastfeeding during discharge (77.2 vs 71.2%, P = 0.019). These findings provide further information for women and caregivers regarding the risks and benefits of a short delay before starting oxytocin.

Amniotomy and early oxytocin infusion vs amniotomy and delayed oxytocin infusion for labour augmentation amongst nulliparous women at term: A randomised controlled trial

OBJECTIVE

to compare the effect of amniotomy with early vs delayed oxytocin infusion on successful vaginal delivery.

DESIGN

randomised controlled trial of nulliparous women with spontaneous labour at term.

SETTING

labour suite of a university teaching hospital in Kuala Lumpur, Malaysia.

PARTICIPANTS

240 women were included (120 randomised into two arms).

INTERVENTIONS

the randomisation sequence was generated using a computer randomisation program in two blocks: oxytocin infused early following amniotomy; and oxytocin infused 2 h after amniotomy.

MEASUREMENTS AND FINDINGS

labour duration, mode of delivery, oxytocin dosage used, uterine hyperstimulation, postpartum haemorrhage, Apgar score and admission to the neonatal intensive care unit were recorded. No differences in vaginal delivery rate (62.9% vs 70.9%; p = 0.248) and second-stage labour were found between the early and delayed oxytocin infusion groups (21.2 ± 18.3 min vs 25.5 ± 19.9 min; p = 0.220). The mean interval from amniotomy to vaginal delivery was significantly shorter for the early group (5.8 ± 1.7 h vs 7.0 ± 1.9 h; p = 0.001), and more women in the early group delivered during/before the planned review at 4 h after amniotomy (53.6% vs 10.6%; p<0.001). Maximum oxytocin usage was lower in the early group (5.6 ± 4.4 mL/hour vs 6.8 ± 5.3 mL/hour; p = 0.104).

KEY CONCLUSIONS

early oxytocin augmentation following amniotomy could be employed in low-risk primigravida, given that it is associated with a shorter labour duration without jeopardising maternal or neonatal outcomes.

IMPLICATIONS FOR PRACTICE

low-risk primigravida benefit from early oxytocin infusion following amniotomy, and this can be offered as an additional practice in labour room care.

Towards an evidence-based approach to optimize the success of labour induction

Induction of labour is a two-step process involving cervical ripening and the initiation of uterine contractions, with the goal of achieving vaginal birth. To optimize the chance of a safe and timely vaginal birth, the process of induction of labour should be evidence based and individualized to the given person and situation. In this study, we lay out a framework for how this should be done, emphasizing on careful clinical assessment and planning, flexibility in the strategy of induction, patience during the ripening and latent phases of labour, and thoughtful consideration regarding changing the strategy if active labour is not initially achieved. The goal of this review is to present the current evidence on this topic in the form of a user-friendly protocol that can be easily adapted to institutional practice.

Outpatient vs inpatient Foley catheter induction of labor in multiparas with unripe cervixes: A randomized trial

INTRODUCTION

Multiparous labor inductions are typically successful, and the process can be rapid, starting from a ripened cervix with a predictable response to amniotomy and oxytocin infusion. Outpatient Foley catheter labor induction in multiparas with unripe cervixes is a feasible option as the mechanical process of ripening is usually without significant uterine contractions and well tolerated. Labor contractions can be initiated by amniotomy and titrated oxytocin infusion in the hospital for well-timed births during working hours as night birth are associated with adverse events. We sought to evaluate outpatient compared with inpatient Foley catheter induction of labor in multiparas for births during working hours and maternal satisfaction.

MATERIAL AND METHODS

A randomized trial was conducted in the University of Malaya Medical Center. A total of 163 term multiparas (no dropouts) with unripe cervixes (Bishop score ≤5) scheduled for labor induction were randomized to outpatient or inpatient Foley catheter. Primary outcomes were delivery during "working hours" 08:00-18:00 h and maternal satisfaction on allocated care (assessed by 11-point visual numerical rating score 0-10, with higher score indicating more satisfied).

CLINICAL TRIAL REGISTRATION

ISRCTN13534944.

RESULTS

Comparing outpatient and inpatient arms, delivery during working hours were 54/82 (65.9%) vs. 48/81 (59.3%) (relative risk 1.1, 95% CI 0.9-1.4, p = 0.421) and median maternal satisfaction visual numerical rating score was 9 (interquartile range 9-9) vs. 9 (interquartile range 8-9, p = 0.134), repectively. Duration of hospital stay and membrane rupture to delivery interval were significantly shorter in the outpatient arm: 35.8 ± 20.2 vs. 45.2 ± 16.2 h (p = 0.001) and 4.1 ± 2.9 vs. 5.3 ± 3.6 h (p = 0.020), respectively. Other maternal and neonatal secondary outcomes were not significantly different.

CONCLUSIONS

The trial failed to demonstrate the anticipated increase in births during working hours with outpatient compared with inpatient induction of labor with Foley catheter in parous women with an unripe cervix. Hospital stay and membrane rupture to delivery interval were significantly shortened in the outpatient group. The rate of maternal satisfaction was high in both groups and no significant differences were found.

Induction of labour from 39 weeks in low-risk multiparas with ripe cervixes: A randomised controlled trial

BACKGROUND

Induction of labour (IOL) in low-risk nulliparas at 39 weeks reduces caesarean delivery. Multiparas with ripe cervixes typically have vaginal delivery within eight hours. Delivery at night and weekend are associated with higher maternal and neonatal mortality.

AIMS

To evaluate IOL in full-term multiparas with ripe cervixes to achieve delivery at normal working hours and improve maternal satisfaction.

METHODS

A randomised trial was performed in a tertiary hospital in Malaysia. Low-risk multiparas with ripe cervixes (Bishop score ≥6) were recruited at 38⁺⁴ -40⁺⁰  weeks, then randomised to planned labour induction at 39⁺⁰  weeks or expectant care. Primary outcomes were delivery during 'normal working hours' 09:00-17:00 hours, Monday-Friday and patient satisfaction by visual numerical rating scale.

RESULTS

For IOL (n = 80) vs expectant care (n = 80) arms respectively, primary outcomes of delivery at normal working hours was 27/80 (34%) vs 29/78 (37%), relative risk (RR) 0.9, 95% CI 0.5-1.7, P = 0.41, patient satisfaction was 8.0 ± 1.8 vs 7.8 ± 1.6, P = 0.41; presentation for spontaneous labour or rupture of membranes were 27/80 (34%) vs 70/79 (89%), RR 0.4, 95% CI 0.3-0.5, P < 0.001; and for labour induction 52/80 (65%) vs 15/79 (19%), RR 3.4, 95% CI 2.1-5.5, P < 0.001. Caesarean delivery was 8/80 (10%) vs 4/79 (5%), RR 2.0, 95% CI 0.62-6.3, P = 0.25; and mean birthweight was 3.1 ± 0.3 vs 3.3 ± 0.4 kg, P = 0.06 for IOL vs expectant care, respectively.

CONCLUSION

Labour induction in low-risk multiparas does not increase births during working hours or improve patient satisfaction. Antenatal clinic visits and non-birth hospitalisation were significantly reduced.

Early versus delayed oxytocin infusion following amniotomy for induction of labor: a meta-analysis of randomized controlled trials

BACKGROUND

Oxytocin infusion prior to confirmation of delay in labor is discouraged by the World Health Organization. However, evidence from the Cochrane library seems to support early amniotomy and oxytocin to reduce the rates of cesarean sections (CS).

OBJECTIVES

To investigate differences in mode of delivery among parturient receiving early versus delayed oxytocin infusion following amniotomy as a mean for augmentation of labor.

SEARCH STRATEGY

We searched Medline, Scopus, EMBASE, Cochrane Central Register of Controlled Trials and Google Scholar databases from inception till February 2020. Selection criteria: Randomized controlled trials.

DATA COLLECTION AND ANALYSIS

Data were collected using a modified Cochrane data collection form for intervention reviews. Meta-analysis was performed using the meta function in RStudio.

MAIN RESULTS

Five studies were included that involved 1.232 parturient. The meta-analysis did not reveal significant differences in the mode of delivery among women that were randomized to receive immediate oxytocin infusion and those that received delayed oxytocin infusion (operative vaginal delivery OR 1.14, 95% CI 0.48, 2.69) and CS OR 0.81, 95% CI 0.53, 1.25)). The interval from amniotomy to delivery was significantly smaller in the immediate oxytocin infusion group; however, prediction intervals were not significant.

CONCLUSIONS

The results of our meta-analysis suggest that there is no difference in the mode of delivery and interval from amniotomy to delivery when oxytocin is delayed for at least one hour following amniotomy. Taking in mind this information as well as current recommendations drawn from the WHO physicians should consider withholding oxytocin infusion at least until protracted labor is confirmed.

Vaginal assessment and expedited amniotomy in oral misoprostol labor induction in nulliparas: a randomized trial

BACKGROUND

Labor is induced in 20-30% of maternities, with an increasing trend of use. Labor induction with oral misoprostol is associated with reduced risk of cesarean deliveries and has a safety and effectiveness profile comparable to those of mechanical methods such as Foley catheter use. Labor induction in nulliparous women continues to be challenging, with the process often quite protracted. The eventual cesarean delivery rate is high, particularly when the cervix is unfavorable and ripening is required. Vaginal examination can cause discomfort and emotional distress particularly to nulliparous women, and plausibly can affect patient satisfaction with the induction and birth process.

OBJECTIVE

The aim of this study was to evaluate regular (4-hourly prior to each oral misoprostol dose with amniotomy when feasible) compared with restricted (only if indicated) vaginal assessments during labor induction with oral misoprostol in term nulliparous women MATERIALS AND METHODS: We performed a randomized trial between November 2016 and September 2017 in a university hospital in Malaysia. Our oral misoprostol labor induction regimen comprised 50 μg of misoprostol administered 4 hourly for up to 3 doses in the first 24 hours. Participants assigned to regular assessment had vaginal examinations before each 4-hourly misoprostol dose with a view to amniotomy as soon as it was feasible. Participants in the restricted arm had vaginal examinations only if indicated. Primary outcomes were patient satisfaction with the birth process (using an 11-point visual numerical rating scale), induction to vaginal delivery interval, and vaginal delivery rate at 24 hours.

RESULTS

Data from 204 participants (101 regular, 103 restricted) were analyzed. The patient satisfaction score with the birth process was as follows (median [interquartile range]): 7 [6-9] vs 8 [6-10], P = .15. The interval of induction to vaginal delivery (mean ± standard deviation) was 24.3 ± 12.8 vs 31.1 ± 15.0 hours (P = .013). The vaginal delivery rate at 24 hours was 27.7% vs 20.4%; (relative risk [RR], 1.4; 95% confidence interval [CI], 0.8-2.3; P = .14) for the regular vs restricted arms, respectively. The cesarean delivery rate was 50% vs 43% (RR, 1.1; 95% CI, 0.9-1.5; P = .36). When assessed after delivery, participants' fidelity to their assigned vaginal examination schedule in a future labor induction was 45% vs 88% (RR, 0.5; 95% CI, 0.4-0.7; P < .001), and they would recommend their assigned schedule to a friend (47% vs 87%; RR, 0.6; 95% CI, 0.5-0.7; P < .001) in the regular compared with the restricted arms, respectively.

CONCLUSION

Despite a shorter induction to vaginal delivery interval with regular vaginal examination and a similar vaginal delivery rate at 24 hours and birth process satisfaction score, women expressed a higher preference for the restricted examination schedule and were more likely to recommend such a schedule to a friend.

Labor Induction Techniques: Which Is the Best?

Induction of labor is a common procedure undertaken whenever the benefits of prompt delivery outweigh the risks of expectant management. Cervical assessment is essential to determine the optimal approach. Indication for induction, clinical presentation and history, safety, cost, and patient preference may factor into the selection of methods. For the unfavorable cervix, several pharmacologic and mechanical methods are available, each with associated advantages and disadvantages. In women with a favorable cervix, combined use of amniotomy and intravenous oxytocin is generally the most effective approach. The goal of labor induction is to ensure the best possible outcome for mother and newborn.

Effects of Increased Frequency, High Dose, and Pulsatile Oxytocin Regimens on Abnormal Labor Delivery

Background

The current guideline for oxytocin regimens in the abnormal labor of delivery is continuous infusion. The objective of the present study was to compare effects and safety measures of various available regimens of oxytocin in abnormal labor delivery.

Material/Methods

In this clinical experimental study, a total of 900 pregnant women admitted for delivery were randomized into 5 group with 162 each. Pregnant women received oxytocin as continuous administration of 16 mU/min (Group I), 1 mU/min (group II), 4 mU/min (group III), 5 mU/min quarter-hourly (group IV), and through a syringe pump (group V). Measurement of the expense of delivery, the ratio of the instrumental delivery, and the other secondary outcome measures was performed to find the best regimen of oxytocin. The 2-tailed paired t test and Mann-Whitney U test following Dunnett’s multiple comparison tests were used at 95% confidence level.

Results

Pulsatile delivery had least risk of instrumental delivery as compared to continuous infusion (p<0.0001, q=6.663) and normal-frequency low-dose (p<0.0001, q=5.638) of oxytocin. The time required from infusion to delivery was longer for group II (p=0.001, q=2.925), group IV (p<0.0001, q=4.829), and group V (p<0.0001, q=41.456) than for group I. The expense of delivery was: group I < group II < group IV < group III < group V.

Conclusions

High-dose and pulsatile preparation of oxytocin had reduced risks of operative delivery vs. continuous administration.

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.