Induction of labor: Comparison of a cohort with uterine scar from previous cesarean section vs. a cohort with intact uterus

OBJECTIVE

To compare the risk of uterine rupture between a cohort of women with previous low-transverse cesarean section (CS) and a cohort with intact uterus.

METHODS

All women with a singleton pregnancy and previous low-transverse CS requiring induction of labor from January 1, 1992 to December 30, 2001 (n = 310) were compared with a cohort of women with intact uterus undergoing induction of labor during the same study period (n = 5420). Protocols of induction using prostaglandin E2 gel and oxytocin infusion were consistent within groups, but differed between the previous CS and the intact uterus group.

RESULTS

Uterine rupture occurred in 0.3% in the previous CS group vs. 0.03% in the intact uterus group (p = 0.37). Logistic regression analysis showed no significant difference in rate of uterine rupture between the previous CS vs. intact uterus group (p = 0.16) after controlling for maternal age, parity, gestational age at delivery, Bishop score on admission, use of prostaglandin and oxytocin, and birth weight. Our study had adequate power to detect a 0.38% difference in rate of uterine rupture between the two groups (alpha = 0.05, beta = 0.80).

CONCLUSION

Induction of labor is not associated with significantly higher rates of uterine rupture among women with previous low-transverse CS compared with women with intact uterus provided a consistent protocol with strict intervention criteria is adopted.

Clinical research in traditional medicine: priorities and methods

This paper explores the challenges and opportunities associated with the evaluation of treatments arising from traditional medical systems (TMS). Globalization and popular consumer-and industry-driven market forces contribute to the spread of traditional treatments, techniques and technologies, but do not necessarily ensure their usefulness or safety. The international scientific community is obliged to evaluate the safety and efficacy of these treatments because of their potential impact on global public health. Clinical evaluations of traditional treatments, however, have complex methodological and practical challenges, depending on the goals of the research and the audience for the results (country of origin; or new host countries and new patient populations). To address these challenges, the authors offer the following recommendations to identify and prioritize treatments to study and how to design study protocols. Evaluations of traditional treatments are best addressed first by collaborative, international, pragmatic studies. Protocols for observational, prospective, pragmatic pilot study (randomized and controlled, when feasible) should be designed collaboratively and executed simultaneously in the culture of origin and in new contexts. This, in turn, could determine the acceptability, usefulness and feasibility of larger randomized controlled trials (RCTs). International multicentre RCTs would have the potential benefits of evaluating safety and effectiveness and also assessing the transferability of a traditional treatment across social and cultural contexts.

A randomised controlled trial of moxibustion for breech presentation

OBJECTIVES

To evaluate the efficacy of moxibustion for the correction of fetal breech presentation in a non-Chinese population.

DESIGN

Single-blind randomised controlled trial (RCT).

SETTING

Six obstetric departments in Italy.

SAMPLE

Healthy non-Chinese nulliparous pregnant women at 32-33 weeks + 3 days of gestational age with the fetus in breech presentation.

METHODS

Random assignment to treatment or observation. Treatment consisted of moxibustion (stimulation with heat from a stick of Artemisia vulgaris) at the BL 67 acupuncture point (Zhiyin) for one or two weeks. Two weeks after recruitment, each participant was subjected to an ultrasonic examination of the fetal presentation.

MAIN OUTCOME MEASURE

Number of participants with cephalic presentation in the 35th week.

RESULTS

The study was interrupted when 123 participants had been recruited (46% of the planned sample). Intermediate data monitoring revealed a high number of treatment interruptions. At this point no difference was found in cephalic presentation in the 35th week (treatment group: 22/65, 34%; control group: 21/58, 36%; RR 0.95; 99% CI 0.59-1.5).

CONCLUSIONS

The results underline the methodological problems evaluating of a traditional treatment transferred from a different cultural context. They do not support either the effectiveness or the ineffectiveness of moxibustion in correcting fetal breech presentation.

Vitamin K acupuncture pint injection for severe primary dysmenorrhea: an international pilot study

CONTEXT

Vitamin K acupuncture point injection, a menstrual pain treatment derived from traditional Chinese medicine, has been a standard treatment in some hospitals in China since the 1980s.

OBJECTIVES

To investigate the effects of vitamin K acupuncture point injection on menstrual pain in young women aged 14 to 25 from different countries and cultural backgrounds who have had unmitigated severe primary dysmenorrhea for 6 months or more.

DESIGN

Prospective, observational, clinical pilot study

SETTINGS

One site in China (a hospital outpatient clinic in Shanghai) and 2 sites in Italy (a hospital clinic in Milan and a private gynecology practice in Verona).

INTERVENTIONS

All subjects were treated with bilateral acupuncture point injection of vitamin K on the first or second day of menstrual pain. Vitamin K3 was used in China and vitamin K4 in Italy.

MAIN OUTCOME MEASURES

Pain intensity, total duration, and average intensity of menstrual distress, hours in bed, normal daily activity restrictions, and numbers of analgesic tablets taken to relieve pain were recorded before the treatment and for 4 subsequent menstrual cycles.

RESULTS

Noticeable pain relief was observed 2 minutes after treatment, and subsequent pain reduction occurred at 30 minutes (P < .001). Subjects reported significantly fewer daily life restrictions, fewer hours in bed, less consumption of analgesic tablets, and lower scores of menstrual pain duration and intensity (P < .001). There were no adverse events. Some women experienced mild, self-limited pain at the injection site.

CONCLUSION

Acupuncture point injection with vitamin K alleviated acute menstrual pain, and relief extended through the nontreatment follow-up cycles in this uncontrolled pilot study conducted in 2 countries. Further investigation employing controlled experimental designs is warranted.

Prognostic Value of Change in Amniotic Fluid Color during Labor

OBJECTIVE

Evidence of meconium-stained amniotic fluid (AF) during labor suggests implementation of close monitoring of fetal well-being. We have investigated whether the presence of meconium in the AF on admission for labor is as important a predictor of neonatal outcome as a change in AF color during labor.

METHODS

AF characteristics on admission for labor at term (37-42 weeks) and their changes during labor were recorded in all singleton pregnancies during an 8-year period (1992-1999). Excluded were stillbirths on admission, congenital anomalies, and elective cesarean sections. The presence of meconium and its consistency (light or thick) were documented on admission by inspection with transcervical amnioscopy in women with intact membranes or in the vaginal pool in those with ruptured membranes. Changes in AF color or consistency during labor were recorded and correlated with the obstetric and neonatal outcome. Statistical analysis utilized chi(2) for trend, with p < 0.05 considered significant.

RESULTS

19,090 women were admitted in labor at term during the study period and fulfilled the study inclusion criteria and had amniotic fluid evaluation available. The appearance of meconium or worsening in thickness of meconium during labor was associated with higher rates of Apgar scores <7 at 5 min (clear AF on admission and at delivery 0.6%; light or thick meconium on admission and no change at delivery 0.8%; clear AF on admission and light or thick meconium at delivery 3.2%, and light meconium on admission and thick meconium at delivery 2.5%; p < 0.001) and umbilical artery pH <7.10 (the respective rates in the four groups were 1.7, 1.8, 3.6, and 3.8%; p < 0.001).

CONCLUSION

The appearance or thickening of meconium during labor has a greater predictive ability for depressed neonates than the presence of meconium on admission.

Risks of induction of labour in women with a uterine scar from previous low transverse caesarean section

OBJECTIVE

Recent studies have shown that among women with uterine scars from previous caesarean section of any type, induction of labour is associated with increased risk of uterine rupture compared with spontaneous labour. We have assessed the risk of uterine rupture in a cohort of women with a previous low transverse caesarean section in whom induction and management of labour were performed according to a strict protocol.

DESIGN

Cohort study.

SETTING

University Hospital.

POPULATION

All women with a singleton pregnancy and a previous low transverse caesarean section requiring induction of labour from 1/1/1992 to 12/30/2001 (n = 310) were compared with a control cohort during the same study period constituted of women with a previous low transverse caesarean section in spontaneous labour (n = 1011).

METHODS

Clinical characteristics and rate of uterine rupture of women with previous caesarean section undergoing induction of labour were compared with those of women with previous caesarean section in spontaneous labour.

MAIN OUTCOME MEASURE

Incidence of uterine rupture.

RESULTS

Uterine rupture occurred in 0.3% in the previous caesarean section--induction group versus 0.3% in the previous caesarean section--spontaneous labour group (P = 0.9). Logistic regression analysis showed no significant difference in the rate of uterine rupture between the induction and spontaneous labour group (P = 0.67) after controlling for maternal age, parity, duration of labour, gestational age at delivery and birthweight.

CONCLUSION

Among women with a previous low transverse caesarean section, induction of labour is not associated with significantly higher rates of uterine rupture compared with spontaneous labour, provided a consistent protocol with strict criteria for intervention is adopted.

Routine use of external cephalic version in three hospitals

BACKGROUND

External cephalic version has been advocated as a safe alternative to vaginal breech delivery or cesarean birth. The purpose of this study was to determine the efficacy of routine use of external cephalic version at 36 weeks or more of gestation in three different levels of hospitals.

METHODS

External cephalic version was performed on 923 women with a single breech fetus at three hospitals in Italy. The procedure was attempted with a tocolytic agent for uterine relaxation and with no maternal analgesia. The version technique adopted was the "forward roll."

RESULTS

Version was successfully performed on 579 fetuses (62.7%); each hospital had a similar success rate, and 56.9 percent of the women delivered vaginally. The procedure was more successful in multiparas and in women with an incomplete type of breech, polyhydramnios, and posterior localization of the placenta. Vaginal bleeding was experienced by 14 women; eight cesarean sections were performed for suspected abruptio placentae, confirmed in four cases. Two cephalic-turned fetuses experienced an episode of persistent bradycardia and were turned again to breech; in five cases a nonstress test recorded after the version showed repeated variable decelerations and in one case a cesarean section was performed. Neonatal outcomes were good in 922 infants. A fracture of the femur attributable to the version was observed in one newborn.

CONCLUSIONS

External cephalic version is effective in reducing the number of cesarean deliveries in term breech infants in different obstetric settings, with no major neonatal adverse outcomes.

Cervical priming and labor induction by multiple doses of intracervical prostaglandin E2 gel

One hundred seventy-two term pregnant women with medical or obstetric conditions requiring induction of labor were treated with intracervical administration of 0.5 mg prostaglandin E2 in tylose gel. Multiple administrations were necessary in 42 cases (24.4%), two administrations in 31 cases (18.0%) and three administrations in 11 cases (6.4%). Intracervical administration of PGE2 tylose gel (0.5 mg dose) is useful to prime the cervix, induce labor, and significantly modify Bishop score.

[Obstetric/neonatological integration and care of healthy newborn infants]

We report how we changed the model of the organization and the assistance in our Department of healthy newborns (2200-2400/years). After we have realized that mothers were not satisfied of the rules of the hospital and personnel was not satisfied of the job, we decided to begin a process of analysis and review of the procedures on full term newborn. During this process we found out that the most important thing was to have clear in mind the problems and the needs of the mother and the baby, and not those of nurses and doctors. A similar process took place in the Department of Obstetrics. In this way we, Obstetrics and Neonatologist together, began to offer a more human approach to birth, and rooming-in began. We stopped to attend every normal delivery, to separate immediately mother and baby, to feed the baby at fixed time, to give him supplementations. We tried to have with the mother a better relationship, visiting the baby in presence of the mother an receiving grom Obstetrics as soon as possible every information about pregnancy. We realized that this was possible only if the Neonatologist and the Obstetric were of the same opinion about a more human approach to birth. We stress this point, well aware that it's impossible to reach this goal unless everybody in any way involved in birth work in great harmony with all the others. A further result of this "new" way of working has been the program of early discharge: if desired, and whenever possible, the mother and the baby go home 48-72 hours after delivery. We report here preliminary data.