Sweeping of the membranes to prevent post-term pregnancy and to induce labour: a systematic review

Membrane Stripping Method’s Effect On Pregnancy Period For Term Pregnants

Amaç: Doğum indüksiyon metodlarından membran sweeping veya stripping yöntemi obstetrikte miadında gebelerde sık kullanılan işlemlerden biridir, non-farmakolojik yöntemlerdendir. Çalışmada bu yöntemin doğum sürecindeki etkileri, doğumu başlatma ve gebelik süresini kısaltma, postterm gebeliği önleme, indüksiyon gereksinimini azaltma yönlerinden etkinliği, etkinliğine etki eden faktörleri ve bu yönteme bağlı fetal ve maternal sonuçları araştırmak hedeflendi. Gereç ve Yöntemler: Çalışmaya, ilk obstetrik değerlendirmede tekil canlı gebeliği olan, 38-40 hafta arası miadında olan, sezaryen veya herhangi bir uterin cerrahi geçirmemiş olan, Bishop skoru 4 veya daha küçük olan, vajinal yoldan doğum için kontrendikasyonu olmayan olgular alındı. Çalışma toplam 213 olgu üzerinde yapıldı. 108 olgu (42 multipar, 66 nullipar) çalışma, 105 olgu (48 multipar, 57 nullipar) kontrol grubunu oluşturdu. Bulgular: Çalışma grubunda uygulamadan doğuma kadar geçen süre ortalaması 7,04 ± 3,96, kontrol grubunda ise 9,24 ± 5,01 bulundu. Çalışma grubunda 7 gün içerisinde vajinal doğum yapma oranı (%68,5), kontrol grubundan (%43,8) istatistiksel olarak ileri düzeyde anlamlı yüksek bulundu. Çalışma grubunda 41. Gebelik haftasından önce doğum yapma oranı (%84,3), kontrol grubundan (%69,5) istatistiksel olarak anlamlı düzeyde yüksek bulundu. İndüksiyon gereksinimi çalışma grubunda (%11,1) kontrol grubuna (%23,8) kıyasla istatistiki olarak anlamlı düzeyde düşük bulunmuştur. Her iki grup doğum şekli, erken membran rüptürü, neonatal sonuçlar, maternal enfeksiyon açısından karşılaştırıldıklarında sonuçlar benzer bulundu. Sonuç: Membran sıyırma yönteminin, komplike olmayan 38-40 hafta arasındaki term gebelerde, maternal-fetal sonuçları değiştirmeden, uygulamadan doğuma kadar geçen süreyi, postterm gebelik oranlarını ve indüksiyon gereksinimini azaltma açısından etkili ve güvenilir bir yöntem olduğu gözlemlenmiştir.

No. 214-Guidelines for the Management of Pregnancy at 41+0 to 42+0 Weeks

OBJECTIVE

To provide evidence-based guidelines for the management of pregnancy at 41+0 to 42+0 weeks.

OUTCOMES

Reduction of perinatal mortality associated with Caesarean section at 41+0 to 42+0 weeks of pregnancy.

EVIDENCE

The Medline database, the Cochrane Library, and the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists, were searched for English language articles published between 1966 and March 2007, using the following key words: prolonged pregnancy, post-term pregnancy, and postdates pregnancy. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.

RECOMMENDATIONS

Membrane sweeping to induce labor in low-risk patients at term pregnancy: a randomised controlled trial

OBJECTIVE

To evaluate the efficacy of membrane sweeping at initiation of labor induction in low-risk patients at term pregnancy (38-40 gestational weeks).

METHODS

This prospective study included 351 antenatal women who were randomly assigned to one of two groups: a sweeping of the membranes group (n = 181) and a no sweeping control group (n = 170). The primary outcome measure was the proportion of women who entered spontaneous labor within 1 week of entry into the study. Secondary outcome measures included mode of delivery and maternal and fetal complications.

RESULTS

Five patients (two in the sweeping group and three in the no sweeping group) were excluded from the study because of breech presentation at labor. There were no statistically significant differences between the two groups regarding maternal age, parity or Bishop score. The proportion of subjects who entered spontaneous labor before 41 weeks of gestation was significantly different between the two groups (p < 0.0001). The mode of delivery did not differ significantly between the groups and there was no statistically significant difference in maternal or fetal complications.

CONCLUSIONS

Sweeping of membranes is a safe method to reduce the length of term in pregnancy and the incidence of prolonged gestation in a low-risk population. There is no evidence that sweeping the membranes increases the risk of maternal or neonatal adverse outcomes.

Guidelines for the management of pregnancy at 41+0 to 42+0 weeks

OBJECTIVE

To provide evidence-based guidelines for the management of pregnancy at 41+0 to 42+0 weeks.

OUTCOMES

Reduction of perinatal mortality associated with Caesarean section at 41+0 to 42+0 weeks of pregnancy.

EVIDENCE

The Medline database, the Cochrane Library, and the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists, were searched for English language articles published between 1966 and March 2007, using the following key words: prolonged pregnancy, post-term pregnancy, and postdates pregnancy. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. Recommendations 1. First trimester ultrasound should be offered, ideally between 11 and 14 weeks, to all women, as it is a more accurate assessment of gestational age than last menstrual period with fewer pregnancies prolonged past 41+0 weeks. (I-A) 2. If there is a difference of greater than 5 days between gestational age dated using the last menstrual period and first trimester ultrasound, the estimated date of delivery should be adjusted as per the first trimester ultrasound. (I-A) 3. If there is a difference of greater than 10 days between gestational age dated using the last menstrual period and second trimester ultrasound, the estimated date of delivery should be adjusted as per the second trimester ultrasound. (I-A) 4. When there has been both a first and second trimester ultrasound, gestational age should be determined by the earliest ultrasound. (I-A) 5. Women should be offered the option of membrane sweeping commencing at 38 to 41 weeks, following a discussion of risks and benefits. (I-A) 6. Women should be offered induction at 41+0 to 42+0 weeks, as the present evidence reveals a decrease in perinatal mortality without increased risk of Caesarean section. (I-A) 7. Antenatal testing used in the monitoring of the 41- to 42-week pregnancy should include at least a non-stress test and an assessment of amniotic fluid volume. (I-A) 8. Each obstetrical department should establish guidelines dependent on local resources for scheduling of labour induction. (I-A).

Concurrent versus sequential methods for labor induction at term

OBJECTIVE

To determine the efficacy and safety of the concurrent administration of oxytocin and prostaglandin E2 (PGE2) for induction of labor at term, prompt delivery, and good maternal and neonatal outcomes.

METHODS

In this comparative cohort study of 70 women conducted in Pakistan, 35 were given oxytocin and PGE2 concurrently and 35 were given the drugs sequentially for labor induction. Two-sample t tests and x(2) tests were used for the evaluation of continuous and categorical data, respectively.

RESULTS

The mean induction to delivery time was shorter by 2.4 h in the concurrent treatment group (P<0.001), and the proportion of vaginal deliveries was higher in that group.

CONCLUSION

The concurrent method of induction of labor resulted in shorter induction to delivery time and a higher proportion of vaginal deliveries.

Effect of membrane sweeping at term pregnancy on duration of pregnancy and labor induction: a randomized trial

AIM

To evaluate the efficacy of sweeping of fetal membranes for induction of labor in uncomplicated term pregnancies.

METHODS

A randomized controlled trial was performed in 122 pregnant women beyond 39 weeks of gestation with no complications. The women were assigned to have their membranes swept or not (controls) for labor induction. The main outcome measures included duration of pregnancy and possible complications of sweeping of membranes, including rupture of membranes, postpartum infections, and vaginal bleeding.

RESULTS

Twenty-one patients did not give birth in our hospital and were, therefore, excluded from the study; 101 women completed the study (51 patients in the control group and 50 women in the study group). There were no statistically significant differences in maternal age, parity, birth weight, and Bishop score in the two groups. The mean interval between sweeping (stripping) and vaginal examination until delivery was 7.7 +/- (SD) 6.9 and 7.1 +/- 5.6 days in the sweeping and in the control group, respectively (p = 0.61). Of the 101 pregnant women, only 6 patients had premature rupture of membranes (2 in the sweeping group and 4 in the control group). There were no statistically significant differences between these individuals (p = 0.68). Significant vaginal bleeding was not observed in the two groups. Meconium-stained amniotic fluid was seen in 13 women: 8 in the sweeping group and 5 in the control group. There were no statistically significant differences among the women who had meconium-stained fluid in case and control groups (p = 0.39). There were no differences between women who had puerperal fever (3 in the sweeping group and 2 in the control group; p = 0.68). 12 of the 101 women (6 in each group) had cesarean section performed, but there was no difference between the two groups.

CONCLUSION

Sweeping of membranes at 39 weeks of gestation has no significant clinical effect on the duration of pregnancy.

Induction of labor

The rate of labor induction continues to rise significantly in the United States because of a growing use of labor induction for postterm pregnancies and elective induction of labor. Although different types and doses of prostaglandins used for cervical ripening often initiate uterine activity, the principal role of these agents is to soften the unripe cervix independent of uterine activity. Several systematic reviews with meta-analyses have shown that prostaglandins are superior to placebo and oxytocin alone in ripening of the cervix. Numerous studies and meta-analyses have assessed misoprostol's efficacy and safety as a labor induction agent. The most appropriate dose and route of administration has not yet been confirmed.

Does sweeping of membranes beyond 40 weeks reduce the need for formal induction of labour?

OBJECTIVE

To assess the efficacy of sweeping of membranes beyond 40 weeks of gestation in reducing the incidence of induction of labour, when induction was planned at 42 weeks.

DESIGN

Prospective randomised controlled trial.

SETTING

A regional obstetric unit in Hong Kong.

POPULATION AND METHODS

A total of 120 women with certain gestational age, determined by early pregnancy ultrasound scan, were recruited from 1st July, 1998 to 31st December, 1999. Sixty women were randomly allocated to sweeping of membranes and the other 60 women acted as control. The satisfaction for women allocated to sweeping of membranes was assessed by a questionnaire after the procedure. The two groups were assessed on intention-to-treat basis.

MAIN OUTCOME MEASURES

The incidence of formal induction of labour was compared between the two groups. Possible complications of sweeping of membranes such as rupture of membranes, intrapartum infection, postpartum infection, and neonatal infection were also assessed. Maternal and perinatal outcomes were also assessed.

RESULTS

The recruitment to delivery interval was significantly shorter among women who had sweeping of membranes (3.2 versus 4.2 days, P < 0.05). The incidence of induction of labour was comparable (35.5% versus 38%, RR 0.91, 95% CI 0.57 - 1.46). The incidences of caesarean section and assisted vaginal delivery were comparable. The incidences of premature rupture of membranes, intrapartum, and postpartum infection were comparable. The perinatal outcomes were also comparable between the two groups. Up to 70% of women found that this procedure was associated with significant discomfort. One third of these women complained of significant pain.

CONCLUSIONS

Sweeping of membranes beyond 40 weeks does not reduce the need for formal induction of labour at 42 weeks. Although it is safe, the majority of women felt uncomfortable during the procedure.