Review of Evidence-Based Methods for Successful Labor Induction

Efficacy and safety of oral and vaginal administration of misoprostol for induction of labor in high-risk obese pregnant women with hypertension or diabetes mellitus

OBJECTIVE

This study aims to compare the safety and efficacy of misoprostol administered orally and vaginally in obese pregnant women at term with either gestational hypertension or diabetes.

METHODS

A total of 264 pregnant women were enrolled and categorized into two groups based on their primary condition: hypertension (134 cases) or diabetes mellitus (130 cases) and were further divided into subgroups for misoprostol administration: orally (Oral group) or vaginally (Vaginal group). The primary outcomes measured were changes in the Bishop score following treatment, induction of labor (IOL) success rates, requirement for oxytocin augmentation, duration of labor, mode of delivery, and cesarean section rates.

RESULTS

Significant enhancements in Bishop scores, decreased cesarean section rates and increased success rates of IOL were noted in both administration groups. The incidence of vaginal delivery within 24 h was significantly higher in the Vaginal group compared to the Oral group. Adverse effects, including nausea, uterine overcontraction, hyperfrequency of uterine contraction and uterine hyperstimulation without fetal heart rate deceleration, were significantly more prevalent in the Vaginal group than in the Oral group.

CONCLUSION

Misoprostol administration, both orally and vaginally, proves effective for labor induction in obese pregnant women with hypertension or diabetes. However, the oral route presents a lower risk of adverse maternal and neonatal outcomes, suggesting its preference for safer labor induction in this demographic.

Prediction of Failure to Progress after Labor Induction: A Multivariable Model Using Pelvic Ultrasound and Clinical Data

Objective: Labor induction is one of the leading causes of obstetric admission. This study aimed to create a simple model for predicting failure to progress after labor induction using pelvic ultrasound and clinical data. Material and Methods: A group of 387 singleton pregnant women at term with unruptured amniotic membranes admitted for labor induction were included in an observational prospective study. Clinical and ultrasonographic variables were collected at admission prior to the onset of contractions, and labor data were collected after delivery. Multivariable logistic regression analysis was applied to create several models to predict cesarean section due to failure to progress. Afterward, the most accurate and reproducible model was selected according to the lowest Akaike Information Criteria (AIC) with a high area under the curve (AUC). Results: Plausible parameters for explaining failure to progress were initially obtained from univariable analysis. With them, several multivariable analyses were evaluated. Those parameters with the highest reproducibility included maternal age (p < 0.05), parity (p < 0.0001), fetal gender (p < 0.05), EFW centile (p < 0.01), cervical length (p < 0.01), and posterior occiput position (p < 0.001), but the angle of descent was disregarded. This model obtained an AIC of 318.3 and an AUC of 0.81 (95% CI 0.76-0.86, p < 0.0001) with detection rates of 24% and 37% for FPRs of 5% and 10%. Conclusions: A simplified clinical and sonographic model may guide the management of pregnancies undergoing labor induction, favoring individualized patient management.

Factors Influencing Duration of Breastfeeding: Insights from a Prospective Study of Maternal Health Literacy and Obstetric Practices

Numerous factors concerning early breastfeeding abandonment have been described, including health literacy (HL). This study's objective was to analyze factors related to early breastfeeding abandonment (<6 months). This prospective multicentric study examined the duration of breastfeeding at 6 months postpartum and was conducted in four different regions of Spain from January 2021 to January 2023. A total of 275 women participated in this study, which focused on maternal HL and obstetric practices. A decrease in the breastfeeding rate was observed from hospital discharge (n = 224, 81.5%) to the sixth month postpartum (n = 117, 42.5%). A Cox regression analysis revealed that inadequate HL levels, lack of mobilization during labour, and induced labour were significantly associated with early breastfeeding cessation (p = 0.022, p = 0.019, and p = 0.010, respectively). The results highlight that women with adequate HL had a 32% lower risk of early breastfeeding abandonment. In comparison, mobilization during labour and induction of labour were linked to a 32.4% reduction and a 53.8% increase in this risk, respectively. These findings emphasize the importance of considering obstetric and HL factors when addressing the breastfeeding duration, indicating opportunities for educational and perinatal care interventions.

Oxytocin and vaginal dinoprostone in labor induction: A systematic review and meta-analysis

BACKGROUND

The comparison between prostaglandin E2 (PGE2) and oxytocin and for induction of labor (IOL) remains controversial.

OBJECTIVE

The present study aimed to determine the safety and efficacy of these two agents in IOL.

SEARCH STRATEGY

PubMed, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov. from the establishment of the database to April 23, 2023.

SELECTION CRITERIA

A search was conducted with keywords "labor, induction, prostaglandin E2/PGE2/dinoprostone, and oxytocin". Only randomized clinical trials comparing oxytocin and vaginal dinoprostone in women who were at least late preterm (gestational age [GA] ≥34 weeks), singleton pregnant, and had intact membranes were enrolled for further meta-analysis.

DATA COLLECTION AND ANALYSIS

We conducted both a descriptive analysis and a meta-analysis. In the meta-analysis, we utilized the Mantel-Haenszel random effects model to analyze dichotomous data, employing the relative risk (RR) as the effect measure along with 95% confidence intervals (CIs). The study quality was evaluated using Cochrane Collaboration's risk of bias assessment tool (RoB 2). A random-effects model was applied for the meta-analysis.

MAIN RESULTS

After screening 3303 articles from five databases, a total of nine randomized controlled studies composed of 1071 patients were included. Our analysis included 534 patients in the PGE2 group and 537 patients in the oxytocin group. The pooled estimate of vaginal deliveries following PGE2 induction stood at 84.2%, while after oxytocin induction, it was 79.8%. The meta-analysis showed no statistical difference between the two groups in terms of the rate of vaginal delivery (pooled RR, 1.05; 95% CI: 0.95-1.16; P value for Q, 0.001; I2 , 71.14%), cesarean section (pooled RR, 0.84; 95% CI: 0.52-1.35; P value for Q, 0.007; I2 , 61.69%) and induction-delivery interval (pooled standard mean difference, 0.09; 95% CI: -0.67 to 0.85; P value for Q, 0.000; I2 , 96.45%). Since the results for fetal distress and uterine hyperstimulation were consistent across all enrolled studies, no further meta-analysis was conducted.

CONCLUSIONS

When amalgamating the available literature, it implies that oxytocin was found to have similar effects as PGE2 on delivery outcomes and safety concerns in pregnant women with GA ≥36 weeks. Although the uterine cervix was unfavorable, both low and high doses of oxytocin were feasible for IOL.

Efficacy and safety of double balloon catheter and dinoprostone for labor induction in multipara at term

PURPOSE

The aim of this study was to comparatively assess the efficacy and safety of double balloon catheter (DBC) and dinoprostone as labor-inducing agents just for multipara at term.

METHODS

A retrospective cohort study was conducted among multipara at term with a Bishop score < 6 who needed planned labor induction from January 1, 2020, to December 30, 2020 in Maternal and Child Health Hospital of Hubei province, Tongji Medical College, Huazhong University of Science and Technology. They were divided into DBC group and dinoprostone group, respectively. Baseline maternal data, maternal and neonatal outcomes were recorded for statistical analysis. Total vaginal delivery rate, rate of vaginal delivery within 24 h, rate of uterine hyperstimulation combined with abnormal fetal heart rate(FHR) were regarded as the primary outcome variables. The difference between groups was considered statistically significant when p value < 0.05.

RESULTS

A total of 202 multiparas was included for analysis (95 women in DBC group vs 107 women in dinoprostone group). There were no significant differences in total vaginal delivery rate and rate of vaginal delivery within 24 h between groups. Uterine hyperstimulation combined with abnormal FHR occurred exclusively in dinoprostone group.

CONCLUSION

DBC and dinoprostone seem to be equally effective, while, DBC seems to be safer than dinoprostone.

Developing a nomogram for estimating the risk of needing to perform a caesarean section after induction of labour in pregnancies using a COOK® Cervical Ripening Balloon

BACKGROUND

Using a COOK® Cervical Ripening Balloon (CCRB) for cervical maturity has become a common clinical practice for the induction of labour (IOL).

OBJECTIVE

To develop and validate a predictive instrument that could estimate the risk of a caesarean after IOL in term pregnancies with CCRB treatment.

METHODS

The medical records of 415 pregnant women requiring IOL from January 2018 to October 2022 were retrospectively reviewed and randomly selected for training (290) and validation (125) sets in a 7:3 ratio. A model for predicting the risk of a caesarean was virtualised by a nomogram using logistic regression analysis.

RESULTS

After completing the multivariate analysis, parity (odds ratio [OR] = 0.226; p= 0.017), modified Bishop score at induction (OR =0.688; p= 0.005) and the artificial rupture of membranes (OR = 0.436; p= 0.010) were identified as the predictors for implementing a caesarean delivery after IOL. The decision curve analysis showed that the model achieved a net benefit across all threshold probabilities.

CONCLUSION

We successfully constructed a nomogram for caesarean delivery after IOL in pregnancies with CCRB treatment using factors including parity, modified Bishop score at induction and the artificial rupture of membrane.

Evidence Based Management of Labor

Importance

Induction of labor (IOL) is a common obstetric intervention. Augmentation of labor and active management of the second stage is frequently required in obstetric practice. However, techniques around labor and induction management vary widely. Evidence-based practice regarding induction and labor management can reduce birth complications such as infection and hemorrhage and decrease rates of cesarean delivery.

Objective

To review existing evidence on IOL and labor management strategies with respect to preparing for induction, cervical ripening, induction and augmentation, and second stage of labor techniques.

Evidence acquisition

Review of recent original research, review articles, and guidelines on IOL using PubMed (2000-2022).

Results

Preinduction, pelvic floor training and perineal massage reduce postpartum urinary incontinence and perineal trauma, respectively. Timely membrane sweeping (38 weeks) can promote spontaneous labor and prevent postterm inductions. Outpatient Foley bulb placement in low-risk nulliparous patients with planned IOL reduces time to delivery. Inpatient Foley bulb use beyond 6 to 12 hours shows no benefit. When synthetic prostaglandins are indicated, vaginal misoprostol should be preferred. For nulliparous patients and those with obesity, oxytocin should be titrated using a high-dose protocol. Once cervical dilation is complete, pushing should begin immediately. Warm compresses and perineal massage decrease risk of perineal trauma.

Conclusion and relevance

Several strategies exist to assist in successful IOL and promote vaginal delivery. Evidence-based strategies should be used to improve outcomes and decrease risk of complications and cesarean delivery. Recommendations should be shared across interdisciplinary team members, creating a model that promotes safe patient care.

The Correct Indication to Induce Labour in a Swiss Cantonal Hospital

BACKGROUND

Induction of labour (IOL) is a way to stimulate the onset of labour using mechanical and pharmacological methods. IOL is one of the most frequently performed obstetric procedures worldwide. We aimed to determine compliance with guidelines and to investigate factors associated with the success of labour.

METHODS

In this retrospective, observational study, we analysed all induced deliveries in a Swiss hospital between January 2020 and December 2022.

RESULTS

Out of 1705 deliveries, 349 women underwent IOL, and 278 were included in this study, with an average age of 32 years (range 19-44 years). Most of the women were induced for missed deadlines (20.1%), the premature rupture of membranes (16.5%), and gestational diabetes mellitus (9.3%), and there was a good adherence to the guideline, especially with the indication and IOL monitoring (100%). However, an improvement needs to be made in measuring and documenting the Bishop score (41%). The success of labour was associated with multiparity (81.8% vs. 62.4% p = 0.001) and maternal non-obesity (73.4 vs. 54.1% p = 0.026).

CONCLUSIONS

An improvement is needed in the measurement and documentation of the Bishop score. Further research is needed to confirm the found associations between parity, obesity, and the success of IOL.