Concurrent oxytocin with dinoprostone pessary versus dinoprostone pessary in labour induction of nulliparas with an unfavourable cervix: a randomised placebo-controlled trial

Objective  To compare concurrent oxytocin with dinoprostone pessary versus dinoprostone pessary in labour induction for nulliparas with an unfavourable cervix.
Design  A randomised double-blind study.
Setting  University Malaya Medical Centre, Malaysia.
Population  Nulliparas at term with intact membranes, Bishop score ≤ 6 and admitted for labour induction.
Methods  All women received 3 mg dinoprostone pessary for labour induction. Those randomised to the oxytocin arm received oxytocin infusion started at 1 mu/minute and doubled every 30 minutes to a maximum 16 mu/minute. Women assigned to placebo received identical volume of saline infusion. After 6 hours, infusion was stopped and vaginal reassessment performed to guide further management.
Main outcome measures  Primary outcome was vaginal delivery within 24 hours.
Results  Concurrent oxytocin infusion with dinoprostone pessary did not significantly increase vaginal delivery rate within 24 hours (48.6 versus 35.9%; P = 0.07, relative risk [RR] 1.4 [95% CI 1.0–1.9]). It reduced the requirement for repeat dinoprostone (37.1 versus 61.2%; P = 0.001, RR 0.61 [95% CI 0.45–0.81]) and improved maternal satisfaction with the birth process (median score of 3 versus 5 on a 10-point visual analogue scale, P = 0.007). Caesarean rates were not different (41.9 versus 44.7%, P = 0.52).
Conclusions  Labour induction with concurrent oxytocin infusion and vaginal dinoprostone could be considered for nulliparas with an unfavourable cervix. Larger studies are needed.     

Comparison of induction of labor with vaginal misoprostol plus oxytocin versus oxytocin alone in term primigravidae

Objective.?To compare the efficacy and complications of intravaginal misoprostol application before starting oxytocin infusion with oxytocin infusion alone for labor induction in term primigravidae pregnancies with low-Bishop score.

Methods.?This randomized study included 101 primigravidae women with singleton pregnancies >38 weeks and a Bishop score of <6. Group 1 (50 patients) received a 50-μg dose of intravaginal misoprostol, with an oxytocin infusion started 3?h later. Group 2 (51 patients) received only an oxytocin infusion for labor induction. The time from induction to delivery, the route of delivery and complications were analyzed.

Results.?The mean time from induction to delivery was 10.4?±?2.1?h in Group 1 and 13.7?±?3.4 in Group 2 (p?<?0.001). The rates of vaginal delivery, Apgar scores at 1st and 5th min, placental abruption, and postpartum hemorrhage were similar between the two groups.

Conclusion.?Intravaginal application of 50-μg misoprostol before starting oxytocin infusion is a more effective method of labor induction than oxytocin infusion alone in term primigravidae pregnant women with low-Bishop scores.     

Unsucessful labour induction in women with unfavourable cervical scores: predictors and management

BACKGROUND: Misoprostol fails to induce labour in 5-20% of women at term. AIM: To analyse possible predictors of unsuccessful induction with 50 microg vaginal misoprostol and effectiveness and the safety of intracervical Foley catheter application in induction failures. METHODS: An observational study was conducted on 1030 women with singleton, live fetuses, vertex presentation, > 34 weeks of gestation and Bishop score < 5. Induction of labour with 50 microg vaginal misoprostol repeated every 6 h was attempted. Women without regular uterine contractions and cervical changes at the end of 24 h were considered to be unsuccessful, and a transcervical Foley balloon catheter was placed and inflated with 50 mL saline. Possible predictors of induction failures were analysed via logistic regression analysis. Neonatal outcomes and vaginal delivery achieved after Foley catheter were also determined. RESULTS: Induction was successful in 918 cases (89.1%) and Foley catheter was placed in 112 (10.8%) women. Increasing gestational age in weeks (odds ratio [OR] 0.77, 95% confidence interval [CI] 0.68-0.88) and increasing Bishop score (OR 0.73, 95% CI 0.60-0.90) decreased the risk of failed induction. Failure rates were 16% (27/169) in post-term nulliparous women with Bishop score 相似文献   

High-dose compared with low-dose oxytocin for induction of labour of nulliparous women at term

Background: The optimal oxytocin infusion regimen to induce labour with the lowest caesarean section rate, instrumental delivery rate and length of active labour is unclear. We compared the effect of a low-dose to high-dose oxytocin regimen to induce labour.

Materials and methods: We conducted a retrospective study of nulliparous women induced at term in a single tertiary centre from 2009 to 2015. The oxytocin induction protocol changed from a high to low-dose regimen in November 2012, affording us the opportunity to compare outcomes 3 years prior to, and following the change in protocol. Main outcome measures were caesarean section rate, instrumental delivery rate and length of active labour.

Results: Four thousand eight hundred and eighty-five participants were included, 2211 were induced via the low-dose regimen, and 2674 using the high-dose regimen. There was no difference in caesarean section rate (adjusted OR 0.99; 95% CI 0.87–1.13) or instrumental delivery rates once adjusted for regional anaesthesia (adjusted OR 1.16; 95% CI 0.99–1.36) between the different regimens. Surprisingly, the length of labour was longer in the high-dose oxytocin group (adjusted mean difference 0.60?h; 95%CI 0.81–0.12). There were significantly more postpartum haemorrhage ≥1000?ml (10.5% versus 7.8%, p?p?=?.03) in the low-dose cohort. There were no differences in neonatal outcomes.

Conclusion: Outcomes between high- and low-dose oxytocin induction regimens are relatively comparable with similar caesarean section and instrumental delivery rates. Therefore, either regimen is acceptable for use for induction of labour.     

A comparison of orally administered misoprostol to intravenous oxytocin for labor induction in women with favorable cervical examinations

OBJECTIVE: The purpose of this study was to compare orally administered misoprostol with intravenous oxytocin infusion for labor induction in women with favorable cervical examinations (defined as a Bishop score of 6 or more). STUDY DESIGN: One hundred ninety-eight women with indications for labor induction and favorable cervical examinations were assigned randomly to receive oral misoprostol or oxytocin induction. Misoprostol, 100 mg, was administered every 4 hours up to 6 doses, or intravenous oxytocin was administered by standardized protocol. RESULTS: One hundred ten (55.6%) women received misoprostol; 88 (44.4%) received intravenous oxytocin. There was no statistically significant difference in the average interval from start of induction to vaginal delivery, being longer in the misoprostol group (789.4 +/- 510.2 minutes) than in the oxytocin group (654.0 +/- 338.2 minutes, P=.19, log-transformed data). Two women had tachysystole develop in each treatment group. More women in the misoprostol group experienced hyperstimulation (7/110, 6.4%) than in the oxytocin group (0/88, P=.02, Fisher exact test). Nine (8.1%) misoprostol-treated women and 8 (9.1%) oxytocin-treated women underwent cesarean deliveries (P=.82). There was a presumed uterine rupture in a misoprostol-treated multipara women. There were no statistically significant differences in neonatal outcomes between the groups. CONCLUSION: Oral misoprostol offers no benefit over intravenous oxytocin for labor induction in women with favorable cervical examinations. It is associated with a higher likelihood of uterine hyperstimulation and may increase the risk of uterine rupture.     

Reduction in caesarean delivery with fetal heart rate monitoring and intermittent pulse oximetry after induction of labour with misoprostol

Objective. To integrate intermittent fetal pulse oximetry (FPO) to intrapartum fetal assessment and reduce the rate of caesarean sections.

Methods. A randomised controlled trial using 37 weeks as a restriction point was conducted in 230 women induced with misoprostol. One hundred-fourteen were assessed with intermittent FPO plus fetal heart rate (FHR) monitoring (study group) and 116 were assessed with FHR monitoring alone (control group). The primary outcome measure was caesarean delivery rates. Secondary outcome measures included induction to delivery interval, number of emergency caesarean deliveries performed for fetal non-reassuring FHR patterns and neonatal outcomes.

Results. There was a reduction both in the overall caesarean deliveries (study n = 18, (15.7%); vs. control n = 31 (26.7%); p = 0.04), and the rate of caesarean deliveries performed for non-reassuring fetal status in the study group (study n = 11, (9.6%); vs. control n = 23 (19.8%); p = 0.03). Induction to delivery interval was similar in between the groups (759 ± 481 min in group 1; vs. 735 ± 453 min in group 2 respectively; p = 0.69).

Conclusion. Intermittent FPO in misoprostol induced deliveries decreases both total caesarean rate and the caesarean rate due to non-reassuring FHR patterns.     

Sublingual compared with vaginal misoprostol for labour induction at term: a randomised controlled trial

OBJECTIVE: To compare the efficacy and safety of 50 microg of sublingual misoprostol with 25 microg of vaginal misoprostol administered for labour induction at term.Design Double-blinded, randomised controlled trial.Setting University Hospital, Kaunas, Lithuania.Sample A total of 140 women at term with indications for labour induction.Methods Women were randomised to receive either 50 microg of sublingual misoprostol with vaginal placebo (n = 70) or sublingual placebo with 25 microg of vaginal misoprostol (n = 70) every 4 hours (maximum six doses).Main outcome measures The number of women delivering vaginally within 24 hours of labour induction.Results Fifty-eight women (83%) in the sublingual misoprostol group and 53 (76%) in the vaginal misoprostol group delivered vaginally within 24 hours [relative risk (RR) 1.1, 95% confidential interval (CI) 0.9-1.3]. However, the induction to vaginal delivery time was significantly shorter in the sublingual group (15.0 +/- 3.7 hours) compared with the vaginal group (16.7 +/- 4.1 hours, P = 0.03). The incidence of tachysystole was more than three-fold higher in the sublingual than in the vaginal group (14 versus 4.3%; RR 3.3, 95% CI 0.9-11.6), but this was not statistically significant. There were no significant differences in the incidence of hypertonus or hyperstimulation syndrome, mode of delivery, interventions for fetal distress or neonatal outcomes between the two groups.Conclusion A 50 microg of sublingual misoprostol 4 hourly for labour induction at term seems to have similar efficacy as 25 microg of vaginal misoprostol. Further studies on safety with larger numbers of women need to be conducted before routine sublingual misoprostol use in this setting.     

Start of induction of labour with oxytocin in the morning or in the evening. A randomised controlled trial

Objective  The objective of this study was to compare outcomes of induced labour with intravenous oxytocin with a start in the evening versus in the morning.
Design  Randomised controlled trial.
Setting  Labour wards of three hospitals in Amsterdam, the Netherlands.
Participants  Women with an indication for induction of labour with intravenous oxytocin.
Methods  Included women were randomized to either the evening group with a start of induction of labour at 21:00 hours, or the morning group with a start at 07:00 hours.
Main outcome measures  Primary outcome was duration of labour. Secondary outcomes were instrumental delivery rate, adverse neonatal outcome defined as an Apgar score below 7 after 5 minutes, number and indications of paediatric consults and neonatal admissions, duration of second stage, number of intrapartum infections and necessity of pain relief.
Results  We randomised 371 women. Mean duration of labour was not significantly different (primiparae: morning 12 hours and 8 minutes versus evening 11 hours and 22 minutes, P value 0.29; multiparae: morning 7 hours and 34 minutes versus evening 7 hours and 46 minutes, P value 0.70). There were no significant differences in instrumental deliveries rates, number of infections or patient satisfaction. Unexpectedly, neonatal outcome was better in women induced in the evening.
Conclusion  Induction of labour with intravenous oxytocin in the evening is equally effective as induction in the morning.     

PGE2 gel for enhancement of priming and induction of labour at term in patients with unfavourable cervix

Fifty women (25 nulliparae and 25 multiparae) with unfavourable cervix at term were enrolled in a clinical experiment to evaluate the safety and efficacy of the intracervical application of 0.5 mg PGE₂ gel for cervical softening and eventual induction of labour; duration of pregnancy (38–42 wk) was confirmed by ultrasonic records. Global analysis revealed 48 (96%) vaginal deliveries, 43 (86%) being spontaneous labour and 5 (10%) instrumentally assisted deliveries (forceps). Caesarean section was required in 2 cases (4%). Three patients, having registered no Bishop score (above 5) progress after the first treatment, went into labour upon the second application of PGE₂ gel. Mean induction-delivery time was 11 h 50 min for nulliparae and 7 h 50 min for multiparae. Mean ROM/amniotomy-delivery time was 5 h 59 min for nulliparae and 3 h 11 min for multiparae. Four neonates with initial Apgar scores below 7 registered immediately higher values after adequate reanimation manouvres.     

A comparison of two methods of labor induction with vaginal misoprostol

Objectives: To evaluate if labor induction with 50 μg of vaginal misoprostol twice per day is as effective as and safer than 100 μg used once per day. Methods: Misoprostol was used to induce labor in 204 consecutive pregnant women assessed as needing labor induction, 104 at the University Hospital of the West Indies in Kingston, Jamaica, and 100 at the Victoria Jubilee Hospital, also in Kingston. At the former institution the women were administered 100 μg of misoprostol once per 24 h and at the latter 50 μg every 12 h. The doses were repeated if there was no cervical change or if the woman was not in labor. Bishop scores were determined before initiation of induction and again 12 h later. Women's records were reviewed after 24 h to determine delivery outcome. Results: The indications for labor induction were similar in each group. There was no significant difference in the group demographics. In the group given 50 μg of misoprostol twice per day the mean time±S.D. from insertion of misoprostol to delivery was significantly shorter than in the other group (560.14±269.20 min vs. 729.90±471.65 min; P<0.01), and the percentage of women who were delivered within 12 h was higher (75% vs. 56.8%; P<0.002). There was no significant difference between the two groups in the rate of cesarean births, the need for oxytocin, or blood loss. Only two patients experienced uterine hyperstimulation, both in the group that had received 100 μg of misoprostol per day. There was no significant difference between the two groups in the birthweight of the neonates and in the number of neonates with Apgar scores less than 7 at 1 min and 5 min. There were, however, significantly fewer neonates who needed resuscitation (6% vs. 14.7%; P=0.04) and admission to the special care nursery (7% vs. 17%; P=0.03) in the group that had received 50 μg of misoprostol twice per day. Conclusions: A dose of 50 μg of misoprostol twice per day appears to be more efficient and safer than a dose of 100 μg once per day, but this may partially be due to weaknesses in the study design.     

Comparison of oral and vaginal misoprostol for induction of labor at term: a randomized controlled trial

OBJECTIVE: To compare the efficacy of oral with vaginal misoprostol for induction of labor at term. METHODS: One hundred and fifty-three pregnant women at term with indications for induction of labor and Bishop score < or = 6 were randomly assigned to receive misoprostol either 100 microg orally or 50 microg vaginally every 6 h for 48 h. Repeated doses were given until Bishop score > or = 8 was achieved or spontaneous rupture of membranes occurred. Those who were not in labor after 48 h had labor induced with amniotomy and oxytocin. The main outcome measure was induction to delivery time. RESULTS: The median induction to vaginal delivery time in the oral group (14.3 h) was not significantly different from that of the vaginal group (15.8 h). The median number of doses was also not significantly different in the oral group compared with the vaginal group. There was a significant higher incidence of uterine tachysystole in the vaginal group compared to the oral group (17.1% vs 5.3%, P = 0.032). There was no hyperstimulation in either group. There were no significant differences between the groups with respect to oxytocin augmentation, cesarean section rate, analgesic requirement, and neonatal outcomes. CONCLUSION: Oral administration of 100 microg misoprostol has similar efficacy to intravaginal administration of 50 microg misoprostol for labor induction with less frequent abnormal uterine contractility. 100 microg of misoprostol orally can be used as an alternative to the vaginal route for labor induction.     

Comparison of elastosonography and digital examination of cervix for consistency to predict successful vaginal delivery after induction of labor with oxytocin

Objective: To compare elastosonography and digital examination of cervix for consistency in the prediction of successful vaginal delivery.

Methods: A total of 64 pregnant women with the indication of induction of labor (IOL) were enrolled to the study. The uterine cervix is evaluated before and after the IOL with elastosonography and digital examination for consistency and sonography for length. Methods were compared in regard to the prediction of successful vaginal delivery.

Results: The median of gestational age was 41.00 (IQR?=?2.32). Out of 64 participants, 40 (62.5%) had vaginal delivery and 24 (37.5%) had cesarean delivery. The preinduction and postinduction elastosonographic indices were insignificant in delivery groups. The preinduction and postinduction evaluations of cervical consistency with digital examination were significant within vaginal delivery group (p?=?0.046), whereas it was insignificant within cesarean delivery group and between the delivery groups. The preinduction and postinduction Bishop scores were significant within vaginal delivery group (p?=?0.005), whereas it was insignificant within cesarean delivery group and between the delivery groups. Postinduction Bishop score was significant between the delivery groups.

Conclusion: Evaluation of cervix for consistency with either elastosonography or digital examination was found to be insignificant in prediction of successful vaginal delivery after IOL with oxytocin.     

A clinical and biochemical assessment of the use of oral prostaglandin E2 compared with intravenous oxytocin for labor induction in multiparous patients

Oral prostaglandin E₂ was compared with intravenous oxytocin for induction of labor in multiparous patients having relatively favorable induction features. The patients were randomly allocated into two treatment groups. There was no significant difference in outcome using these agents. It is suggested that oral prostaglandin E₂ therapy is a safe, rational, and more convenient alternative to using intravenous oxytocin for a considerable part of the routine obstetric work load. However, the fact that episodes of hypertonus may occur in labor induced with either oxytocin or prostaglandins administered by different routes indicates the necessity of cardiotocographic supervision of all labors.     

Induction of labour in nulliparous and multiparous women: a UK, multicentre, open-label study of intravaginal misoprostol in comparison with dinoprostone

Objective  To compare the efficacy and safety of a 25-microgram vaginal tablet of misoprostol (APL202) with dinoprostone (3-mg vaginal tablet) in cervical ripening and labour induction.
Design  A randomised, open-label, noninferiority, comparative study in two maternal populations.
Setting  Eighteen NHS study centres across the UK.
Population  Nulliparous or multiparous women with a singleton pregnancy eligible for induction of labour.
Methods  Women were randomised to receive either misoprostol, initially 25 micrograms (50 micrograms in nulliparous women with Bishop score ≤4) followed by 25 micrograms after 4 and 8 hours, or dinoprostone, initially 3 mg followed by 3 mg after 6 hours. Clinical noninferiority of misoprostol was defined as an absolute difference between treatments of no more than 10% for the primary outcome.
Main outcome measures  The number of vaginal deliveries achieved within 24 hours of labour induction. Maternal and fetal safety outcomes.
Results  A total of 626 women were randomised to misoprostol ( n = 318) or dinoprostone ( n = 308) treatment. The rate of vaginal deliveries achieved within 24 hours of induction did not significantly differ between the misoprostol and dinoprostone (43 versus 47%; 3.74% difference, 95% CI −3.58 to 11.05, respectively) treatment groups. The treatments were generally comparable for other secondary efficacy measures. Maternal and fetal adverse events were similarly distributed across the misoprostol and dinoprostone groups.
Conclusions  Low-dose misoprostol is efficacious in cervical ripening and labour induction and demonstrates a similar fetal and maternal safety profile to dinoprostone.     

Pre-induction sonographic assessment of the cervix in the prediction of successful induction of labour in nulliparous women

OBJECTIVE: To compare the efficacy of ultrasonographic cervical assessment with Bishop score before induction of labour in predicting the success of labour induction in nulliparous women. METHODS: This is a prospective study conducted in 138 women who underwent cervical assessment with transvaginal sonography followed by digital cervical assessment using Bishop score before induction of labour. Ultrasonographic parameters evaluated were cervical length, posterior cervical angle and funnelling were blinded to the managing physicians. Statistical analysis was carried out using Mann-Whitney test, chi2 test, receiver operating characteristics curves and logistic regression analysis. RESULTS: Induction of labour was successful in 106 (76.8%) of the women. Multiple logistic regression analysis demonstrated cervical length and posterior cervical angle assessed by transvaginal sonography as independent predictors of successful outcome after induction of labour. Neither Bishop score nor its individual parameters were found to be significant in the regression analysis. The area under the receiver operating characteristic curve for cervical length and posterior cervical angle was greater than that of the Bishop score in predicting a successful labour induction. The best cut-off point for the parameters in receiver operating characteristics curve was 3.0 cm for cervical length and 100 degrees for posterior cervical angle. Cervical length of 3.0 cm had a sensitivity of 84.9%, and a specificity of 90.6% and a posterior cervical angle of 100 degrees with 65% and 72%, respectively. CONCLUSIONS: Transvaginal sonographic assessment of cervical length and posterior cervical angle is better than conventional Bishop score in predicting successful labour induction in nulliparous women.     

Placement of laminaria tents does not improve time to delivery in patients undergoing second trimester labor induction with misoprostol

Objective.?We sought to determine whether placement of laminaria tents improve time to delivery compared with misoprostol alone in second trimester labor induction.

Methods.?We retrospectively reviewed all patients undergoing second trimester labor induction. Patients with ruptured membranes, abruption, cervical dilation and chorioamnionitis at presentation were excluded. Complications were defined as chorioamnionitis, retained placenta or other surgical procedures. Patients who received laminaria and vaginal misoprostol, 200?μg every 12?h, were compared to those who received misoprostol without laminaria.

Results.?Forty-three patients met inclusion criteria, 19 underwent induction with misoprostol alone and 24 with laminaria and misoprostol. The median times to fetal and placenta deliveries were 16.4 and 0.0?h in the misoprostol group, and 20.6 and 0.2?h in the laminaria group. There was no difference in complications. Post-hoc power analysis revealed >80% power to detect a difference in time to delivery of >12?h, and >90% power to detect a difference in time to placental delivery of ≥30?min.

Conclusions.?Placement of laminaria does not improve fetal or placental delivery times in patients undergoing second trimester pregnancy termination by labor induction.     

Maternal and perinatal outcomes in women with and without hypertensive syndromes submitted to induction of labor with misoprostol

Objectives: To determine maternal and perinatal outcomes according to the mode of delivery in normotensive and hypertensive women bearing a live, full-term fetus, who were submitted to labor induction with misoprostol. Methods: Retrospective cohort study. The endpoints were tachysystole, uterine hyperstimulation, indications for cesarean section, severe maternal morbidity, side effects, maternal death, 1st/5th minute Apgar, neonatal death, requirement for neonatal intensive care, and birth weight (grams). The chi-square or Fisher’s exact test was applied at a significance level of 5%. Risk ratios (RRs) and their 95% confidence intervals (95% CI) were calculated. Results: No significant differences were found in maternal outcome as a function of mode of delivery. First-minute Apgar score <7 was less common with vaginal deliveries in normotensive women (RR = 0.41; 95% CI: 0.18–0.90), this being the only significant difference in perinatal outcome. Conclusion: Maternal and perinatal outcomes were similar in hypertensive and normotensive women submitted to labor induction with misoprostol.     

Utility of misoprostol for labor induction in severe pre-eclampsia and eclampsia

OBJECTIVES: To determine the effectiveness and safety of misoprostol in severe pre-eclampsia and eclampsia patients with unripe cervix. METHODS: A prospective observational study was carried out in 135 severe pre-eclampsia and eclampsia patients who required termination of pregnancy at the Department of Obstetrics and Gynecology, Khulna Medical College Hospital, Khulna, Bangladesh during January 2002 to October 2003. Fifty micrograms of misoprostol was used every 4 h in cases of unripe cervix (Bishop score < or = 6) in severe pre-eclampsia and eclampsia patients. Maternal and perinatal outcome as well as any complications were recorded. RESULTS: In severe pre-eclampsia and eclampsia patients vaginal delivery occurred in 79.3 and 80.5% of cases, and cesarean section was performed in 20.6 and 19.4% of cases, respectively. The maximum required responsive dose was 50-150 microg. Oxytocin augmentation was required in 29.3 and 35% of cases, respectively. Induction to delivery time was median 8 h, interquartile ranges 4.2-8.2 h in the severe pre-eclampsia group, and median 9 h, interquartile ranges 6.8-12.5 h in the eclampsia group, and average hospital stay was 3.4 +/- 1.8 and 3.7 +/- 1.7 days, respectively. The only maternal complications were hyperstimulation which occurred in 6.8 and 5.1% of cases, respectively. Neonatal death occurred in five (11.3%) and eight cases (12.1%), respectively. CONCLUSION: Intravaginal misoprostol is well tolerated and very effective for the induction of labor in severe pre-eclampsia and eclampsia patients with unripe cervix.