Vaginal delivery after previous caesarean section for failure of second stage of labour

Objective To determine the outcome of subsequent labour in primiparous women after a caesarean section for delay in descent in the second stage of labour in cephalic presentations with or without trial of instrumental vaginal delivery.
Design Retrospective follow up study.
Setting Medical Centre Leeuwarden, The Netherlands.
Participants All primiparous parturients who delivered after prior caesarean section during the second stage of labour in the period 1986–1998.
Methods Data concerning the outcome of the first subsequent delivery were gathered from delivery notes and patients charts. The group of women was subdivided into those with or without trial of instrumental vaginal delivery during the previous labour.
Results Of 132 women, 29 (22%) underwent a planned repeat caesarean section. Of the 103 women who were allowed a trial of labour, 82 (80%) were successful in having a vaginal delivery, and 21 (20%) had a second caesarean section. Of the 74 women with a failed trial of instrumental delivery during the previous labour, 19 had a planned repeat caesarean section and 41 of the remaining 55 (75%) had a successful trial of labour.
Conclusions In women with a cephalic presentation who had an arrest of descent in the second stage of labour during their first delivery, the chances of vaginal delivery in their next pregnancy are high, even after a failed instrumented vaginal delivery, and a trial of labour can usually be pursued.     

A randomised controlled trial of early versus delayed oxytocin augmentation to treat primary dysfunctional labour in nulliparous women

Background  Oxytocin is widely used to speed up slow labour, especially in nulliparous women, but randomised trials, apart from one reported only in abstract, have been too small to exclude important effects.
Objective  To test the hypothesis that early use of oxytocin reduces the need for caesarean delivery.
Design  A randomised controlled trial.
Setting  Twelve obstetric units within the Northern and Yorkshire regions in the North East of England.
Participants  A total of 412 low-risk nulliparous women in spontaneous labour at term, who had been diagnosed with primary dysfunctional labour were recruited from January 1999 to December 2001.
Intervention  Immediate oxytocin administration (active group) or oxytocin withheld for up to 8 hours (conservative group).
Main outcome measures  Caesarean section and operative vaginal delivery rates. The length of labour measured from the time of randomisation to delivery. The rate of maternal Edinburgh Postnatal Depression Scale (EPDS) greater than 12 (major depression) within 48 hours of delivery.
Results  The caesarean section rates were 13.5% active versus 13.7% controls (OR 0.98, 95% CI 0.6–1.7). Operative delivery, 24.5% versus 30.9% (OR 0.73, 95% CI 0.5–1.1). The median (interquartile range) randomisation to delivery interval in the active group was 5 hours 52 minutes (3:57–8:28) and in the conservative group 9 hours 8 minutes (5:06–13:16) ( P < 0.001). The rate of EPDS >12 was 20% in the active arm versus 15% among controls (OR 1.26, 95% CI 0.7–2.2). There was one perinatal death in each group and no major differences in perinatal outcomes.
Conclusions  Among nulliparous women with primary dysfunctional labour, early use of oxytocin does not reduce caesarean section or short-term postnatal depression. However, it shortens labour considerably and may reduce operative vaginal deliveries.     

Early versus delayed oxytocin augmentation in nulliparous women with prolonged labour—a randomised controlled trial

Objective  To study the effects of early versus delayed oxytocin augmentation on the obstetrical and neonatal outcome in nulliparous women with spontaneous but prolonged labour.
Design  Randomised controlled study.
Setting  Two delivery units in Sweden.
Population  Healthy nulliparous women with normal pregnancies, spontaneous onset of active labour, a cervical dilatation of 4–9 cm and no progress in cervical dilatation for 2 hours and for an additional hour if amniotomy was performed due to slow progress.
Methods  Women ( n = 630) were randomly allocated either to labour augmentation by oxytocin infusion (early oxytocin group) or to postponement of oxytocin augmentation for another 3 hours (expectant group).
Main outcome measure  Mode of delivery (spontaneous vaginal or instrumental vaginal delivery or caesarean section) and time from randomisation to delivery.
Results  The caesarean section rate was 29 of 314 (9%) in the early oxytocin group and 34 of 316 (11%) in the expectant group (OR 0.8, 95% CI 0.5–1.4), and instrumental vaginal delivery 54 of 314 (17%) in the early oxytocin versus 38 of 316 (12%) in the expectant group (OR 1.5, 95% CI 0.97–2.4). Early initiation of oxytocin resulted in a mean decrease of 85 minutes in the randomisation to delivery interval.
Conclusion  Early administration of oxytocin did not change the rate of caesarean section or instrumental vaginal delivery but shortened labour duration significantly in women with a 2-hour arrest in cervical dilatation. No other clear benefits or harms were seen between early and delayed administration of oxytocin.     

Trial of labour after two or three previous caesarean sections

OBJECTIVE: To investigate the safety of a trial of labour (TOL) after two or three previous caesarean sections. STUDY DESIGN: Retrospective analysis of medical records of women with a history of more than one previous caesarean section who gave birth during a 10-year period (1988-1997) in two large university hospitals in The Netherlands. RESULTS: Women numbering 30,132 gave birth with a hospital caesarean birth rate of 14.8%. There were 246 women with a history of more than one previous caesarean section: 187 (76%) delivered by elective repeat caesarean section (ERCS); 59 (24%) had a trial of labour, of whom 49 (83%) had a vaginal birth. Three uterine ruptures occurred after previous lower segment caesarean sections without maternal or perinatal mortality related to the uterine rupture; only one rupture was during a trial of labour. In the study group there was no maternal mortality. Maternal morbidity did not differ between women with an elective repeat caesarean or a failed trial of labour. Perinatal mortality was not related to the mode of delivery. CONCLUSION: Elective repeat caesarean section is not the only answer to a woman with two or three previous caesarean sections. A trial of labour can be a safe option for a selected group of women.     

Randomised trial comparing a policy of early with selective amniotomy in uncomplicated labour at term

Objective To compare two management policies: rupture of the fetal membranes when women are in normal labour or leave them intact as long as feasible.
Setting The labour ward of a city university hospital.
Design Automated randomised clinical trial.
Participants 1540 women in uncomplicated term labour. Data on labour duration, blood loss, oxytocin use and fetal condition were collected from 1132 women. Some data from nulliparous women has been presented earlier by the UK Amniotomy Group.
Main outcome measures Duration of labour, Apgar score, fetal morbidity and maternal morbidity including perineal injury, mode of delivery, epidural rates and the total number of vaginal examinations in the first stage of labour after amniotomy.
Interventions Amniotomy at the next vaginal examination or amniotomy only if indicated. The median cervical dilatation at membrane rupture was 2 cm greater in the first group.
Results A policy of routine amniotomy in labour had no measurable advantage over selective amniotomy for parous women (difference = 4 min) but shortened labour in nulliparous women by 1 h (Mann-Whitney U test:   P < 0.05  ). There was a suggestion of a higher caesarean section rate (OR 1.9; 95% CI 0.9–3.5), and there were more vaginal examinations after membrane rupture in the group allocated routine amniotomy. There were no measurable differences in oxytocin use, fetal condition at birth, retained placenta rates, blood loss, pain or analgesia requirements.
Conclusion Routine amniotomy may shorten the first labour but not subsequent ones. There is a suggestion that routine surgical interference may be harmful by increasing the risk of caesarean section, and this agrees with data from other trials (common odds ratio 1.2; 95% CI 0.92–1.6).     

A randomised trial comparing low dose vaginal misoprostol and dinoprostone for labour induction

Objective   To compare vaginal misoprostol with dinoprostone for induction of labour.
Design   Randomised multicentre trial.
Setting   Labour wards of one university hospital and two teaching hospitals.
Population   Six hundred and eighty-one women with indication for labour induction at ≥36 weeks of gestation, singleton pregnancy and no previous ceasarean section.
Methods   Misoprostol (25 mcg, hospital-prepared capsule) in the posterior vaginal fornix, every four hours, maximum three times daily or dinoprostone gel (1 mg) every four hours. Oxytocin was administered if necessary.
Main outcome measures   Primary: 'adverse neonatal outcome' (5-minute Apgar score <7 and/or umbilical cord pH <7.15). Secondary: labour duration, mode of delivery and patient satisfaction.
Results   Three hundred and forty-one women received misoprostol and 340 dinoprostone. The median induction–delivery interval was longer in the misoprostol group compared with the dinoprostone group (25 versus 19 hours, P = 0.008). The caesarean section rate was lower in the misoprostol group: 16.1% versus 21%, but this difference was not statistically significant RR = 0.8 (95% CI 0.6–1.04). 'Adverse neonatal outcome' was found to be similar in both groups: 21% in the misoprostol and 23% in the dinoprostone groups. Significantly fewer neonates were admitted to NICU in the misoprostol group compared with dinoprostone 19% versus 26% (RR = 0.7, 95% CI 0.5–0.98).
Conclusions   Misoprostol in this dosing regimen is a safe method of labour induction. NICU admission rates were lower in the misoprostol group. No difference could be detected in patient satisfaction between groups.     

A multicentre randomised controlled trial comparing elective and selective caesarean section for the delivery of the preterm breech infant

Objective To determine the optimum mode of delivery for women in preterm breech labour at a gestational age of 26 to 32 weeks.
Design A multicentre randomised controlled trial. Setting Twenty-six hospitals in England, UK.
Participants Women with a singleton breech fetus in spontaneous preterm labour between 26 and 32 completed weeks of gestation, with no clear indication for a caesarean section or vaginal breech delivery.
Intervention Random allocation to either 'intention to delivery vaginally' or 'intention to deliver by caesarean section'.
Main outcome measures Perinatal mortality, neonatal morbidity, maternal morbidity and gestation at delivery.
Results The trial was closed after 17 months because of low recruitment, by which time substantial numbers of women had been in the eligible gestation period. Thirteen women from six hospitals were recruited. One infant, randomised to and delivered vaginally, was stillborn. Three fetal presentations were cephalic at delivery despite a diagnosis of breech presentation at trial entry. No formal statistical analysis was performed due to the small numbers.
Conclusions No conclusions about the optimum mode of delivery for women in preterm labour with a fetus presenting by the breech can be drawn from this trial. The low accrual rate was due to clinicians' reluctance to randomise eligible women, reflecting the circumstances and nature of the trial.     

Titrated oral misoprostol solution for induction of labour: a multi-centre, randomised trial

Objectives To determine the effects of titrated oral misoprostol solution, compared with vaginal dinoprostone.
Study design Open, randomised clinical trial.
Setting Academic hospitals in South Africa and Liverpool, UK.
Methods Women undergoing induction of labour after 34 weeks of pregnancy were allocated by randomised, sealed opaque envelopes, to induction of labour with titrated oral misoprostol solution, or two doses of vaginal dinoprostone (2mg) administered six hours apart. Failure to deliver within 24 hours of randomisation was the primary outcome on which the sample size was based. The data were analysed by intention-to-treat.
Results Six hundred and ninety-five women were randomly allocated: 346 to oral misoprostol and 349 to vaginal dinoprostone. There were no significant differences in substantive outcomes. Vaginal delivery within 24 hours was not achieved in 38% of women in the oral misoprostol group and 36% in the vaginal dinoprostone group (RR 1.08; 95% CI 0.89-1.31). The caesarean section rates were 16% and 20%, respectively (RR 0.80; 95% CI 0.58-1.11). Hyperstimulation with fetal heart rate changes occurred in 4% of women in the oral misoprostol group and 3% after vaginal dinoprostone (RR 1.32, 95% CI 0.59–2.98). The response to induction of labour in women with unfavourable cervices was somewhat slower with misoprostol when membranes were intact, and with dinoprostone when membranes were ruptured. There were no differences in neonatal outcome between the two groups.
Conclusions This new approach to oral misoprostol administration was successful in minimising the risk of uterine hyperstimulation, which has been a feature of misoprostol use for induction of labour, at the expense of a somewhat slower response in women with intact membranes and unfavourable cervices. Misoprostol is not registered for use in pregnant women, and further research is needed to confirm optimal and safe dosages.     

Vaginal delivery after two or more previous caesarean sections: is trial of labour contraindicated?

A retrospective study was conducted involving 308 patients with previous caesarean sections and current singleton pregnancy. All the women delivered at the University Teaching Hospital Zaria, after having been in established labour. The aim was to determine any significant maternal and fetal risk attributable to labour in patients with more than one previous caesarean which may mitigate against a trial of vaginal delivery. The study analysis involved a group of patients with one previous caesarean section compared with those with more than one (multiple) caesarean section who delivered vaginally or abdominally after having been in established labour. The results showed that there was no significant difference in maternal and perinatal mortality rates and perinatal morbidity rates between the two groups. The patients with multiple caesarean sections who failed to deliver vaginally had increased rates of postoperative pyrexia (18.7%), anaemia (23.4%) and blood transfusion (35.3%). The study showed that the risk of fatal outcome related to labour in patients with multiple caesarean sections was low and could be eliminated by careful patient selection and close intrapartum care. A positive review of policy towards a trial of vaginal delivery in multiple caesarean sections is therefore advocated in view of the advances in patient management in contemporary obstetric care. The gains in terms of patient compliance towards hospital care and supervised delivery will be considerable. A multicentre, prospective case-controlled trial will clearly define the risks attributable to this policy change.     

Elective or selective caesarean delivery of the small baby? A systematic review of the controlled trials

Objective To compare a policy of elective caesarean delivery with a policy of selective caesarean delivery for women in spontaneous preterm labour.
Design Systematic review of relevant randomised controlled trials.
Participants One hundred and twenty-two women from six trials.
Interventions Random allocation to 'intention to deliver by caesarean section' (elective caesarean policy), compared with 'intention to deliver vaginally' (selective caesarean policy).
Main outcome measures Actual use of caesarean delivery, low Apgar score, neonatal intubation, intracranial pathology, perinatal death, and major maternal complications.
Results One in six women in both groups were not delivered as allocated. Typical odds ratios for all adverse neonatal outcomes tended to favour the elective group, but for all outcomes studied the confidence intervals were wide and did not exclude clinically important hazards of the policy. The odds of serious maternal morbidity were increased in the caesarean section group (OR 6–2; 95% CI 1.3–30.1).
Conclusion A policy of elective caesarean delivery increases the risks of maternal morbidity, but it remains unclear whether these are offset by benefits for the infant.     

Caesarean section and subsequent fertility in sub-Saharan Africa

OBJECTIVE: To determine the impact of caesarean section on fertility among women in sub-Saharan Africa. DESIGN: Analysis of standardised cross-sectional surveys (Demographic and Health Surveys). SETTING: Twenty-two countries in sub-Saharan Africa, 1993-2003. SAMPLE: A total of 35 398 women of childbearing age (15-49 years). METHODS: Time to subsequent pregnancy was compared by mode of delivery using Cox proportional hazards regression models. MAIN OUTCOME MEASURES: Natural fertility rates subsequent to delivery by caesarean section compared with natural fertility rates subsequent to vaginal delivery. RESULTS: The natural fertility rate subsequent to delivery by caesarean section was 17% lower than the natural fertility rate subsequent to vaginal delivery (hazard ratio = 0.83, 95% CI 0.73-0.96, P < 0.01; controlling for age, parity, level of education, urban/rural residence and young age at first intercourse). Caesarean section was also associated with prior fertility and desire for further children: among multiparous women, an interval > or =3 versus <3 years between the index birth and the previous birth was associated with higher odds of caesarean section at the index birth (OR = 1.4, 95% CI 1.1-1.7, P= 0.005); among all women, the odds of desiring further children were lower among women who had previously delivered by caesarean section (OR = 0.67, 95% CI 0.54-0.84, P < 0.001). Caesarean section did not appear to increase the risk of a subsequent pregnancy ending in miscarriage, abortion or stillbirth. CONCLUSIONS: Among women in sub-Saharan Africa, caesarean section is associated with lower subsequent natural fertility. Although this reflects findings from developed countries, the roles of pathological and psychological factors may be quite different because a much higher proportion of caesarean sections in sub-Saharan Africa are emergency procedures for maternal indication.     

Vaginal delivery after one caesarean section in Nigerian women.

A total of 120 Nigerian women at term pregnancy with one previous caesarean delivery were studied between June 1988 and May 1993. Elective caesarean section was performed in 3 (2.5%). Vaginal delivery was achieved in 101 (86.5%) of those allowed a trial of labour. Intrapartum caesarean section was done in 16 (13.7%) cases. Rupture of the uterus occurred in 3 cases (2.6%) with perinatal loss of 2 babies. There was no maternal mortality. There was no significant correlation between vaginal delivery and birth weight, gestational age or initial indication for the primary caesarean section. It is concluded that trial of labour is safe after a previous caesarean section in selected patients.     

Aromatherapy in childbirth: a pilot randomised controlled trial

Objectives  We aimed to determine the feasibility of conducting a randomised controlled trial (RCT) on the use of aromatherapy during labour as a care option that could improve maternal and neonatal outcomes.
Design  RCT comparing aromatherapy with standard care during labour.
Setting  District general maternity unit in Italy.
Sample  Two hundred and fifty-one women randomised to aromatherapy and 262 controls.
Methods  Participants randomly assigned to administration of selected essential oils during labour by midwives specifically trained in their use and modes of application.
Main outcome measures  Intrapartum outcomes were the following: operative delivery, spontaneous delivery, first- and second-stage augmentation, pharmacological pain relief, artificial rupture of membranes, vaginal examinations, episiotomy, labour length, neonatal wellbeing (Apgar scores) and transfer to neonatal intensive care unit (NICU).
Results  There were no significant differences for the following outcomes: caesarean section (relative risk [RR] 0.99, 95% CI: 0.70–1.41), ventouse (RR 1.5, 95% CI: 0.31–7.62), Kristeller manoeuvre (RR 0.97, 95% CI: 0.64–1.48), spontaneous vaginal delivery (RR 0.99, 95% CI: 0.75–1.3), first-stage augmentation (RR 1.01, 95% CI: 0.83–1.4) and second-stage augmentation (RR 1.18, 95% CI: 0.82–1.7). Significantly more babies born to control participants were transferred to NICU, 0 versus 6 (2%), P = 0.017. Pain perception was reduced in aromatherapy group for nulliparae. The study, however, was underpowered.
Conclusion  This study demonstrated that it is possible to undertake an RCT using aromatherapy as an intervention to examine a range of intrapartum outcomes, and it provides useful information for future sample size calculations.     

Risk factors for uterine rupture and neonatal consequences of uterine rupture: a population-based study of successive pregnancies in Sweden

Objective  Uterine rupture is a rare but a catastrophic event. The aim of the present study was to explore the risk factors for uterine rupture and associated neonatal morbidity and mortality among a cohort of Swedish women attempting vaginal birth in their second delivery.
Design  Population-based cohort study.
Setting  Sweden.
Population  A total of 300 200 Swedish women delivering two single consecutive births between 1983 and 2001.
Methods  Swedish population-based registers were used to obtain information concerning demographics, pregnancy and birth characteristics, and neonatal outcomes. Logistic regression was used to analyse potential risk factors for uterine rupture and risk of neonatal mortality associated with uterine rupture. Odds ratios were used to estimate relative risks using 95% CI.
Main outcome measure  Uterine rupture and neonatal mortality in the second pregnancy.
Results  Compared with women who delivered vaginally in their first birth, women who underwent a caesarean delivery were, during their second delivery, at increased risk of uterine rupture (adjusted OR 41.79; 95% CI 29.73–57.00). Induction of labour, high (≥4000 g) birthweight, postterm (≥42 weeks) births, high (≥35 years) maternal age, and short (≤164 cm) maternal stature were also associated with increased risk of uterine rupture. Uterine rupture was associated with a substantially increased risk in neonatal mortality (adjusted OR 65.62; 95% CI 32.60–132.08).
Conclusion  The risk of uterine rupture in subsequent deliveries is not only markedly increased among women with a previous caesarean delivery but also influenced by induction of labour, birthweight, gestational age, and maternal characteristics.     

Maternal anthropometric risk factors for caesarean delivery before or after onset of labour

Objective  To quantify the effects of pre-pregnancy body mass and gestational weight gain, above and beyond their known effects on birthweight, on the risk of primary and repeat caesarean delivery performed before or after the onset of labour.
Design  Hospital-based historical cohort study.
Setting  Canadian university-affiliated hospital.
Population  A total of 63 390 singleton term (≥37 weeks gestation) infants with cephalic presentation.
Methods  We studied prospectively archived deliveries at the Royal Victoria Hospital in Montreal, Canada, from 1 January 1978 to 31 March 2001 using multiple logistic regression models to estimate relative odds of caesarean delivery.
Main outcome measure  Caesarean delivery, primary or repeat and before or after the onset of labour.
Results  Pregravid obesity (body mass index ≥30 kg/m²) increased the likelihood of primary caesarean delivery before (OR = 2.01, 95% CI 1.39–2.90) and after (OR = 2.12, 95% CI 1.86–2.42) the onset of labour. High net rate of gestational weight gain (>0.50 kg/week) increased the risk but only after labour onset (OR = 1.40, 95% CI 1.23–1.60). Among women with a previous caesarean, high weight gain modestly increased risk but only before labour (OR = 1.38, 95% CI 1.04–1.83), whereas obesity increased the risk of caesarean delivery both before (OR = 1.85, 95% CI 1.44–2.37) and after (OR = 1.96, 95% CI 1.11–3.47) labour onset. Increased risks of macrosomia accounted for the association between pregravid adiposity and repeat caesarean delivery performed after but not before the onset of labour.
Conclusions  Pregravid obesity increases the risk of caesarean delivery both before and after the onset of labour and both with and without a history of caesarean.     

Vaginal delivery following caesarean section-the use of oxytocin and prostaglandins.

Five hundred and twenty women with one previous caesarean section underwent a trial of labour in our department during the past five years. They were divided into three groups-those receiving oxytocin, those receiving prostaglandins, and those unstimulated who had spontaneous labour. The obstetric outcomes were compared. Rates of vaginal delivery in the three groups were 65%, 67% and 72%, respectively. No mother died and there were no cases of complete uterine rupture. Our results confirm similar reports that vaginal delivery after a previous caesarean section can be safely achieved in about two-thirds of patients. Serious complications are minimal when the use of oxytocin and prostaglandins is carefully monitored.     

An audit of trial of labour after previous caesarean section.

The first aim of the study was to assess the success rate of vaginal delivery after a trial of labour in women with history of caesarean delivery. The second, was to analyse the management used and suggest recommendations that might improve the outcome. The caesarean section rate in Tameside hospital, in the period of 1995 and 1996, was (11%), 20% of which were repeat caesarean sections Fifty-one per cent of those with a history of previous caesarean section were allowed a trial of labour. The success rate of vaginal delivery in cases allowed trial of labour was 70%. But, if we include the 49% of cases who had elective repeat caesarean section in the calculation, the success rate for vaginal delivery would drop to 36%. More than one previous caesarean section was the main indication for elective repeat caesarean section. The second most common indication was cephalopelvic disproportion based on X-ray pelvimetry. Other indications included pregnancy-induced hypertension, breech presentation and maternal request. The main indication for repeat emergency caesarean section was fetal distress. Other causes included failure to progress, cephalo-pelvic disproportion, tender scar, ante-partum haemorhage and one case of ruptured uterus.     

Vaginal birth after one previous caesarean section in a tertiary institution in Nigeria.

Vaginal birth after one previous lower segment caesarean section represents one of the most significant and challenging issues in obstetric practice. A 5-year retrospective study was carried out at the University of Benin Teaching Hospital between January 1999 and December 2003, to determine the incidence, the maternal and fetal outcome following vaginal delivery after one previous caesarean section with a view to evaluating its safety and efficacy. There were 5234 deliveries, with 395 cases of one previous caesarean section, giving an incidence of 7.5%. The incidences of emergency caesarean section, elective caesarean section and spontaneous vaginal delivery following trial of vaginal delivery were 34.7%, 9.4% and 48.1%, respectively. During the study period there were 1317 cases of caesarean section, giving an incidence of 25.2% caesarean section rate. The incidence of one previous section among all caesarean section births was 30%. The major morbidity following vaginal delivery was uterine rupture with an incidence of 1.5% and hysterectomy of 0.8%. Three of the uterine ruptures occurred before admission because the patients laboured at home. One maternal death occurred as a result of uterine rupture and postpartum haemorrhage, giving a maternal mortality ratio of 19/100,000 and a case fatality rate of 0.3%. The corrected perinatal mortality rate was 15.2/1000, mainly from obstructed labour, abruptio placenta and fetal distress. Both maternal and fetal mortalities from vaginal birth after one previous section were significantly less than the respective overall maternal and fetal mortality from the institution. The 1-minute apgar score of babies delivered by elective section was significantly (P < 0.001) higher than the apgar score of babies delivered by emergency section and vaginally. There was only one patient with wound dehiscence at elective section without associated perinatal death. Vaginal delivery following caesarean section is relatively safe. However, women in developing countries will continue to require counselling to counter the myths of aversion to operative delivery even at the expense of losing their lives. Our hospitals should have adequate monitoring equipment for high-risk pregnancies so that patients and their babies can be assured of survival.     

Vaginal delivery compared with caesarean section in early preterm breech delivery: a comparison of long term outcome

Objective To determine the optimum mode of delivery of the early preterm fetus in breech presentation.
Design Retrospective comparison of two cohorts of preterm breech fetus.
Setting Two tertiary care centres: at one centre the preferred management for preterm breech presentation was vaginal delivery; at the other centre, the preferred method was caesarean section.
Population All singleton infants delivered after breech presentation from 1984 through 1989, at a gestational age of 26 to 31 weeks. Those with lethal congenital abnormalities, placenta praevia, placental abruption, fetal death or fetal distress before the onset of labour were excluded.
Main outcome measures Survival without disability or handicap documented at two years corrected age. The influence of a number of relevant variables on this outcome was assessed by logistic regression analysis.
Results There was no difference in survival without disability or handicap between the centres (odds ratio 1.5, 95% CI 0.6–3.9 vaginal delivery compared with caesarean section). Survival without disability or handicap was positively influenced by increasing birthweight and corticosteroids > 24 h before birth, and negatively influenced by footling presentation.
Conclusion A policy of caesarean section for early preterm (26–31 weeks) breech delivery is not associated with increased survival without disability or handicap.     

Effects of early augmentation of labour with amniotomy and oxytocin in nulliparous women: a meta-analysis

Objectives To estimate the effects among nulliparae of early augmentation with amniotomy and oxytocin on caesarean delivery, and on other indicators of maternal and neonatal morbidity including transfusion, Apgar score < 7 at 5 minutes, and admission to the special care nursery.
Design Meta-analysis.
Methods Published studies were identified through manual and computerised searches. Two unpublished studies were identified through direct communication with the investigators. Twelve trials were identified which compared a policy of early labour augmentation including amniotomy followed by oxytocin with a less active form of management. Two methodologically unacceptable studies were excluded. Studies were grouped according to whether they admitted only women with abnormal progress (therapy trials: n = 3) or accepted women with normal labour (prevention trials: n = 7).
Results Unstratified analysis did not provide support for the hypothesis that early augmentation reduces the risk of caesarean section (typical odds ratio [OR] 0.9; 95% CI 0.7–1.1). The typical odds ratio for prevention trials was similar to that obtained in the unstratified analysis (typical OR 0.9, 95% CI 0.7–1.2). Although only a small number of women have been randomised in therapy trials, a trend toward a reduction in the rate of caesarean section with early intervention was seen in this group (typical OR 0.6,95% CI 0.2–1.4).
Conclusions Early augmentation does not appear to provide benefit over a more conservative form of management in the context of care of nulliparous women with mild delays in the progress of labour. In the context of established delay in labour, an active policy of augmentation may reduce the risk of caesarean section. However, only three small trials have been performed in this context, and they do not have adequate power to allow firm conclusions to be drawn.