Intervention Rates after Elective Induction of Labor Compared to Labor with a Spontaneous Onset

The ARRIVE Trial

Timing of delivery such that maternal and perinatal outcomes are optimized is among the most important and commonplace decisions in obstetric care. Given the importance of this determination, it is somewhat surprising that there has been, until relatively recently, little in the way of high-quality evidence to guide obstetric clinicians in this decision. This chapter describes the evolution of studies examining the effects of labor induction and the importance of the ARRIVE trial in that context.

Failed induction of labor

Induction of labor is a widely used practice. From 2016 to 2019, >1 in 3 women giving birth in the United States did so after undergoing labor induction. The obvious goal of labor induction is vaginal birth with minimal maternal or neonatal morbidity. To achieve this goal, criteria for failed labor induction are needed. Herein, we provide an evidence-based approach to safely prevent unnecessary cesarean deliveries for failed induction. Although there are no randomized trials comparing failed labor induction criteria, the observational data have been consistent: if the status of the mother and the fetus permits, at least 12 to 18 hours of oxytocin should be administered after membrane rupture before deeming an induction of labor to have failed because of nonprogression to the active phase of labor.

Elective Induction of Labour at 39 Weeks Compared With Expectant Management in Nulliparous Persons Delivering in a Community Hospital

OBJECTIVE

To determine the impact of offering elective labour induction at 39 weeks gestation on perinatal and maternal outcomes in nulliparous people with low-risk pregnancies.

METHODS

The charts of all pregnant people who delivered at Brockville General Hospital between September 2018 and December 2021 were retrospectively reviewed. Perinatal and maternal outcomes of low-risk nulliparous pregnant people who underwent elective induction at 39 weeks and over were extracted and compared with those of low-risk nulliparous pregnant people who underwent expectant management. Exclusion criteria included multiparous people, high-risk pregnancies, multiple gestations, deliveries at less than 39 weeks gestation, and elective cesarean deliveries. Univariate and multivariate analysis was performed.

RESULTS

A total of 174 patients were included. Of these patients, 56 (32.2%) underwent elective induction of labour between 39⁰ and 39⁶ weeks gestation over the period of June 2020 to December 2021, whereas 118 (67.8%) were expectantly managed from 39⁰ weeks gestation over the period of September 2018 to March 2020. Compared with expectant management, those in the 39⁺ weeks induction group had a significantly lower risk of cesarean delivery (odds ratio [OR] 0.39; 95% confidence interval [CI] 0.15-0.99), composite adverse maternal outcomes (OR 0.34; 95% CI 0.12-0.97), and composite adverse perinatal outcomes (OR 0.26; 95% CI 0.074-0.92).

CONCLUSION

Our results suggest that elective induction of labour at 39 weeks gestation and over in low-risk nulliparous people is associated with lower risks of cesarean delivery, composite adverse maternal outcomes, and composite adverse perinatal outcomes than expectant management.

Neonatal Adverse Outcomes of Induction and Expectant Management in Fetal Growth Restriction: A Systematic Review and Meta-Analysis

Background and Objective: Fetal growth restriction (FGR) is a pathological condition in which the fetus cannot reach its expected growth potential. When it is diagnosed as a suspected FGR, it remains an unsolved problem whether to direct induction or continue expectant management. To effectively reduce the incidence of neonatal adverse outcomes, we aimed to evaluate whether either method was associated with a lower incidence of neonatal adverse outcomes. Methods: We searched the relevant literature through the PubMed, Web of Science, and Cochrane Library from inception to January 10, 2020. We defined induction as the experimental group and expectant management as the control group. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models owing to heterogeneity. Furthermore, we conducted a sensitivity analysis to explore the robustness of the included literature. We used the Newcastle-Ottawa scale (NOS) to evaluate the quality of the available studies. We applied the funnel plot to describe the publication bias. Additionally, subgroup analysis based on the study method, sample size, area, NOS score, Apgar score <7 at 5 min, definition of suspected FGR, severity, and neonatal adverse outcomes were performed to further evaluate the differences between the induction and expectant management. Results: Our study included a total of eight articles with 6,706 patients, which consisted of four randomized controlled trials (RCTs), three retrospective cohort studies, and one prospective cohort study. The total pooled OR and 95% CI between the induction group and the expected management group was 1.38 (95% CI, 0.84-2.28) in the random model. The heterogeneity was I 2 = 84%, P < 0.01. The sensitivity analysis showed that the neonatal adverse outcomes of induction vs. expectant management still presented similar outcomes after omitting of any one of these studies. The funnel plot and linear regression equation showed that there was no publication bias in our study (P = 0.75). Subgroup analysis showed that induction increased the neonatal adverse outcome risks of hypoglycemia and respiratory insufficiency (ORneonatal hypoglycaemia = 8.76, 95% CI: 2.57-29.90; ORrespiratory insufficiency = 1.74, 95% CI: 1.35-2.24, respectively). However, no significant differences were observed based on the other subgroups (all P > 0.05). Conclusion: Regardless of induction or expectant management of a suspected FGR, the neonatal adverse outcomes showed no obvious differences. More studies should be conducted and confounding factors should be taken into consideration to elucidate the differential outcomes of the two approaches for suspected FGR.

Delivery at 39 Weeks of Gestation: The Time Has Come

It has long been observed that neonates born between 39 and 40 gestational weeks have the best perinatal outcomes. What has not been known, until recently, is whether these ideal perinatal outcomes would be achieved in neonates whose delivery was brought on intentionally in this window by labor induction. Recent randomized trials and large observational cohorts have answered this question: labor induction, as compared with expectant management, lowers the rate of cesarean delivery (without increasing other adverse maternal outcomes) and improves perinatal outcomes. For those women still pregnant, delivery at 39 weeks of gestation would simultaneously lower the number of cesarean deliveries and reduce the number of stillbirths and neonatal deaths in the United States.

Maternal and perinatal outcome of preeclampsia without severe feature among pregnant women managed at a tertiary referral hospital in urban Ethiopia

Background

Preeclampsia refers to the new onset of hypertension and proteinuria after 20 weeks of gestation in a previously normotensive woman. Pregnant women with preeclampsia are at an increased risk of adverse maternal, fetal and neonatal complications. The objective of the study is, therefore, to determine the maternal and perinatal outcome of preeclampsia without severity feature among women managed at a tertiary referral hospital in urban Ethiopia.

Methods

A hospital-based prospective observational study was conducted to evaluate the maternal and perinatal outcome of pregnant women who were on expectant management with the diagnosis of preeclampsia without severe feature at a referral hospital in urban Ethiopia from August 2018 to January 2019.

Results

There were a total of 5400 deliveries during the study period, among which 164 (3%) women were diagnosed with preeclampsia without severe features. Fifty-one (31.1%) patients with preeclampsia without severe features presented at a gestational age between 28 to 33 weeks plus six days, while 113 (68.9%) presented at a gestational age between 34 weeks to 36 weeks. Fifty-two (31.7%) women had maternal complication of which, 32 (19.5%) progressed to preeclampsia with severe feature Those patients with early onset of preeclampsia without severe feature were 5.22 and 25.9 times more likely to develop maternal and perinatal complication respectively compared to late-onset after 34 weeks with P-value of <0.0001, (95% CI 2.01–13.6) and <0.0001(95% CI 5.75–115.6) respectively.

Conclusion

In a setting where home-based self-care is poor expectant outpatient management of preeclampsia without severe features with a once per week visit is not adequate. It’s associated with an increased risk of maternal and perinatal morbidity and mortality. Our findings call for special consideration and close surveillance of those women with early-onset diseases.

Health resource utilization of labor induction versus expectant management

BACKGROUND

Although induction of labor of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains, given that this intervention historically has been thought to incur greater resource utilization.

OBJECTIVE

The objective of the study was to determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum.

STUDY DESIGN

This is a planned secondary analysis of a multicenter randomized trial in which low-risk nulliparous women were assigned to induction of labor at 39 weeks or expectant management. We assessed resource utilization after randomization in 3 time periods: antepartum, delivery admission, and discharge through 8 weeks postpartum.

RESULTS

Of 6096 women with data available, those in the induction of labor group (n = 3059) were significantly less likely in the antepartum period after randomization to have at least 1 ambulatory visit for routine prenatal care (32.4% vs 68.4%), unanticipated care (0.5% vs 2.6%), or urgent care (16.2% vs 44.3%), or at least 1 antepartum hospitalization (0.8% vs 2.2%, P < .001 for all). They also had fewer tests (eg, sonograms, blood tests) and treatments (eg, antibiotics, intravenous hydration) prior to delivery. During the delivery admission, women in the induction of labor group spent a longer time in labor and delivery (median, 0.83 vs 0.57 days), but both women (P = .002) and their neonates (P < .001) had shorter postpartum stays. Women and neonates in both groups had similar frequencies of postpartum urgent care and hospital readmissions (P > .05 for all).

CONCLUSION

Women randomized to induction of labor had longer durations in labor and delivery but significantly fewer antepartum visits, tests, and treatments and shorter maternal and neonatal hospital durations after delivery. These results demonstrate that the health outcome advantages associated with induction of labor are gained without incurring uniformly greater health care resource use.

Elective induction of labor at 39 weeks compared with expectant management: a meta-analysis of cohort studies

BACKGROUND

Elective induction of labor at 39 weeks among low-risk nulliparous women has reduced the chance of cesarean and other adverse maternal and perinatal outcomes in a randomized trial, although its clinical effectiveness in nonresearch settings remains uncertain.

OBJECTIVE

To perform a systematic review of observational studies that compared elective induction of labor at 39 weeks among nulliparous women with expectant management and to use meta-analytic techniques to estimate the association of elective induction with cesarean delivery, as well as other maternal and perinatal outcomes.

STUDY DESIGN

Studies were eligible for this meta-analysis only if they: (1) were observational; (2) compared women undergoing labor induction at 39 weeks with women undergoing expectant management beyond that gestational age; (3) included women in the induction group only if they had no other indication for labor induction at 39 weeks; and (4) provided data specifically for nulliparous women. The predefined primary outcome was cesarean delivery, and secondary outcomes representing other maternal and perinatal morbidities also were evaluated. Outcome data from different studies were combined to estimate pooled relative risks with 95% confidence intervals using random-effects models.

RESULTS

Of 375 studies identified by the initial search, 6 cohort studies, which included 66,019 women undergoing elective labor induction at 39 weeks and 584,390 undergoing expectant management, met inclusion criteria. Elective induction of labor at 39 weeks was associated with a significantly lower frequency of cesarean delivery (26.4% vs 29.1%; relative risk, 0.83; 95% confidence interval, 0.74-0.93), as well as of peripartum infection (2.8% vs 5.2%; relative risk, 0.53; 95% confidence interval, 0.39-0.72). Neonates of women in the induction group were less likely to have respiratory morbidity (0.7% vs 1.5%; relative risk, 0.71; 95% confidence interval, 0.59-0.85); meconium aspiration syndrome (0.7% vs 3.0%; relative risk, 0.49; 95% confidence interval, 0.26-0.92); and neonatal intensive care unit admission (3.5% vs 5.5%; relative risk, 0.80; 95% confidence interval, 0.72-0.88). There also was a lower risk of perinatal mortality (0.04% vs 0.2%; relative risk, 0.27; 95% confidence interval, 0.09-0.76).

CONCLUSION

This meta-analysis of 6 cohort studies demonstrates that elective induction of labor at 39 weeks, compared with expectant management beyond that gestational age, was associated with a significantly lower risk of cesarean delivery, maternal peripartum infection, and perinatal adverse outcomes, including respiratory morbidity, intensive care unit admission, and mortality.

Use of labor induction with dinoprostone vaginal suppositories in pregnant women with gestational hypertension

AIM

Gestational hypertension is a common disorder of pregnancy. This study aims to evaluate the effect of labor induction with dinoprostone vaginal suppositories (Propess) on pregnancy outcomes in pregnant women with gestational hypertension.

METHODS

The retrospective study included 375 patients with gestational hypertension. All patients were included into three groups according to the characteristics at admission. Women who had initiated labor spontaneously at admission were enrolled in Spontaneous labor group. According to Bishop score, other patients underwent labor induction with Propess or oxytocin were enrolled in Propess group or Oxytocin group. Demographic information and perinatal outcome data were collected.

RESULTS

The vaginal delivery rate of the women with gestational hypertension was respectively 93.5% (Spontaneous labor group), 77.0% (Propess group), and 52.5% (Oxytocin group) in three groups with significant difference (P < 0.001). The duration of labor was 8.29 ± 3.70 h (Spontaneous labor group), 8.45 ± 5.21 h (Propess group) and 12.37 ± 11.47 h (Oxytocin group) in three groups, respectively. No differences were found in the intrapartum fever (P = 0.588), intrapartum hemorrhage (P = 0.953), intrapartum maximum blood pressure (P = 0.301 and P = 0.535) and post-partum hemorrhage (P = 0.075) among three groups. Neonatal outcomes were similar among three groups (Neonatal hospitalization rate, P = 0.437; 1-min Apgar score, P = 0.304; 5-min Apgar score, P = 0.340; Birth weight, P = 0.089). No poor maternal and neonatal outcomes occurred.

CONCLUSION

Pregnant women with gestational hypertension could have favorable pregnancy outcomes. Using Propess as a mode of labor induction in gestational hypertension is safe and effective, without increasing intrapartum blood pressure and inducing poor pregnancy outcomes.

Delivery or expectant management for prevention of adverse maternal and neonatal outcomes in hypertensive disorders of pregnancy: an individual participant data meta-analysis

OBJECTIVE

Hypertensive disorders affect 3-10% of pregnancies. Delayed delivery carries maternal risks, while early delivery increases fetal risk, so appropriate timing is important. The aim of this study was to compare immediate delivery with expectant management for prevention of adverse maternal and neonatal outcomes in women with hypertensive disease in pregnancy.

METHODS

CENTRAL, PubMed, MEDLINE and ClinicalTrials.gov were searched for randomized controlled trials comparing immediate delivery to expectant management in women presenting with gestational hypertension or pre-eclampsia without severe features from 34 weeks of gestation. The primary neonatal outcome was respiratory distress syndrome (RDS) and the primary maternal outcome was a composite of HELLP syndrome and eclampsia. The PRISMA-IPD guideline was followed and a two-stage meta-analysis approach was used. Relative risks (RR) and numbers needed to treat or harm (NNT/NNH) with 95% CI were calculated to evaluate the effect of the intervention.

RESULTS

Main outcomes were available for 1724 eligible women. Compared with expectant management, immediate delivery reduced the composite risk of HELLP syndrome and eclampsia in all women (0.8% vs 2.8%; RR, 0.33 (95% CI, 0.15-0.73); I2  = 0%; NNT, 51 (95% CI, 31.1-139.3)) as well as in the pre-eclampsia subgroup (1.1% vs 3.5%; RR, 0.39 (95% CI, 0.15-0.98); I2  = 0%). Immediate delivery increased RDS risk (3.4% vs 1.6%; RR, 1.94 (95% CI 1.05-3.6); I2  = 24%; NNH, 58 (95% CI, 31.1-363.1)), but depended upon gestational age. Immediate delivery in the 35th week of gestation increased RDS risk (5.1% vs 0.6%; RR, 5.5 (95% CI, 1.0-29.6); I2  = 0%), but immediate delivery in the 36th week did not (1.5% vs 0.4%; RR, 3.4 (95% CI, 0.4-30.3); I2 not applicable).

CONCLUSION

In women with hypertension in pregnancy, immediate delivery reduces the risk of maternal complications, whilst the effect on the neonate depends on gestational age. Specifically, women with a-priori higher risk of progression to HELLP, such as those already presenting with pre-eclampsia instead of gestational hypertension, were shown to benefit from earlier delivery. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

[To the question of elective induction of labor at 39 weeks of gestation, the answer lies in the question]

The goal of induction of labor is to achieve vaginal delivery when the benefits of expeditious delivery outweigh the risks of continuing the pregnancy. In order to correctly understand the problematic of the elective induction of labor at 39 weeks of gestation (WG), two questions must be raised. (i) What is the perinatal mortality evolution according the gestational age at delivery? All the most recent and methodologically well-conducted studies are convergent: they show that the fetal mortality risk exceeds the perinatal/infant (during the first year of life) mortality risk from 39 WG. The benefit/risk balance related to the expectant management is therefore reversed from 39 WG in favor of the elective induction of labor when the considered issue is the perinatal mortality. (ii) What are the associated risks with elective induction of labor? While some observational studies suggested that the elective induction of labor after 37 WG was associated with an increased risk of cesarean sections, these studies presented a major methodological bias: an error in the control group selection. Indeed, the control group consisted of women in spontaneous labor, whereas the appropriate comparison group must be an expectant management group. Several large cohort studies using a rigorous methodology have shown that elective induction of labor at 39 WG reduces the cesarean section risk compared to an expectant management. Three systematic reviews with meta-analysis of randomized controlled trials comparing induction of labor with expectant management were published: two showed that the cesarean section risk was lowered with the induction of labor compared to an expectant management and the third that the cesarean section rates were similar. Finally, the most recent randomized controlled trial, published in 2016, showed no significant difference between the 2 arms in the cesarean section rate. In all, the most recent literature data, free from comparative bias, show that elective induction of labor at term is associated with a significant reduction in the cesarean section risk and perinatal morbidity and mortality compared to an expectant management.

Pregnant Women&apos;s Labor Progress, Childbirth Outcome, and Childbirth Satisfaction according to the Presence or Absence of Labor Induction

PURPOSE

To provide accurate information on induced labor and find strategies to enhance women's childbirth satisfaction.

METHODS

Participants were pregnant women expected to have normal vaginal delivery. A total of 113 women with induced labor and 61 women with spontaneous labor were surveyed. Data were collected using a questionnaire and electronic medical records.

RESULTS

The following variables related to labor progress showed significant differences between the induced labor group and the spontaneous labor group: length of the first stage of labor in primigravidas, use of analgesic, incidence of uterine hyperstimulation, incidence of fetal distress, and medical treatment for the expectant mother. Delivery type and the incidence of postpartum complications showed significant difference between the two groups. Induced labor women's childbirth satisfaction was mainly affected by the process of labor whereas spontaneous labor women's childbirth satisfaction was affected by the outcome of childbirth.

CONCLUSION

Medical staff should have accurate information on the risk of induced labor and the benefits of a natural delivery. Moreover, medical staff should provide necessary information and environment for women to participate in the decision-making process.

Induction of Labour in Late and Postterm Pregnancies and its Impact on Maternal and Neonatal Outcome

INTRODUCTION

This study aimed to determine the effects of induction of labour in late-term pregnancies on the mode of delivery, maternal and neonatal outcome.

METHODS

We retrospectively analyzed deliveries between 2000 and 2014 at the University Hospital of Cologne. Women with a pregnancy aged between 41 + 0 to 42 + 6 weeks were included. Those who underwent induction of labour were compared with women who were expectantly managed. Maternal and neonatal outcomes were evaluated.

RESULTS

856 patients were included into the study. The rate of cesarean deliveries was significantly higher for the induction of labour group (33.8 vs. 21.1 %, p < 0.001). Aside from the more frequent occurrence of perineal lacerations (induction of labour group vs. expectantly managed group = 38.1 % compared with 26.4 %, p = 0.002) and all types of lacerations (induction of labour group vs. expectantly managed group = 61.5% vs. 52.2 %, p = 0.021) in women with vaginal delivery, there were no significant differences in maternal outcome. Besides, no differences regarding neonatal outcome were observed.

CONCLUSIONS

Our study suggests that induction of labour in late and postterm pregnancies is associated with a significantly higher cesarean section rate. Other maternal and fetal parameters were not influenced by induction of labour.

Caesarean section rates and adverse neonatal outcomes after induction of labour versus expectant management in women with an unripe cervix: a secondary analysis of the HYPITAT and DIGITAT trials

OBJECTIVE

To evaluate caesarean section and adverse neonatal outcome rates after induction of labour or expectant management in women with an unripe cervix at or near term.

DESIGN

Secondary analysis of data from two randomised clinical trials.

SETTING

Data were collected in two nationwide Dutch trials.

POPULATION

Women with hypertensive disease (HYPITAT trial) or suspected fetal growth restriction (DIGITAT trial) and a Bishop score ≤6.

METHODS

Comparison of outcomes after induction of labour and expectant management.

MAIN OUTCOME MEASURES

Rates of caesarean section and adverse neonatal outcome, defined as 5-minute Apgar score ≤6 and/or arterial umbilical cord pH <7.05 and/or neonatal intensive care unit admission and/or seizures and/or perinatal death.

RESULTS

Of 1172 included women with an unripe cervix, 572 had induction of labour and 600 had expectant management. We found no significant difference in the overall caesarean rate (difference -1.1%, 95% CI -5.4 to 3.2). Induction of labour did not increase caesarean rates in women with Bishop scores from 3 to 6 (difference -2.7%, 95% CI -7.6 to 2.2) or adverse neonatal outcome rates (difference -1.5%, 95% CI -4.3 to 1.3). However, there was a significant difference in the rates of arterial umbilical cord pH <7.05 favouring induction (difference -3.2%, 95% CI -5.6 to -0.9). The number needed to treat to prevent one case of umbilical arterial pH <7.05 was 32.

CONCLUSIONS

We found no evidence that induction of labour increases the caesarean rate or compromises neonatal outcome as compared with expectant management. Concerns over increased risk of failed induction in women with a Bishop score from 3 to 6 seem unwarranted.

TWEETABLE ABSTRACT

Induction of labour at low Bishop scores does not increase caesarean section rate or poor neonatal outcome.

Reducing Length of Labor and Cesarean Surgery Rate Using a Peanut Ball for Women Laboring With an Epidural

One strategy for reducing the primary cesarean surgery rate and length of labor is using a peanut-shaped exercise ball for women laboring under epidural analgesia. A randomized, controlled study was conducted to determine whether use of a "peanut ball" decreased length of labor and increased the rate of vaginal birth. Women who used the peanut ball (n = 107) versus those who did not (n = 91) demonstrated shorter first stage labor by 29 min (p = .053) and second stage labor by 11 min (p < .001). The intervention was associated with a significantly lower incidence of cesarean surgery (OR = 0.41, p = .04). The peanut ball is potentially a successful nursing intervention to help progress labor and support vaginal birth for women laboring under epidural analgesia.

Timing of delivery and neonatal outcomes for small-for-gestational-age fetuses

OBJECTIVES

To investigate whether antenatal recognition of small-for-gestational-age (SGA) fetuses with normal maternal and fetal Doppler values delivered after 34 weeks' gestation is associated with changes in the risk of adverse maternal and neonatal outcomes.

METHODS

In this retrospective study, we included 313 singleton SGA fetuses and 313 appropriate-for-gestational-age control fetuses born between 34 and 42 weeks' gestation from 2009 to 2012. Small-for-gestational-age fetuses identified before delivery (n = 124), for whom antenatal surveillance was performed until delivery (estimated fetal weight twice weekly and Doppler evaluation of the fetal compartment once weekly), were compared to those not identified at delivery (n = 189). The latter group did not undergo antenatal surveillance for several reasons (women for whom a sonographic evaluation or gynecologic consultation was not performed in the third trimester and incorrect sonographic biometric evaluation in the third trimester). Main outcome measures were mode of delivery, perinatal complications, and neonatal intensive care unit admission. The risk of serious fetal complications was assessed by cross-tabulation analysis adjusted for gestational age and degree of SGA.

RESULTS

Prenatally recognized SGA fetuses were smaller and delivered earlier than unrecognized SGA fetuses (P< .05). Fetal acidemia (pH <7.10) was significantly more common in unrecognized SGA fetuses (3.7% versus 0%). Small-for-gestational-age fetuses at or below the 3rd percentile were more commonly recognized prenatally and hospitalized in the neonatal intensive care unit. Unrecognized SGA fetuses also had worse fetal outcomes compared to controls (P< .05). Recognized and unrecognized SGA fetuses were born significantly more frequently by cesarean delivery (P < .05). No significant differences in perinatal outcomes were found between recognized SGA deliveries with or without medical induction.

CONCLUSIONS

Antenatal recognition of SGA fetuses delivered after 34 weeks' gestation might improve perinatal outcomes. Medical induction of labor did not modify neonatal outcomes among prenatally recognized SGA fetuses.

Pregnancy outcomes of expectant management of stable mild to moderate chronic hypertension as compared with planned delivery

OBJECTIVE

To compare outcomes between elective delivery at 37 weeks of pregnancy and expectant management among pregnant women with mild to moderate chronic hypertension.

METHODS

In a two-center study, 76 women with mild to moderate chronic hypertension were randomly allocated to planned delivery at 37 completed weeks (group A) or expectant management for spontaneous onset of labor or reaching 41 weeks (group B) between April 2012 and October 2013. Differences were compared by t test, χ(2) test, or Fisher exact test. Odds ratios (ORs) with 95% confidence interval (CIs) were determined.

RESULTS

There were no differences in superimposed pre-eclampsia (SPE), severe hypertension, preterm delivery, placental abruption, oligohydramnios, intrauterine growth restriction, or perinatal mortality between the groups. Group B had higher gestational age at delivery (P=0.001) and birth weight (P=0.01), but lower cesarean (OR 3.4; 95% CI, 1.2-10.3; P=0.03) and neonatal care unit admission (OR 5.4; 95% CI, 1.4-21.0; P=0.01) rates. More women with SPE were diagnosed before than after 37 weeks in group B (P=0.01). Overall, patients who developed SPE had more adverse pregnancy outcomes than those who did not.

CONCLUSION

Mild to moderate chronic hypertension could be managed expectantly up to 41 weeks if SPE did not develop.

Elective induction versus spontaneous labour in Latin America

OBJECTIVE

To assess the frequency of elective induction of labour and its determinants in selected Latin America countries; quantify success in attaining vaginal delivery, and compare rates of caesarean and adverse maternal and perinatal outcomes after elective induction versus spontaneous labour in low-risk pregnancies.

METHODS

Of 37,444 deliveries in women with low-risk pregnancies, 1847 (4.9%) were electively induced. The factors associated with adverse maternal and perinatal outcomes among cases of spontaneous and induced onset of labour were compared. Odds ratios for factors potentially associated with adverse outcomes were calculated, as were the relative risks of having an adverse maternal or perinatal outcome (both with their 95% confidence intervals). Adjustment using multiple logistic regression models followed these analyses.

FINDINGS

Of 11,077 cases of induced labour, 1847 (16.7%) were elective. Elective inductions occurred in 4.9% of women with low-risk pregnancies (37,444). Oxytocin was the most common method used (83% of cases), either alone or combined with another. Of induced deliveries, 88.2% were vaginal. The most common maternal adverse events were: (i) a higher postpartum need for uterotonic drugs, (ii) a nearly threefold risk of admission to the intensive care unit; (iii) a fivefold risk of postpartum hysterectomy, and (iv) an increased need for anaesthesia/analgesia. Perinatal outcomes were satisfactory except for a 22% higher risk of delayed breastfeeding (i.e. initiation between 1 hour and 7 days postpartum).

CONCLUSION

Caution is mandatory when indicating elective labour induction because the increased risk of maternal and perinatal adverse outcomes is not outweighed by clear benefits.

Elective induction compared with expectant management in nulliparous women with an unfavorable cervix

OBJECTIVES

To compare outcomes of labor between nulliparas with an unfavorable cervix who underwent either elective labor induction or expectant management beyond 39 weeks of gestation.

METHODS

We conducted a retrospective cohort study of nulliparous women with a singleton gestation who had an unfavorable cervix (modified Bishop score less than 5) and delivered between 2006 and 2008. One hundred two nulliparous women who underwent elective induction of labor between 39 and 40 5/7 weeks of gestation were compared with 102 nulliparous women who were expectantly managed beyond 39 weeks of gestation.

RESULTS

The primary outcome, cesarean delivery, was not statistically different between women who were expectantly managed and those who underwent elective labor induction (34.3% compared with 43.1%, respectively, P=.16). Aside from the more frequent occurrence of meconium in the expectantly managed group (36.3% compared with 7.0%, P<.001), there were no significant differences in other maternal (eg, chorioamnionitis, operative vaginal delivery, third-degree and fourth-degree lacerations, postpartum hemorrhage) or neonatal (arterial cord pH less than 7.0, Apgar score less than 7 at 5 minutes, neonatal intensive care unit admission) outcomes. Women who underwent an elective induction of labor did have longer duration of labor and delivery between admission and delivery (median 16.5 compared with 12.7 hours, P<.001).

CONCLUSIONS

For nulliparous women with an unfavorable cervix, elective labor induction increased utilization of labor and delivery resources but did not result in other significant differences in most clinical outcomes.

Induction versus expectant monitoring for intrauterine growth restriction at term: randomised equivalence trial (DIGITAT)

OBJECTIVE

To compare the effect of induction of labour with a policy of expectant monitoring for intrauterine growth restriction near term.

DESIGN

Multicentre randomised equivalence trial (the Disproportionate Intrauterine Growth Intervention Trial At Term (DIGITAT)).

SETTING

Eight academic and 44 non-academic hospitals in the Netherlands between November 2004 and November 2008.

PARTICIPANTS

Pregnant women who had a singleton pregnancy beyond 36+0 weeks' gestation with suspected intrauterine growth restriction.

INTERVENTIONS

Induction of labour or expectant monitoring.

MAIN OUTCOME MEASURES

The primary outcome was a composite measure of adverse neonatal outcome, defined as death before hospital discharge, five minute Apgar score of less than 7, umbilical artery pH of less than 7.05, or admission to the intensive care unit. Operative delivery (vaginal instrumental delivery or caesarean section) was a secondary outcome. Analysis was by intention to treat, with confidence intervals calculated for the differences in percentages or means.

RESULTS

321 pregnant women were randomly allocated to induction and 329 to expectant monitoring. Induction group infants were delivered 10 days earlier (mean difference -9.9 days, 95% CI -11.3 to -8.6) and weighed 130 g less (mean difference -130 g, 95% CI -188 g to -71 g) than babies in the expectant monitoring group. A total of 17 (5.3%) infants in the induction group experienced the composite adverse neonatal outcome, compared with 20 (6.1%) in the expectant monitoring group (difference -0.8%, 95% CI -4.3% to 3.2%). Caesarean sections were performed on 45 (14.0%) mothers in the induction group and 45 (13.7%) in the expectant monitoring group (difference 0.3%, 95% CI -5.0% to 5.6%).

CONCLUSIONS

In women with suspected intrauterine growth restriction at term, we found no important differences in adverse outcomes between induction of labour and expectant monitoring. Patients who are keen on non-intervention can safely choose expectant management with intensive maternal and fetal monitoring; however, it is rational to choose induction to prevent possible neonatal morbidity and stillbirth.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial number ISRCTN10363217.

Labour and neonatal outcome in small for gestational age babies delivered beyond 36+0 weeks: a retrospective cohort study

OBJECTIVE

Small for gestational age (SGA) is associated with increased neonatal morbidity and mortality. At present, evidence on whether these pregnancies should be managed expectantly or by induction is lacking. To get insight in current policy we analysed data of the National Dutch Perinatal Registry (PRN).

METHODS

We used data of all nulliparae between 2000 and 2005 with a singleton in cephalic presentation beyond 36+0 weeks, with a birth weight below the 10th percentile. We analysed two groups of pregnancies: (I) with isolated SGA and (II) with both SGA and hypertensive disorders. Onset of labour was related to route of delivery and neonatal outcome.

RESULTS

Induction was associated with a higher risk of emergency caesarean section (CS), without improvement in neonatal outcome. For women with isolated SGA the relative risk of emergency CS after induction was 2.3 (95% Confidence Interval [CI] 2.1 to 2.5) and for women with both SGA and hypertensive disorders the relative risk was 2.7 (95% CI 2.3 to 3.1).

CONCLUSION

Induction in pregnancies complicated by SGA at term is associated with a higher risk of instrumental deliveries without improvement of neonatal outcome. Prospective studies are needed to determine the best strategy in suspected IUGR at term.

Elective induction compared with expectant management in nulliparous women with a favorable cervix

OBJECTIVE

To compare outcomes of labor between nulliparous women with a favorable cervix who underwent either elective labor induction or expectant management beyond 39 weeks of gestation.

METHODS

A retrospective cohort study was conducted of nulliparous women with a singleton gestation who had a favorable cervix (modified Bishop score of at least 5) and delivered between 2006 and 2008. Two hundred ninety-four nulliparous women who underwent elective induction of labor between 39 and 40 5/7 weeks of gestation were compared with 294 nulliparous women who were expectantly managed beyond 39 weeks of gestation.

RESULTS

The primary outcome, cesarean delivery, was similar between the two groups (20.8% compared with 20.1%, respectively, P=.84), a result that did not change in multivariable analysis. There were also no significant differences in other maternal (eg, chorioamnionitis, meconium, operative vaginal delivery, third- and fourth-degree lacerations, postpartum hemorrhage), or neonatal (arterial cord pH less than 7.0, Apgar score less than 4 at 5 minutes, neonatal intensive care unit admission) outcomes. Women who underwent an elective labor induction did have longer duration in labor and delivery between admission and delivery (median 12.7 compared with 9.0 hours, P<.001).

CONCLUSION

For nulliparous women with a favorable cervix, elective labor induction has a similar chance of resulting in cesarean delivery as expectant management, although it appears to result in an increase in resource use.

LEVEL OF EVIDENCE

II.

Is induced labour in the nullipara associated with more maternal and perinatal morbidity?

PURPOSE

To ascertain any differences in foetomaternal outcomes in induced and spontaneous labour among nulliparous women delivering at term.

METHODS

A retrospective matched cohort study consisting of 403 nulliparous women induced at ≥ 292 days and 806 nulliparous women with spontaneous labour at 285-291 days.

RESULTS

Compared to those in spontaneous labour, women who had induction of labour were three times more likely to have a caesarean delivery (OR 3.1, 95% CI 2.4-4.1; P < 0.001). Women who had induction of labour were 2.2 times more likely to have oxytocin augmentation (OR 2.2, 95% CI 1.7-2.8; P < 0.001), 3.6 times more likely to have epidural anaesthesia (OR 3.6, 95% CI 2.8-4.6; P < 0.001), 1.7 times more likely to have uterine hyperstimulation (OR 1.7, 95% CI 1.1-2.6), 2 times more likely to have a suspicious foetal heart rate trace (OR 2.0, 95% CI 1.5-2.6), 4.1 times more likely to have blood loss over 500 ml (OR 4.1, 95% CI 2.9-5.5; P < 0.001), and 2.9 times more likely to stay in hospital beyond 5 days (OR 2.9, 95% CI 1.5-5.6; P < 0.001). Babies born to mothers who had induction of labour were significantly more likely to have an Apgar score of <5 at 5 min and an arterial cord pH of <7.0.

CONCLUSION

Compared to those with spontaneous labour, nulliparous women with induced labours are more likely to have uterine hyperstimulation, caesarean delivery, and babies with low Apgar scores. Nulliparous women should be made aware of this, as well as potential risks of expectant management during counseling.

Práticas obstétricas e resultados maternos e neonatais: análise fatorial de correspondência múltipla em dois centros de parto normal

OBJETIVO: Descrever as práticas obstétricas e os resultados maternos e neonatais de dois Centros de Parto Normal do Município de São Paulo, comparandose as unidades intra e extra-hospitalares. MÉTODOS: Estudo observacional, transversal e retrospectivo com dados secundários provenientes de 192 prontuários das instituições envolvidas. As variáveis de estudo foram as práticas selecionadas para o parto normal: a utilização de ocitocina, o tipo de rompimento das membranas amnióticas, a realização de episiotomia ou perineotomia e o tempo de permanência materna e neonatal. Foi elaborado um instrumento informatizado para coleta de dados com base nas variáveis de estudo. Os dados foram tratados através de análise estatística multivariada. RESULTADOS: O centro de parto normal intra-hospitalar utilizou com maior frequência às intervenções relacionadas à utilização de ocitocina, rompimento artificial de membranas amnióticas e tempo de permanência materna e neonatal superior às 48h, após o parto. O centro de parto normal extra-hospitalar apresentou maior frequência de parturientes com períneo íntegro após o parto, rompimento de membranas de maneira espontânea e tempo de permanência materna e neonatal inferior a 48 horas pós-parto. Os resultados maternos e neonatais não evidenciaram complicações relacionadas às práticas utilizadas. CONCLUSÃO: As práticas obstétricas pouco diferiram, comparando-se os dois tipos de Centros de Parto Normal; ambos seguem as recomendações da Organização Mundial de Saúde e aplicam as intervenções somente nos casos indicados.

Guidelines for the management of postterm pregnancy

A pregnancy reaching 42 completed weeks (294 days) is defined as postterm (PT). The use of ultrasound in early pregnancy for precise dating significantly reduces the number of PT pregnancies compared to dating based on the last menstrual period. Although the fetal, maternal and neonatal risks increase beyond 41 weeks, there is no conclusive evidence that prolongation of pregnancy, per se, is the major risk factor. Other specific risk factors for adverse outcomes have been identified, the most important of which are restricted fetal growth and fetal malformations. In order to prevent PT and associated complications routine induction before 42 weeks has been proposed. There is no conclusive evidence that this policy improves fetal, maternal and neonatal outcomes as compared to expectant management. It is also unclear if the rate of cesarean sections is different between the two management strategies. After careful identification and exclusion of specific risks, it would seem appropriate to let women make an informed decision about which management they wish to undertake. There is consensus that the number of inductions necessary to possibly avoid one stillbirth is very high. If induction is preferred, procedures for cervical ripening should be used, especially in nulliparous women. Close intrapartum fetal surveillance should be offered, irrespective of whether labor was induced or not.

Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial

BACKGROUND

Robust evidence to direct management of pregnant women with mild hypertensive disease at term is scarce. We investigated whether induction of labour in women with a singleton pregnancy complicated by gestational hypertension or mild pre-eclampsia reduces severe maternal morbidity.

METHODS

We undertook a multicentre, parallel, open-label randomised controlled trial in six academic and 32 non-academic hospitals in the Netherlands between October, 2005, and March, 2008. We enrolled patients with a singleton pregnancy at 36-41 weeks' gestation, and who had gestational hypertension or mild pre-eclampsia. Participants were randomly allocated in a 1:1 ratio by block randomisation with a web-based application system to receive either induction of labour or expectant monitoring. Masking of intervention allocation was not possible. The primary outcome was a composite measure of poor maternal outcome--maternal mortality, maternal morbidity (eclampsia, HELLP syndrome, pulmonary oedema, thromboembolic disease, and placental abruption), progression to severe hypertension or proteinuria, and major post-partum haemorrhage (>1000 mL blood loss). Analysis was by intention to treat and treatment effect is presented as relative risk. This study is registered, number ISRCTN08132825.

FINDINGS

756 patients were allocated to receive induction of labour (n=377 patients) or expectant monitoring (n=379). 397 patients refused randomisation but authorised use of their medical records. Of women who were randomised, 117 (31%) allocated to induction of labour developed poor maternal outcome compared with 166 (44%) allocated to expectant monitoring (relative risk 0.71, 95% CI 0.59-0.86, p<0.0001). No cases of maternal or neonatal death or eclampsia were recorded.

INTERPRETATION

Induction of labour is associated with improved maternal outcome and should be advised for women with mild hypertensive disease beyond 37 weeks' gestation.

FUNDING

ZonMw.

Accuracy of serum uric acid as a predictive test for maternal complications in pre-eclampsia: bivariate meta-analysis and decision analysis

The aim of this study is to determine the accuracy and clinical value of serum uric acid in predicting maternal complications in women with pre-eclampsia. An existing meta-analysis on the subject was updated. The accuracy of serum uric acid for the prediction of maternal complications was assessed with a bivariate model estimating a summary Receiver Operating Characteristic (sROC) curve. Subsequently, a clinical decision analysis was performed, in which three alternative strategies were modelled: (I) expectant management with monitoring until spontaneous labour; (II) induction of labour; (III) serum uric acid as test for predicting maternal complications. In the latter strategy, accuracy data of serum uric acid derived from the sROC curve were used to assess the value of serum uric acid in the management of women with pre-eclampsia. In this strategy, women with an increased serum uric acid were supposed to have labour induced, whereas women with serum uric acid levels below the threshold were managed expectantly. The decision whether to use the policy expectant management, to induce labour or to test serum uric acid levels, is based on the expected utility of each strategy. The expected utility depends on the probability of occurrence of severe maternal complications (i.e. severe hypertension, haemolysis, elevated liver enzymes and low platelet count (HELLP syndrome) or eclampsia) and the mode of delivery (caesarean section versus vaginal delivery). Valuation of the outcomes was performed using a distress ratio, which expresses how much worse a complication of pre-eclampsia is valued as compared to a caesarean section. Eight studies, testing 1565 women with pre-eclampsia, met the inclusion criteria. If the distress ratio was 10, the strategy regarding serum uric acid would be the preferred strategy when the probability of complications was between 2.9 and 6.3%. At higher complication rates induction of labour would be preferred, whereas at lower complication rates expectant management would be the best treatment option. These findings were stable in sensitivity analyses, using different distress ratios. Based on the decision analysis, serum uric acid seems to be a useful test in the management of pre-eclampsia under realistic assumptions.

Induction of labour versus expectant monitoring in women with pregnancy induced hypertension or mild preeclampsia at term: the HYPITAT trial

BACKGROUND

Hypertensive disorders, i.e. pregnancy induced hypertension and preeclampsia, complicate 10 to 15% of all pregnancies at term and are a major cause of maternal and perinatal morbidity and mortality. The only causal treatment is delivery. In case of preterm pregnancies conservative management is advocated if the risks for mother and child remain acceptable. In contrast, there is no consensus on how to manage mild hypertensive disease in pregnancies at term. Induction of labour might prevent maternal and neonatal complications at the expense of increased instrumental vaginal delivery rates and caesarean section rates.

METHODS/DESIGN

Women with a pregnancy complicated by pregnancy induced hypertension or mild preeclampsia at a gestational age between 36+0 and 41+0 weeks will be asked to participate in a multi-centre randomised controlled trial. Women will be randomised to either induction of labour or expectant management for spontaneous delivery. The primary outcome of this study is severe maternal morbidity, which can be complicated by maternal mortality in rare cases. Secondary outcome measures are neonatal mortality and morbidity, caesarean and vaginal instrumental delivery rates, maternal quality of life and costs. Analysis will be by intention to treat. In total, 720 pregnant women have to be randomised to show a reduction in severe maternal complications of hypertensive disease from 12 to 6%.

DISCUSSION

This trial will provide evidence as to whether or not induction of labour in women with pregnancy induced hypertension or mild preeclampsia (nearly) at term is an effective treatment to prevent severe maternal complications.

TRIAL REGISTRATION

The protocol is registered in the clinical trial register number ISRCTN08132825.

Elective Induction: When? Ever?

The frequency of labor induction has increased significantly in recent years. Although medically indicated inductions comprise a portion of this increase, elective inductions have increased in frequency as well. Given that elective inductions, by definition, provide no benefit from a strictly medical standpoint, it is particularly important to evaluate whether women who undergo these inductions incur greater risks than those who labor spontaneously. This article will assess whether elective inductions are associated with changes in pregnancy outcomes, and evaluate how these associations are influenced by parity and cervical ripeness.

Obstetric management of the next pregnancy after an unexplained stillbirth: An anonymous postal survey of Australian obstetricians

BACKGROUND

Women who have an unexplained stillbirth are more likely to be delivered early, by induced labour or Caesarean section, in their next pregnancy. It is unclear whether these birth outcomes result from characteristics of the next pregnancy, or represent management strategies of obstetricians.

AIM

To investigate obstetricians' management strategies in the next pregnancy after an unexplained stillbirth.

METHODS

Anonymous postal survey of Australian obstetricians. Respondents were given a clinical scenario regarding a previous unexplained stillbirth and were asked about management.

RESULTS

The response rate was 69%. Tests of 'fetal well-being' were undertaken by the majority of respondents. Additional third trimester ultrasound surveillance was recommended by 87% of respondents, regular cardiotograph monitoring by 72% and formal fetal movement charting by 39%. Elective induction of labour (in the absence of any other obstetric indication) was recommended by 93% of respondents, and elective Caesarean delivery by 35%.

CONCLUSIONS

The tendency for subsequent pregnancies after an unexplained stillbirth to be delivered earlier, and more often by Caesarean section, may be due in part to altered management strategies, not solely as a result of complications of the pregnancy itself.

Intrauterine growth restriction at term: Induction or spontaneous labour?

OBJECTIVE

To test the hypothesis that in pregnancies with a clinically suspected growth restricted foetus at term, induction of labour is as safe as expectant management, and does not lead to increased obstetrical interventions or perinatal morbidity.

STUDY DESIGN

In one obstetric centre, 33 women with a clinically suspected growth restricted foetus at term were randomly allocated after stratification for parity to either induction or to expectant management. Obstetric and neonatal outcome variables were compared.

RESULTS

There was a lower gestational age at labour (median 38(0) weeks versus 40(1) weeks) with a corresponding tendency to lower birth weight (mean 2428 g versus 2651 g), and a reduced need for ante partum medical surveillance, in the induction group. No significant differences in obstetrical interventions (25% versus 24%) and neonatal morbidity rates (50% versus 35%) were found.

CONCLUSION

A larger multicenter study with a sufficient power and long-term follow-up to decide the best policy for the term growth restricted foetus is feasible.

Analgesia and Anesthesia in Labor

Whether given as an epidural, spinal, or combination, regional anesthesia is an integral part of obstetrics in the United States. A variety of drugs and dosages are used in various combinations, with no one protocol exceeding others in terms of efficacy and safety. The availability of anesthesia and analgesia has had an extraordinary impact on the field of obstetrics in the twentieth century. Knowledge of the techniques and medications used, their potential toxicities, and effects on the labor process itself can only enhance obstetricians' management of the parturient in labor.

Obstetric "conveniences": elective induction of labor, cesarean birth on demand, and other potentially unnecessary interventions

Common obstetric interventions are often for "convenience" rather than for clinical indications. Before proceeding, it should be clear who is the beneficiary of the convenience. The primary healthcare provider must make sure that women and their partners have a full understanding of what is known about the associated risks, benefits, and alternative approaches of the proposed intervention. Thorough and accurate information allows women to choose what is best for them and their infant on the basis of the individual clinical situation. Ideally, this discussion takes place during the prenatal period when there is ample opportunity to ask questions, reflect on the potential implications, and confer with partners and family members. A review of common obstetric interventions is provided. While these interventions often are medically indicated for the well-being of mothers and infants, the evidence supporting their benefits when used electively is controversial.

Bishop Score and Risk of Cesarean Delivery After Induction of Labor in Nulliparous Women

OBJECTIVE

To quantify the risk and risk factors for cesarean delivery associated with medical and elective induction of labor in nulliparous women.

METHODS

A prospective cohort study was performed in nulliparous women at term with vertex singleton gestations who had labor induced at 2 obstetrical centers. Medical and elective indications and Bishop scores were recorded before labor induction. Obstetric and neonatal data were analyzed and compared with the results in women with a spontaneous onset of labor. Data were analyzed using univariate and multivariable regression modeling.

RESULTS

A total of 1,389 women were included in the study. The cesarean delivery rate was 12.0% in women with a spontaneous onset of labor (n = 765), 23.4% in women undergoing labor induction for medical reasons (n = 435) (unadjusted odds ratio [OR] 2.24; 95% confidence interval [CI] 1.64-3.06), and 23.8% in women whose labor was electively induced (n = 189) (unadjusted OR 2.29; 95% CI 1.53-3.41). However, after adjusting for the Bishop score at admission, no significant differences in cesarean delivery rates were found among the 3 groups. A Bishop score of 5 or less was a predominant risk factor for a cesarean delivery in all 3 groups (adjusted OR 2.32; 95% CI 1.66-3.25). Other variables with significantly increased risk for cesarean delivery included maternal age of 30 years or older, body mass index of 31 or higher, use of epidural analgesia during the first stage of labor, and birth weight of 3,500 g or higher. In both induction groups, more newborns required neonatal care, more mothers needed a blood transfusion, and the maternal hospital stay was longer.

CONCLUSION

Compared with spontaneous onset of labor, medical and elective induction of labor in nulliparous women at term with a single fetus in cephalic presentation is associated with an increased risk of cesarean delivery, predominantly related to an unfavorable Bishop score at admission.

LEVEL OF EVIDENCE

II-2.