Risk factors for cesarean delivery after induction of labor in nulliparous women with an unfavorable cervix at or beyond 41 weeks of gestation

Two different regimens of outpatient Foley catheter induction of labor in nulliparas: A randomized trial

OBJECTIVES

To evaluate expectant compared to immediate return to hospital upon outpatient Foley catheter expulsion predicated on maternal satisfaction and amniotomy-titrated oxytocin infusion to delivery interval.

METHODS

This randomized trial was conducted in a tertiary university hospital in Malaysia from September 2020 to February 2022. A total of 330 nulliparous women at term with unripe cervices (Bishop score ≤5), singleton viable fetus in cephalic presentation, reassuring preinduction fetal heart rate tracing and intact membranes who underwent planned outpatient Foley catheter induction of labor (IOL) were included. Women were randomized to expectant or immediate return to hospital if the Foley was spontaneously expelled at home before their scheduled hospital admission the following day. Primary outcomes were amniotomy-titrated oxytocin infusion to delivery interval and maternal satisfaction on the induction process (assessed by 0-10 visual numerical rating scale [VNRS]).

RESULTS

Amniotomy-titrated oxytocin infusion to delivery interval was 8.7 ± 4.1 versus 8.9 ± 3.9 h, P = 0.605 (mean difference - 0.228 95% CI: -1.1 to +0.6 h) and maternal satisfaction VNRS score was median (interquartile range) 8 (7-9) versus 8 (7-9), P = 0.782. Early return to hospital rates were 37/165 (22.4%) versus 72/165 (43.6%), RR 0.51 (95% CI: 0.37-0.72), P ≤ 0.001, Cesarean delivery rates were 80/165 (48.5%) versus 80/165 (48.5%), RR 1.00 (95% CI: 0.80-1.25), P = 1.00 and duration of hospital stay was 54.4 ± 22.9 versus 56.7 ± 22.8 h, P = 0.364 for the expectant versus immediate return groups respectively.

CONCLUSION

In outpatient Foley catheter IOL, expectant compared to immediate return to hospital following Foley dislodgement results in similarly high maternal satisfaction. The amniotomy-titrated oxytocin to delivery duration is non-inferior with expectant management.

Effectiveness of Dinoprostone and Cook's Balloon for Labor Induction in Primipara Women at Term

Labor induction is commonly used for achieving successful vaginal delivery. This study aimed to compare the effectiveness of dinoprostone and Cook's balloon as labor-inducing agents in primipara women at term. A retrospective cohort study among primipara women was conducted in Hubei Maternity and Child Health Hospital. Basic clinical characteristics were collected. The main outcomes were vaginal delivery rate, cesarean section rate and forceps delivery rate. Obstetric and perinatal outcomes were also compared. Univariate and multivariate analyses were further performed to evaluate the predictors for vaginal delivery within 24 h. A total of 845 eligible primipara women undergoing labor induction were recruited. Of them, 141 women were induced with dinoprostone (dinoprostone group, DG), and 704 with Cook's balloon (Cook's balloon group, CG). Groups were homogeneous except more women with premature rupture of membranes in DG, with gestational hypertension in CG (P<0.05). The vaginal delivery rate within 12 h was 1.98% and 16.52% in CG and DG respectively (P=0.0001). Besides, the vaginal delivery rate within 24 h was 37.62% and 52.26% in CG and DG respectively (P=0.0079). DG showed the lower rate of oxytocin augmentation, artificial rupture of membrane and postpartum hemorrhage and the shorter interval from insertion to active labor than CG (P<0.05). Multivariate regression analysis revealed that abortion history, oxytocin augmentation, artificial rupture of membrane, and obstetric analgesia were independent predictors for vaginal delivery within 24 h. In conclusion, dinoprostone was more effective than Cook's balloon to induce labor and achieve vaginal birth in the sample of primipara women at term.

Predictors of response after a second attempt of pharmacological labor induction: a retrospective study

PURPOSE

The aim of our study was to assess the outcomes of a prolonged induction carried out with a second sequential cycle of pharmacological stimulation after unsatisfactory response to a first attempt, and to highlight variables correlated with higher response rates.

METHODS

A retrospective study was carried out on 157 women who underwent a two-step labor induction by vaginal prostaglandins followed by a second cycle of prostaglandins or intravenous oxytocin. Outcomes assessed were mode of delivery and maternal and neonatal morbidity. Main variables of pregnancy and delivery were collected to identify factors predicting the mode of delivery.

RESULTS

Among 157 patients, 63 (40.1%) achieved a vaginal delivery, whereas 94 (59.9%) underwent Cesarean section, 9 women (5.7%) had postpartum hemorrhage; in 2 cases (1.3%), an Apgar score < 7 at 5 min from birth was reported. Higher risk of Cesarean section was observed with advanced maternal age (OR 1.13 for additional year, CI 1.04-1.22) and nulliparity (OR 8.84, CI 2.69-29.06), whereas the response rates were better in carriers of group B streptococcus colonization (OR 0.38, CI 0.17-0.84) and in women with favorable cervical status after the first stimulation (OR 0.81 for additional point of Bishop score, CI 0.70-0.94).

CONCLUSION

Labor induction with two cycles of pharmacological stimulation is a procedure with fairly good success rates and a low risk of maternal and neonatal complications. Factors predicting its success encompass younger age, parity, a positive recto-vaginal swab for group B streptococcus and a favorable cervix following the first cycle of stimulation.

Advanced cervical dilatation as a predictor for low emergency cesarean delivery: a comparison between migrant and non-migrant Primiparae - secondary analysis in Berlin, Germany

Background

Cesarean rates are higher in women admitted to labor ward during early stages rather than at later stages of labor. In a study in Germany, crude cesarean rates among Turkish and Lebanese immigrant women were low compared to non-immigrant women. We evaluated whether these immigrant women were admitted during later stages of labor, and if so, whether this explains their lower cesarean rates.

Methods

We enrolled 1413 nulliparous women with vertex pregnancies, singleton birth, and 37+ week of gestation, excluding elective cesarean deliveries, in three Berlin obstetric hospitals. We applied binary logistic regression to adjust for social and obstetric factors; and standardized coefficients to rank predictors derived from the regression model.

Results

At the time of admission to labor ward, a smaller proportion of Turkish migrant women was in the active phase of labor (cervical dilation: 4+ cm), compared to women of Lebanese origin and non-immigrant women. Rates of cesarean deliveries were lower in women of Turkish and Lebanese origin (15.8 and 13.9%) than in non-immigrant women (23.9%). In the logistic regression analysis, more advanced cervical dilatation was inversely associated with the outcome cesarean delivery (OR: 0.76, 95%CI: 0.70–0.82). In addition, higher maternal age (OR: 1.06, 95%CI: 1.04–1.09), application of oxytocic agents (OR: 0.55, 95%CI: 0.42–0.72), and obesity (OR: 2.25, 95%CI: 1.51–3.34) were associated with the outcome. Ranking of predictors indicate that cervical dilatation is the most relevant predictor derived from the regression model.

Conclusions

Advanced cervical dilatation at the time of admission to labor ward does not explain lower emergency cesarean delivery rates in Turkish and Lebanese migrant women, despite the fact that this is the strongest among the predictors for emergency cesarean delivery identified in this study.

Perinatal outcomes following labor induction with dinoprostone in pregnancies with borderline amniotic fluid index at term: A clinical observation study

AIM

To compare perinatal outcomes of dinoprostone for induced labor in pregnancies with a borderline versus normal amniotic fluid index (AFI) at term, and to investigate the related factors affecting outcomes of cesarean section.

METHODS

The retrospective study was carried out in Hubei Maternal and Child Health Hospital with singleton pregnancies of 37-42 weeks' gestation from January to August 2016. A total of 992 subjects were divided into two groups: borderline AFI group (n =125) with 5 < AFI ≤ 8 and normal AFI group (n = 867) with 8 < AFI ≤ 24.

RESULTS

Time to delivery (P =0.004) and use of oxytocin augmentation (P = 0.011) were significantly lower in pregnancies with borderline AFI. There were no significant differences between the two groups in terms of delivery mode, time to onset of labor, fetal distress, Apgar scores, meconium-stained amniotic fluid, birth weight, or incidences of admission to neonatal intensive care unit (NICU). Gestational hypertension and birth weight were the major factors affecting outcomes of cesarean section in the borderline group (odds ratio [OR] = 13.61, 95% confidence interval [CI] 1.96-94.49, P =0.008 and OR = 1.003, 95% CI 1.001-1.005, P =0.001, respectively). Maternal age (OR = 1.12, 95% CI 1.06-1.19, P < 0.001), parity (OR = 7.57, 95% CI 3.05-18.76, P < 0.001), biparietal diameter (OR = 0.55, 95% CI 0.33-0.91, P = 0.021), and meconium-stained amniotic fluid (OR = 1.56, 95% CI 1.12-2.17, P = 0.009) were related factors in the normal group.

CONCLUSION

The perinatal outcomes of dinoprostone for induced labor are comparable between the two groups. Gestational hypertension and birth weight are factors related to outcomes of cesarean section in the borderline group.

Risk of cesarean section after induced versus spontaneous labor at term gestation

Objective

To investigate whether the cesarean section (CS) rate is increased in women whose labor was induced compared to those who had spontaneous labor at term pregnancy.

Methods

A retrospective study was performed in women whose labor was either induced (induction group, n=497) or spontaneous (spontaneous group, n=878) at 37+0 to 41+6 weeks of gestation from January 2008 to June 2009. Maternal age, parity, body mass index (BMI), Bishop scores, gestational age, hypertension, diabetes, delivery mode, indications for CS, neonatal outcome were compared between the two groups. Multiple logistic regression analysis was used to examine the association between the CS rate and labor induction after adjusting for potential confounding variables.

Results

CS (17.3% vs. 5.3%, P<0.001) and vacuum-assisted delivery (10.7% vs. 6.4%, P<0.001) rates were significantly higher in the induction group compared to the spontaneous group. The CS rate in the induction group was higher than the spontaneous group not only in nulliparous women (25.3% vs. 8.6%, P<0.001), but also in multiparous women (3.8% vs. 0.3%, P=0.002). However, after adjusting confounding factors, the higher CS rate was significantly associated with advanced maternal age, higher BMI, lower Bishop scores and nulliparity, with no demonstrable tie to labor induction. Neonatal outcome in the two groups were comparable.

Conclusion

Although CS rate was higher in women whose labor was induced than those who had spontaneous labor, this higher rate was associated with maternal age, BMI, Bishop scores and parity, but was not impacted by labor induction per se.

Evaluation of bone density measurement in type 2 diabetic postmenopausal women with hypertension and hyperlipidemia

Objectives

The aim of the study was to compare bone mineral density (BMD) in healthy postmenopausal women to BMD in type 2 diabetic hypertensive postmenopausal women with hyperlipidemia.

Methods

Fifty type 2 diabetic and hypertensive postmenopausal women with hyperlipidemia and 51 age and body mass index (BMI) matched healthy postmenopausal women were included. Lumbar spine and femoral neck BMD were noted in both groups. BMD was measured using dual energy X-ray absorptiometry (DXA). Serum alkaline phosphatase (ALP), calcium and phosphorous were also measured. Pearson correlation coefficients were used to establish the relationship between various clinical characteristics.

Results

There were no significant differences between two groups in respect to lumbar and vertebral BMD values, age, BMI, gravidity, parity. Serum cholesterol and fasting glucose levels were significantly different between each groups (P = 0.0001, P = 0.002).

Conclusion

We found that, accompanying chronic diseases such as diabetes, hypertension and hyperlipidemia don't affect the BMD measurements at postmenopausal period. So these postmenopausal women don't have excess risk regarding osteoporosis.

Clinical value of maternal bile Acid quantification in intrahepatic cholestasis of pregnancy as an adverse perinatal outcome predictor

AIMS

To evaluate the correlation between perinatal outcome and bile acid levels in intrahepatic cholestasis of pregnancy (ICP), and to evaluate variations in the mean bile acid level when stratifying by maternal and perinatal factors. A comparison between mild and severe ICP was made.

METHODS

A prospective observational study was performed in pregnant patients who underwent blood tests for bile acids due to persistent pruritus. Based on bile acid levels, maternal and neonatal data were obtained and were compared between patients presenting with ICP and gestational pruritus (normal bile acid level).

RESULTS

A total of 145 patients were included, 47 of whom were diagnosed as ICP (52 newborns) and 98 as gestational pruritus (102 newborns). The ICP group had a higher rate of NICU admission (14/42 vs. 6/98, p < 0.001) and global neonatal morbidity (13/42 vs. 9/98, p = 0.002), but these differences were no longer seen after adjusting for gestational age, singleton pregnancies and induction of labour. Patients presenting with severe ICP (maximum bile acids levels above 40 µmol/l) showed a higher rate of meconium-stained amniotic fluid (0/28 vs. 4/14, p = 0.009), NICU admission (9/34 vs. 11/17, p = 0.01) and neonatal global morbidity (5/32 vs. 8/17, p = 0.02).

CONCLUSIONS

ICP patients have higher rates of adverse neonatal outcomes when compared to those with gestational pruritus. Some of this neonatal morbidity may be secondary to late spontaneous preterm deliveries, multiple gestation and a policy of elective induction of labour after 37 weeks of gestation. A comparison of outcomes among patients with mild and severe ICP shows that the severely affected group has higher rates of meconium-stained amniotic fluid and neonatal morbidity.

Effect of music on labor pain relief, anxiety level and postpartum analgesic requirement: a randomized controlled clinical trial

BACKGROUND/AIMS

The control of labor pain and the prevention of suffering are major concerns of clinicians and their patients. The aim of this study was to evaluate the effect of music on labor pain and anxiety, maternal hemodynamics, fetal-neonatal parameters and postpartum analgesic requirement in primiparous women.

METHODS

Overall, 156 primiparous women who expected vaginal delivery were recruited and randomly assigned to a music group (n = 77) or a control group (n = 79). Women in the music group listened to music during labor. Pain intensity and anxiety level were measured using a visual analogue scale (0-10 cm). The two groups were compared in terms of pain severity, anxiety level, maternal hemodynamics, fetal-neonatal parameters and postpartum analgesic requirement.

RESULTS

Mothers in the music therapy group had a lower level of pain and anxiety compared with those in the control group at all stages of labor (p < 0.001). A significant difference was observed between the two groups in terms of maternal hemodynamics and fetal heart rate after intervention (p < 0.01). Postpartum analgesic requirement significantly decreased in the music therapy group (p < 0.01).

CONCLUSION

Listening to music during labor has a positive impact on labor pain and anxiety, maternal-fetal parameters and analgesic requirement.

Vaginal misoprostol versus a rectal nonsteroidal anti-inflammatory drug to reduce pain during Pipelle endometrial biopsies: a prospective, randomized, placebo-controlled trial

BACKGROUND

To evaluate and compare the efficacy of vaginal misoprostol and a rectal nonsteroidal anti-inflammatory drug (NSAID) on pain relief during Pipelle endometrial biopsies in a placebo-controlled randomized study.

METHODS

One hundred and fifty-one women who had an indication for a Pipelle endometrial biopsy were randomized into three groups as follows: group 1, vaginal misoprostol; group 2, rectal NSAID, and group 3, control. After the procedure, the women were asked to record their pain severity on a visual analog scale. The secondary outcome of the study was patient acceptability, and vasovagal symptoms and analgesic requirements after the procedure were also recorded.

RESULTS

There were no statistically significant differences in the demographic characteristics of the patients. The primary study outcome was the comparison of the median visual analog scale pain scores of groups 1 and 2 versus group 3 (controls); no statistically significant differences were found (p = 0.502). In addition, the patient acceptability (Likert scale), vasovagal symptoms and analgesic requirements after the procedure were similar among the groups (p = 0.204, 1 and 0.546, respectively).

CONCLUSION

Our study did not demonstrate a reduction in pain relief during Pipelle endometrial biopsies for patients receiving vaginal misoprostol or a rectal NSAID when compared to patients receiving placebo treatment.