Society of Family Planning clinical recommendations: Cervical preparation for dilation and evacuation at 20-24 weeks' gestation

Although only 1.3% of abortions in the United States are between 20 and 24 weeks' gestation, these procedures are associated with elevated risks of morbidity and mortality. Adequate cervical preparation before dilation and evacuation (D&E) at 20-24 weeks' gestation reduces procedural risk. For this gestational range, at least one day of cervical preparation with osmotic dilators is recommended before D&E. The use of overnight osmotic dilators alone is sufficient for most D&Es at 20-24 weeks' gestation. Dilapan-S® dilators require a shorter time to achieve maximum dilation, may be more effective than laminaria and may increase the likelihood of success on the first D&E attempt. The use of adjunctive mifepristone administered one-day pre-operatively at the time of osmotic dilator placement, should be considered because evidence demonstrates that it makes D&E subjectively easier at 20-24 weeks without increasing side effects. While older studies suggest that two-days of serial osmotic dilators provide greater dilation than one day of dilators, adjunctive mifepristone may be comparable to a second day of dilators. Adjunctive misoprostol administered on the day of D&E does not appear to affect initial cervical dilation and procedure time and compared with mifepristone is associated with more side effects, such as pain and nausea. Using overnight mifepristone and same-day misoprostol without osmotic dilators at 20-24 weeks' gestation lengthens D&E procedure time and appears to increase immediate complications, at least among less experienced providers. Some evidence shows the feasibility of same-day cervical preparation before D&E at 20-24 weeks using Dilapan-S® with adjunctive misoprostol or serial repeat dosing of misoprostol, but same-day preparation should be limited to providers with significant experience with these regimens. The Society of Family Planning recommends preoperative cervical preparation before D&E at 20-24 weeks' gestation. Further studies are needed to clarify the best means of preparing the cervix in order to minimize abortion complications and improve outcomes in this gestational range.

Effect of led photobiomodulation on analgesia during labor: Study protocol for a randomized clinical trial

BACKGROUND

Labor pain is one of the most intense pains experienced by women, which leads to an increase in the number of women opting to undergo a cesarean delivery. Pharmacological and nonpharmacological analgesia methods are used to control labor pain. Epidural analgesia is the most commonly used pharmacological analgesia method. However, it may have side effects on the fetus and the mother. Light-emitting diode (LED) photobiomodulation is an effective and noninvasive alternative to pharmacological methods.

OBJECTIVES

To evaluate the effects of LED photobiomodulation on analgesia during labor.

METHODS

In total, 60 women in labor admitted to a public maternity hospital will be selected for a randomized controlled trial. The participants will be randomized into 2 groups: intervention group [analgesia with LED therapy (n = 30)] and control group [analgesia with bath therapy (n = 30)]. The perception of pain will be assessed using the visual analogue scale (VAS), with a score from 0 to 10 at baseline, that is, before the intervention. In both the groups, the procedures will last 10 minutes and will be performed at 3 time points during labor: during cervical dilation of 4 to 5 cm, 6 to 7 cm, and 8 to 9 cm. At all 3 time points, pain perception will be evaluated using VAS shortly after the intervention. In addition, the evaluation of membrane characteristics (intact or damaged), heart rate, uterine dynamics, and cardiotocography will be performed at all time points.

EXPECTED OUTCOMES

The use of LED photobiomodulation will have an analgesic effect superior to that of the bath therapy.

Epidural fentanyl does not affect cervical dilation and progress of first stage of vaginal delivery: a randomized, double-blind study

OBJECTIVE

Local anesthetics combined with opioids are commonly used in labor epidural analgesic schemes. This study investigated if the addition of fentanyl to epidural ropivacaine can affect cervical dilation and progress of vaginal delivery.

METHODS

Sixty-two nulliparous parturients were randomized to receive epidurally 8 ml ropivacaine 0.2% combined with fentanyl 20 μg (F/R-group, n = 31) or with normal saline 0.4 ml (R-group, n = 31), every hour. Rescue doses of 5 ml ropivacaine 0.2% were also administered. Measurements were performed every 60 min until full cervical dilation. The primary end-point was the time to reach 10-cm cervical dilation. Secondary outcomes were Bishop scores, mode of delivery, total ropivacaine dose, pain, and satisfaction scores (numerical scale, 0-10).

RESULTS

Data from 60 parturients (29 in the F/R and 31 in the R-group) were analyzed. The F/R-group had 26 vaginal deliveries (four instrumentally assisted), and three cesarean deliveries. The R-group had 27 vaginal deliveries (six instrumentally assisted) and 4 cesarean deliveries. Time to 10-cm cervical dilation did not differ between the groups (4 ± 2.4 h in the F/R-group vs 4.4 ± 2.1 h in the R-group, p = .341). The number of women remaining in the study every hour until full cervical dilation and Bishop scores for a 4-h period did not differ between the groups (p = .617). Total ropivacaine dose was comparable between the groups, but the F/R-group reported significantly lower pain (p = .01) and higher satisfaction scores (p = .001).

CONCLUSIONS

The addition of fentanyl to ropivacaine 0.2% solution did not affect cervical dilation and progress of the first stage of labor, but improved both analgesia and satisfaction.

Different routes of misoprostol for cervical priming in first trimester surgical abortions: a randomized blind trial

PURPOSE

To compare effectiveness and patient satisfaction of different routes of misoprostol for short-term (same day) cervical priming in first trimester surgical abortions.

METHODS

In a blind randomized trial, patients undergoing surgical abortion at a gestational age of 6 + 0-14 + 6 were administered oral, vaginal, or sub-lingual 400 mcg misoprostol, 1.5 to 4 h prior to procedure. Surgeons blinded to patient allocation evaluated cervical priming. The primary outcome was initial cervical dilatation. Secondary outcomes were cervical consistency, ease of dilation, patient discomfort, and side effects.

RESULTS

From July 2015 through May 2016, 120 patients were randomized as follows: 40 to oral, 40 to vaginal, and 40 to sublingual misoprostol administration. No differences were noted in patient age, gestational age, curettage indication (termination/delayed miscarriage), past vaginal delivery, and administration to procedure interval. Initial cervical dilatation was similar between the groups, as were cervical consistency and ease of dilation. Patients noted the greatest discomfort and side effects with sublingual administration. The followings were found to be independently associated with cervical dilatation in a linear regression analysis: sublingual administration, gestational age, missed abortion, and previous vaginal delivery. Side effects and administration to procedure interval were found non-significant.

CONCLUSION

The same day cervical priming for first trimester surgical abortion is similarly achieved with all routes of misoprostol administration. In cases of termination of pregnancy with no prior vaginal delivery, sublingual administration may be considered, but entails a higher rate of side effects and patient discomfort.

Sublingual misoprostol plus laminaria for cervical preparation before surgical management of late first trimester missed abortions, a randomized controlled trial

OBJECTIVE

Comparing the efficacy of low-dose sublingual misoprostol plus laminaria to medium-dose sublingual misoprostol alone for cervical dilation before surgical management of late first trimester missed abortions.

METHODS

Randomized, controlled trial evaluated 70 women with missed abortion, admitted for surgical termination of pregnancy. The patients were randomly assigned to receive 200 μg sublingual misoprostol with cervical laminaria (intervention group) or 400 μg sublingual misoprostol without laminaria (control group), four hours before surgical process. The study is registered at www.irct.ir (IRCT2014070711020N4).

RESULTS

More patients in the intervention group achieved the desired cervical dilation (≥Hegar7) before surgical process than the control group (91.4% versus 17.1%, p < 0.001). Patients in the intervention group experienced less pain during the waiting period (mean Visual Analog Scale scores: 30.8 ± 3.7 versus 43.7 ± 5.9, p < 0.001), and had higher satisfaction level (highly satisfied: 97.1% versus 77.1%, p = 0.02). Four patients in the intervention group and none in the control group had spontaneous expulsion of pregnancy products (p = 0.11).

CONCLUSIONS

Compared to medium-dose sublingual misoprostol alone, using a combination of cervical laminaria plus low-dose sublingual misoprostol before surgical process is associated with significantly more effective and rapid cervical dilation, lower requirement for mechanical dilation, lower abdominal pain and discomfort during the waiting period and higher patients' satisfaction.

Mechanical and Pharmacologic Methods of Labor Induction: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effectiveness of four commonly used induction methods.

METHODS

This randomized trial compared four induction methods: misoprostol alone, Foley alone, misoprostol-cervical Foley concurrently, and Foley-oxytocin concurrently. Women undergoing labor induction with full-term (37 weeks of gestation or greater), singleton, vertex-presenting gestations, with no contraindication to vaginal delivery, intact membranes, Bishop score 6 or less, and cervical dilation 2 cm or less were included. Women were enrolled only once during the study period. Our primary outcome was time to delivery. Neither patients nor health care providers were blinded to assigned treatment group because examinations are required for placement of all methods; however, research personnel were blinded during data abstraction. A sample size of 123 per group (n=492) was planned to compare the four groups pairwise (P≤.008) with a 4-hour reduction in delivery time considered clinically meaningful.

RESULTS

From May 2013 through June 2015, 997 women were screened and 491 were randomized and analyzed. Demographic and clinical characteristics were similar among the four treatment groups. When comparing all induction method groups, combination methods achieved a faster median time to delivery than single-agent methods (misoprostol-Foley: 13.1 hours, Foley-oxytocin: 14.5 hours, misoprostol: 17.6 hours, Foley: 17.7 hours, P<.001). When censored for cesarean delivery and adjusting for parity, women who received misoprostol-Foley were almost twice as likely to deliver before women who received misoprostol alone (hazard ratio 1.92, 95% confidence interval [CI] 1.42-2.59) or Foley alone (hazard ratio 1.87, 95% CI 1.87 1.39-2.52), whereas Foley-oxytocin was not statistically different from single-agent methods.

CONCLUSION

After censoring for cesarean delivery and adjusting for parity, misoprostol-cervical Foley resulted in twice the chance of delivering before either single-agent method.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov, NCT01916681.

Discontinuation of Tocolytics for Preterm Labor in an Academic Safety Net Hospital: Impact on the Duration of Betamethasone Exposure

OBJECTIVE

To evaluate the impact of discontinuation of tocolytics on the completion of the corticosteroid course among preterm neonates in an academic safety net hospital.

STUDY DESIGN

Retrospective cohort study of all singleton pregnancies with preterm labor resulting in delivery between 24 and 34 weeks' gestation at Denver Health Medical Center (DHMC) between 1/1/2004 and 5/31/2009. In January 2007 DHMC discontinued the use of tocolytic therapy for preterm labor. Study subjects were grouped based on whether their delivery occurred before or after the change in policy. Multivariable logistic regression was used to determine whether the use of tocolysis increased the odds of completion of the betamethasone while adjusting for cervical examination at admission.

RESULTS

Of 169 infant/mother pairs who met inclusion criteria, 102 delivered prior to the discontinuation of tocolytics and 67 delivered after the discontinuation of tocolytics. Treatment with tocolysis increased the odds of completing the 48-hour betamethasone window (OR 2.59, 95% CI 1.16-5.79). Each centimeter increase in cervical dilation at the time of admission decreased the odds of completing the betamethasone window (OR 0.50, 95% CI 0.39-0.62).

CONCLUSION

The use of tocolytics increased the odds of completion of the betamethasone window in an academic safety net hospital among neonates born between 24 and 34 weeks' gestation.

Laminaria vs. vaginal misoprostol for cervical preparation before second-trimester surgical abortion: a randomized clinical trial

OBJECTIVE

To compare the efficacy and tolerability of vaginal misoprostol and laminaria for cervical preparation before second-trimester surgical abortion.

STUDY DESIGN

We performed a prospective, randomized trial comparing midnight administration of misoprostol 600 mcg vaginally to midnight placement of laminaria, before surgical abortions among women at 13-20 weeks of gestation. The primary outcome was preoperative cervical dilation. Secondary outcomes were the need for further dilation, procedure duration and difficulty, immediate complications and side effects.

RESULTS

Eighty-four women were randomized, with a median gestational age of 16.5 weeks. The mean time interval between misoprostol and laminaria placement and dilatation and evacuation initiation was 11.0±2.9 and 11.2±2.0h, respectively (p=.17). Cervical dilation was not greater in the laminaria group as compared to the misoprostol group (12.8 vs. 12.4mm, respectively; p=.32). No difference was demonstrated regarding the need for additional dilation or the difficulty of the procedure. Procedures performed after laminaria insertion were 1 min longer (median 11 vs. 10 min, p=.04). Participants found laminaria placement more uncomfortable than vaginal misoprostol placement. Other than pain, additional side effects occurred only in the misoprostol group, primarily nausea and vomiting. One participant in the misoprostol group experienced fetal expulsion during the night before the intended procedure.

CONCLUSION

Either vaginal misoprostol or laminaria provides adequate dilation for second-trimester surgical abortion. Laminaria causes more pain at insertion and misoprostol causes more side effects.

IMPLICATIONS STATEMENT

We found that cervical preparation in an inpatient setting for approximately 11h with misoprostol 600 mcg vaginally is comparable to 11h of laminaria. However, given the potential for spontaneous expulsion and more side effects with misoprostol, laminaria is likely a better general option in such a setting.

The estimation of branching curves in the presence of subject-specific random effects

Branching curves are a technique for modeling curves that change trajectory at a change (branching) point. Currently, the estimation framework is limited to independent data, and smoothing splines are used for estimation. This article aims to extend the branching curve framework to the longitudinal data setting where the branching point varies by subject. If the branching point is modeled as a random effect, then the longitudinal branching curve framework is a semiparametric nonlinear mixed effects model. Given existing issues with using random effects within a smoothing spline, we express the model as a B-spline based semiparametric nonlinear mixed effects model. Simple, clever smoothness constraints are enforced on the B-splines at the change point. The method is applied to Women's Health data where we model the shape of the labor curve (cervical dilation measured longitudinally) before and after treatment with oxytocin (a labor stimulant).

Induction of cervical dilation for transcervical embryo transfer in ewes

BACKGROUND

A major limitation in the application of assisted reproductive technologies in sheep arises from the inability to easily traverse the uterine cervix. The cervix of the non-pregnant ewe is a narrow and rigid structure, with 5-7 spiral folds and crypts that block its lumen. The first two folds closest to the vagina appear to be the greatest obstacle for the instrument insertion into the sheep cervix. Therefore, the dilation of the distal part of the cervix could provide the conformational change necessary to perform non-invasive transcervical procedures. The present study set out to assess the efficacy of Cervidil®, a patented dinoprostone (PgE2)-containing vaginal insert with a controlled-release mechanism, to safely induce sufficient cervical dilation for the purpose of transcervical embryo transfer (TCET) in cyclic ewes.

METHODS

The transfer of frozen-thawed ovine embryos was attempted in 22 cross-bred Rideau Arcott x Polled Dorset ewes, with or without the pre-treatment with Cervidil® for 12 or 24 h prior to TCET.

RESULTS

Cervical penetration rate was significantly improved after Cervidil® pre-treatment, with 55% (6/11) of treated versus 9% (1/11) of control animals successfully penetrated (χ2-test, p < 0.05). Within the treated ewes that were penetrated, 67% (4/6) had been exposed to Cervidil(R) for 24 h and 33% (2/6) had had a 12-h exposure (p > 0.05). Variations in the age, weight, genotype, parity, lifetime lamb production (LLP) and post-partum interval (PPI) between penetrated and non-penetrated ewes were not significant (p > 0.05). The time taken to traverse the uterine cervix was negatively correlated (p < 0.05) with the age, parity, LLP and PPI. Progesterone assays and ultrasonographic examinations performed 25 days after ET confirmed pregnancy in 2 of 7 penetrated ewes, but no fetuses were detected ultrasonographically 55 days post-TCET.

CONCLUSIONS

The present results indicate a significant benefit of using Cervidil® for inducing cervical dilation during the mid-luteal phase in ewes but the reason(s) for impaired fertility after the transfer of frozen-thawed ovine embryos remains to be elucidated.

High-dose versus low-dose oxytocin for augmentation of delayed labour

BACKGROUND

A major cause of failure to achieve spontaneous vaginal birth is delay in labour due to presumed inefficient uterine action. Oxytocin is given to increase contractions and high-dose regimens may potentially increase the number of spontaneous vaginal births, but as oxytocin can cause hyperstimulation of the uterus, there is a possibility of increased adverse events.

OBJECTIVES

To compare starting dose and increment dose of oxytocin for augmentation for women delayed in labour to determine whether augmentation by high-dose regimens of oxytocin improves labour outcomes and to examine the effect on both maternal/neonatal outcomes and women's birth experiences.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013) and reference lists of retrieved studies.

SELECTION CRITERIA

We included all randomised and quasi-randomised controlled trials for women in delayed labour requiring augmentation by oxytocin comparing high-dose regimens (defined as starting dose and increment of equal to or more than 4 mU per minute) with low-dose regimens (defined as starting dose and an increment of less than 4 mU per minute). Increase interval: between 15 and 40 minutes. The separation of low- and high-dose regimens is based on an arbitrary decision.

DATA COLLECTION AND ANALYSIS

Four review authors undertook assessment of trial eligibility, risk of bias, and data extraction independently.

MAIN RESULTS

We included four studies involving 644 pregnant women. Three studies were randomised controlled trials and one trial was a quasi-randomised study. A higher dose of oxytocin was associated with a significant reduction in length of labour reported from one trial (mean difference (MD) -3.50 hours; 95% confidence interval (CI) -6.38 to -0.62; one trial, 40 women). There was a decrease in the rate of caesarean section (risk ratio (RR) 0.62; 95% CI 0.44 to 0.86 four trials, 644 women) and an increase in the rate of spontaneous vaginal birth in the high-dose group (RR 1.35; 95% CI 1.13 to 1.62, three trials, 444 women), although for both of these outcomes there were inconsistencies between studies in the size of effect. When we carried out sensitivity analysis (temporarily removing a study at high risk of bias) the differences between groups were no longer statistically significantThere were no significant differences between high- and low-dose regimens for instrumental vaginal birth, epidural analgesia, hyperstimulation, postpartum haemorrhage, chorioamnionitis or women's perceptions of experiences. For neonatal outcomes, there was no significant difference between groups for Apgar scores, umbilical cord pH, admission to special care baby unit, or neonatal mortality. The following outcomes were not evaluated in the included studies: perinatal mortality, uterine rupture, abnormal cardiotocography, women's pyrexia, dystocia and neonatal neurological morbidity.

AUTHORS' CONCLUSIONS

Higher-dose regimens of oxytocin (4 mU per minute or more) were associated with a reduction in the length of labour and in caesarean section, and an increase in spontaneous vaginal birth. However, there is insufficient evidence to recommend that high-dose regimens are advised routinely for women with delay in the first stage of labour. Further research should evaluate the effect of high-dose regimens of oxytocin for women delayed in labour and should include maternal and neonatal outcomes as well as the effects on women.

Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour

BACKGROUND

Slow progress in the first stage of spontaneous labour is associated with an increased caesarean section rate and fetal and maternal morbidity. Oxytocin has long been advocated as a treatment for slow progress in labour but it is unclear to what extent it improves the outcomes for that labour and whether it actually reduces the caesarean section rate or maternal and fetal morbidity. This review will address the use of oxytocin and whether it improves the outcomes for women who are progressing slowly in labour compared to situations where it is not used or where its administration is delayed.

OBJECTIVES

To determine if the use of oxytocin for the treatment of slow progress in the first stage of spontaneous labour is associated with a reduction in the incidence of caesarean sections, or maternal and fetal morbidity compared to situations where it is not used or where its administration is delayed.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 February 2013) and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised controlled trials which compared oxytocin with either placebo, no treatment or delayed oxytocin in the active stage of spontaneous labour in low-risk women at term.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion, assessed risk of bias and extracted data. We sought additional information from trial authors.

MAIN RESULTS

We included eight studies in the review involving a total of 1338 low-risk women in the first stage of spontaneous labour at term. Two comparisons were made; 1) the use of oxytocin versus placebo or no treatment (three trials); 2) the early use of oxytocin versus its delayed use (five trials). There were no significant differences in the rates of caesarean section or instrumental vaginal delivery in either comparison. Early use of oxytocin resulted in an increase in uterine hyperstimulation associated with fetal heart changes. However, the early use of oxytocin versus its delayed use resulted in no significant differences in a range of neonatal and maternal outcomes. Use of early oxytocin resulted in a statistically significant reduction in the mean duration in labour of approximately two hours but did not increase the normal delivery rate. There was significant heterogeneity for this analysis and we carried out a random-effects meta-analysis; however, all of the trials are strongly in the same direction so it is reasonable to conclude that this is the true effect. We also performed a random-effects meta-analysis for the four other analyses which showed substantial heterogeneity in the review.

AUTHORS' CONCLUSIONS

For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernable difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.

Antispasmodics for labour

BACKGROUND

Prolonged labour can lead to increased maternal and neonatal mortality and morbidity due to increased risks of maternal exhaustion, postpartum haemorrhage and sepsis, fetal distress and asphyxia and requires early detection and appropriate clinical response. The risks for complications of prolonged labour are much greater in poor resource settings. Active management of labour versus physiological, expectant management, has shown to decrease the occurrence of prolonged labour. Administering antispasmodics during labour could also lead to faster and more effective dilatation of the cervix. Interventions to shorten labour, such as antispasmodics, can be used as a preventative or a treatment strategy in order to decrease the incidence of prolonged labour. As the evidence to support this is still largely anecdotal around the world, there is a need to systematically review the available evidence to obtain a valid answer.

OBJECTIVES

To assess the effects of antispasmodics on labour in term pregnancies.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2013), the ProQuest dissertation and thesis database, the dissertation database of the University of Stellenbosch and Google Scholar (28 February 2013) and reference lists of articles. We also contacted pharmaceutical companies and experts in the field. We did not apply language restrictions.

SELECTION CRITERIA

Randomised controlled trials comparing antispasmodics with placebo or no medication in women with term pregnancies.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts and selected studies for inclusion, assessed risk of bias and extracted data. Data were checked for accuracy. We contacted trial authors when data were missing.

MAIN RESULTS

Twenty-one trials (n = 3286) were included in the review. Seventeen trials (n = 2617) were included in the meta-analysis. Antispasmodics used included valethamate bromide, hyoscine butyl-bromide, drotaverine hydrochloride, rociverine and camylofin dihydrochloride. Most studies included antispasmodics as part of their package of active management of labour. Overall, the quality of studies was poor, as only four trials were assessed as low risk of bias. Thirteen trials (n = 1995) reported on the duration of first stage of labour, which was significantly reduced by an average of 74.34 minutes when antispasmodics were administered (mean difference (MD) -74.34 minutes; 95% confidence Interval (CI) -98.76 to -49.93). Seven studies (n = 797) reported on the total duration of labour, which was significantly reduced by an average of 85.51 minutes (MD -85.51 minutes; 95% CI -121.81 to -49.20). Six studies (n = 820) had data for the outcome: rate of cervical dilatation. Administration of antispasmodics significantly increased the rate of cervical dilatation by an average of 0.61 cm/hour (MD 0.61 cm/hour; 95% CI 0.34 to 0.88). Antispasmodics did not affect the duration of second and third stage of labour. The rate of normal vertex deliveries was not affected either. Only one study explored pain relief following administration of antispasmodics and no conclusions can be drawn on this outcome. There was significant heterogeneity for most outcomes and therefore, we undertook random-effects meta-analysis. Subgroup analysis was undertaken to explore heterogeneity, but remained largely unexplained. Maternal and neonatal adverse events were reported inconsistently. The main maternal adverse event reported was tachycardia. No serious neonatal adverse events were reported.

AUTHORS' CONCLUSIONS

There is low quality evidence that antispasmodics reduce the duration of first stage of labour and increase the cervical dilatation rate. There is very low quality evidence that antispasmodics reduce the total duration of labour. There is moderate quality evidence that antispasmodics do not affect the rate of normal vertex deliveries. There is insufficient evidence to make any conclusions regarding the safety of these drugs for both mother and baby. Large, rigorous randomised controlled trials are needed to evaluate the effect of antispasmodics on prolonged labour and to evaluate their effect on labour in a context of expectant management of labour.

Hyoscine-N-butylbromide versus atropine as labour accelerant and analgesic: a randomized clinical trial

The aim of this study was to compare the efficacy of atropine and hyoscine-N-butyl bromide in reducing the pain and time length of the first stage of labour. In a single blind randomized clinical trial, 120 term pregnancies were enrolled from July 2009 to March 2011. A parallel design was used to randomly assign subjects into two equal groups including 60 participants in each group. Hyoscine-N-butylbromide was administered 40 mg intravenously in the first group and intravenous atropine was given in second group at a dose of 0.5 mg. The participants of the two trial arms were similar according to the distribution of background variables. The pain trend through the study follow up was found to be different between groups (p < 0.05). Mean length of the first stage of labor was 218.5 min (SD: 81.4) in hyoscine versus 339 min (SD: 83.3) in atropine group (p < 0.001). Mean 1st and 5th min APGAR score was similar in both groups. Drug side effects were less frequent in hyoscine group observed in 13 cases compared to atropine group observed in 56 cases (p < 0.001). Hyoscine appeared to be preferable to atropine specially in reducing the length of first stage of pregnancy.

Effect of hyoscine butylbromide first stage of labour in multiparus women

BACKGROUND

Prolonged labor is one of the most important risk factors for perinatal compromise and, if caused by obstructed labor, it carries the risk of uterine rupture, postpartum hemorrhage (PPH), puerperal sepsis, and maternal death.

OBJECTIVE

To determine whether or not hyoscine butylbromide shortens the stages of labor, without an increase in maternal or neonatal complications.

METHOD

In single-blinded randomized clinical trial study, 188 multiparas women in active phase of labor who were admitted to Shahid Sadoughi Hospital from October 2006 to April 2007 in Yazd - Iran, were evaluated. They were divided hyoscine group (n = 94) received 20mg (1ml) of hyoscine and control group (n = 94) received 1 ml of normal saline was given as placebo, intravenously. The effects of hyoscine in shortening labor time; and neonatal Apgar score was compared.

RESULTS

Duration of the first (mean± SD: 186.8 ± 125.6 minutes vs. 260.4 ± 120.9 minutes, p= 0.00 1) and second stage of labor (mean± SD: 20.0 ± 8.1minutes vs. 25.8 ± 9.4 minutes, p= 0.03) was shorter in hyoscine group. Frequency of cesarean section and mean of neonatal Apgar score at minutes of one and 5 were not different in both groups. No serious adverse events were seen in the two groups.

CONCLUSION

Injection of hyoscine in active phase of labor can be effective in shortening of labor without any adverse effect on mother and fetus.

Mifepristone vs. osmotic dilator insertion for cervical preparation prior to surgical abortion at 14-16 weeks: a randomized trial

BACKGROUND

Cervical preparation is recommended before second-trimester abortion. We investigated the use of a pharmacologic method of preparation, mifepristone, as compared to osmotic dilators for surgical abortions at 14-16 weeks.

STUDY DESIGN

This was a randomized, parallel-group study with concealed allocation. Women were allocated to receive osmotic dilators or mifepristone 200 mg orally 24 h prior to abortion. The study population was 50 women seeking surgical abortion at 14-16 menstrual weeks in a hospital-based abortion service. The primary outcome was the length of time to perform the procedure; the study had 80% power to detect a difference of more than 3 min in procedure time. Secondary outcomes included cervical dilation, side effects and acceptability.

RESULTS

The mean abortion time for the osmotic dilator group was 8.00 min [95% confidence interval (CI) 6.75-11.47], and that for the mifepristone group was 9.87 min (95% CI 8.93-11.36). Side effects of pain were more common in the osmotic dilator group.

CONCLUSION

Mifepristone did not increase the time for abortion by more than the prespecified margin (3 min). Women preferred mifepristone to osmotic dilators.

Antispasmodics for labour

BACKGROUND

Prolonged labour can lead to increased maternal and neonatal mortality and morbidity due to increased risks of maternal exhaustion, postpartum haemorrhage and sepsis, fetal distress and asphyxia and requires early detection and appropriate clinical response. The risks for complications of prolonged labour are much greater in poor resource settings. Active management of labour versus physiological, expectant management, has shown to decrease the occurrence of prolonged labour. Administering antispasmodics during labour could also lead to faster and more effective dilatation of the cervix. Interventions to shorten labour, such as antispasmodics, can be used as a preventative or a treatment strategy in order to decrease the incidence of prolonged labour. As the evidence to support this is still largely anecdotal around the world, there is a need to systematically review the available evidence to obtain a valid answer.

OBJECTIVES

To assess the effects of antispasmodics on labour in term pregnancies.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (2 September 2011), the ProQuest dissertation and thesis database, the dissertation database of the University of Stellenbosch (2 September 2011), Google Scholar (2 September 2011) and reference lists of articles. We also contacted pharmaceutical companies and experts in the field. We did not apply language restrictions.

SELECTION CRITERIA

Randomised controlled trials comparing antispasmodics with placebo or no medication in women with term pregnancies.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts and selected studies for inclusion, assessed risk of bias and extracted data. Data were checked for accuracy. We contacted trial authors when data were missing.

MAIN RESULTS

Nineteen trials (n = 2798) were included in the review. Fifteen trials (n = 2129) were included in the meta-analysis. Antispasmodics used included valethamate bromide, hyoscine butyl-bromide, drotaverine hydrochloride, rociverine and camylofin dihydrochloride. Most studies included antispasmodics as part of their package of active management of labour. Overall, the quality of studies was poor, as only four trials were assessed as low risk of bias. Eleven trials (n = 1507) reported on the duration of first stage of labour, which was significantly reduced by an average of 65.80 minutes when antispasmodics were administered (mean difference (MD) -65.80 minutes; 95% confidence Interval (CI) -92.32 to -39.28). Seven studies (n = 797) reported on the total duration of labour, which was significantly reduced by an average of 85.51 minutes (MD -85.51 minutes; 95% CI -121.81 to -49.20). Five studies (n = 632) had data for the outcome: rate of cervical dilatation. Administration of antispasmodics significantly increased the rate of cervical dilatation by an average of 0.55 cm/h (MD 0.55 cm/h; 95% CI 0.22 to 0.87). Antispasmodics did not affect the duration of second and third stage of labour. The rate of normal vertex deliveries was not affected either. Only one study explored pain relief following administration of antispasmodics and no conclusions can be drawn on this outcome. There was significant heterogeneity for most outcomes and therefore, we undertook random-effects meta-analysis. Subgroup analysis was undertaken to explore heterogeneity, but remained largely unexplained. Maternal and neonatal adverse events were reported inconsistently. The main maternal adverse event reported was tachycardia. No serious neonatal adverse events were reported.

AUTHORS' CONCLUSIONS

There is low quality evidence that antispasmodics reduce the duration of first stage of labour and increase the cervical dilatation rate. There is very low quality evidence that antispasmodics reduce the total duration of labour. There is moderate quality evidence that antispasmodics do not affect the rate of normal vertex deliveries. There is insufficient evidence to make any conclusions regarding the safety of these drugs for both mother and baby. Large, rigorous randomised controlled trials are needed to evaluate the effect of antispasmodics on prolonged labour and to evaluate their effect on labour in a context of expectant management of labour.

Laminaria tent versus Misoprostol for cervical ripening before surgical process in missed abortion

OBJECTIVE

To compare the efficacy of Laminaria tents with Misoprostol for cervical ripening before surgical process in missed abortion.

METHOD

In a prospective study, 70 women with missed abortion were assigned to have either insertion of a 3 mm intracervical Laminaria tent (n = 35) or vaginal Misoprostol 400 μg (n = 35) on the day prior to suction dilation and curettage (D/C). The women were interviewed just prior to the D/C with regard to pain, vaginal bleeding, and cervical dilator preference.

RESULT

Cervical dilation was greater in the Laminaria group but not significantly different from that in the Misoprostol group. However, additional cervical dilation before D/C was required in more patients in the Misoprostol group (45.7 vs 14.3%, P = 0.001). Women who received Laminaria reported significantly more pain at the time of insertion (62.8% in Laminaria group vs 22.8% in Misoprostol group) compared with women who received Misoprostol. Conversely, Misoprostol was associated with more nausea, vomiting, diarrhea and vaginal bleeding.

CONCLUSIONS

Laminaria tents are more effective cervical dilators than vaginal Misoprostol when inserted the day prior to suction D and C. Vaginal Misoprostol insertion is more comfortable, although it is associated with an increased risk of vaginal bleeding.

[The influence of patient-controlled epidural analgesia on labor progress and neonatal outcome]

AIM

The aim of the study was to check the influence of patient control epidural analgesia on labor progress and neonatal outcome.

MATERIAL AND METHODS

144 parturients were included into the clinical trial. In 73 cases patient control epidural analgesia was used and in 71 cases pethidine (meperidine) solution was given intravenously. Apgar score, umbilical artery pH, pain intensity the time of the first, second and third stage of labor the rate of episiotomy and uterine postpartum abrasions and the rate of caesarean sections and vaginal operative delivery were compared.

RESULTS

The time of the second stage of labor was significantly longer in the study group (40.99 vs 26.49 min, p- < 0.005), the neonatal outcome was comparable in both groups. There were no differences in the time of the first and the second stage of labor in primiparas and multiparas analyzed separately. Visual Analogue Score was lower in the study group (Ch(2)-12,48, p-0.25), especially in the subgroups of primiparas and multiparas.

CONCLUSIONS

Patient control epidural analgesia does not affect the time of the first and second stage of labor, oxytocin augmentation of labor may be the reason of that. This method is a more effective way of relieving labor pain. An increase of operative delivery is not observed after patient control epidural analgesia on condition that low doses and concentrations of analgesic drugs are used.

Cervical ripening prior to hysteroscopy: is the application of misoprostol useful?

Cervical dilatation has to be considered a fundamental step in operative hysteroscopy. Different methods are used to facilitate cervical dilatation. The aim of this review is to evaluate the efficacy of Misoprostol in cervical ripening prior to operative hysteroscopy through the evaluation of published studies. Initially designed for the treatment of peptic ulcers caused by non-steroidal anti-inflammatory drugs, misoprostol, a prostaglandin E1 analogue, is commonly used for medical abortion in the first and second trimesters, cervical priming before vacuum aspiration or dilation and curettage, induction of labor, and the prevention and treatment of postpartum hemorrhage. Misoprostol was licensed for oral administration, but a large number of clinical studies have reported that vaginal administration is more effective in cervical ripening. Misoprostol is effective in inducing an adequate cervical dilatation prior to an operative hysteroscopy. Vaginal administration could be necessary for all conditions where cervical ripening is difficult to perform. Patients given GnRH analogue therapy before hysteroscopy may benefit from the application of Misoprostol. However, its use in postmenopausal patients may not be efficacious. As far as the application of Misoprostol prior to diagnostic hysteroscopy is concerned, the number of patients that may find an advantage in the treatment is probably very small. Misoprostol has some important advantages, such as easy application, very low price, and greater acceptability by doctors and patients.

Regional versus IV analgesics in labor

AIM

The aim of this study was to compare combined spinal epidural (CSE), epidural (E) and IV pethidine analgesia and their effects on the mother, fetus, newborn and the labor course.

METHODS

This is a prospective parallel single blind study, where 60 women in active labor were recruited and were allocated to five subgroups to receive analgesia by different routes. The mother and the fetus were assessed. The results were recorded and compared using Visual Analogue Scale (VAS) and modified Bromage scale for motor block, in addition to other clinical findings.

RESULT

The duration of first stage of labor was significantly longer in the E group, compared with the CSE and IV pethidine groups. When the pain control achieved by CSE bupivacaine and lidocaine was compared with the corresponding epidural, it was found that the first technique achieved better pain control. Women who received pethidine had higher incidence of nausea and vomiting compared to those received CSE or E analgesia. There was no significant difference between the five groups with respect to other side effects.

CONCLUSION

Regional analgesia especially CSE using bupivacaine or lidocaine is a safe effective method for analgesia in labor with relative better efficacy of bupivacaine.

Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour

BACKGROUND

Slow progress in the first stage of spontaneous labour is associated with an increased caesarean section rate and fetal and maternal morbidity. Oxytocin has long been advocated as a treatment for slow progress in labour but it is unclear to what extent it improves the outcomes for that labour and whether it actually reduces the caesarean section rate or maternal and fetal morbidity. This review will address the use of oxytocin and whether it improves the outcomes for women who are progressing slowly in labour compared to situations where it is not used or where its administration is delayed.

OBJECTIVES

To determine if the use of oxytocin for the treatment of slow progress in the first stage of spontaneous labour is associated with a reduction in the incidence of caesarean sections, or maternal and fetal morbidity compared to situations where it is not used or where its administration is delayed.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2011) and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised controlled trials which compared oxytocin with either placebo, no treatment or delayed oxytocin in the active stage of spontaneous labour in low-risk women at term.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion, assessed risk of bias and extracted data. We sought additional information from trial authors.

MAIN RESULTS

We included eight studies in the review involving a total of 1338 low-risk women in the first stage of spontaneous labour at term. Two comparisons were made; 1) the use of oxytocin versus placebo or no treatment (three trials); 2) the early use of oxytocin versus its delayed use (five trials). There were no significant differences in the rates of caesarean section or instrumental vaginal delivery in either comparison. Early use of oxytocin resulted in an increase in uterine hyperstimulation associated with fetal heart changes. However, the early use of oxytocin versus its delayed use resulted in no significant differences in a range of neonatal and maternal outcomes. Use of early oxytocin resulted in a statistically significant reduction in the mean duration in labour of approximately two hours but did not increase the normal delivery rate. There was significant heterogeneity for this analysis and we carried out a random-effects meta-analysis; however, all of the trials are strongly in the same direction so it is reasonable to conclude that this is the true effect. We also performed a random-effects meta-analysis for the four other analyses which showed substantial heterogeneity in the review.

AUTHORS' CONCLUSIONS

For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernable difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.

Comparison of different preoperative sublingual misoprostol regimens for surgical termination of first trimester pregnancies: a prospective randomized trial

OBJECTIVE

To determine the appropriate dose of sublingual misoprostol administration before dilation and curettage (D&C) of the uterus in first trimester pregnancies.

STUDY DESIGN

Ninety nulliparous women who underwent surgical termination of first trimester pregnancy were analyzed prospectively. The first group (n = 30) received a single 200-microg dose, and the second (n = 30) and third (n = 30) groups were administered 2x 200 microg (400 microg) and 3 x 200 microg (600 microg) doses of misoprostol sublingually, respectively, with 1-hour intervals. The main outcomes evaluated were the degree of difficulty of cervical dilation, adverse effects of misoprostol according to dose administered, and participant satisfaction rate with the procedure.

RESULTS

The improvement in cervical dilation and the ease of the D&C procedure were more significant in the 600-microg misoprostol arm (p = 0.008). Because the prevalence and severity of the side effects of misoprostol were increased in a dose-dependent manner, the 400-microg arm was found to be the most efficient dose of the study with its high satisfaction rate (p < 0.001).

CONCLUSION

Premedication with misoprostol makes the D&C procedure easier by leading to cervical ripening. By sublingual route 400 microg of misoprostol regimen seems to be appropriate for planned first trimester surgical pregnancy termination under local anesthesia. Misoprostol should be administered only to select and hospitalized patients.

Cervical preparation for second trimester dilation and evacuation

BACKGROUND

Abortion during the second trimester of pregnancy accounts for 10-15% of abortions performed worldwide. Dilation and evacuation (D&E) is the preferred method of second-trimester abortion in most parts of the developed world. Cervical preparation is recommended for dilation and curettage (D&C) after 12 weeks gestation and is standard practice for D&E beyond 14 weeks gestation. Prostaglandins, osmotic dilators, and Foley balloon catheters have been used and studied as cervical preparation prior to second-trimester D&E. However, no consensus exists as to which cervical preparation method is superior with regards to safety, procedure time, need for additional dilation, ability to perform the procedure, or patient and provider acceptability. Despite the fact that the advent of osmotic dilation has improved the safety of the D&E procedure during the second trimester, it is unclear whether a certain type of osmotic dilator is superior to another or whether osmotic dilation with adjuvant prostaglandin is superior to osmotic dilation alone or to prostaglandins alone.

OBJECTIVES

This review evaluates cervical preparation methods for second-trimester surgical abortion with respect to differences in procedure time, dilation achieved, need for additional dilation, complications, ability to complete the procedure, patient pain scores, and patient and provider acceptability and satisfaction.

SEARCH STRATEGY

We searched for trials of cervical preparation prior to second-trimester D&E.

SELECTION CRITERIA

We included all randomized controlled trials that compared osmotic, mechanical, antiprogesterone, prostaglandin, or other medical agents of cervical preparation for second-trimester surgical abortion from 14-24 weeks of gestation.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors and data entry was verified by a third author. Mean difference and Peto Odds Ratio were calculated.

MAIN RESULTS

Osmotic dilators were found to be superior to prostaglandins with respect to cervical dilation throughout the second trimester and with respect to procedure time within the early second trimester. Addition of prostaglandins to osmotic dilators was not found to increase cervical dilation, except after 19 weeks gestation, however, no impact was seen on procedure time. Addition of Mifepristone to misoprostol was found to improve cervical dilation, yet increase procedure time and frequency of pre-procedural expulsions. Two-day cervical preparation was found to produce greater cervical preparation than one-day, but had no impact on procedure time. Serious complication rates or ability to complete the procedure did not differ significantly between any of the preparation methods reviewed.

AUTHORS' CONCLUSIONS

Cervical preparation with osmotic dilators and/or misoprostol before second-trimester D&E is safe and effective. Osmotic dilators appear to provide superior cervical dilation when compared to prostaglandins alone or when combined with prostaglandins, however this difference in cervical dilation does not appear to result in differences in procedure time or complication rates. There does not appear to be clear clinical benefit from two days of cervical preparation compared to one-day prior to second-trimester D&E below 19 weeks gestational duration. Mifepristone plus misoprostol was associated with high rates of pre-procedural expulsions and does not appear to be a useful method of cervical preparation before second-trimester dilation and evacuation. Same-day procedures appear to be a safe and reasonable option in the early second trimester, however, more research is needed to assess the effectiveness and safety of same-day procedures in the later second trimester.

A randomised controlled study comparing Drotaverine hydrochloride and Valethamate bromide in the augmentation of labour

OBJECTIVES

Cervical dilatation is a poorly understood process. Various drugs have been used to facilitate this process and reduce the duration of labour and thereby reduce feto-maternal complications. The present study is an attempt to compare and evaluate the efficacy of Drotaverine hydrochloride and Valethamate bromide in the process of cervical dilatation and labour augmentation.

STUDY DESIGN

A prospective randomised trial of 146 low-risk women in spontaneous labour was conducted. 49 women were given Drotaverine (Group 1), 49 women were given Valethamate (Group 2) and 48 women were given placebo (Group 3). At 4 cm of cervical dilatation, elective amniotomy was done and the injection was given intramuscularly, and repeated every hour for a maximum of three doses.

RESULTS

There was a statistically significant difference in the mean injection-delivery times (time from first injection to delivery of the baby), which was 183.2 min (SD 78.8) in the Drotaverine group compared to 206.5 min (SD 69.7) in the Valethamate group, and 245 min (SD 70.9) in the control group. The mean cervical dilatation rate (cm/h) was 3 (SD 1.4), 2.4 (SD 0.9) and 1.9 (SD 0.6) in groups 1, 2 and 3, respectively, and these differences were statistically significant. There were no statistically significant differences in the duration of second and third stage of labour. Transient side effects such as foeto-maternal tachycardia, flushing of the face and dryness of mouth were noted with Valethamate. A few patients complained of headache in the Drotaverine group.

CONCLUSIONS

Both Drotaverine and Valethamate appear to significantly help cervical dilatation and augment first stage of labour. But, Drotaverine is superior to Valethamate with fewer side effects.

Mifepristone for induction of labour

BACKGROUND

The steroid hormone, progesterone, inhibits contractions of the pregnant uterus at all gestations. Antiprogestins (including mifepristone) have been developed to antagonise the action of progesterone, and have a recognised role in medical termination of early or mid-trimester pregnancy. Animal studies have suggested that mifepristone may also have a role in inducing labour in late pregnancy.

OBJECTIVES

To determine the effects of mifepristone for third trimester cervical ripening or induction of labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register and reference lists of relevant papers (May 2009).

SELECTION CRITERIA

Clinical trials comparing mifepristone used for third trimester cervical ripening or labour induction with placebo/no treatment or other labour induction methods.

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. For this update, two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Ten trials (1108 women) are included. Compared to placebo, mifepristone treated women were more likely to be in labour or to have a favourable cervix at 48 hours (risk ratio (RR) 2.41, 95% confidence intervals (CI) 1.70 to 3.42) and this effect persisted at 96 hours (RR 3.40, 95% CI 1.96 to 5.92). They were less likely to need augmentation with oxytocin (RR 0.80, 95% CI 0.66 to 0.97). Mifepristone treated women were less likely to undergo caesarean section (RR 0.74, 95% CI 0.60 to 0.92) but more likely to have an instrumental delivery (RR 1.43, 95% CI 1.04 to 1.96). Women receiving mifepristone were less likely to undergo a caesarean section as a result of failure to induce labour (RR 0.40, 95% CI 0.20 to 0.80). There is insufficient evidence to support a particular dose but a single dose of 200 mg mifepristone appears to be the lowest effective dose for cervical ripening (increased likelihood of cervical ripening at 72 hours (RR 2.13, 95% CI 1.15 to 3.97). Abnormal fetal heart rate patterns were more common after mifepristone treatment (RR 1.85, 95% CI 1.17 to 2.93), but there was no evidence of differences in other neonatal outcomes. There is insufficient information on the occurrence of uterine rupture/dehiscence in the reviewed studies.

AUTHORS' CONCLUSIONS

There is insufficient information available from clinical trials to support the use of mifepristone to induce labour. However, the studies suggest that mifepristone is better than placebo in reducing the likelihood of caesarean sections being performed for failed induction of labour; therefore, this may justify future trials comparing mifepristone with the routine cervical ripening agents currently in use. There is little information on effects on the baby.

Is misoprostol safe for labor induction in twin gestations?

OBJECTIVE

To compare the safety and efficacy of intravaginal misoprostol to oxytocin for the induction of labor in twin gestations.

METHODS

All twin gestations that underwent induction of labor with misoprostol or oxytocin during a 4-year period were identified from the Mount Sinai obstetrical database. Only twins > or = 34 weeks with a vertex presenting twin A were included. Labor and delivery characteristics, maternal complications and neonatal outcomes were compared between the two groups.

RESULTS

Of 134 patients with twins, 57 initially received misoprostol and 77 received oxytocin. These groups had similar demographics, but women who received misoprostol had less cervical dilation (0.8 vs. 2.2 cm, p < 0.0001) and were less likely to be multiparous (19% vs. 44%, p = 0.003). There was a shorter length of induction to delivery (7.8 hours vs. 15.1 hours, p = 0.001) and a trend toward a lower cesarean section rate (16.9% vs. 31.6%, p = 0.06) in the oxytocin-only group. There were no cases of uterine rupture or maternal mortality in this series. There were no significant differences in neonatal outcomes between the two groups, but the sample size was underpowered to detect significant differences between the groups.

CONCLUSIONS

Misoprostol and oxytocin both appear to be safe and efficacious for use in inductions of labor in twins in this limited retrospective investigation. The safety of these agents with regard to neonatal outcomes should be confirmed by larger studies.

Cervical ripening before operative hysteroscopy in premenopausal women: a randomized, double-blind, placebo-controlled comparison of vaginal and oral misoprostol

OBJECTIVE

To compare the effectiveness of oral and vaginal misoprostol for preoperative cervical ripening in premenopausal women before hysteroscopic surgery.

DESIGN

Placebo-controlled, double blind, randomized trial.

SETTING

University hospital.

PATIENT(S)

Eighty-six premenopausal women eligible for operative hysteroscopy were recruited. Nine women were excluded from the study.

INTERVENTION(S)

Patients were randomly assigned to receive 400 microg of misoprostol orally (n = 39) or vaginally (n = 38), 10-12 hours before operative hysteroscopy.

MAIN OUTCOME MEASURE(S)

Extent of initial cervical width, percentage of patients requiring cervical dilatation, duration of cervical dilatation and surgical procedure, complications during procedure, and associated side effects.

RESULT(S)

Mean cervical widths in the vaginal and oral misoprostol groups after treatment were 7.3 +/- 1.6 mm and 6.0 +/- 1.5 mm, respectively, which was a statistically significant difference. Time required for cervical dilatation (98.6 +/- 88.7 s vs. 49.1 +/- 34.9 s) and duration of surgery (14.5 +/- 6 vs. 7.7 +/- 4.0 min) was statistically significantly shorter in the vaginal misoprostol group. The percentage of women with an initial cervical width of 9 mm was statistically significantly higher in the vaginal misoprostol group (36.8% vs. 5.1%). Uterine perforation occurred in two patients in the oral misoprostol group and in none in the vaginal misoprostol group. Side effects were comparable between the two treatment groups.

CONCLUSION(S)

Vaginal administration of misoprostol is more effective than the oral route for preoperative cervical ripening in premenopausal women.

Cervical preparation for second-trimester surgical abortion prior to 20 weeks of gestation

Roughly 11% of induced abortions in the United States are performed after 14 weeks of gestation, most commonly by dilation and evacuation (D&E). For a D&E procedure, the cervix must be dilated sufficiently to allow passage of operative instruments and products of conception without injuring the uterus or cervical canal. Preoperative preparation of the cervix reduces the risk of cervical laceration and uterine perforation. The cervix may be prepared with osmotic dilators, prostaglandin analogues, or both. Osmotic dilators currently available in the United States include Dilapan-S, Lamicel, and laminaria. Laminaria tents are made from dehydrated seaweed and require 12-24 h to achieve greatest dilation. The synthetic products, Dilapan-S and Lamicel, achieve maximum effect within 6 h. Dilapan-S achieves greater dilation than the others and, thus, requires fewer dilators to be placed but may be more difficult to remove. For same day procedures, Dilapan-S and Lamicel are preferable to laminaria. A single set of one to several dilators is usually adequate for D&E before 20 weeks of gestation. Additional sets over 1-2 days may be needed in challenging cases. Misoprostol, a prostaglandin analogue, is sometimes used instead of osmotic dilators; however, the data to support such use are limited. Misoprostol is inferior to overnight dilation with laminaria for cervical priming prior to D&E. Misoprostol use as an adjunct to overnight osmotic dilation is only marginally beneficial for priming beyond 16 weeks and does not truly demonstrate any benefit before 19 weeks of gestation. Limited data demonstrate the safety of misoprostol prior to D&E in patients with a uterine scar. The Society of Family Planning recommends preoperative cervical preparation to decrease the risk of complications when performing a D&E prior to 20 weeks of gestation. The three currently available osmotic dilators (laminaria, Lamicel, and Dilapan-S) are safe and effective for this use. Since no single protocol has been found to be superior, clinical judgment is warranted when selecting a method of preoperative cervical preparation.

The effect of hyoscine butylbromide on the first stage of labour in term pregnancies

OBJECTIVE

To determine whether hyoscine butylbromide shortens the first stage of labour, without an increase in maternal or neonatal complications.

DESIGN

Randomised, double-blinded, controlled trial.

SETTING

The Antenatal clinics and Labour and Delivery ward of the University Hospital of the West Indies, Kingston, Jamaica.

POPULATION

Women in spontaneous labour at term.

METHODS

Either drug or placebo was given intravenously once the women entered active labour.

MAIN OUTCOME MEASURES

The duration of the first stage of labour. Secondary outcomes included comparisons of the duration of the second and third stages of labour, blood loss at delivery, rate of caesarean section, and APGAR scores in the neonates between the two groups.

RESULTS

A total of 129 women yielded data for analysis. Of these, 69 women received the placebo and 60 received hyoscine butylbromide. The mean time for the first stage in the control group was 228 minutes, compared with 156 minutes in the drug group, representing a decrease of 31.7% (P = 0.001). There was no significant change in the duration of the second and third stages of labour, and no difference in blood loss or in APGAR scores. There was a slight (but statistically insignificant) increase in the caesarean section rate.

CONCLUSION

Hyoscine butylbromide is effective in significantly reducing the duration of the first stage of labour, and it is not associated with any obvious adverse outcomes in mother or neonate.

The experience of childbrith in first-time mothers who received narcotic analgesics during the first stage of labour

This research has focused on the birthing experience of first-time mothers who received the narcotic analgesic combination of Pethidine and Hydroxyzine during the first stage of labour. A qualitative research methodology was used to collect data. Unstructured interviews were held with first-time mothers to obtain accounts of their experience of childbirth. These narrations were audio-taped while the participants were still being cared for in the postnatal ward of the hospital where delivery took place. Nine interviews were conducted with first-time mothers who gave birth normally vaginally after a normal pregnancy and who received a narcotic analgesic in the first stage of labour. The transcribed interviews were analyzed using Tesch's method of descriptive analysis (in Creswell, 1994:115). Four themes with sub-themes emerged from the analysis. The participants reported on the physical experience of labour and described experiencing a lot of pain for which analgesics were given. They also described how these drugs dulled the pain but made them sleepy and unable to cooperate with the midwives. They described their emotional experiences, which included joy and happiness as well as anxiety, anger and despondence. They also reported that they were not sufficiently informed about labour and child-birth. In the last theme they described the methods they used to help them cope with labour including distracting techniques, leaning on a supportive person or praying. Guidelines to help midwives overcome these problems were developed.

Predicting a failed induction

BACKGROUND

A failed induction usually refers to failure to progress to the active phase of labour; however, there is no consensus regarding when an induction has failed.

AIMS

To investigate the factors (particularly length of latent phase) that may influence mode of birth for women undergoing Syntocinon induction of labour.

METHODS

A retrospective analysis of 978 nulliparous women undergoing Syntocinon induction of labour following artificial or spontaneous rupture of membranes was performed.

RESULTS

As the length of the latent phase increased, the likelihood of birth by caesarean section increased significantly (P < 0.001). After ten hours of Syntocinon administration, the 8% of women not in the active phase of labour had approximately a 75% chance of being delivered by emergency caesarean section and after 12 h the chance was almost 90%. Multivariate analysis also suggested an association between birth by caesarean section and use of prostaglandin gel (P < 0.001) or mechanical methods of cervical priming (P = 0.004), maternal height < 155 cm (P = 0.020) and cervical dilation prior to commencement of Syntocinon (P = 0.018).

CONCLUSIONS

It would seem reasonable to continue a Syntocinon infusion for at least ten hours in women undergoing induction who have yet to reach the active phase of labour ( 4 cm), and unclear benefit in continuing an induction beyond 12 h. The duration of latent phase is a helpful predictor of subsequent mode of birth.

Local Anesthetics and Mode of Delivery: Bupivacaine Versus Ropivacaine Versus Levobupivacaine

BACKGROUND

The influence of the labor epidural local anesthetic (LA) on mode of delivery has not been adequately studied. In this study, we sought to determine if there is a difference in mode of delivery among parturients who receive epidural bupivacaine, ropivacaine, or levobupivacaine.

METHODS

Nulliparous women at term requesting labor analgesia with a cervical dilation <5 cm were randomized to receive epidural bupivacaine, ropivacaine, or levobupivacaine. Analgesia was initiated with a bolus of 15 mL of 0.0625% of the assigned LA with fentanyl 2 microg/mL. Analgesia was maintained with an infusion of the same solution at 10 mL/h. The primary endpoint was the operative delivery rate (instrumental assisted vaginal delivery plus cesarean delivery).

RESULTS

Ninety-eight women received bupivacaine, 90 ropivacaine, and 34 levobupivacaine (before it was removed from the US market). There was no significant difference in the operative delivery rate (bupivacaine = 46%, ropivacaine = 39%, and levobupivacaine = 32%, P = 0.35) among groups. There was less motor block in the levobupivacaine group when compared with the ropivacaine and bupivacaine groups, P < 0.05. There was no significant difference in the duration of the first or second stage of labor, the total dose of LA received per hour of labor, or neonatal outcome among groups.

CONCLUSIONS

Bupivacaine, ropivacaine, and levobupivacaine all confer adequate labor epidural analgesia, with no significant influence on mode of delivery, duration of labor, or neonatal outcome.

Study of drotaverine on first stage of labour and pregnancy outcome

A prospective randomised study of 200 women with spontaneous onset of labour was carried out in 100 women who were given 40mg of drotaverine hydrochloride intravenously at > or = 3cm dilatation of the cervix, the other 100 were taken as control. The effects of the drug on the progress and outcome of labour were noted. The mean durations of active phase of labour in primigravida and multigravida were 148.9 minutes and 99.5 minutes in drotaverine group whereas in control group were 331.6 minutes and 227.9 minutes respectively. It was concluded that drotaverine is highly effective in reducing the duration of active phase of labour by hastening cervical dilatation, more effective when given in more dilated cervix than with less dilatation and more effective in multigravida than in primigravida. There was no interference with uterine contractility and no increase in operative delivery. It reduces the incidence of traumatic postpartum haemorrhage by reducing the incidence of cervical tear. It is a safe drug for the mother as well as for the baby.

Efficacy of patient-controlled epidural analgesia after initiation with epidural or combined spinal-epidural analgesia

BACKGROUND

The aim of the present study was to compare the efficacy of patient-controlled epidural analgesia after initiation with either epidural or combined spinal-epidural analgesia.

METHODS

Forty ASA I parturients at 37-42 weeks' gestation and cervical dilatation <6 cm were randomly allocated to receive either epidural analgesia (group EA) or combined spinal-epidural analgesia (group CSEA). Analgesia was initiated with a 7-mL epidural bolus 0.1% bupivacaine containing fentanyl 50 mug (group EA, n=20) or with intrathecal fentanyl 20 mug (group CSEA, n=20). In both groups, analgesia was provided by a 5-mL bolus on demand via PCEA with a 10-min lock-out interval and a 15-mL/h limit.

RESULTS

No significant differences were observed in the rate of cervical dilatation, delivery type or duration of delivery between the groups. The time to first analgesic demand was shorter in the CSEA than in the EA group. Total bupivacaine dose was comparable in both groups, but total fentanyl dose in group CSEA was significantly lower than that of group EA because of the initial dose used for the induction of EA and CSEA. The incidence of pruritus in group CSEA was significantly higher than in group EA.

CONCLUSION

Both regional analgesia techniques followed by demand-only PCEA provided efficient pain relief for labor without changing the duration of labor or rate of cesarean section.

Clinical practice evaluation of atosiban in preterm labour management in six European countries

OBJECTIVE

To evaluate the efficacy and safety of early administration compared with standard administration of atosiban, when predefined eligibility criteria were met.

DESIGN

A prospective, open-label, randomised clinical trial. Women were randomised to receive atosiban either immediately (early) or when specified criteria, in terms of duration/frequency of uterine contraction or status of cervical dilation/effacement, were fulfilled (standard).

SETTING

Carried out at 105 centres in six European countries.

POPULATION

Pregnant women admitted to hospital in threatened preterm labour between 24 and 34 weeks of gestation, comprising a subgroup of women enrolled in the Tractocile Efficacy Assessment Survey in Europe (TREASURE) clinical experience review.

MAIN OUTCOME MEASURES

Efficacy was defined as the successful delay of delivery with no alternative tocolytic agent for 48 hours.

RESULTS

More women in the early group remained undelivered at 48 hours with no alternative tocolytic agent compared with those who received atosiban when specified criteria were fulfilled (88.9 versus 76.1%; P = 0.03). Safety was comparable between the groups. There were no statistical differences in maternal, fetal or neonatal adverse events between the early and standard atosiban arms.

CONCLUSIONS

The use of atosiban was effective for the delay of preterm labour and presented no safety concerns irrespective of the time it was administered.

Effects of epidural analgesia using ropivacaine on the mother and the newborn during labor

OBJECTIVE

To evaluate the effects of epidural analgesia using 0.2% Ropivacaine on the mother, newborn and during labor.

METHODS

This study was conducted at the Zeynep Kamil Obstetric, Gynecology, and Pediatric Research and Training Hospital in Istanbul, Turkey, between July 2003 and April 2004. Eighty pregnant women of 37-41 weeks' gestation were enrolled in the study. Forty cases received epidural analgesia (group 1) and the control group composed 40 cases (group 2). Duration of labor, systolic and diastolic blood pressures at initial, 15th, 30th, 45th and 60th minutes, and number of breathing per minute, pulse rates, fetal heart rates and presence of motor block were recorded. Blood gas assessments from the umbilical cord, 1st and 5th minute Apgar scores were noted following the delivery. Way of delivery, adverse effects and complications of the epidural analgesia were recorded.

RESULTS

Mean age of the cases was 24.79 +/- 4.72 years. Duration between full cervical dilation and delivery (phase 2) was significantly longer in group 1 (p<0.01). Sixty minutes systolic arterial pressure was significantly lower in group 1 (p<0.05). In group 1, diastolic arterial pressures at 15th, 45th, 60th minutes (p<0.01) and 30th minute (p<0.05) were significantly lower when compared to the initial values. No significant differences were recorded in terms of breathing rates, umbilical cord CO2, O2, pH levels and Apgar scores between the 2 groups. The most common adverse effect of epidural analgesia was sedation (59%). The second dose of Ropivacaine was needed in 24 (61.5%) cases in group 1. In group 1, 29 (74.4%) patients expressed their pleasure as very good regarding the epidural analgesia.

CONCLUSION

Epidural analgesia, if administered by a specialist to a properly selected patient at proper time, leads to a comfortable delivery by relieving the pain. It can be performed safely after taking an informed consent.

Oral misoprostol for induction of labor in prelabor rupture of membranes (PROM) at term: a randomized control trial

OBJECTIVE

To compare the efficacy of two different dosages of oral misoprostol (50 and 100 microg) with control, in medical induction of labor for patients with prelabor rupture of membranes (PROM) at term.

METHODS

One hundred women with PROM at term were randomized to receive placebo (vitamin B6 50 mg, control), 50 microg (treatment group 1), or 100 microg (treatment group 2) of oral misoprostol every 4 h to a maximum of six doses. The main outcome measures included time interval from onset of PROM to delivery, duration of first stage of labor, and occurrence of vaginal delivery within 24 h from PROM.

RESULTS

The time intervals from PROM to delivery were significantly reduced in both treatment groups compared to control (control, 25.1+/-10.5 h; treatment group 1, 14.5+/-6.2 h; and treatment group 2, 13.0+/-6.1 h, p<0.0001 for both). The duration of the first stage of labor was significantly shortened only in treatment group 2 compared to control (3.3+/-2.5 versus 6.2+/-3.4 h, p=0.01). Of those who delivered vaginally (93% in treatment group 1 and 97% in treatment group 2), significantly more women delivered within 24 h of PROM in the treatment group compared to the control group (50%, p<0.05).

CONCLUSIONS

Oral misoprostol 50 microg every 4 h is safe, cheap, and as effective as 100 microg in reducing the PROM to delivery time interval and labor duration in primiparous women. The same effect is not observed in a multiparous group.

A double blind, randomized trial on augmentation of labour with a combination of intravenous propranolol and oxytocin versus oxytocin only

OBJECTIVE

To compare the combination of intravenous propranolol and oxytocin with oxytocin only in augmentation of labour.

STUDY DESIGN

A prospective randomized double-blind study in an obstetric department of a large university hospital in Finland. A total of 107 parturients with arrested first stage of labour owing to inadequate uterine contractility were randomized to receive intravenously once or twice a 2 mg dose of propranolol or placebo combined with oxytocin infusion. The main outcome measure was the effect of intravenous propranolol on the frequency of Caesarean section among parturients with arrested labour. The secondary outcome measures were the duration of labour, the required dosage of oxytocin, CTG readings, neonatal outcome and maternal and cord plasma levels of beta-adrenoceptor-binding component of propranolol. Categorial variables between the groups were compared using Chi square and Fisher's exact tests. Continuous variables were compared using the Mann-Whitney U-test and Student's t-test.

RESULTS

No reduction in Caesarean section rate was found in the propranolol group. Seventy-three percent of the parturients in the propranolol group and 85% in the placebo group had spontaneous vaginal delivery, RR=0.86 (95% CI 0.70-1.05). The percentage proportion of the augmented part of labour was significantly shorter in the propranolol group than in the placebo group. No differences in the required oxytocin dosage or CTG pathology were found between the groups. Propranolol was found to be safe for the neonates. The concentrations of its beta-adrenoceptor-binding component after a 2mg intravenous dose were quite similar in parturients and neonates at the time of delivery. The active drug component crossed placental barriers with an average neonate umbilical artery/parturient venous plasma ratio of 0.7. After a 4 mg dose the active drug concentrations in parturients were rather similar to those measured after 2 mg dose, whereas in neonates there were signs of drug accumulation. No picture could be obtained from the kinetics of the beta-adrenoceptor-binding component of propranolol from the data.

CONCLUSIONS

Propranolol (2 or 4 mg i.v.) combined with oxytocin, as treatment for arrested labour did not affect the Caesarean section rate compared with placebo plus oxytocin. The percentage proportion of the augmented part of labour was significantly shorter after propranolol. Propranolol was safe for the neonates and can be used as an additional medication among parturients with arrested labour.

[Epidural analgesia and the course of delivery in term primiparas]

OBJECTIVES

Epidural analgesia provides the most effective pain control during labor. Of great concern is its influence on the course of delivery and perinatal complications.

DESIGN

The aim of the study was to assess the effect of epidural analgesia on the course of delivery and perinatal outcome.

MATERIALS AND METHODS

609 deliveries among 1334 (323 women with epidural analgesia (53%) and 548 without epidural analgesia (47%)) met the following criteria: primipara, singleton, live pregnancy, > =37 weeks' gestation, cephalic presentation of a fetus, lack of contraindication for vaginal delivery. The incidence of instrumental deliveries and fetal distress, duration of the first, second and third stage of labor, perinatal outcome, perinatal complications and perinatal blood loss and were analyzed.

RESULTS

The incidence of fetal distress during second stage of labor was significantly higher in the epidural group (12.69 vs. 6.99%, P=0.02). The incidence of fetal distress during first stage of labor did not differ in both groups (10.53% vs. 8.74%, NS). Cesarean sections rate was similar in epidural and non-epidural group (17.7 vs. 18.2%, NS). Among vaginal deliveries duration of the first and second stage of labor was longer in epidural group (6.5+/-2.4 vs. 5.4+/-2.5 godz., P=0,000003 and 47.3+/-34.8 vs. 29.1+/-25.8 min., P=0.000003) and this was independent of period of time between onset of first stage of labor and epidural analgesia. Oxitocin use was significantly more frequent in the epidural group (20.6 vs. 10.3%, P<0.004). There were no statistically significant differences in the rates of instrumental vaginal deliveries, 1 and 5-minute Apgar scores, length of third stage of labor and perinatal blood loss in patients with and without epidural analgesia. Perinatal outcome did not depend on previous use of epidural analgesia or mode of analgesia for the operation in cesarean section subgroup.

CONCLUSION

Epidural labor analgesia is associated with slower progress of labor but has no adverse effect on perinatal outcome and perinatal complications.

Fear, pain and stress hormones during childbirth

AIMS

To investigate the course of fear, pain and stress hormones during labor, and the associations between fear, pain, stress hormones and duration of labor in nulliparous women with and without epidural analgesia (EDA).

METHOD

One day during gestation weeks 37-39, urinary and salivary samples were collected to measure catecholamines and cortisol. Hourly during labor, the participants answered the Delivery Fear Scale and a pain intensity scale, and urinary and salivary samples were collected to measure stress hormones.

RESULTS

The course of fear, pain and stress hormones differed throughout labor in women with and without EDA. Pain and cortisol increased throughout labor in women without EDA. Women who received EDA had more fear, but not more pain, before the administration of the EDA than women who did not receive EDA. Pain, fear and catecholamines decreased when women received EDA, but fear and pain increased again later in labor. Fear and pain correlated, as well as levels of fear in the different phases of labor. During phase one of labor epinephrine and duration of the phase were negatively correlated.

CONCLUSION

The course of fear, pain and concentrations of stress hormones differed, highly influenced by the administration of EDA. Fear and pain correlated more pronounced than stress hormones and fear, pain and duration of labor.

Efficacy of hyoscine-N-butyl bromide (Buscopan) suppositories as a cervical spasmolytic agent in labour

OBJECTIVE

To evaluate the efficacy and safety of hyoscine-N-butyl bromide (Buscopan) suppositories in the active phase of labour, i.e. once the labour is established.

METHODS

A non-randomised controlled prospective study was carried out on 200 women in labour. In the active phase of labour, at 3 cm or more cervical dilatation, 100 women were administered Buscopan via suppository and 100 women (control) were not given any drug.

RESULTS

The duration of first stage of labour was 123.86 +/- 68.89 (mean(+)-standard deviation) minutes in the study group and 368.05 +/- 133.0 min in the control group. These differences were statistically significant. There were no differences in the duration of the second and third stages of labour. There was no increased incidence of operative deliveries in the study group. No adverse effects were noted on the mother or fetus.

CONCLUSION

Hyoscine-N-butyl bromide (HBB, Buscopan) suppositories were highly effective in shortening the duration of the first stage of labour.

Phloroglucinol for acceleration of labour: double blind, randomized controlled trial

OBJECTIVES

To determine the effects of Phloroglucinol in acceleration of labour and its adverse effects on mother and foetus.

METHODS

A double blind randomized, placebo controlled trial was conducted on 100 patients in active phase of uncomplicated labour selected by convenient sampling. Patients were given Phloroglucinol or Placebo (distilled water) intravenously. Progress of labour was plotted on Partogram. Any adverse effects of the drug on mother and fetus were noted. Student's t-test was applied for statistical analysis.

RESULTS

In patients receiving Phloroglucinol there was a mean 34% reduction in duration of 1st stage of labour and a mean 23% reduction in 2nd stage as compared to Placebo group respectively. Blood loss >500ml was observed in 2% patients. Otherwise there were no adverse effects on mother or foetus.

CONCLUSION

Phloroglucinol shortens the duration of labour, is non toxic to both mother and fetus and does not cause primary post partum haemorrhage.

Meperidine for dystocia during the first stage of labor: A randomized controlled trial

OBJECTIVE

This study was undertaken to evaluate whether the administration of meperidine decreases the length of labor in patients with a diagnosis of dystocia during the first stage of labor.

STUDY DESIGN

Women with term singleton pregnancies who received a diagnosis of dystocia and required an active management of labor were randomly assigned to receive either 100 mg of meperidine or placebo. The primary outcome measure was length of labor.

RESULTS

Four hundred seven pregnant women were included. There were no significant statistical differences between meperidine and placebo groups in length of labor and operative delivery rates such as forceps and cesarean section by intention-to-treat analysis. Low Apgar scores, umbilical artery acidosis, and admission to neonatal care units were increased in the meperidine group.

CONCLUSION

Because of the absence of any benefits in patients with dystocia in labor and the presence of harmful effects on neonatal outcomes, meperidine should not be used during labor for this specific indication.

[Effects of Spasfon on course of labor]

OBJECTIVE

To observe the effects of Spasfon on improving dilatation of cervix and promoting the progression of labor.

METHODS

Ninety seven normal primiparae with cervical edema were randomly divided into Spasfon group (group A, n = 46) and atropine group (group B, n = 51) when the cervix dilated 2 - 3 cm. Group A was given 80 mg of Spasfon intravenously, and group B was injected atropine 0.5 mg into the cervix.

RESULTS

(1) The mean time period from drug administration to full dilation of the cervix was (3.1 +/- 0.3) h in group A, and (4.4 +/- 0.4) h in group B (P < 0.01). (2) The disappearance ratio of cervical edema 2 h after drug administration in group A was 95.6%, while in group B it was 90.2% (P > 0.05); the mean dilatation of cervix between the 2 hours in group A was (4.3 +/- 0.2) cm, while in group B it was (2.5 +/- 0.3) cm (P < 0.01). (3) There were no obvious side effects in group A. While eight women in group B complained of thirst and 22 women had increased heart rate accompanied with elevated baseline FHR, which all recovered in about 60 minutes. (4) Vaginal delivery rate in group A was 95.7%, and 90.2% in group B (P > 0.05). (5) There was no statistically significant difference in the color of amniotic fluid, suffocation state and weight of the newborns between the two groups (P > 0.05). (6) There was no statistically significant difference in postpartum hemorrhage between the two groups, either (P > 0.05).

CONCLUSION

Spasfon can effectively improve cervical dilatation during labor and it is well tolerated by both mother and newborn.

High and low dose oxytocin in augmentation of labor

OBJECTIVE

To compare the efficacy and safety of high dose oxytocin in the augmentation of labor.

METHOD

Two hundred pregnant women requiring augmentation of labor were randomly assigned to receive oxytocin by either a low dose protocol (1.5 microm/min initially, increased by 1.5 microm/min every 30 min) or a high dose protocol (4.5 microm/min initially, increased by 4.5 microm/min every 30 min).

RESULTS

High dose of oxytocin was associated with a significant shortening of labor 4 (1.10-10) vs. 6 (1-10) h, p<0.0001 without a significant difference in cesarean delivery rate, neonatal and maternal outcome.

CONCLUSION

The use of high dose oxytocin is associated with significantly shorter labor without any adverse fetal and maternal effects.

A randomized comparison of sublingual and vaginal misoprostol for cervical priming before suction termination of first-trimester pregnancy

This randomized trial compares the efficacy and side effects of sublingual and vaginal misoprostol for cervical priming before first-trimester pregnancy termination. One-hundred pregnant women between 6 and 12 weeks of gestation opting for termination of pregnancy by suction evacuation were included in this study. The women were randomly allocated into two groups. Group 1 received 400 microg of sublingual misoprostol and group 2 received 400 microg of vaginal misoprostol 2 h prior to suction evacuation. The abortion was carried out by suction evacuation using a Karman's cannula attached to an electrically operated suction machine under intravenous analgesia. Baseline cervical dilatation, duration of the procedure, operative blood loss, side effects and complications were noted in both groups. There was a significant difference between the sublingual and vaginal misoprostol groups with respect to mean cervical dilatation (8.6 mm vs. 6.8 mm, p < 0.05). However, the duration of the procedure (3.03 min vs. 3.16 min) and the amount of blood loss (29 mL vs. 31.2 mL) were not significantly different between the two groups. The women in the sublingual group experienced significantly more shivering and preoperative vaginal bleeding (68% vs. 56%, p < 0.05). None of the women in the two groups had either uterine perforation or excessive hemorrhage. In our study, sublingual misoprostol (400 microg) was significantly more effective in facilitating cervical dilation prior to surgical abortion than vaginal misoprostol.