Obesity at term: What to consider? How to deliver?

Obesity presents significant challenges during pregnancy, increasing the risk of complications and adverse outcomes for both mother and baby. With the rising prevalence of obesity among pregnant women, questions arise regarding optimal management, including timing of delivery and choice of delivery mode. Labour induction in obese women may require a combination of mechanical and pharmacological methods due to increased risk of failed induction. Caesarean section in obese women presents unique challenges, requiring comprehensive perioperative planning and specialized care to optimize outcomes. However, specific guidelines tailored to obese patients undergoing caesarean sections are lacking. Postpartum care should include vigilant monitoring for complications. Addressing obesity in pregnancy necessitates a multidisciplinary approach and specialized care to ensure the best outcomes.

Perceptions of healthcare professionals regarding labour induction and augmentation: A qualitative systematic review

BACKGROUND

Labour induction and augmentation procedures are commonly used in maternity units with or without medical indications. Research shows that healthcare professionals play a significant role in women's childbirth decisions.

AIM

To consolidate healthcare professionals' perceptions about labour induction and augmentation.

METHODS

Seven electronic databases were searched from their inception dates till January 2023: PubMed, Embase, CINAHL, PsycINFO, Web of Science, Scopus, ProQuest Dissertations, and Theses Global. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Sandelowski and Barroso's guidelines guided this review. Included studies' quality was appraised by the Critical Appraisal Skills Program tool. Data were thematically synthesised. Review findings were assessed using the Grading of Recommendations Assessment, Development, and Evaluation-Confidence in the Evidence from Reviews of Qualitative research approach.

FINDINGS

Three main themes were identified from the 17 included studies: 1) Making sense of the phenomenon, 2) Two sides of the coin, and 3) The enlightened path ahead.

DISCUSSION

Healthcare professionals' labour induction and augmentation decisions were affected by personal (knowledge and moral philosophies), and external factors (women, community members, colleagues, and healthcare institutions). Some clinicians were unfamiliar with the proper labour induction/augmentation procedures, while others were worried about their decisions and outcomes.

CONCLUSION

Suggestions for improvement include conducting labour induction/augmentation training for clinicians, having sufficient resources in facilities, and developing appropriate labour induction/augmentation clinical guidelines. Women and their partners, community members, and traditional healers could benefit from receiving labour induction/augmentation education. To improve health outcomes, healthcare professionals could deliver woman-centred care and collaborate.

Effect of misoprostol versus oxytocin on delivery outcomes after labour induction in pregnant women: A systematic review and meta-analysis of randomized controlled trials

A large number of randomized controlled trials (RCTs) have been published on the effects of oral/vaginal misoprostol and oxytocin on delivery outcomes; however, data from these RCTs are conflicting. Although some meta-analyses summarized available findings in this regard, several eligible RCTs have been published since the release of those meta-analyses. Therefore, the current updated systematic review and meta-analysis of RCTs was conducted to compare the effects of oral/vaginal misoprostol and oxytocin on delivery and neonatal outcomes. A systematic search, using relevant keywords, was done in the online databases of PubMed/Medline, Scopus, and ISI Web of Science, up to April 2023, to identify eligible articles investigating the effect of oral/vaginal misoprostol and oxytocin on delivery outcomes including maternal [cesarean/vaginal delivery within 24 h after labour induction, Tachysystole, hypertonicity, hyper-stimulation, postpartum hemorrhage (PPH)] and neonatal outcomes [mean Apgar score, admission to neonatal intensive care unit (NICU), and death]. In total, 45 RCTs with a total sample size of 8406 participants were included. Meta-analysis revealed that vaginal misoprostol administration, compared with oxytocin, resulted in a significant reduction in the rate of cesarean and a significant increase in the rate of vaginal delivery and Tachysystole risk. Also, oral misoprostol was associated with a significant reduction in the rate of cesarean and a significant increase in the risk of hypertonicity compared with oxytocin. However, oral misoprostol had no significant effect on vaginal delivery compared with oxytocin. For other outcomes including hyper-stimulation, perinatal death, NICU admission, and mean Apgar score among newborns, we found no significant difference between oral/vaginal misoprostol and oxytocin. In total, vaginal/oral misoprostol might be a better method for labour induction compared with oxytocin. PROSPERO registration: CRD42023412325.

Extended balloon labour induction: A single arm proof of concept trial

Background

Mechanical labour induction with a transcervical balloon is as effective as pharmacological methods, with fewer adverse effects. Its use has been limited to labour induction with an unfavourable cervix able to retain the balloon. We have developed an innovative approach using 2-3 balloons side-by-side to extend the benefits of mechanical labour induction/augmentation with a favourable cervix without having to resort to amniotomy or uterotonics.

Objectives

To assess the effectiveness of side-by-side balloons for extended labour induction/augmentation.

Methods

We conducted a single arm proof of concept trial at Princess Marina Hospital (PMH) in Gaborone, Botswana. Participants were assessed as unsuitable for single balloon labour induction based on a modified Bishop cervical score of 7 or more. Three Foley catheters taped symmetrically side by side were passed through the cervix and inflated with 60mls each. Traction was applied with a weight of 250mls water suspended over the bed-end. The use of uterotonics, time from induction to birth, mode of birth, Apgar scores and adverse maternal and neonatal outcomes were recorded. Participants' satisfaction with the method of labour induction was assessed using a descriptive scale.

Results

We enrolled 20 participants of whom two were nulliparous. Indications for labour induction were mainly late term (70%) and hypertensive disorders of pregnancy (25%). The mean cervical score was 7.2. Overall, 17 (85%) of the participants achieved a vaginal birth, of whom 5 required oxytocin for labour augmentation. Four of these had requested removal of the balloons, one due to discomfort and three felt the process was taking too long. Three participants underwent caesarean birth. The mean time from initiation of labour induction to vaginal birth was 16 h (standard deviation (SD) 8.4) and 20 h for caesarean birth (SD 10.5). There were no 5-minute Apgar scores below 7 nor neonatal admissions. One baby required brief resuscitation. There were no adverse maternal outcomes.

Conclusion

This proof-of-concept study suggests that use of side-by-side balloons in participants with favourable cervix is effective in achieving vaginal birth in most participants without uterotonics or amniotomy. There were no adverse outcomes, though the study was too small to exclude the possibility of rare adverse outcomes. This offers a novel option for labour induction/augmentation, particularly where uterotonics or amniotomy are best avoided such as prior caesarean birth, vertical infection transmission risk and in settings with limited capacity for fetal surveillance. The results clearly justify larger randomized trials to evaluate this novel approach with greater precision. On the basis of the current study we are developing a purpose-designed balloon for extended balloon labour induction.

A nationwide, prospective, cohort study on exogenous oxytocin and delays in early child development: the Japan environment and children's study

Although it remains debatable, exogenous oxytocin, commonly used for labour induction and augmentation, reportedly increases risks of neurodevelopment delay, attention-deficit/hyperactivity disorder, and autism spectrum disorder among children prenatally exposed to exogenous oxytocin. However, only few studies have objectively examined exogenous oxytocin's impact on early childhood development through scoring evaluations. This study investigated the association between exogenous oxytocin exposure and neurodevelopment in 3-year-old children using the Ages and Stages Questionnaires, Third Edition. In this nationwide prospective cohort study, we extracted data from 104,062 foetal records regarding exogenous oxytocin use during labour from the Japan Environment and Children's Study. Participants completed questionnaires throughout the pregnancy and postpartum periods. Outcomes comprised the developmental status less than each cut-off value for the five domains of the Ages and Stages Questionnaire, Third Edition. We conducted multivariable logistic regression analyses on the data of 55,400 children after controlling for confounders. Among the 55,400 included women, 19.0% (n = 10,506) used exogenous oxytocin during labour and 81.0% (n = 44,894) did not. Children exposed to exogenous oxytocin showed no significantly increased risk of developmental delay in any domain (communication: odds ratio [OR] 1.04, 95% confidence interval [CI] 0.92-1.16; gross motor: OR 0.97, 95% CI 0.87-1.08; fine motor: OR 1.00, 95% CI 0.92-1.09; problem-solving: OR 1.02, 95% CI 0.94-1.11; personal-social: OR 0.91, 95% CI 0.80-1.03).   Conclusion: Exogenous oxytocin for labour induction did not adversely affect early childhood development. Further studies accounting for the degree of exogenous oxytocin exposure are required to confirm these results. What is Known: • In developed countries, labour is induced in 20-25% of all pregnancies, for which oxytocin is commonly used. • Studies have associated risks of neurodevelopment delay, attention-deficit/hyperactivity disorder, and autism spectrum disorder with exposure to exogenous oxytocin. What is New: • Evaluation with the Ages and Stages Questionnaire, Third Edition, revealed that exogenous oxytocin use did not adversely affect early childhood development. • This prospective study reinforced the lack of evidence of an association between exogenous oxytocin use and early childhood development after adjustment for confounding and rigorous bias elimination.

Synthetic osmotic dilators (Dilapan-S) or dinoprostone vaginal inserts (Propess) for inpatient induction of labour: A UK cost-consequence model

OBJECTIVE

To estimate the costs of synthetic osmotic dilators (Dilapan-S) compared to dinoprostone vaginal inserts (Propess) for inpatient induction of labour (IOL).

STUDY DESIGN

A population-level, Markov model-based cost-consequence analysis was developed to compare the impact of using Dilapan-S versus Propess. The time horizon was modelled from admission to birth. The target population was women requiring inpatient IOL from 37 weeks with an unfavourable cervix in the UK. Mean population characteristics reflected those of the SOLVE (NCT03001661) trial. No patient data were included in this analysis. The care pathways and staff workload were modelled using data from the SOLVE trial and clinical experience. Cost and clinical inputs were sourced from the SOLVE trial and peer-reviewed literature. Costs were inflated to 2020 British pounds (GBP, £). Outcomes were reported as an average per woman for total costs and required staff time (minutes) from admission for IOL until birth. The model robustness was assessed using a probabilistic, multivariate sensitivity analysis of 2,000 simulations with results presented as the median (interquartile range, IQR).

RESULTS

Dilapan-S was cost neutral compared to Propess. Midwife and obstetrician times were decreased by 146 min (-11%) and 11 min (-54%), respectively. Sensitivity analysis showed that in 78% of simulations, use of Dilapan-S reduced midwife time with a median of -160 min (IQR -277 to -24 min). Costs were reduced in 54% of simulations (median -£33, IQR -£319 to £282).

CONCLUSIONS

The model indicates that adoption of Dilapan-S is likely to be cost-neutral and reduce staff workload in comparison to Propess. Results require support from real-world data and further exploration of Dilapan-S is to be encouraged.

Titrated oral misoprostol versus static regimen of oral misoprostol for induction of labour: a systematic review and meta-analysis

We aimed to conduct a systematic review and meta-analysis to compare the efficacy and safety of titrated oral misoprostol versus static oral misoprostol for labour induction. We searched for the available randomised clinical trials (RCTs) in the Cochrane Library, PubMed, ISI web of science, Scopus, and ClinicalTrials.gov. We included RCTs compared titrated oral misoprostol versus static regimen of oral misoprostol during labour induction. Our main outcomes were vaginal and caesarean delivery rates, uterine tachysystole, misoprostol side effects, and neonatal adverse events. Three RCTs met our inclusion criteria with a total number of 360 patients. The vaginal delivery rate did not significantly differ between both groups (p = 0.49). Titrated oral misoprostol was associated with significant increase in the caesarean delivery rate compared to static oral misoprostol (p = 0.04). Moreover, titrated oral misoprostol led to significant increase in the uterine tachysystole and misoprostol side effects (p = 0.01 & p = 0.003, respectively). There were no differences among both groups regarding different neonatal adverse events. In conclusion, titrated oral misoprostol increases the incidence of caesarean delivery, uterine tachysystole, and misoprostol side effects with a similar vaginal delivery rate compared to static dose misoprostol. Thus, static oral misoprostol should be used instead of titrated oral misoprostol during labour induction. Impact StatementWhat is already known on this subject? Different studies have evaluated titrated oral misoprostol administration for induction of labour and proved their efficacy in comparison with other induction methods. However, there is controversy among the published studies between titrated oral misoprostol and static oral misoprostol during induction of labour. A recent study concluded that hourly titrated misoprostol and static oral misoprostol are equally safe and effective when utilised for induction of labour with no fear of any adverse events. However, another study recommended static oral misoprostol administration for labour induction as it was linked to a lower caesarean section incidence, fewer drug side effects, and decline in complication rates in comparison with titrated oral misoprostol.What the results of this study add? Titrated oral misoprostol increases the incidence of caesarean delivery, uterine tachysystole, and misoprostol side effects with a similar vaginal delivery rate compared to static dose misoprostol.What the implications are of these findings for clinical practice and/or further research? Static oral misoprostol should be used instead of titrated oral misoprostol during labour induction. More future trials are required to confirm our findings.

Cervical ripening and labour induction: A critical review of the available methods

Induction of labour is one of the most common interventions experienced by pregnant women. There are two overlapping components to labour induction, which include cervical ripening and the initiation of regular contractions. A large number of clinical studies have been conducted for evaluating the methods used for induction of labour, their effectiveness and safety, and pregnancy outcomes. Randomised controlled trials (RCTs) provide the strongest form of evidence for clinical practice. These data are brought together in systematic reviews and have been incorporated into national and international guidelines. Despite this, there is considerable variation in the recommendations between guidelines. Heterogeneity between studies, inconsistency in the definitions of trial outcomes, and underpowered sample size contribute to the difficulty in making robust recommendations. There are pharmacological and non-pharmacological approaches that can be compared with each other and with placebo or no treatment. There are also complementary therapies that may appeal to women but lack evidence of their effectiveness. These issues have been addressed in the current chapter, with a critical review of the research evidence presented in clinical trials and systematic reviews.

Labour induction in twin pregnancies

Medically-indicated deliveries are common in twin pregnancies given the increased risk of various obstetric complications in twin compared to singleton pregnancies, mainly hypertensive disorders of pregnancy and foetal growth restriction. Due to the unique characteristics of twin pregnancies, the success rates and safety of labour induction may be different than in singleton pregnancies. However, while there are abundant data regarding induction of labour in singleton pregnancies, the efficacy and safety of labour induction in twin pregnancies have been far less studied. In the current manuscript we summarize available data on various aspects of labour induction in twin pregnancies including incidence, success rate, prognostic factors, safety and methods for labour induction in twins. This information may assist healthcare providers in counselling patients with twin pregnancies when labour induction is indicated.

Novel side by side Foley catheter balloons for 'extended labour induction': Concept, simulation study and clinical application

OBJECTIVE

To introduce the concept of extended or prolonged mechanical balloon labour induction as opposed to pharmacological methods and amniotomy after single balloon expulsion, by the novel use of side-by-side Foley catheter balloons. This method is of particular relevance when there is prior uterine surgery, fetal reserve is uncertain, the risk of vertical infection is high, or facilities for labour monitoring are limited.

STUDY DESIGN

We conducted simulation studies to compare balloon circumferences and resistance to passage through a simulation cervix between different gauge, fluid distension volume and number of Foley catheters. We describe an illustrative clinical case.

RESULTS

In simulation studies we found modest increases in Foley catheter balloon circumference with increased catheter gauge and with increasing volume of distending fluid. We found that retention of Foley balloon(s) by a flexible simulated cervix was increased with the gauge, distending volume and number of balloons used side-by-side. We describe the case of a mother with pre-eclampsia with severe features and compromised fetal reserve in whom the side-by-side balloon method achieved spontaneous delivery after a single balloon had been expelled without labour commencing.

CONCLUSIONS

Institutional protocols for Balloon labour inductions should take into account the characteristics of locally-available balloon catheters. Further research is justified to determine the usefulness of extended mechanical labour induction with side-by-side balloon catheters, particularly with prior caesarean section, uncertain fetal reserve and settings with limited fetal monitoring capacity.

The history of labour induction: How did we get here?

The mean duration of human pregnancy is 280 days but the range is wide, and "term" has been defined to range from 37 to 42 weeks. In the 18th and 19th centuries, labour induction was used mainly in cases of pelvic deformity, before the foetus grew too large to be delivered. Induction methods were unreliable until the 20th century, when pituitary extract, and then synthetic oxytocin and prostaglandins, became available. "Disproportion" was the leading indication for induction until the 1950s, when it became clear that prolonged pregnancy was associated with increased perinatal mortality. Pregnancy dating was improved by ultrasound, which also showed that foetal growth slows at term. Induction rates rose during the 1970s, causing public concern about obstetric intervention. In the 21st century, large-scale randomised trials showed that perinatal mortality is lowest at 39-40 weeks, and that induction at that time does not increase the rate of operative delivery.

Prevalence and risk factors for caesarean delivery following labor induction at a tertiary hospital in North Tanzania: a retrospective cohort study (2000-2015)

BACKGROUND

Labor induction is among the common and widely practiced obstetric interventions aiming at achieving vaginal delivery. However, cesarean section (CS) delivery incidences have been reported following its use. This study aimed at determining the prevalence and risk factors for caesarean delivery following labor induction among women who gave birth at a tertiary hospital in north-Tanzania.

METHODS

A hospital-based retrospective cohort study was designed using maternally-linked data from Kilimanjaro Christian Medical Centre (KCMC) birth registry among women who gave birth to singleton babies from the year 2000 to 2015. All induced deliveries done in this period were studied. Women with multiple pregnancy, missing information on delivery mode and those with history of CS delivery were excluded. Relative risk and 95% Confidence Interval for risk factors for CS delivery following labor induction were estimated using log-binomial regression models. Robust variance estimation was used to account for repeated deliveries from the same subject.

RESULTS

A total of 1088 deliveries were analysed. The prevalence of CS following labour induction was 26.75%. Independent risk factors for CS delivery were; primiparity (RR = 1.46; 95% CI: 1.18-1.81), high birthweight (RR =1.28; 95% CI: 1.02-1.61), post-term pregnancy (RR = 1.45; 95% CI: 1.09-1.93), and urban residence (RR =1.29; 95%CI: 1.05-1.58).

CONCLUSION

In patients undergoing labor induction, primiparity, high birthweight, post dates and urban residence were found to associate with an elevated risk of caesarean delivery. Assessment of these factors prior to labor induction intervention is warranted to reduce adverse pregnancy outcomes associated with emergency caesarean delivery.

Socioeconomic risk factors for labour induction in the United Kingdom

Background

Labour induction is a childbirth intervention experienced by a growing number of women globally each year. While the maternal and socioeconomic indicators of labour induction are well documented in countries like the United States, considerably less research has been done into which women have a higher likelihood of labour induction in the United Kingdom. This paper explores the relationship between labour induction and maternal demographic, socioeconomic, and health indicators by parity in the United Kingdom.

Method

Logistic regression analyses were conducted using the first sweep of the Millennium Cohort Study, including a wide range of socioeconomic factors such as maternal educational attainment, marital status, and electoral ward deprivation, in addition to maternal and infant health indicators.

Results

In fully adjusted models, nulliparous and multiparous women with fewer educational qualifications and those living in disadvantaged places had a greater likelihood of labour induction than women with higher qualifications and women in advantaged electoral wards.

Conclusions

This paper highlights which UK women are at higher risk of labour induction and how this risk varies by socioeconomic status, demonstrating that less advantaged women are more likely to experience labour induction. This evidence could help health care professionals identify which patients may be at higher risk of childbirth intervention.

Effect of premature rupture of membranes on time to delivery and outcomes in full-term pregnancies with vaginal dinoprostone-induced labour

OBJECTIVE

The aim of this study was to assess the effect of premature rupture of membranes (PROM) in full-term pregnancies with dinoprostone-induced labour.

PATIENTS AND METHODS

This historical cohort study analysed 2166 full-term pregnancies with dinoprostone-induced labour between 1 August 2016 and 30 April 2018. A group that underwent induction of labour for PROM (PROM group) was compared to a group that underwent labour induction for other indications (no-PROM group). Time to delivery and perinatal outcome were compared between the two groups.

RESULTS

A total of 2166 pregnancies (662 PROM and 1504 no-PROM) were included. The two groups demonstrated no significant differences except in biparietal diameter and gestational age (P < 0.001). The caesarean section delivery rate in the PROM group was significantly lower than in the non-PROM group (26.89 vs. 33.58%, P < 0.0001). In the PROM group, the induction-to-delivery time was shorter (P < 0.0001) and the rates of vaginal birth within 24 h (P < 0.0001) and 48 h (P < 0.0001) were higher than those in the control group. The incidence rate of amniotic fluid contamination in the PROM group was significantly lower than that in the non-PROM group (19.18 vs. 25.20%, P = 0.002).

CONCLUSION

PROM significantly affects perinatal outcome in Chinese women who undergo dinoprostone-induced labour, especially the caesarean delivery rate and the induction-to-delivery time.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Labour and Induction]

OBJECTIVES

To issue guidelines on management of labour induction and breech vaginal delivery.

MATERIALS AND METHODS

Bibliographic search restricted to French and English languages using Medline database®, Cochrane Library and international guidelines of medical societies.

RESULTS

Breech delivery must take place in a maternity ward, in the presence of an obstetrician and gynaecologist and with the immediate availability of an anesthesiologist and a pediatrician during active second stage (Professional consensus). Term breech is not a contraindication to labour induction when the criteria for acceptance of vaginal delivery are met (Grade C). In this case, oxytocin or prostaglandins can be used (Grade C). Epidural analgesia with low concentrations of local anesthetics should be encouraged in case of vaginal delivery attempt (Professional consensus). It is recommended to use continuous monitoring of the CTG (Professional consensus). The use of second-line fetal monitoring is not recommended (Professional consensus). The administration of oxytocin is possible for labour augmentation (Professional consensus). It is better to start the expulsive efforts when the presentation is engaged as low as possible in the pelvic excavation (Professional consensus). Breech presentation is not an indication of episiotomy (Professional consensus). Due to insufficient data, it was not possible to make recommendations on specificities of preterm breech delivery.

CONCLUSION

In case of planned vaginal delivery, labour induction is possible for term breech fetuses, even with unfarable cervix. Guidelines for labour and vaginal delivery management have a low level of evidence.

Double- versus single-balloon catheters for labour induction and cervical ripening: a meta-analysis

Background

The induction of labour is an increasingly common procedure in the obstetrics field. Various methods have been used to induce labour, among which balloon catheters play an important role. Whether the specifically designed double-balloon catheter is better than the single-balloon device in terms of efficacy, efficiency, safety and patient satisfaction remains controversial. Identifying even small differences between these two devices could be useful to guide clinical practices, to further explore their mechanisms, and to promote a better understanding of the optimal methods for inducing labour.

Methods

Using the population, intervention, comparison, outcomes and study designs (PICOS) principle, we searched the PubMed, EMBASE, OVID, SCI, CENTRAL, ClinicalTrial.gov, and CDSR databases to identify relevant randomised controlled trials (RCTs) from inception through February 14, 2018. The primary outcome was the caesarean delivery rate, and the secondary outcomes focused on efficacy, efficiency, safety, and patient satisfaction. The relative risks or mean differences, including their 95% confidence intervals, were calculated using fixed-effects or random-effects models. All statistical analyses were completed with RevMan version 5.3.

Results

From a total of 1326 articles, 7 RCTs involving 1159 women were included. There were no significant differences in primary outcomes (RR, 0.88 [0.65, 1.2]; p-value, 0.43) or secondary outcomes identified between single- and double-balloon catheters. However, heterogeneity existed for some aspects.

Conclusion

Both kinds of balloon catheter have similar levels of efficacy, efficiency, safety and patient satisfaction; however, the single-balloon method is considered to be more cost-effective.

Gestational age at delivery of twins and perinatal outcomes: a cohort study in Aberdeen, Scotland

Background: Twin pregnancy is associated with a threefold increase in perinatal death compared to singletons.  The objective of this study was to determine the risk of perinatal death in twins by week of gestation and to quantify the effect of known risk factors. Methods: A cohort analysis was performed using data from the Aberdeen Maternity and Neonatal Databank (AMND).  The exposure was gestational age at delivery and the primary outcome was perinatal death.  Adjusted hazard ratios (aHRs) for perinatal death according to gestational age at delivery were determined by multivariate Cox proportional hazards regression modelling with robust standard errors to account for clustering in the twin infants.  Confounders and risk factors quantified and adjusted for in the model included maternal age, smoking, parity, marital status and year of birth.  Kaplan-Meier time to event analysis was used to determine the differences in survival according to chorionicity and assisted reproduction technologies (ART) conception status. Results: The population comprised of 7,420 twin babies born between 1950 and 2013 in the Grampian area of Northern Scotland.  There were 272 stillbirths in the cohort (3.67%) and 273 neonatal deaths (3.68%). Compared to delivery at 37-38 weeks, delivery before 37 weeks was associated with a 2-fold increase in perinatal death. Monochorionic twins had a 2-fold increase in perinatal death compared to dichorionic twins (aHR 2.15, 95% CI 1.60-2.90). Twins conceived by ART did not have a greater risk of perinatal death compared to those naturally conceived (aHR 1.21, 95% CI 0.87-1.68) Conclusion:  This study suggests that delivery of twins at 37-38 weeks is associated with the lowest risk of perinatal death.

Efficacy comparison of titrated oral solution of misoprostol and intravenous oxytocin on labour induction in women with full-term pregnancy

A double-blind randomised trial was conducted on women with gestational age of 40-42 weeks of pregnancy and Bishop score of more than 5. The first group received oxytocin infusion and the second group received a titrated oral solution of misoprostol. Then, the two groups were compared by the primary outcome (the number of deliveries in the first 24 hours of intervention). The two groups did not have any significant difference in maternal and gestational age at the time of intervention, primary Bishop score, parity and neonatal weight. The number of deliveries in the first 24 hours was greater in the misoprostol group. Duration of onset of intervention to proper contractions was longer in the misoprostol group. However, the number of deliveries between 6-12 hours, 12-18 hours and 18-24 hours after induction was greater in the misoprostol group. The incidence of tachysystole and meconium was greater in the misoprostol group.Impact statementWhat is already known on this subject? Labour induction is widely used where the continuation of pregnancy might be dangerous for the mother or the baby. Of the various methods used for induction, misoprostol which is a prostaglandin E1 analogue has been reviewed more in recent years. Misoprostol has various routes of administration but in most studies only vaginal administration has been evaluated, leaving us with limited data about oral administration.What do the results of this study add? Oral misoprostol is a suitable method for labour induction and can be used as an alternative to oxytocin.What are the implications of these findings for clinical practice and/or further research? Misoprostol is not expensive, has a long shelf life, accessible in underdeveloped countries and rural areas and has several routes of administrations such as oral, sublingual and vaginal. Despite the fact that the oral route of misoprostol has a fast absorption and easier administration, there are relatively few studies assessing the the use of the oral route of misoprostol. Misoprostol is a suitable method for Labour induction and it has the potentials of being used as an alternative for oxytocin, however, the optimum dosages, the preferred route of administration, the maximum dose, the maximum time for administration, and maternal and neonatal safety should be studied more.

Interest of cervical ripening using double balloon catheters for labour induction in term nulliparous women

OBJECTIVE

To compare the efficiency of double balloon catheters with that of intravaginal prostaglandins alone for the labor induction of unfavourable cervices in term nulliparous women.

METHODS

50 nulliparous patients induced with a double balloon device were compared to 53 patients induced using intravaginal prostaglandins alone. The main outcome measure was labour induction failure, characterized by the absence of active labour. The secondary outcome measures were the improvement of the Bishop score, the average durations of ripening and labour induction, the average time to active labour, the need for a second cervical ripening agent, the total dose of prostaglandins used in each group, the use of oxytocins, as well as the rates of vaginal delivery, abnormal foetal heart rate during labour and perinatal maternal infection.

RESULTS

The rate of failed labour induction was of 28% in the double balloon group, against 13% in the prostaglandins group. The average durations of ripening and labour induction, as well as the time to active labour were higher in the double balloon group. The improvement of the Bishop score was significantly lower in the double balloon group.

DISCUSSION AND CONCLUSION

In our study, the use of double balloon catheters does not seem to reduce the rate of failed labour induction in nulliparous women when compared to the use of prostaglandins alone. In addition, it could lengthen the labour induction duration, although more powerful studies would be necessary not to recommend its use for nulliparous women.

Comparing birth experience and birth outcome of vaginal births between induced and spontaneous onset of labour: a prospective study

PURPOSE

In developed countries, around 25% of all births involve labour induction. Studies have indicated that labour induction negatively influences the birth experience as well as the birth process. However, the impact of labour induction when only considering vaginal deliveries has not been studied yet, which was the purpose of the present study.

METHODS

186 women who gave birth vaginally took part in this prospective study. 95 women gave birth after spontaneous onset of labour (SL-group) and 91 women received a labour induction (LI-group). Eight to 72 h after birth, the women filled in the revised version of the standardised Childbirth Experience Questionnaire, which examines the birth experience in four dimensions (Own Capacity, Perceived Safety, Participation and Professional Support). Medical details regarding birth and fetal outcomes were taken from the medical records.

RESULTS

Birth outcomes (the number of epidural anaesthesia, the duration of birth, birth risks and childbirth injuries) as well as fetal outcomes (APGAR after 1 and 5 min and arterial cord pH) did not differ between the groups. Regarding the subjective birth experience, the LI-group indicated significantly lower values for Perceived Safety and Participation compared to the SL-group, while there were no differences for the dimensions Own Capacity and Professional Support.

DISCUSSION

Successful labour induction resulting in a vaginal birth did not negatively influence birth and fetal outcomes and only partly affected the women's birth experience. The negative impact of labour induction on the dimensions Perceived Safety and Participation should sensitize midwives in order to provide optimal support.

Gestational age at delivery of twins and perinatal outcomes: a cohort study in Aberdeen, Scotland

Background: Twin pregnancy is associated with a threefold increase in perinatal death compared to singletons.  The objective of this study was to determine the risk of perinatal death in twins by week of gestation and to quantify the effect of known risk factors. Methods: A cohort analysis was performed using data from the Aberdeen Maternity and Neonatal Databank (AMND).  The exposure was gestational age at delivery and the primary outcome was perinatal death.  Adjusted hazard ratios (aHRs) for perinatal death according to gestational age at delivery were determined by multivariate Cox proportional hazards regression modelling with robust standard errors to account for clustering in the twin infants.  Confounders and risk factors quantified and adjusted for in the model included maternal age, smoking, parity, marital status and year of birth.  Kaplan-Meier time to event analysis was used to determine the differences in survival according to chorionicity and assisted reproduction technologies (ART) conception status. Results: The population comprised of 7,420 twin babies born between 1950 and 2013 in the Grampian area of Northern Scotland.  There were 272 stillbirths in the cohort (3.67%) and 273 neonatal deaths (3.68%). Compared to delivery at 37-38 weeks, delivery at or beyond 39 weeks was associated with a significant increase in perinatal death (aHR 2.00 [95% CI 1.45-2.78]).  Monochorionic twins had a 2-fold increase in perinatal death compared to dichorionic twins (aHR 2.15, 95% CI 1.60-2.90). Twins conceived by ART did not have a greater risk of perinatal death compared to those naturally conceived (aHR 1.21, 95% CI 0.87-1.68) Conclusion:  This study suggests that delivery of twins at 37-38 weeks is associated with the lowest risk of perinatal death.

Acupuncture in Postdate Pregnancy Management

OBJECTIVES

Pharmacological labor induction is obtained through prostaglandins application and/or oxytocin infusion; however, the use seems to be related to fetal and maternal side effects. Traditional Chinese Medicine advocates the use of acupuncture to soften the cervix and induce uterine contractions. at which presented for The primary outcome was the rate of women admitted for labour induction in case of prolonged pregnancy at 41 + 5 weeks, and the secondary outcome was the rate of induction planning for other indications.

METHODS

After obtaining informed consent, 375 undelivered women after 40 + 2 gestational age were enrolled for the study: 112 women received acupuncture and 263, routine care. Acupuncture was applied every odd day starting from 40 + 2 weeks up to 41 + 4 weeks. Women allocated to the control group received standard care. At 41 + 5 weeks, a pharmacological induction was planned.

RESULTS

The rate of labor induction significantly differed between acupuncture and observation groups (19.6% vs. 38%; p < 0.01); in particular, women receiving acupuncture showed a lower rate of induction, indicating prolonged pregnancy (5.3% vs. 10.1%; p < 0.01). As far as the pharmacological device is concerned, no differences were observed with regard to the prostaglandins use, whereas oxytocin infusion rate was lower in the acupuncture group than in the observation group.

CONCLUSIONS

The present study suggested that acupuncture applied at term of pregnancy seems to be effective in reducing the rate of labor induction which is performed for prolonged pregnancy at 41 + 5 weeks. Moreover, acupuncture also seems to be able to reduce oxytocin use; such a "saving" effect could play a role in childhood, considering that a recent study underlined the adverse effect of oxytocin on birth outcomes.

Influence of maternal factors and mode of induction on labour outcomes: a pragmatic retrospective cohort study

Since recent research indicates that other modalities are at a minimum non-inferior to the NICE-recommended hormonal agent prostaglandin E₂ (PGE₂), a retrospective cohort study was conducted on 1971 consecutively induced singleton pregnancies. Multinominal regression analysis showed that the odds ratio (OR) for vaginal delivery with balloon-mediated labour induction (84% vaginal deliveries; OR 1.6; 95% CI 0.7-3.5) is similar to the PGE₂ agents propess (81%; OR 1.2; 95% CI 0.68-1.98) and prostin (79%; OR 0.99; 95% CI 0.55-1.79) when using a triple multi-agent induction as a reference. On the other hand, combining the propess and prostin (60% vaginal deliveries; OR 0.45; 95% CI 0.21-0.96) and attempting quadruple combinations of the induction modalities (56%; OR 0.37; 95% CI 0.16-0.85) yields significantly poorer outcomes. However, compared to the known factors associated with increased caesarean section rates, such as an increased maternal age, nulliparous pregnancies and a history of caesarean section, the differential impact of different induction modalities appear less pronounced. Impact statement What is already known on this subject? Recent published data from controlled clinical trials have shown that other labour-inducing agents, including balloon catheters, are as effective as prostaglandin E₂ (PGE₂) in achieving a vaginal delivery. What do the results of this study add? The data from this pragmatic retrospective cohort study supports the findings of others that the use of a balloon is as effective as PGE₂. It also demonstrates that regular clinical practice can differ from an experimental environment, with patients receiving multiple induction modalities in a daily practice. Both the combination of different PGE₂ medications and a quadruple labour induction approach are associated with poorer results, as measured by the vaginal delivery rate. The data presented here also confirms that a nulliparous status, a maternal age and a history of caesarean section are associated with reduced odds of achieving a vaginal delivery. What are the implications of these findings for clinical practice and/or further research? The body of evidence showing favourable results with a balloon induction is growing. Furthermore, there are limits to the effectiveness of combining the different induction modalities. Maternal and perinatal factors associated with a risk of caesarean section further complicate labour induction management.

Long term cognitive outcomes of early term (37-38 weeks) and late preterm (34-36 weeks) births: A systematic review

Background: There is a paucity of evidence regarding long-term outcomes of late preterm (34-36 weeks) and early term (37-38 weeks) delivery.  The objective of this systematic review was to assess long-term cognitive outcomes of children born at these gestations.

Methods: Four electronic databases (Medline, Embase, clinicaltrials.gov and PsycINFO) were searched.  Last search was 5 ^th August 2016.  Studies were included if they reported gestational age, IQ measure and the ages assessed.  The protocol was registered with the International prospective register of systematic reviews (PROSPERO Record CRD42015015472).  Two independent reviewers assessed the studies.  Data were abstracted and critical appraisal performed of eligible papers.

Results: Of 11,905 potential articles, seven studies reporting on 41,344 children were included.  For early term births, four studies (n = 35,711) consistently showed an increase in cognitive scores for infants born at full term (39-41 weeks) compared to those born at early term (37-38 weeks) with increases for each week of term (difference between 37 and 40 weeks of around 3 IQ points), despite differences in age of testing and method of IQ/cognitive testing.  Four studies (n = 5644) reporting childhood cognitive outcomes of late preterm births (34 – 36 weeks) also differed in study design (cohort and case control); age of testing; and method of IQ testing, and found no differences in outcomes between late preterm and term births, although risk of bias was high in included studies.

Conclusion:  Children born at 39-41 weeks have higher cognitive outcome scores compared to those born at early term (37-38 weeks).  This should be considered when discussing timing of delivery.  For children born late preterm, the data is scarce and when compared to full term (37-42 weeks) did not show any difference in IQ scores.

Variation in clinical decision-making for induction of labour: a qualitative study

Background

Unexplained variation in induction of labour (IOL) rates exist between hospitals, even after accounting for casemix and hospital differences. We aimed to explore factors that influence clinical decision-making for IOL that may be contributing to the variation in IOL rates between hospitals.

Methods

We undertook a qualitative study involving semi-structured, audio-recorded interviews with obstetricians and midwives. Using purposive sampling, participants known to have diverse opinions on IOL were selected from ten Australian maternity hospitals (based on differences in hospital IOL rate, size, location and case-mix complexities). Transcripts were indexed, coded, and analysed using the Framework Approach to identify main themes and subthemes.

Results

Forty-five participants were interviewed (21 midwives, 24 obstetric medical staff). Variations in decision-making for IOL were based on the obstetrician’s perception of medical risk in the pregnancy (influenced by the obstetrician’s personality and knowledge), their care relationship with the woman, how they involved the woman in decision-making, and resource availability. The role of a ‘gatekeeper’ in the procedural aspects of arranging an IOL also influenced decision-making. There was wide variation in the clinical decision-making practices of obstetricians and less accountability for decision-making in hospitals with a high IOL rate, with the converse occurring in hospitals with low IOL rates.

Conclusion

Improved communication, standardised risk assessment and accountability for IOL offer potential for reducing variation in hospital IOL rates.

Predictors of perinatal outcomes and economic costs for late-term induction of labour

OBJECTIVE

We aimed to predict the perinatal outcomes and costs of health services following labour induction for late-term pregnancies.

MATERIALS AND METHODS

We conducted a cohort study of 245 women who underwent labour induction during their 41st week of gestation. The cervical condition was assessed upon admission using the Bishop score and ultrasound cervical length measurements. We estimated the direct costs of labour induction, and a predictive model for perinatal outcomes was constructed using the decision tree analysis algorithm and a logit model.

RESULTS

A very unfavourable Bishop score at admission (Bishop score <2) (OR, 3.43 [95% CI, 1.77-6.59]), and a history of previous caesarean section (OR, 7.72 [95% CI, 2.43-24.43]) or previous vaginal delivery (OR, 0.24 [95% CI, 0.09-0.58]) were the only variables with predictive capacity for caesarean section in our model. The mean cost of labour induction was €3465.56 (95% confidence interval [CI], 3339.53-3591.58). Unfavourable Bishop scores upon admission and no history of previous deliveries significantly increased the cost of labour induction. Both of these criteria significantly predicted the likelihood of a caesarean section in the decision tree analysis.

CONCLUSION

The cost of labour induction mostly depends on the likelihood of successful trial of labour. Combined use of the Bishop score and previous vaginal or caesarean deliveries improves the ability to predict the likelihood of a caesarean section and the economic costs associated with labour induction for late-term pregnancies. This information is useful for patient counselling.

[Indicated preterm birth in a type 3 maternity ward: Evaluation of practices]

The purpose of this study was to evaluate the proportion of indicated preterm births among all preterm births in a type 3 maternity ward; to assess practices in terms of mode of delivery in such cases; and to analyse the observed outcomes for such deliveries.

MATERIALS AND METHODS

A retrospective study was conducted in the obstetrics department of the regional university hospital of Tours (type 3 maternity ward) over a 22-month period. Women with an indicated preterm birth between 22 and 37 weeks of gestation, for whom vaginal delivery was possible, were included in the study. For every woman, the choice of mode of delivery (caesarean before labour or induction of labour) as well as maternal, obstetrical and neonatal factors were recorded.

RESULTS

From January 2012 to October 2013, 539 deliveries were preterm among which 42.5% were indicated preterm births. Out of 114 women for whom vaginal delivery was possible, 33.3% had a caesarean before labour and 66.7% had an induction of labour. The choice of mode of delivery is influenced by various factors such as local conditions, gestational age and type of obstetrical pathologies. Moreover, birth weight and Apgar score are significantly lower and the hospitalisation rate of newborns is significantly higher in the "caesarean before labour" group.

CONCLUSION

Indicated preterm births represent almost half of preterm births in the maternity ward. A third of these indicated preterm births were caesareans before labour. Due to the neonatal morbidity resulting from indicated preterm birth, it is essential to regularly reassess indications of indicated preterm birth.

Unregulated usage of labour-inducing medication in a region of Pakistan with poor drug regulatory control: characteristics and risk patterns

Background

In developing countries such as Pakistan, poor training of mid-level cadres of health providers, combined with unregulated availability of labour-inducing medication can carry considerable risk for mother and child during labour. Here, we describe the exposure to labour-inducing medication and its possible risks in a vulnerable population in a conflict-affected region of Pakistan.

Methods

A retrospective cohort study using programme data, compared the outcomes of obstetric risk groups of women treated with unregulated oxytocin, with those of women with regulated treatment.

Results

Of the 6379 women included in the study, 607 (9.5%) received labour-inducing medication prior to reaching the hospital; of these, 528 (87.0%) received unregulated medication. Out of 528 labour-inducing medication administrators, 197 (37.3%) traditional birth attendants (also known as dai) and 157 (29.7%) lady health workers provided unregulated treatment most frequently. Women given unregulated medication who were diagnosed with obstructed/prolonged labour were at risk for uterine rupture (RR 4.1, 95% CI: 1.7–9.9) and severe birth asphyxia (RR 3.9, 95% CI: 2.5–6.1), and those with antepartum haemorrhage were at risk for stillbirth (RR 1.8, 95% CI: 1.0–3.1).

Conclusions

In a conflict-affected region of Pakistan, exposure to unregulated treatment with labour-inducing medication is common, and carries great risk for mother and child. Tighter regulatory control of labour-inducing drugs is needed, and enhanced training of the mid-level cadres of healthcare workers is required.

[Double-balloon device and intravaginal dinoprostone for cervical ripening in women with unfavourable cervix]

OBJECTIVES

To compare the efficiency of a double cervical ripening (mechanical agent and dinoprostone) to a dinoprostone-only ripening in women with an unfavourable cervix.

METHODS

In a retrospective study from January 2008 to October 2013, 96 patients were included with the following criteria: pregnancies over 37 weeks, singleton, vertex presentation, medical indication for induction of labor, no premature rupture of membranes and very unfavourable cervix (Bishop score ≤ 3). Patients were classified into 2 groups: intravaginal dinoprostone for 24h (prostaglandin group, n=38) and double-balloon device for 12h followed by intravaginal dinoprostone for 24h (balloon+prostaglandin group, n=58).

RESULTS

There was no difference in vaginal delivery rates between the 2 groups (balloon+prostaglandin group 51.7%, prostaglandin group 50%, P=0.87). The Bishop score after cervical ripening was significantly higher in the balloon+prostaglandin group (4.4 versus 2.4, P<0.0001), but the interval between the induction and the delivery was longer (33.6h versus 24.9h, P=0.0044). There was no significant difference for maternal and neonatal complications.

CONCLUSION

A double cervical ripening (with mechanical agent and dinoprostone) allows the Bishop score to be improved without increasing the rate of vaginal delivery, for patients with a Bishop score ≤ 3.

[Induction of labor in twin pregnancies compared to singleton pregnancies; risk factors for failure]

OBJECTIVES

The aim of this study was to evaluate the modalities of induction of labour in twin pregnancies compared with singleton pregnancies and to identify risk factors for failure.

MATERIALS ET METHODS

A retrospective population-based study was conducted at the Toulouse University Hospital to compare a cohort of diamniotic twin gestations (Twin A in vertex presentation), with induction of labour ≥36 weeks of gestation, between January 2007 and December 2012, to a singleton's cohort that were induced ≥36 weeks of gestation during the 2007 year. One singleton pregnancy was matched for each twin pregnancy with parity and gestational age.

RESULTS

One hundred and fifty-six twins pregnancies met the inclusion criteria for an induction of labor and were compared to 156 single pregnancies. The same and standard protocol of induction of labor was used for the two cohorts (intrauterine balloon catheter±dinoprostone/ocytocine). The cesarean section rate for failed labor induction (cesarean in latent phase) was similar in the 2 populations (14.7% for twin vs 13.5% for single; P=0.66). The factors associated to failed induction of labor in the total population were nulliparity (OR=1.49) and Bishop score<6 at the beginning of the induction (OR=2.83).

CONCLUSION

Twin did not appear as risk of failed induction. The protocol for induction of labor in singletons may be safely proposed to twin gestations.

Comparison of Blood Loss in Induced vs. Spontaneous Vaginal Delivery Using Specialized Blood Collection Bag

OBJECTIVE

To compare third stage blood loss in induced vs. spontaneous vaginal deliveries and to correlate the amount of blood loss with the decrease in haemoglobin following deliveries.

SETTING

Department of Obstetrics and Gynaecology, Kasturba Hospital Manipal, Karnataka, India.

MATERIALS AND METHODS

Blood loss following placental deliveries was measured by using special collection bags in 150 pregnant ladies who delivered vaginally by labour induction and it was compared with that of another 50 women who had spontaneous vaginal deliveries. Haemoglobin values were recorded for each patient prior to labour and after delivery of child.

RESULTS

The mean blood loss in induced group was 30 mL more than that in spontaneous group (202 ± 117 mL vs. 172 ± 114 mL), but this was not statistically significant (p=0.12). However, when different methods of induction were compared, oxytocin group was found to have significantly higher blood loss (327 ± 140 mL) as compared to that in other types of labour inductions as well as spontaneous deliveries. Labour induction using prostaglandins did not produce more blood loss as compared that produced by spontaneous deliveries. Both induced and spontaneous delivery groups showed statistically significant drops in post-delivery haemoglobin values, but the drop was relatively more in induced group as compared to that in spontaneous vaginal delivery group (0.96gm/dL vs. 0.56gm/dL), which appeared to be statistically significant (p=0.002).

CONCLUSION

Labour induction using prostaglandins is safe as compared to oxytocin usage. Accurate estimation of blood loss is important in all types of deliveries, in order to detect postpartum haemorrhage early, so that appropriate measures can be undertaken.

Comparative study of oral and vaginal misoprostol for induction of labour, maternal and foetal outcome

BACKGROUND

Misoprostol is a new promising agent for cervical ripening and induction of labour .The ideal dose, route and frequency of administration of misoprostol are still under investigation. Although, vaginal application of misoprostol has been validated as a reasonable mean of induction, there is a patient resistance to digital examination and there is a risk of ascending infection. For this reason, oral administration of misoprostol for cervical ripening and labour induction has been tried.

AIMS AND OBJECTIVES

To compare 50μg of oral misoprostol versus 25μg of intravaginal misoprostol for induction of labour at term and maternal, foetal outcomes.

METHODS

Two hundred women who were at term, with indication for induction of labour and Bishop scores of ≤5 were randomly assigned to receive misoprostol 50μg or 25μg intravaginal, every 4-6 hours, for a maximum of 5 doses. In either group, pregnant females with inadequate uterine contractions despite being given maximum 5 doses of misoprostol, were augmented using oxytocin. The primary outcome measure was time-interval from induction to vaginal delivery and vaginal delivery rate within 24 hours.

RESULTS

The median induction to vaginal delivery time in oral group (12.92h) and vaginal group (14.04 h) was not significant. Oral misoprostol resulted in more number of vaginal deliveries as compared to vaginal misoprostol (94% as compared to 86%), which was not significant. There was a significantly higher incidence of uterine tachysystole in the vaginal group, as compared to oral group. There were no significant differences between the groups with respect to oxytocin augmentation, caesarean section rate, analgesic requirement and neonatal outcome.

CONCLUSION

Oral misoprostol is as efficacious as vaginal misoprostol because of shorter induction delivery interval, lower caesarean section rates, and lower incidence of failed induction rates. Lower incidence of foetal distress and easy intake are observed if the drug is administered orally.

Which intrauterine growth restricted fetuses at term benefit from early labour induction? A secondary analysis of the DIGITAT randomised trial

OBJECTIVE

The Disproportionate Intrauterine Growth Intervention Trial at Term (DIGITAT trial) showed that in women with suspected intrauterine growth restriction (IUGR) at term, there were no substantial outcome differences between induction of labour and expectant monitoring. The objective of the present analysis is to evaluate whether maternal or fetal markers could identify IUGR fetuses who would benefit from early labour induction.

STUDY DESIGN

The DIGITAT trial was a multicenter, parallel and open-label randomised controlled trial in women who had a singleton pregnancy beyond 36+0 weeks' gestation with suspected IUGR (n=650). Women had been randomly allocated to either labour induction or expectant monitoring. The primary outcome was a composite measure of adverse neonatal outcome, defined as neonatal death before hospital discharge, Apgar score <7, umbilical artery pH <7.05, or admission to neonatal intensive care. Using logistic regression modelling, we investigated associations between outcome and 17 markers, maternal characteristics and fetal sonographic and Doppler velocimetry measurements, all collected at study entry.

RESULTS

17 (5.3%) infants in the induction group had an adverse neonatal outcome compared to 20 (6.1%) in the expectant monitoring group. The only potentially informative marker for inducing labour was maternal pre-pregnancy body mass index (BMI). Otherwise, we observed at best weak associations between a benefit from labour induction and maternal age, ethnicity, smoking, parity, pregnancy-induced hypertension or preeclampsia, Bishop score and gestational age, or fetal sonographic markers (gender, estimated fetal weight, body measurements, oligohydramnios, or umbilical artery pulsatility index and end diastolic flow).

CONCLUSION

In late preterm and term pregnancies complicated by suspected intrauterine growth restriction, most of the known prognostic markers seem unlikely to be helpful in identifying women who could benefit from labour induction, except for maternal pre-pregnancy BMI.

Foley catheter or prostaglandin E2 inserts for induction of labour at term: an open-label randomized controlled trial (PROBAAT-P trial) and systematic review of literature

OBJECTIVE

To assess the safety and effectiveness of a transcervical Foley catheter compared to vaginal prostaglandin E2 inserts for term induction of labour.

STUDY DESIGN

We conducted an open-label randomized controlled trial in five hospitals in the Netherlands. Women with a singleton term pregnancy in cephalic presentation, intact membranes, unfavourable cervix, and no prior caesarean section were enrolled. Participants were randomly allocated by a web-based randomization system to induction of labour with a 30 ml Foley catheter or 10mg slow-release vaginal prostaglandin E2 inserts in a 1:1 ratio. Due to the nature of the intervention this study was not blinded. The primary outcome was the caesarean section rate. Secondary outcomes were maternal and neonatal morbidity and time from intervention to birth. Additionally, we carried out a systematic review and meta-analysis of similar studies.

RESULTS

We analyzed 226 women: 107 received a Foley catheter and 119 inserts. Caesarean section rates were comparable (20% versus 22%, RR 0.90, 95% CI 0.54-1.50). Secondary outcomes showed no differences. We observed no serious maternal or neonatal morbidity. Meta-analysis showed comparable caesarean section rates, but significantly fewer cases of hyperstimulation during the ripening phase when a Foley catheter was used.

CONCLUSIONS

We found, in this relatively small study, no differences in effectiveness and safety of induction of labour with a Foley catheter and 10mg slow release vaginal prostaglandin E2 inserts. Meta-analysis confirmed a comparable caesarean section rate, and showed fewer cases of hyperstimulation when a Foley catheter was used.