Obstetric management and outcome of pregnancy in women with a history of caesarean section in the Netherlands

OBJECTIVE: To determine mode of delivery and occurrence of uterine rupture in women with a previous caesarean section (CS) in the Netherlands. MATERIALS AND METHODS: During a 1-year period 38 hospitals in the Netherlands registered prospectively mode of delivery, use of prostaglandins or oxytocin and occurrence of uterine rupture in all women with a previous CS. RESULTS: There were 4569 women with a previous CS. Trial of labour (TOL) was attempted in 71.7%, of whom 76.0% delivered vaginally. The vaginal birth after caesarean (VBAC)-rate was 54.4%. Forty-nine uterine ruptures occurred (1.1%), of which 48 occurred during a TOL (1.5%). There were four perinatal deaths (1.2/1000 TOL) and 3 hysterectomies (0.9/1000 TOL) related to the rupture. Use of prostaglandin E2 alone or combined with oxytocin was significantly associated with an increased risk of uterine rupture (OR 6.8, 95% CI 3.2-14.3, OR 4.8, 95% CI 1.6-14.6, respectively). The same held for augmentation with oxytocin (OR 2.2, 95% CI 1.04-5.0). CONCLUSION: The success rate of TOL was 76%, resulting in a VBAC rate of 54%. Uterine rupture occurred in 1.5% during a TOL, with a risk of perinatal death of 1.2 per 1000. The risk of uterine rupture increased significantly when labour was induced with prostaglandins alone or combined with oxytocin or when labour was augmented with oxytocin.     

Obstetric outcomes subsequent to intrauterine death in the first pregnancy

Objective  To compare obstetric outcomes in the pregnancy subsequent to intrauterine death with that following live birth in first pregnancy.
Design  Retrospective cohort study.
Setting  Grampian region of Scotland, UK.
Population  All women who had their first and second deliveries in Grampian between 1976 and 2006.
Methods  All women delivering for the first time between 1976 and 2002 had follow up until 2006 to study their next pregnancy. Those women who had an intrauterine death in their first pregnancy formed the exposed cohort, while those who had a live birth formed the unexposed cohort.
Main outcome measures  Maternal and neonatal outcomes in the second pregnancy, including pre-eclampsia, placental abruption, induction of labour, instrumental delivery, caesarean delivery, malpresentation, prematurity, low birthweight and stillbirth.
Results  The exposed cohort ( n = 364) was at increased risk of pre-eclampsia (OR 3.1, 95% CI 1.7–5.7); placental abruption (OR 9.4, 95% CI 4.5–19.7); induction of labour (OR 3.2, 95% CI 2.4–4.2); instrumental delivery (OR 2.0, 95% CI 1.4–3.0); elective (OR 3.1, 95% CI 2–4.8) and emergency caesarean deliveries (OR 2.1, 95% CI 1.5–3.0); and prematurity (OR 2.8, 95% CI 1.9–4.2), low birthweight (OR 2.8, 95% CI 1.7–4.5) and malpresentation (OR 2.8, 95% CI 2.0–3.9) of the infant as compared with the unexposed cohort ( n = 33 715). The adjusted odds ratio for stillbirth was 1.2 and 95% CI 0.4–3.4.
Conclusion  While the majority of women with a previous stillbirth have a live birth in the subsequent pregnancy, they are a high-risk group with an increased incidence of adverse maternal and neonatal outcomes.     

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.     

Pregnancy-associated plasma protein-A polymorphism and the risk of recurrent pregnancy loss

Pregnancy-associated plasma protein-A (PAPP-A)/insulin-like growth factor-binding protein-4 (IGFBP4) protease is a member of the metzincin family of metalloproteases, known as a sensitive biomarker of adverse pregnancy outcomes. Recently, a missense A/C (Tyr/Ser) polymorphism (dbSNP: rs7020782) in the PAPPA gene has been reported. To examine the association between recurrent pregnancy loss (RPL) and this polymorphism, a case-control study of 215 cases with two or more pregnancy losses (PLs) and 420 fertile controls was performed. Genotyping of the PAPPA polymorphism was determined by allelic discrimination using fluorogenic probes and the 5′ nuclease assay. Sixty-nine cases (32.1%) were heterozygous and 11 cases (5.1%) were homozygous for the C allele of PAPPA; the respective figures were 127 (30.2%) and 11 (2.6%) in the controls. Women carrying the C allele had a tendency to increased risk of RPL (AA genotype [reference]; AC genotype: odds ratio [OR], 1.17; 95% confidence interval [CI], 0.82–1.68; CC genotype: OR, 2.06; 95% CI, 0.87–4.90), but it was not significant. Women with three or more PLs had a similar tendency (AA genotype [reference]; AC genotype: OR, 1.04; 95% CI, 0.66–1.64; CC genotype: OR, 2.20; 95% CI, 0.82–5.91). The risk of RPL with at least one PL after 9 weeks’ gestation significantly increased in women carrying the C allele (AA genotype [reference]; AC genotype: OR, 1.54; 95% CI, 0.95–2.49; CC genotype: OR, 2.83; 95% CI, 1.00–8.05; AC + CC genotypes: OR, 1.65; CI, 1.04–2.62). This is the first report on the PAPPA gene polymorphism in women with RPL, demonstrating some association between the investigated polymorphism and the risk of RPL.     

Prediction of adverse outcome associated with vaginal misoprostol for labor induction

Objective: To identify predictors of adverse outcome in pregnant women at term receiving 50 μg of intravaginal misoprostol for labor induction. Study design: A prospective observational study was conducted of 720 pregnant women at term with an unfavorable cervix and a medical or obstetric indication for labor induction. All patients received 50 μg of intravaginal misoprostol every 4 h up to three doses. The primary outcome measure was “adverse outcome” defined as: neonatal death, fetal acidemia and emergent cesarean delivery performed for non-reassuring fetal heart rate tracings. A stepwise logistic regression analysis was used to identify predictors of adverse outcome. Results: Tachysystole (frequent uterine contractions) (odds ratio (OR), 3.7; 95% confidence interval (CI), 1.2–10.8) and fetal tachycardia (OR, 4.8; 95% CI, 1.4–16.2) were determined as significant predictors of adverse outcome. The specificity of the model was 94.2%, whereas the sensitivity was 20.4%. Conclusion: In the absence of tachysystole and fetal tachycardia, an uneventful delivery might be expected for women receiving 50 μg of intravaginal misoprostol.     

A randomised comparison of early versus late amniotomy following cervical ripening with a Foley catheter

Objectives Ripening of the cervix with a Foley catheter commonly results in cervical dilatation without contractions. We examined the outcome of labour in women who underwent induction of labour using a Foley catheter, followed by either 1. early amniotomy, or 2. augmentation of labour by oxytocin and late amniotomy
Design Prospective randomised clinical trial
Setting Labour and delivery ward of a university teaching hospital
Participants Pregnant women ≥38 weeks of a singleton gestation, who had had no prior caesarean section
Methods All women underwent cervical ripening using a Foley catheter. Following removal of the catheter, women were randomly assigned to either early (   n = 80  ) or late amniotomy (   n = 88  ).
Main outcome measures Comparison of mode of delivery and duration of labour between the two groups
Results The rate of caesarean section was significantly higher in the early amniotomy group compared with the late amniotomy group (25% vs 7.9%; relative risk 1.74; 95% CI 1.3 – 2.34). The increase in caesarean section rate was due primarily to dystocia (15% vs 3.3%; relative risk 1.8; 95% CI 1.32 – 2.45). When excluding caesarean deliveries, no significant difference was found in duration of labour between the groups (8.3 hours (3.8) vs 7.7 hours (2.9))
Conclusions In women who undergo cervical ripening with a Foley catheter, augmentation of labour by oxytocin followed by amniotomy during active labour results in a lower rate of caesarean delivery for dystocia     

Outcome of subsequent delivery after a previous early preterm cesarean section.

OBJECTIVE: To determine the vaginal birth after cesarean section (VBAC) rate and risk of uterine rupture in women with a previous early preterm cesarean section. METHODS: Women who delivered their first child by cesarean section between 26 and 34 weeks of gestation were included in a retrospective cohort study. Medical charts were reviewed for characteristics of the index pregnancy and delivery. Information of the subsequent delivery was obtained from the medical charts or from information of the attending gynecologist if the delivery was elsewhere. RESULTS: Two hundred and forty-six women were included: 131 (53.3%) women had a subsequent pregnancy, 64 (26.0%) had no subsequent pregnancy, and from 51 (20.7%) women no information could be obtained. Of the 131 women with a subsequent pregnancy, 93 (71.0%) underwent a trial of labor (TOL) and 80 (86.0%) achieved a vaginal delivery, resulting in a VBAC rate of 61.1%. One uterine rupture occurred with favorable neonatal outcome. The uterine rupture rate for the whole cohort was 0.8% (95% CI 0.02-4.0) and for the group of women undergoing a TOL 1.1% (95% CI 0.03-5.8). CONCLUSION: In this small series of women with a previous early preterm cesarean section the VBAC rate was high (61.1%) and the uterine rupture rate was 1.1%.     

Inflammatory bowel disease and preterm delivery

Objective: The present study investigates pregnancy outcome in women with IBD and examines the effect of pregnancy on the severity of IBD. Method: A case-control study comparing deliveries by mothers with IBD between January 1988 and January 2005 was performed. For every birth by a mother with IBD, four births by non-IBD mothers were randomly selected and adjusted for ethnicity and year of delivery. Result: During the study period there were 48 deliveries to patients with Crohn's disease and 79 deliveries to patients with ulcerative colitis. Higher rates of preterm delivery (< 37 weeks) were found among patients with IBD as compared to the controls (odds ratios (OR) = 2.2; 95% confidence interval (CI) = 1.3–3.8). This association remained significant after adjustment for labor induction and multiple gestations, using the Mantel–Haenszel technique (weighted OR = 2.1; 95% CI 1.3–3.5 and weighted OR = 2.0; 95% CI 1.2–3.5; P = 0.012; respectively). In addition, these patients had higher rates of fertility treatments (OR = 2.2; 95% CI = 1.1–4.4). Using a multivariate analysis, controlling for maternal age and fertility treatments, preterm delivery was seen to be significantly associated with IBD (adjusted OR = 2.0; 95% CI = 1.2–3.5). Perinatal outcomes, such as perinatal mortality, low Apgar scores, and congenital malformations, were comparable to the outcomes in the control group. Conclusion: Maternal IBD is an independent risk factor for preterm delivery. IBD is not associated with adverse perinatal outcome.     

Vaginal birth after caesarean section in a population with a low overall caesarean section rate

OBJECTIVE: To determine the clinical outcome of vaginal birth after caesarean section (VBAC) in a Dutch population with a low overall caesarean section (CS) rate of 6.5%. STUDY DESIGN: Prospective population based cohort study of 252 patients with a previous caesarean section (CS). Outcome parameters were trial of labour (TOL), success rate and VBAC rate. RESULTS: The TOL rate in the study cohort was 73%, success rate 77%, VBAC rate 56%. The reason for the previous CS influenced success rate. Complications, morbidity and mortality were not different between elective, emergency CS and TOL group, except for a higher incidence of haemorrhage more than 500 ml in the elective CS compared to the TOL group (29% versus 17%, relative risk (RR) 1.74 (1.15--2.34)). CONCLUSIONS: In this Dutch study the success rate is comparable to rate in US study reports. Increase of the VBAC rate can mainly be achieved by increasing the number of women attempting TOL.     

Induction of labour after a previous caesarean section: a retrospective study in a district general hospital.

A retrospective study was undertaken in a district general hospital to identify factors associated with vaginal delivery, as opposed to caesarean section, in women undergoing induction of labour after a previous caesarean section. The study was undertaken over 9 years (April 1994 - May 2003) and included patients in their second or subsequent pregnancy who had previously had one lower segment caesarean delivery and in whom labour had been induced. Records were extracted from a database and anonymised. Vaginal delivery after induction of labour was attempted in 81 patients of whom 64 (79.0%) subsequently delivered vaginally. There were few complications and no cases of uterine rupture. Two factors had a statistical significant relationship with vaginal birth after induction of labour; occipito-anterior position (OR 10.18, 95% CI 1.42 - 112.7, Yates corrected chi2; p = 0.001) and more than one previous birth (OR 4.76, 95% CI 1.28 - 21.67, p = 0.017). Other associations were explored but were not statistically significant. This paper contributes to the literature on factors associated with vaginal delivery after induction of labour and previous caesarean section, which may inform the selection of cases, and consequent success rates for vaginal delivery.     

Risk factors associated with preterm (<37+0 weeks) and early preterm birth (<32+0 weeks): univariate and multivariate analysis of 106?345 singleton births from the 1994 statewide perinatal survey of Bavaria

Objective: The study was conducted to identify medical, obstetrical and social risk factors associated with early preterm births (<32 + 0 gestational weeks). Study design: The Statewide Perinatal Survey of Bavaria is a collection of perinatal data from all Bavarian maternity units using a uniform numbered questionnaire. Data on 106 345 singleton births from the 1994 Survey were analysed using univariate and multivariate logistic regression analysis. Results: In the multivariate analysis, early preterm birth was associated with premature rupture of the membranes (odds ratio (OR) 1.6, 95% confidence interval (CI) 1.37-1.86), treatment for infertility (OR 1.7, 95% CI 1.19-2.34), previous induced abortion (OR 1.8, 95% CI 1.57-2.13), maternal age>35 years (OR 1.8, 95% CI 1.47-2.16), premature cervical dilatation (OR 2.3, 95% CI 1.86-2.94), a history of stillbirth (OR 3.2, 95% CI 2.13-4.83), a history of preterm birth (OR 3.3, 95% CI 2.45-4.48), maternal age <18 years (OR 3.4, 95% CI 2.03-5.61), malpresentation (OR 3.9, 95% CI 3.10-4.93), preeclampsia (OR 4.0, 95% CI 3.20-4.94), uterine bleeding (OR 5.0, 95% CI 4.08-6.02), preterm labour (OR 7.0, 95% CI 5.94-8.22), and chorioamnionitis (OR 22.3, 95% CI 17.40-28.66). Conclusion: These data identify a subgroup of women at an increased risk for early preterm birth and may benefit from an intensified prenatal care. Risk factors related to the obstetrical history, genital infections, preeclampsia and maternal age are the most relevant for early preterm birth.     

Impact of Audits and Multifaceted Intervention on Vaginal Birth After Caesarean: Secondary Analysis of the QUARISMA Trial

Objectives

This study estimated the effect that a multifaceted intervention aiming to improve the quality of obstetrical care and reduce Caesarean section (CS) had on the rate of vaginal birth after Caesarean (VBAC).

Rupture of the uterine scar during term labour: contractility or biochemistry?

OBJECTIVE: Vaginal birth after a prior low transverse caesarean section (VBAC) is advocated as a safe and effective method to reduce the total caesarean section rate. However, the risk of uterine rupture has dampened the enthusiasm of practising clinicians for VBAC. Uterine rupture occurs more frequently in women receiving prostaglandins in preparation for the induction of labour. We hypothesised that similar to the cervix, prostaglandins induces biochemical changes in the uterine scar favouring dissolution, predisposing the uterus to rupture at the scar of the lower segment as opposed to elsewhere. DESIGN: We tested aspects of this hypothesis by investigating the location of uterine rupture associated with prostaglandins and compared it with the sites of rupture in the absence of prostaglandins. SETTINGS: Two North American University Hospitals. POPULATION: Twenty-six women with a prior caesarean section, experiencing uterine rupture in active labour. METHODS: Retrospective review of all pregnancies complicated by uterine rupture at two North American teaching hospitals from 1991 to 2000. MAIN OUTCOME MEASURE: Site of the uterine rupture. RESULTS: Thirty-four women experienced rupture after a previous caesarean section with low transverse uterine incision. Ten of the women who ruptured (29%) received prostaglandins for cervical ripening (dinoprostone: n= 8 or misoprostol: n= 2) followed by either spontaneous contractions (n= 3) or oxytocin augmentation during labour (n= 7). In 16 women (47%), oxytocin alone was sufficient for the induction/augmentation of labour. Eight (23%) women ruptured at term before reaching the active phase of labour in the absence of pro-contractile agents or attempted VBAC. There were no differences among the groups in terms of age, body mass index, parity, gestational age, fetal weight or umbilical cord pH measurements. Women treated with prostaglandins experienced rupture at the site of their old scar more frequently than women in the oxytocin-alone group whose rupture tended to occur remote from their old scar (prostaglandins 90%vs oxytocin 44%; OR: 11.6, 95% CI: 1.2-114.3). CONCLUSION: Women in active labour treated with prostaglandins for cervical ripening appear more likely to rupture at the site of their old scar than women augmented without prostaglandins. We propose that prostaglandins induce local, biochemical modifications that weaken the scar, predisposing it to rupture.     

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.     

Caesarean delivery at full cervical dilatation versus caesarean delivery in the first stage of labour: comparison of maternal and perinatal morbidity

OBJECTIVE: To compare perinatal and maternal morbidity associated with caesarean sections performed in the first with that performed in the second stages of labour. PATIENTS AND METHODS: Comparative analyses between nulliparous women with singleton term pregnancies who had a caesarean section in the first stage of labour and those who had a second stage caesarean section were completed using standard statistical methods. A subgroup analysis, according to indication for caesarean section, was also performed. RESULTS: Of 627 women, 81% had caesarean delivery in the first stage and 19% had caesarean delivery in the second stage of labour. Women undergoing caesarean delivery at full cervical dilatation were 1.9 times more likely to have an augmented labour (95% CI 1.2-3.4, P < 0.001) and 2.8 times more likely to have epidural anaesthesia in labour (95% CI 1.5-5.2, P < 0.001) than those in the first stage. Compared with caesarean delivery in the first stage of labour, women undergoing caesarean delivery at full cervical dilatation were 4.6 times more likely to have composite intraoperative complications (95% CI 2.7-7.9, P < 0.001), 3.1 times more likely to have blood loss greater than 1,000 ml (95% CI 1.3-7.4, P = 0.01), and 2.9 times more likely to have a blood transfusion (95% CI 1.5-5.6, P < 0.001). The risk of neonatal morbidity was higher in first stage caesareans when they were performed for presumed fetal compromise (66.3 vs. 26.3%, P = 0.002), and lower when they were performed for failure to progress (18.4 vs. 42%, P = 0.02). CONCLUSION: Caesarean section in the second stage of labour is associated with a higher risk of maternal but not perinatal morbidity.     

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).     

Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care with standard hospital care

Objective To test whether a new community-based model of continuity of care provided by midwives and obstetricians improved maternal clinical outcomes, in particular a reduced caesarean section rate.
Design Randomised controlled trial.
Setting A public teaching hospital in metropolitan Sydney, Australia.
Sample 1089 women randomised to either the community-based model (   n = 550  ) or standard hospital-based care (   n = 539  ) prior to their first antenatal booking visit at an Australian metropolitan public hospital.
Main outcome measures Data were collected on onset and outcomes of labour, antenatal, intrapartum and postnatal complications, antenatal admissions to hospital and neonatal mortality and morbidity.
Results There was a significant difference in the caesarean section rate between the groups, 13.3% (73/550) in the community-based group and 17.8% in the control group (96/539). This difference was maintained after controlling for known contributing factors to caesarean section (OR=0.6, 95% CI 0.4–0.9,   P = 0.02  ). There were no other significant differences in the events during labour and birth. Eighty babies (14.5%) from the community-based group and 102 (18.9%) from the control group were admitted to the special care nursery, but this difference was not significant (OR 0.75, 95% CI 0.5-1.1,   P = 0.12  ). Eight infants died during the perinatal period (four from each group), for an overall perinatal mortality rate of 7.3 per 1000 births.
Conclusion Community-based continuity of maternity care provided by midwives and obstetricians resulted in a significantly reduced caesarean section rate. There were no other differences in clinical outcomes.     

Sweeping of the membranes is an effective method of induction of labour in prolonged pregnancy: a report of a randomized trial.

OBJECTIVE: To determine whether sweeping of the membranes is an effective method of induction of labour in women with prolonged pregnancy. DESIGN: Randomized controlled trial. SETTING: A district maternity hospital. SUBJECTS: 65 women attending an antenatal clinic; 33 randomized to sweeping of the membranes and 32 to a control group. MAIN OUTCOME MEASURE: Proportion of women achieving spontaneous labour. RESULTS: Spontaneous labour occurred more often in the sweeping of the membranes group than in the control group (25/33 (76%) vs 12/32 (38%); odds ratio (OR) 4.65; 95% confidence interval (CI) 1.75 to 12.31; P = 0.002). In addition a greater proportion of women in the sweeping group had a cervical dilatation of 4 cm or more at the first vaginal examination in the labour ward (16/33 (49%) vs 5/32 (16%); OR 4.39; 95% CI 1.56 to 12.32; P = 0.005). There were fewer maternal infections in the sweeping group (0/33 vs 4/32 (12%); OR 0.12; 95% CI 0.02 to 0.88; P = 0.04). There were no differences in the type of analgesia used in labour, the mode of delivery or neonatal outcome. CONCLUSIONS: Sweeping of the membranes is an effective method of induction of labour in women with prolonged pregnancy.     

Ultrasonographic occiput position in early labour in the prediction of caesarean section

OBJECTIVE: To investigate the value of ultrasonographically determined occiput position in the early stages of the active phase of labour, in addition to traditional maternal, fetal and labour-related characteristics, in the prediction of the likelihood of caesarean section. DESIGN: Prospective observational study. SETTING: District general hospital in the UK. POPULATION: Six hundred and one singleton pregnancies with cephalic presentation in active labour at term with cervical dilatation of 3-5 cm. METHODS: Transabdominal sonography to determine fetal occiput position was carried out by an appropriately trained sonographer immediately before or after the routine clinical examination by the attending midwife or obstetrician. MAIN OUTCOME MEASURE: Caesarean section. RESULTS: Delivery was vaginal in 514 (86%) cases and by caesarean section in 87 (14%). The fetal occiput position was posterior in 209 (35%) cases and in this group the incidence of caesarean section was 19% (40 cases), compared with 11% (47 of 392) in the non-occiput posterior group. Multiple regression analysis revealed that significant independent contribution in the prediction of caesarean section was provided by maternal age (OR 1.1, 95% CI 1.0-1.2), Afro-Caribbean origin (OR 2.4, 95% CI 1.2-4.6), height (OR 0.93, 95% CI 0.89-0.97), parity (OR 0.2, 95% CI 0.1-0.4), type of labour (OR 2.2, 95% CI 1.3-3.8), gestation (OR 1.4, 95% CI 1.1-1.7), fetal head descent (OR 0.6, 95% CI 0.4-0.9), occiput posterior position (OR 2.2, 95% CI 1.3-3.7) and male gender (OR 2.0, 95% CI 1.2-3.5). CONCLUSIONS: The risk of caesarean section can be estimated during the early stage of active labour by the sonographically determined occiput position, in addition to traditional maternal, fetal and labour-related characteristics.     

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.