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.     

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).     

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.     

A randomised controlled trial of early versus delayed use of amniotomy and oxytocin infusion in nulliparous labour

Objective To compare routine amniotomy and early intravenous oxytocin (active management of labour) with a more selective use of amniotomy and oxytocin in women in true labour who received comparable continuous supportive midwifery care.
Design Randomised controlled trial of nulliparous clinic patients in spontaneous labour at term. Setting Labour and delivery ward of a university teaching hospital.
Participants Three hundred and six parturients: 152 received active management of labour; 154 were more selectively managed.
Interventions 1. Active management: early amniotomy, early use of oxytocin. 2. Selective intervention management: no routine amniotomy and more selective use of oxytocin.
Outcome measures Use of oxytocin and amniotomy. Labour duration, mode of delivery.
Results Maternal characteristics were comparable in both groups. Amniotomy was more often performed (91% versus 57%,   P < 0.01  ) and oxytocin more often used (53% versus 27%, P < 001) in the active management group. The first stage of labour, however, was only shortened by half an hour in the active management group (254 min versus 283 min,   P = 0.087  ). Caesarean section rate (3.9% versus 2.6%), spontaneous vaginal delivery rate (78% versus 79%) and neonatal outcome were not significantly different between groups.
Conclusion Within a set-up of strict labour diagnosis and supportive midwifery care, routine amniotomy and early use of oxytocin offered no advantage over a more selective use of amniotomy and oxytocin in terms of mode of delivery and labour duration.     

Fear of childbirth and risk for birth complications in nulliparous women in the Danish National Birth Cohort

Objectives  To examine the associations between fear of childbirth and emergency caesarean section and between fear of childbirth and dystocia or protracted labour and fetal distress.
Design  Prospective cohort study.
Setting  Danish National Birth Cohort.
Population  A total of 25 297 healthy nulliparous women in spontaneous labour with a single fetus in cephalic presentation at term following an uncomplicated pregnancy.
Methods  Data were collected during 1997–2003 from computer-assisted telephone interviews twice in pregnancy linked with national health registers.
Main outcome measures  Risk for emergency caesarean section of women who feared childbirth; risk for dystocia/protracted labour or fetal distress of women who feared childbirth.
Results  Fear of childbirth in early (16 weeks, 6 ± 29 days) and late (31 weeks, 4 ± 21 days) pregnancy was associated with emergency caesarean section: OR, 1.23 (1.05–1.47) and 1.32 (1.13–1.55), respectively. When fear of childbirth was expressed at both interviews, the OR was 1.43 (1.13–1.80). Women who feared childbirth had an increased risk for dystocia or protracted labour (OR, 1.33; 1.15–1.54), but not for fetal distress (OR, 0.94; 0.72–1.23).
Conclusions  Fear of childbirth during pregnancy was associated with dystocia and emergency caesarean section but not with fetal distress.     

Cervical ripening with transcervical foley catheter and the risk of uterine rupture

OBJECTIVE: To estimate whether the rate of uterine rupture in patients with a previous cesarean delivery is related to labor induction and/or cervical ripening using transcervical Foley catheter. METHODS: Charts of all patients who had a trial of labor after a previous cesarean delivery in our institution between 1988 and 2002 were reviewed. The rates of successful vaginal birth after cesarean delivery and uterine rupture in patients with spontaneous labor (control group) were compared with those of patients who underwent a labor induction by means of amniotomy with or without oxytocin and patients who underwent a labor induction/cervical ripening using a transcervical Foley catheter. Logistic regression analysis was performed to adjust for confounding variables. RESULTS: Of 2479 patients, 1807 had a spontaneous labor, 417 had labor induced by amniotomy with or without oxytocin, and 255 had labor induced by using transcervical Foley catheter. The rate of successful vaginal birth after cesarean delivery was significantly different among the groups (78.0% versus 77.9% versus 55.7%, P <.001), but not the rate of uterine rupture (1.1% versus 1.2% versus 1.6%, P =.81). After adjusting for confounding variables, the odds ratio (OR) for successful vaginal birth after cesarean delivery was 0.68 (95% confidence interval [CI] 0.41, 1.15), and the OR for uterine rupture was 0.47 (95% CI 0.06, 3.59) in patients who underwent an induction of labor using a transcervical Foley catheter when compared with patients with spontaneous labor. CONCLUSION: Labor induction using a transcervical Foley catheter was not associated with an increased risk of uterine rupture.     

Early amniotomy increases the frequency of fetal heart rate abnormalities

Objective To determine whether early amniotomy, when practised as an isolated intervention, increases the hourly rate of fetal heart rate record abnormalities.
Design This is a secondary analysis of the results of a multicentre randomised trial of early versus late amniotomy in labour.
Setting Secondary and tertiary level teaching hospitals.
Intervention Early amniotomy versus an attempt to conserve the amniotic membranes.
Main outcome measures The hourly rates of early, mild variable, severe variable and late decelerations; caesarean section rates.
Results Severe variable decelerations, when classified as categorical events ( 1/h to 2/h, 2/h to < 4/h, 4/h), were more frequent in the amniotomy group (χ² for trend = 5.7,   P = 0.017  ). The mean hourly rates of severe variable and late fetal heart rate decelerations were increased in the amniotomy group (severe variable: amniotomy group 1.4/h, control 0.7/h,   P = 0.021  ; late: amniotomy group 3.3/h, control 2.3/h,   P = 0.011  ). Although the overall rate of caesarean was similar in the two groups (OR 1.2; 95% CI 0.8–1.8), there was an increase in caesarean section for fetal distress (OR 2.3; 95% CI 1.1–4.5) associated with amniotomy.
Conclusion Our data suggest that early amniotomy increases the hourly rate of severe variable fetal heart rate decelerations without evidence of an adverse effect on neonatal outcome. In settings where the diagnosis of fetal compromise is based primarily on electronic monitoring, caesarean section for fetal distress may be increased by early amniotomy.     

The effect of amniotomy on the outcome of spontaneous labour in uncomplicated pregnancy.

The objective of this study is to determine the effect of amniotomy on the outcome of spontaneous labour in uncomplicated pregnancy. A prospective randomised study of low-risk parous women with spontaneous onset of labour at term with singleton fetus in cephalic presentation and intact amniotic membranes and a cervical dilatation between 4 and 5 cm were randomly assigned to have amniotomy (Case) or no amniotomy (Control) during the course of labour. Maternal demographics, labour-delivery data and newborn outcome were compared. A total of 128 women were studied. The duration of labour was significantly shorter in the amniotomy group than the control group (208 vs 292 min; p < 0.05) with the only difference being in the first stage of labour. There was however no difference on the oxytocin requirement for labour augmentation, caesarean section rate, incidence of suspected fetal distress or instrumental delivery in both groups. Newborn outcome measured by Apgar scores at 1 and 5 min showed no significant difference. In conclusion, amniotomy significantly reduced the duration of the first stage of labour without affecting the oxytocin requirement, the rate of caesarean section and newborn outcome.     

Pre-induction cervical ripening: transcervical foley catheter versus intravaginal misoprostol.

The object of this study was to compare the effectiveness of the intravaginal Misoprostol and transcervical Foley catheters as pre-induction cervical ripening agents, to estimate the proportion of patients achieving vaginal delivery and to compare the complications of labour and foetal outcome between the two groups. The study was a prospective, randomised study of pregnant women, with singleton pregnancies who presented for antenatal care and delivery at the University College Hospital (UCH), Ibadan, Nigeria. Ninety-nine patients were invited to participate and ninety-six (96) agreed. No patient withdrew from the study. The patients were assigned by means of computer-generated random numbers to receive transcervical Foley catheters (Size 16F, with 30 ml balloon capacity) or 50 microg intravaginal Misoprostol (Cytotec tablet, Searle & Co., Chicago). Fifty (50) patients received intravaginal Misoprostol and Forty-six (46) received Transcervical Foley catheters. The proportions of nulliparous, primiparous and multiparous patients were 52, 20 and 28% in the misoprostol group and 43.5, 26.1 and 30.4%, respectively, in the Foley catheter group. The time to achieve a favourable cervical status was significantly shorter in the Misoprostol group, with 98.0% of the subjects attaining Bishop score > or = 6 within 6-12 hours of insertion of the study agent, in contrast to 69.0% of the subjects in the Foley catheters group (P<0.001). Thirteen (26.6%) and three (6.5%) patients in the Misoprostol and Foley catheters groups, respectively, went into labour while undergoing cervical ripening and all had uneventful vaginal deliveries (P<0.05). The induction-delivery interval did not differ significantly between the groups. The incidence of caesarean delivery was 6.0% in the Misoprostol group compared with 2.2% in the Foley catheter group (P=0.62). Instrumental vaginal delivery rates were similar in both groups. Overall, the mode of delivery did not differ significantly between the groups. The number of neonates with 1-minute Apgar score <7 did not differ significantly in both groups and no neonate had 5-minute Apgar score <7. Meconium stained liquor was noticed in 5 (Misoprostol) vs 2 (Foley catheters) patients in labour. None of the neonates had any features suggestive of meconium aspiration. Labour complications were mainly precipitate labour {2 (Misoprostol) vs 1 (Foley catheters) } and 1 patient with transient tachysystole (> or =6 contractions in 10 minutes for two consecutive 10-minute periods) in the Misoprostol group. Hyperstimulation was not noticed in any of the patients in either arm of the study groups. Intravaginal Misoprostol is as effective a pre-induction cervical ripening agent as transcervical Foley catheters, with added advantages of shorter duration of cervical ripening, reduced oxytocin requirement for induction of labour and greater acceptability to patients. The incidence of caesarean sections, other labour complications and the foetal outcome were similar with both methods.     

Management of oxytocin for labour augmentation in relation to mode of birth in Robson group 1

ObjectiveTo compare mode of birth in Robson group 1 according to administration of oxytocin for labour augmentation.Design and participantsA retrospective review of 724 medical records from women in Robson group 1 was performed. The outcome measurements were: mode of birth in relation to presence of labour dystocia when initiating augmentation with oxytocin, duration of augmentation with oxytocin, increase of the oxytocin infusion according to recommendations and cervical dilation when initiating augmentation with oxytocin.SettingThe review was based on medical records from a medium-sized tertiary level obstetric unit in southern Sweden, with approximately 3700 births per year. Data was collected between January 2017 and October 2017.Measurements and FindingsOxytocin for labour augmentation was used in 64.1% of the births. Oxytocin administered according to the national recommendations was related to a greater likelihood of vaginal birth than when these recommendations were not followed. Only 47.8% of the women who underwent a caesarean section was treated according to recommendations. Receiving augmentation with oxytocin at a later stage of labour was related to a greater likelihood of a vaginal birth. The total time treated with oxytocin was significantly longer in women who had an assisted vaginal birth or a caesarean section than those who had a vaginal birth with augmentation.Key conclusionsOxytocin for labour augmentation was over-used in Robson group 1. Oxytocin early in labour, a long duration of stimulation with oxytocin and a slower increase of the infusion than recommended had a relationship with caesarean section.Implication for practiceDue to risks for adverse maternal and neonatal outcomes when using oxytocin for labour augmentation, caregivers should implement strict protocols for its use. According to a high use of oxytocin there is a need to describe women's experiences of labour augmentation in labour dystocia but also when received despite normal labour progress.     

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.     

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.     

Labor induction in women with an unfavorable Bishop score: randomized controlled trial of intrauterine Foley catheter with concurrent oxytocin infusion versus Foley catheter with extra-amniotic saline infusion with concurrent oxytocin infusion

OBJECTIVES: This study was undertaken to determine whether the addition of extra-amniotic saline infusion improves the efficacy of the Foley catheter in women undergoing cervical ripening and induction of labor with an unfavorable cervical examination. STUDY DESIGN: One hundred consenting women with a Bishop score less than 5 with singleton gestation, intact membranes, vertex presentation, who required induction of labor were randomly assigned to 2 groups: Foley alone (Foley, n=49) or to the Foley catheter with extra-amniotic saline infusion (EASI, 30 mL of NS per hour infused through the distal port of the Foley, n=51). All women received concurrent dilute oxytocin infusion per protocol. The primary analysis was intent to treat. Nonparametric tests were used as indicated. RESULTS: At randomization, the groups were well balanced for potential confounders including: parity, gestational age, prior cesarean delivery, preeclampsia, mean dilation, effacement, and Bishop score. There were no differences between the groups for time to delivery (Foley 17.7 +/- 10.5 hours vs EASI 17.4 +/- 11.7 hours, P=.9), the proportion of women delivered before 24 hours (Foley 41/49 [84%] vs EASI 39/51 [77%], P=.37) or cesarean rates (Foley 9/49 [17.7%] vs EASI 9/51 [18.4%], P=.92). There were also no differences in complications, including chorioamnionitis, endometritis, and neonatal morbidity. CONCLUSION: EASI does not increase the efficacy of cervical ripening and induction of labor with a Foley catheter and concurrent oxytocin infusion.     

Preparation for Induction of Labour of the Unfavourable Cervix with Foley Catheter Compared with Vaginal Prostaglandin

Ripening of the unfavourable cervix prior to induction of labour using traction on a Foley catheter (32 patients) was compared with 40 mg of prostaglandin F2 alpha in Tylose gel applied to the external cervical os and held in place for 12 hours with a vaginal diaphragm (25 patients). Each patient in the above groups had a modified Bishop score of 0-3 and was randomly allocated to one or other group. Comparison was made with a further 25 patients in whom the cervical score was 4-6. Timing of amniotomy and commencement of Syntocinon infusion were equivalent for all patients. Prostaglandins conferred no advantage over Foley catheter in terms of amniotomy-delivery interval, operative delivery rate, and condition of the baby one minute after birth. The disadvantages of prostaglandins for cervical ripening are a longer preparation-delivery interval, and cost ($77 versus $4.75 for the Foley catheter). Currently, prostaglandins are not officially approved for use in Australia for induction of labour. It is suggested, therefore, that the Foley catheter is preferable for ripening the unfavourable cervix as a prelude to amniotomy.     

A randomized trial comparing a 30-mL and an 80-mL Foley catheter balloon for preinduction cervical ripening

OBJECTIVES: The purpose of this study was to compare the efficacy of cervical ripening with 2 Foley catheter balloon volumes. STUDY DESIGN: Pregnant women admitted for induction of labor with a term singleton gestation were randomly assigned for cervical ripening by a balloon inflated with 30 mL or 80 mL of sterile saline. RESULTS: Two hundred and three women were included in the analysis. Ripening of the cervix with the larger balloon volume was associated with a significantly higher rate of post-ripening dilatation of 3 cm or more (76.0% vs 52.4%, P < .001). In primiparous women, the larger balloon volume resulted in a significantly higher rate of deliveries by 24 hours (71.4% vs 49%, P < .05), and a significantly less requirement of augmentation with oxytocin (69.3% vs 90.4%, P < .05). CONCLUSION: Ripening of the unfavorable cervix in primiparous women with a Foley catheter balloon inflated with 80 mL provided effective more dilatation, faster labor, and decreased need for oxytocin than with a balloon inflated with 30 mL of sterile saline.     

Geburtseinleitung am Termin

Mechanical methods (balloon catheter, natural or synthetic dilators, amniotomy, sweeping of membranes) are the oldest methods to ripen the cervix or to induce labor. Synthetic prostaglandins have, however, increasingly replaced the use of mechanical methods in industrialized countries while in developing countries these methods are still the most frequently used as they are cheap, reversible, and usually do not require fetal monitoring. The mechanical methods in use today usually employ a Foley catheter. Compared with prostaglandins or oxytocin, Foley catheters are equally safe and effective. Moreover, in women with unfavorable cervix, cervical ripening with a Foley catheter seems to be more effective and associated with a lower operative delivery rate. In particular, in women with a previous cesarean delivery, the use of the intracervical Foley catheter must be considered the method of choice for maturation of the cervix, since it is safe with a uterine rupture rate similar to that associated with spontaneous labor.     

Hyaluronidase versus Foley catheter for cervical ripening in high-risk term and post term pregnancies.

OBJECTIVE: To evaluate the effectiveness and safety of Foley catheter and hyaluronidase for cervical ripening. METHOD: Randomized controlled trial where 140 pregnant women, with gestational age > or = 37 weeks, indication for labor induction and an unripe cervix, were enrolled, allocated in two groups according to the method of cervical ripening before labor induction. Statistical analysis used Student's t-test, Mann-Whitney, Chi-square test, survival analysis, risk ratios and number needed to treat. RESULTS: Time of induction, dose of oxytocin and mode of delivery had better results in the Foley catheter group. Comfort with the method was higher in the hyaluronidase group. CONCLUSIONS: Both methods were effective and safe for cervical ripening. The Foley catheter group experienced a shorter period of induction, required a lower dose of oxytocin and had higher vaginal delivery rates, while the women who used hyaluronidase declared greater comfort with the method.     

Oxytocin augmentation in dysfunctional labour after previous caesarean section

Summary. Uterine activity was quantified in women with a previous caesarean scar and a slow progress of labour who needed oxytocin augmentation. Of the 63 women 49 (78%) progressed well (mean cervical dilatation rate of 1·5 cm/h) and were delivered vaginally. Fourteen women had slow progress of labour (0·3 cm/h) and were delivered by caesarean section despite adequate and similar augmented uterine activity to that in the women who were delivered vaginally. Those who were delivered by caesarean section had a significantly higher mean maximum dose of oxytocin and a longer period of augmentation. All caesarean sections were for cephalopelvic disproportion and the mean birthweight of babies born by caesarean section (3598 g) was significantly higher than that of babies born vaginally (3230g). Satisfactory rate of cervical dilatation in the presence of optimal uterine activity is predictive of favourable outcome when oxytocin is used for dysfunctional labour after previous caesarean section.     

Cervical ripening and induction of labor with misoprostol,dinoprostone gel,and a Foley catheter: a randomized trial of 3 techniques

OBJECTIVE: The purpose of this study was to compare the efficacy of 3 different techniques of cervical ripening and induction. STUDY DESIGN: Patients who required cervical ripening and induction were randomized to one of 3 groups: (1) supracervical Foley catheter and intravaginal dinoprostone gel, (2) supracervical Foley catheter and 100 microg oral doses of misoprostol, or (3) serial 100-microg oral doses of misoprostol. Intravenous oxytocin was administered when a protraction disorder of labor was identified. RESULTS: There were 339 women randomized. There was no significant difference in the time from first intervention to delivery in the 3 groups (P =.546). In each group, a similar percentage of women required oxytocin (P =.103). The rates of cesarean delivery were equivalent among the groups (P =.722). Rates of tachysystole were high but statistically equivalent among the 3 groups. There were no significant differences in Apgar scores or umbilical artery pH. CONCLUSION: Oral 100 microg serial doses of misoprostol, with or without the use of a supracervical Foley catheter, were equivalent to the use of a supracervical Foley catheter and serial 4-mg doses of dinoprostone gel for cervical ripening and the induction of labor.     

Oxytocin augmentation in dysfunctional labour after previous caesarean section

Uterine activity was quantified in women with a previous caesarean scar and a slow progress of labour who needed oxytocin augmentation. Of the 63 women 49 (78%) progressed well (mean cervical dilatation rate of 1.5 cm/h) and were delivered vaginally. Fourteen women had slow progress of labour (0.3 cm/h) and were delivered by caesarean section despite adequate and similar augmented uterine activity to that in the women who were delivered vaginally. Those who were delivered by caesarean section had a significantly higher mean maximum dose of oxytocin and a longer period of augmentation. All caesarean sections were for cephalopelvic disproportion and the mean birthweight of babies born by caesarean section (3598 g) was significantly higher than that of babies born vaginally (3230 g). Satisfactory rate of cervical dilatation in the presence of optimal uterine activity is predictive of favourable outcome when oxytocin is used for dysfunctional labour after previous caesarean section.