Induction of Labour: Post-term Pregnancy and Term Prelabour Rupture of the Membranes—Evidence for Practice

Post-term pregnancy and prelabour rupture of the membranes at term are two common clinical problems in obstetric practice. Appropriate management of these situations has been controversial, and has centred on the choice between induction of labour, its timing and method, and expectant management. We now have the benefit of results from two large randomized trials, one involving only Canadian centres (post-term pregnancy), and the other trial, coordinated in Canada and involving centres in Canada and five other countries (term prelabour rupture of the membranes) which should help guide practice in these two important areas. The Post-term Trial results showed that a policy of induction was associated with a lower Caesarean section rate than a policy of expectant management, with no differences in perinatal mortality or morbidity. When the results of this trial are combined with all other trials in a meta-analysis, a policy of induction is associated with a significant reduction in perinatal mortality. The recently completed international trial on prelabour rupture of the membranes (Term PROM) showed no differences in serious neonatal infection or Caesarean section rates between a policy of induction of labour and expectant management, but maternal infection was reduced in the induction/oxytocin arm of the trial, and women viewed a policy of induction more positively than expectant management.     

Prelabour rupture of membranes at term: early induction of labour versus expectant management

Objectives: To compare expectant management with early induction of labour in pregnant patients with prelabour rupture of membranes at term and unfavourable cervix. Study design: A prospective, randomised study of 154 women with prelabour rupture of membranes at term of whom 80 had been managed expectantly, and 74 had undergone oxytocin induction at a rate of 2.5 mU/min. Digital examination was not performed before oxytocin infusion, and the first was delayed until 4 h (nulliparae), or 2 h (multiparae) of regular uterine contractions. Results: The mean period from rupture of membranes to delivery was significantly shorter in the induction group. The mean duration of labour was significantly shorter in the expectant group. Operative vaginal deliveries were more common in the induction group, and fetal distress was the most common cause of operative vaginal deliveries. The caesarean rates were low and similar in both groups. Maternal and neonatal infectious morbidity was similar and no difference was found in the length of hospitalisation. Conclusions: Expectant management in patients with ruptured membranes at term is safe and reduces the frequency of operative vaginal deliveries.     

A randomised trial of two expectant managements of prelabour rupture of the membranes at 34 to 42 weeks

Objective To compare obstetric and perinatal outcome between two different expectant managements in women with prelabour rupture of the membranes (PROM).
Design A randomised study.
Participants One thousand three hundred and eighty-five women with rupture of the membranes at 34 to 42 weeks without contractions.
Interventions Women without contractions 2 h after admission were randomised to early induction the following morning after PROM (early induction group) or induction two days later (late induction group). Women with contractions starting within 2 h after admission were included in the calculations as a short latency group. Digital examinations of the cervix were avoided until onset of active labour. Labour was induced with oxytocin in both groups if no spontaneous contractions occurred or if chorioamnionitis or fetal distress was detected.
Main outcome measures The frequency of spontaneous deliveries, operative deliveries, maternal and neonatal infections.
Results In nulliparous women, a higher rate of spontaneous deliveries was found in the late induction group (89%) compared with the early induction group (81%) (   P < 0.05  ). The ventouse extraction rate was 7% and 14% respectively (   P < 0.05  ). A low (2–4%) caesarean section rate was recorded and did not differ between the groups. Endometritis was detected in six women after delivery. Sixty-one children were treated with antibiotics, and no difference could be detected between the groups.
Conclusions A higher rate of spontaneous deliveries was found among nulliparous women with prolonged latency as compared with brief latency prior to induction. A protocol of no digital examination before labour was associated with infrequent maternal and fetal morbidity, regardless of latency.     

Induction of labour with a favourable cervix and/or pre-labour rupture of membranes

Premature rupture of membranes (PROM) occurs in 8% of term deliveries. In this situation labour induction with prostaglandins, compared with expectant management, results in a reduced risk of chorioamnionitis, neonatal antibiotic therapy, neonatal intensive care (NICU) admission, and increased maternal satisfaction. The use of prostaglandin is associated with an increased rate of diarrhoea and use of analgesia/anaesthesia. Compared with oxytocin, prostaglandin induction results in a lower rate of epidural use and internal fetal heart rate monitoring but a greater risk of chorioamnionitis, nausea, vomiting, more vaginal examinations, neonatal antibiotic therapy, NICU admission and neonatal infection. Women should be informed of the risks and benefits of each method of induction.Misoprostol is gaining increasing interest as an alternative induction agent. It appears to be an effective method of labour induction with term PROM. Further research is needed to identify the preferred dosage, route and interval of administration, and to assess uncommon maternal and neonatal outcomes.There has been limited research on the use of prostaglandins, including misoprostol, for induction of labour with a favourable cervix and intact membranes. Compared with intravenous oxytocin (with and without amniotomy), labour induction using vaginal prostaglandins in women with a favourable cervix (with and without PROM) results in a higher rate of vaginal delivery within 24 hours and increased maternal satisfaction. In women with a favourable cervix, artificial rupture of membranes followed by oral misoprostol has similar time to vaginal delivery compared with artificial rupture of membranes followed by oxytocin. Further research with prostaglandins, including misoprostol, is needed to evaluate other maternal and neonatal outcomes in women being induced with a favourable cervix.No form of prostaglandin induction in women with PROM or favourable cervix has proven clearly superior to oxytocin infusion.     

Misoprostol versus expectant management in premature rupture of membranes at term

OBJECTIVE: To compare the effectiveness of immediate induction of labour with vaginal misoprostol versus expectant management for 24 hours followed by oxytocin induction in women with premature rupture of membranes at term (term PROM). DESIGN: An open, randomised, controlled trial. SETTING: Public university hospital in Campinas City, Brazil. POPULATION: One hundred and fifty pregnancies, half of them allocated to each group. METHODS: Statistical analysis used Student's t test, the chi2 test, Fisher's exact test, survival analysis and risk ratio estimates with 95% CI. MAIN OUTCOME MEASURES: Latency period, recruitment to delivery period, period of hospitalisation, mode of delivery, contractility pattern, fetal wellbeing, labour and delivery complications, neonatal and maternal morbidity. RESULTS: Both groups had similar general characteristics, but the misoprostol group had a significantly shorter latency period (9.4 vs 15.8 hours), a shorter time interval from recruitment to delivery (18.9 vs 27.5 hours), a shorter period of maternal hospitalisation and a slightly higher proportion of alterations of contractility when compared with the expectant group. Caesarean section rates were 20% in the misoprostol group and 30.7% in the other. There were no differences between them regarding fetal wellbeing, complications during labour and delivery and neonatal or postpartum maternal morbidity. Within 24 hours, 44% of women had delivered in the expectant group against 73.3% in the misoprostol group. CONCLUSIONS: Immediate labour induction with misoprostol in cases of term PROM shortens the latency period, the total time between recruitment to delivery and the time of maternal hospitalisation, increasing the occurrence of alterations of contractility without any maternal and perinatal outcomes disadvantages.     

Postterm with favorable cervix: is induction necessary?

OBJECTIVE: To study the cesarean rate between expectant management and immediate induction in the otherwise uncomplicated postterm pregnancy with favorable cervix. STUDY DESIGN: A total of 249 women with uncomplicated pregnancies at 41 weeks plus 3 days (290 days) with favorable cervix (Bishop score > or =6) were randomized to either expectant management (n=125) or immediate induction of labor (n=124). The women in the induction group were sent to labor ward for induction by artificial rupture of membranes (ARM) and/or oxytocin infusion. The women with expectant management had nonstress test (NST) and amniotic fluid index (AFI) performed once a week and twice a week after 43 weeks of gestation until spontaneous labor. RESULTS: The cesarean rate was not different between expectant management and immediate induction (21.6% versus 26.6%; P=0.36). Ninety-five percent of the expectant group delivered within 1 week after enrollment, and all of them delivered within 9 days after randomization. Maternal and fetal complications in both groups were not different. There was also no difference in the mean birth weight (P=0.24) and the frequency of macrosomia (birth weight > or = 4000 g) between the two groups (P=0.23). CONCLUSION: Cesarean section rate between expectant management and immediate induction in the otherwise uncomplicated postterm pregnancy with favorable cervix was not different. Due to the very low adverse perinatal outcome, both expectant management and immediate induction are acceptable.     

Labour characteristics and uterine activity: misoprostol compared with oxytocin in women at term with prelabour rupture of the membranes

Objective To compare the labour pattern and uterine activity of oral misoprostol with oxytocin for labour induction in women presenting with prelabour rupture of membranes at term.
Design Prospective randomised study.
Setting Department of Obstetrics and Gynaecology, Queen Mary Hospital, Hong Kong.
Participants Eighty women presenting with prelabour rupture of membranes at term.
Methods The women were randomised to receive either 100 μg misoprostol orally every 4 hours to a maximum of three doses, or intravenous oxytocin infusion according to the hospital protocol. Intrauterine pressure transducers were inserted one hour before induction of labour in both groups of women. We compared the pattern of uterine activity, the induction-to-delivery interval, duration of labour, mode of delivery and neonatal outcome between the two groups.
Results Both oxytocin and oral misoprostol caused an increase in uterine activity within one hour of labour induction. Peak uterine activity was reached 6–8 h after oral misoprostol, with persistent effects, and 8–10 h after oxytocin, requiring continuous titration of medication. The duration of labour was significantly reduced in nulliparous women, but not in those who were multiparous in the misoprostol group. The induction-to-delivery interval, the mode of delivery and the perinatal outcome were similar for the two groups.
Conclusion Oral misoprostol caused earlier peak uterine activity, compared with oxytocin (6–8 h vs 8–10 h). Oral misoprostol was not only as effective as oxytocin in inducing labour in women at term with prelabour rupture of the membranes, but it reduced significantly the duration of labour in nulliparous women.     

A comparison of early and delayed induction of labor with spontaneous rupture of membranes at term

The management of women with spontaneous rupture of membranes at term in the absence of labor and with a cervix unfavorable for induction of labor is controversial. In this randomized study of 182 patients, we report the effects of delayed versus early induction of labor on maternal and neonatal outcome. Qualifying patients not in labor at 6 hours after spontaneous rupture of membranes were randomized to either immediate oxytocin induction (86 women) or expectant management with oxytocin induction at 24 hours if labor had not occurred spontaneously (96 women). The cesarean section rate did not differ between the two groups. Women in the delayed group had significantly longer hospitalization (P less than .003), and their infants were significantly more likely to receive antibiotics (P = .006). Infectious morbidity (positive cultures or x-ray-documented pneumonia) occurred in five of the neonates in the delayed group, all of whose mothers had an initial digital cervical examination, but in none of the neonates in the early group, a difference that did not reach statistical significance (P = .061). Five (28%) of 18 infants from the delayed group whose mothers had received an initial digital cervical examination became infected, compared with none of the 78 infants from the delayed group whose mothers did not have digital examinations (P less than .001). We conclude that there is no advantage to delaying induction of labor when women present at term with spontaneous rupture of membranes.     

Prelabor rupture of membranes at term: induction techniques

The clinical management of premature rupture of membranes (PROM) at term has been a matter of considerable controversy. Management options have included expectant management or induction of labor with oxytocin, dinoprostone (PGE2), or misoprostol. Early studies suggested that immediate oxytocin induction of labor might reduce maternal and neonatal infections while increasing risk for cesarean section. The definitive TermPROM study found no difference in neonatal infections between immediate and delayed induction with oxytocin and PGE2. However, neither PGE2 nor delayed induction resulted in fewer cesarean sections than immediate oxytocin. Misoprostol offers several theoretical advantages over oxytocin in the setting of PROM at term. However, randomized trials to date have found no significant advantage for misoprostol administration compared with other agents for women with PROM.     

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.     

Misoprostol for labor induction in women with term premature rupture of membranes: a meta-analysis

OBJECTIVE: To systematically review published data evaluating the comparative use of misoprostol with placebo/expectant management or oxytocin for labor induction in women with term (> or = 36 weeks of gestation) premature rupture of membranes. DATA SOURCES: PubMed (1966-2005), Ovid (1966-2005), CINAHL, The Cochrane Library, ACP Journal Club, OCLC, abstracts from scientific forums, and bibliographies of published articles were searched using the following keywords: premature rupture of membranes, misoprostol, labor induction, and cervical ripening. Primary authors were contacted directly if the data sought were unavailable or only published in abstract form. METHODS OF STUDY SELECTION: Only randomized controlled trials evaluating the efficacy and safety of misoprostol in comparison with placebo or expectant management (n = 6) and oxytocin (n = 9) published in either article or abstract form were analyzed and included in the meta-analysis. TABULATION, INTEGRATION, AND RESULTS: Studies were reviewed independently by all authors. Meta-analysis was performed, and the relative risks (RRs) were calculated and pooled for each study outcome. Misoprostol, compared with placebo, significantly increased vaginal delivery less than 12 hours (RR 2.71, 95% confidence interval [CI] 1.87-3.92, P < .001). Misoprostol was similar to oxytocin with respect to vaginal delivery less than 24 hours (RR 1.07, 95% CI 0.88-1.31, P = .50) and less than 12 hours (RR 0.98, 95% CI 0.71-1.35, P = .90). Misoprostol was not associated with an increased risk of tachysystole, hypertonus, or hyperstimulation syndrome when compared with oxytocin and had similar risks for adverse neonatal and maternal outcomes. CONCLUSION: Misoprostol is an effective and safe agent for induction of labor in women with term premature rupture of membranes. When compared with oxytocin, the risk of contraction abnormalities and the rate of maternal and neonatal complications were similar among the 2 groups.     

Prelabor rupture of the membranes at term: when to induce labor?

OBJECTIVES: To determine the significant predictors of clinical chorioamionitis and neonatal infection in patients with prelabor rupture of the membranes at term, and to apply this information to determination of optimal timing of labor induction. STUDY DESIGN: A retrospective case control series of women at > or =37 weeks' with prelabor rupture of the membranes. The study group consisted of women with evidence of maternal or neonatal infection. Controls had no evidence of infection. Three types of management were compared. (1) Immediate induction of labor, (2) expectant management up to 24 h followed by induction of labor if still necessary, or (3) expectant management for over 24 h. Univariate and multivariate analyses were performed by stepwise logistic regression (SPSS software package). The size of the study and the control groups was calculated for a 90% power with two sided P value of 0.05 in order to demonstrate an odds ratio of 2 for expectant management (two groups: early and late) versus immediate induction of labor (132 and 279 women in the study and the control groups, respectively). RESULTS: The rate of expectant management for over 24 h versus expectant management until 24 h followed by induction of labor when still necessary, was higher among cases than among controls ( OR = 1.84; P < 0.017; 95% CI, 1.127-3.003). Conversely, the rate of immediate induction of labor versus expectant management until 24 h followed by induction of labor when still necessary, was also higher among cases ( OR = 2.66; P < 0.001; 95% CI, 0.222-0.644). CONCLUSION: In women with prelabor rupture of the membranes at term, the best approach is to induce labor if spontaneous labor has not begun after 24 h.     

Interleukin-18 in cervical mucus and amniotic fluid: relationship to microbial invasion of the amniotic fluid,intra-amniotic inflammation and preterm delivery

Objective To evaluate the relationship between interleukin (IL)-18 in cervical mucus and amniotic fluid and microbial invasion of amniotic fluid, preterm delivery and intra-amniotic inflammation in women in preterm labour, with preterm prelabour rupture of membranes and at term.
Design A prospective follow up study.
Setting Sahlgrenska University Hospital, Göteborg, Sweden.
Sample Women with singleton pregnancies (  <34 weeks  ) presenting with preterm labour (   n = 87  ) or preterm prelabour rupture of membranes (   n = 47  ) and women, not in labour, at term (   n = 28  ).
Methods Amniotic fluid was retrieved transabdominally. Cervical mucus was taken from the uterine cervix of women in preterm labour and at term. IL-18 was analysed with enzyme-linked immunosorbent assay.
Main outcome measures IL-18 in relation to microbial invasion of the amniotic fluid, delivery within seven days or  <34 weeks  of gestation and intra-amniotic inflammation.
Results The levels of IL-18 in cervical mucus and amniotic fluid were higher in women with preterm labour than in those not in labour at term. In the preterm labour group, significant associations were found between elevated IL-18 in amniotic fluid and microbial invasion of the amniotic fluid, as well as between delivery within seven days or  <34 weeks  of gestation and intra-amniotic inflammation. Delivery was delayed longer in the preterm prelabour rupture of membranes subgroup with  IL-18 ≥1.0 ng/mL than in that with IL-18 <1.0 ng/mL  .
Conclusions In the preterm labour group, high IL-18 in amniotic fluid (but not in the cervix) was associated with microbial invasion of the amniotic fluid, intra-amniotic inflammation and prompt delivery. On the other hand, elevated IL-18 in preterm prelabour rupture of the membranes group correlated with a longer interval to delivery.     

Induction of labour for women with a previous Caesarean birth: a systematic review of the literature

AIMS: To compare the benefits and harms of planned elective repeat Caesarean section with induction of labour and to assess different methods of cervical ripening and induction of labour for women with a previous Caesarean birth who require induction of labour in a subsequent pregnancy. METHODS: The Cochrane controlled trials register and MEDLINE (1966-current) were searched using the following terms: vaginal birth after C(a)esare(i)an, trial of labo(u)r, elective C(a)esare(i)an, C(a)esare(i)an repeat, induction of labo(u)r, prostaglandins, prostaglandin E(2), misoprostol, prostaglandin E(1) analogs, mifepristone, oxytocin, Syntocinon, randomis(z)ed controlled trial, randomis(z)ed trial and clinical trial, to identify all published randomised controlled trials with reported data comparing outcomes for women and infants who have a planned elective repeat Caesarean section with induction of labour; and different methods of induction of labour, where a prior birth was by Caesarean section. RESULTS: There were no randomised controlled trials identified where women with a prior Caesarean birth, whose labour required induction in a subsequent pregnancy, compared elective repeat Caesarean section with induction of labour. There were three randomised controlled trials identified in which women with a prior Caesarean section were allocated to different methods of induction of labour - vaginal prostaglandin E(2) versus intravenous oxytocin; mifepristone versus placebo; and vaginal misoprostol versus intravenous oxytocin. These studies varied considerably in the methods used and meta-analysis was not appropriate. CONCLUSIONS: There is a paucity of safety information for induction of labour agents in the women with a scarred uterus, and caution should be exercised in their use.     

Symptoms and Signs with Scar Rupture - Value of Uterine Activity Measurements

To evaluate the symptoms and signs of scar rupture with special reference to intrauterine pressure measurement a retrospective analysis of labour records of those women who had trial of labour with a previous Caesarean scar in the National University Hospital over a period of 6 years (1985-1990) was carried out. Known symptoms and signs associated with scar rupture, cardiotocographic tracings and fetal and maternal outcome in these patients were studied. Of the 1,018 women with previous Caesarean scar (4.2% of our pregnant population at term) 722 (70.9%) had trial of labour; 70% delivered vaginally. There were 4 (0.55%) incomplete and 5 (0.69%) complete scar ruptures. All 9 women had an oxytocin infusion; 3 were diagnosed postdelivery (all 3 had complete ruptures); 3 of the 6 who had rupture prior to delivery had sudden reduction in uterine activity, 1 had scar pain and prolonged bradycardia and 2 had no symptoms or signs. Continuous cardiotocography with intrauterine pressure measurements may help to identify scar rupture early and may be of value especially in those who have an oxytocin infusion.     

Management of prelabour rupture of the membranes in term primigravidae: report of a randomized prospective trial.

OBJECTIVE: To compare a conservative and an active policy (immediate oxytocin infusion) of management of prelabour rupture of the membranes in term primigravidae. DESIGN: Randomized trial involving 444 women. SETTING: District maternity hospital. MAIN OUTCOME MEASURES: Caesarean section rate in each group; also the rate of forceps deliveries, spontaneous deliveries, length of labour, number of vaginal examinations, type of analgesia, pyrexia in labour or the puerperium and antibiotic use in the mother and the infant in each group. The caesarean section rate for the whole trial where the latent period was greater than 12 h was compared to that where the latent period was less than or equal to 12 h. RESULTS: There were fewer caesarean sections in the conservative group (odds ratio (OR) 0.60, 95% confidence interval (CI) 0.35 to 1.02; P = 0.06). There was a similar number of forceps deliveries (OR 0.79; 95% CI 0.52 to 1.19; P = 0.26) but more spontaneous deliveries (OR 1.57; 95% CI 1.08 to 2.29; P = 0.02) in the conservative group. More women managed conservatively required inhalational analgesia only for pain relief in labour (OR 2.88; 95% CI 1.46 to 5.68; P = 0.003), a similar number required pethidine (OR 1.29; 95% CI 0.85 to 1.94; P = 0.23), and fewer required epidural analgesia (OR 0.57; 95% CI 0.39 to 0.84; P = 0.005). The number of vaginal examinations was less in the conservative group (difference between mean 0.53; 95% CI 0.25 to 0.80; P less than 0.001). Fewer women managed conservatively experienced four or more vaginal examinations in labour (OR 0.58; 95% CI 0.39 to 0.86; P = 0.007). There were no differences in the lengths of labour, the proportions of women who developed pyrexia in labour or the puerperium or who required antibiotics or in the proportions of infants who required antibiotics. CONCLUSIONS: These results argue in favour of a conservative policy in managing primigravidae at term with prelabour rupture of the membranes.     

Does Routine Induction of Labour at 41 Weeks Really Reduce the Rate of Caesarean Section Compared With Expectant Management?

ObjectiveIt is contended that routine induction of labour at 41 completed weeks of gestation reduces, or at least does not increase, a woman’s chance of Caesarean section (CS), compared with expectant management. We wanted to know if this was true in our own hospital.MethodsWe performed a retrospective review of 1367 nulliparous women who had reached 41+0 weeks undelivered with a live, singleton, fetus with a cephalic presentation. The women comprised two non-randomized contemporaneous cohorts: in one group, expectant management was planned, and in the second group the intention was to induce labour at 41 weeks. The primary outcome measure was the rate of CS in each group.ResultsOf 645 women in whom expectant management was planned, 17.7% delivered by CS. Of 722 women in whom induction of labour was planned, 21.3% delivered by CS (P = 0.09). Of the total of 907 women in whom expectant management was planned or who laboured spontaneously before planned induction could be carried out, 16.6% delivered by CS. Of 460 women in whom induction was planned and actually carried out, 25.4% delivered by CS (P = 0.001).ConclusionThe contention that routine induction of labour at 41 weeks reduces a woman’s chance of delivery by Caesarean section was not supported by the findings of our study. Inducing labour may actually increase the nulliparous woman’s risk of delivery by CS.     

Dysfunctional labour: a randomised trial

Sixty-one women making slow progress in the active phase of spontaneous labour with intact membranes were randomised to oxytocin and amniotomy, amniotomy only or expectant management. The data show that oxytocin significantly increases the rate of cervical dilatation and shortens prolonged labour, when compared with amniotomy alone and expectant management (   P = 0.144  and 0–0.06, respectively). The impact on the operative delivery rate and neonatal outcome is difficult to assess due to the small number of relevant adverse outcomes. Women reported higher satisfaction score in the two groups where intervention followed the diagnosis of dysfunctional labour.     

Management of premature rupture of membranes and unfavorable cervix in term pregnancy

One hundred thirty-four indigent patients at term who had premature rupture of membranes and a cervix unfavorable for induction of labor (80% effacement or less, 2 cm dilation or less) were randomized to compare expectant with intervention management. Women with any medical or obstetric condition warranting immediate intervention were excluded from the study. Patients treated expectantly were placed at bed rest and observed for labor or infection. Patients managed by intervention were given oxytocin if labor did not ensue within 12 hours of rupture of the membranes. Patients in the intervention protocol had longer labor (P less than .02) and a higher incidence of both cesarean delivery (P less than .05) and intraamniotic infection (P less than .05). There was only one case of proven neonatal sepsis, and this occurred in a patient managed by induction of labor. There was no statistically significant difference between groups in mean length of maternal hospitalization.