Maternal and perinatal outcomes of indicated inductions of labor

Purpose: The purpose of this study was to evaluate the labor characteristics and maternal/perinatal consequences following indicated induction of labor.

Methods: This retrospective study examined all of the indicated inductions over 24 months and at two institutions evaluated mode of delivery (vaginal versus cesarean) as well as a comprehensive list of labor characteristics and maternal/perinatal outcomes.

Results: There were 1577 indicated inductions with 1097/1577 (69.6%) delivering vaginally. Women with a cesarean delivery had lower parity (p?<?(0).0001) and Bishop’s score (p?<?(0).0001), and higher body mass indices (p?=?0.022). Indication for induction due to preeclampsia increased the risk of a cesarean delivery (p?=?0.008). Chorioamnionitis, post-partum complications and NICU admissions were greater in the women delivered by cesarean section.

Conclusions: Indicated inductions which result in cesarean delivery were more likely in women with higher body mass indexes, lower parity, and Bishops scores, as well as preeclampsia.     

A comparison of obstetrical outcomes with labor induction agents used at term

Abstract

Objective: To compare the obstetrical outcomes of term pregnancies induced with one of four commonly used labor induction agents.

Methods: This is a retrospective cohort study of induced deliveries between 1 August 1995 and 31 December 2007 occurring at the Los Angeles County?+?University of Southern California Medical Center. Viable, singleton, term pregnancies undergoing induction were identified. Exclusion criteria included gestational age less than 37 weeks, previous cesarean delivery, breech presentation, stillbirth, premature rupture of membranes, and fetal anomaly. Induction methods studied were oxytocin, misoprostol, dinoprostone and Foley catheter. Our primary outcome was cesarean delivery rate among the four induction agents. Secondary outcomes included rate of failed induction, obstetrical complications, and immediate neonatal complications.

Results: A total of 3707 women were included in the study (1486 nulliparous; 2221 multiparous). Outcomes were compared across induction methods using Chi-square Tests (Pearson or Fisher’s, as appropriate). Among the nulliparous patients, there was no statistical difference among the four induction agents with regards to cesarean delivery rate (p?=?0.51), frequency of failed inductions (p?=?0.49), the cesarean delivery frequency for “fetal distress” (p?=?0.82) and five minute Apgar score <7 (p?=?0.24). Among parous patients, the cesarean delivery rate varied significantly by induction method (p?<?0.001), being lowest among those receiving misoprostol (10%). Those receiving oxytocin and transcervical Foley catheter had cesarean rates of 22%, followed by dinoprostone at 18%. The rate of failed inductions was 2% among those receiving misoprostol, compared to 7–8% among those in the other groups (p?<?0.01). Although cases of “fetal distress” between the four induction agents was not significantly different amongst multipara women, the cesarean delivery indication for “fetal distress” was higher among multipara receiving misoprostol (p?=?0.004). There was no difference among the different induction agents with regards to five minute Apgar <7 (p?=?0.34).

Conclusion: Among nulliparous women, all induction methods have similar rate of cesarean delivery. The use of misoprostol appears to be associated with a lower risk of cesarean birth among parous women induced at our institution.     

Is preeclampsia associated with an increased risk of cesarean delivery if labor is induced?

Objective.?To determine whether preeclampsia is associated with an increased risk of cesarean delivery if labor is induced.

Methods.?This retrospective cohort study of 3505 women ≥24 weeks gestation with singleton pregnancies undergoing labor induction compares cesarean delivery rates between preeclamptics and non-preeclamptics. Multivariable logistic regression analysis was used to control for potential confounders including unfavorable cervix (Bishop score ≤5), method of labor induction, maternal age, parity, gestational age, race/ethnicity, epidural use, medical insurance, and marital status.

Results.?Among term nulliparous women undergoing labor induction, preeclamptics had a higher cesarean delivery rate then non-preeclamptics (81/267, 30% vs. 363/1568, 23%; p?=?0.011), as did preeclamptic compared with non-preeclamptic women who were term and multiparous (10/64, 16% vs. 55/900, 6%, p?=?0.003). Preterm preeclamptics also had more cesarean deliveries compared with non-preeclamptics among nulliparous (48/164, 29% vs. 16/245, 7%; p?<?0.001) and multiparous (13/72, 18% vs. 18/225, 8%; p?=?0.015) women. In multivariable analysis, preeclampsia still conferred an increased risk of cesarean delivery if labor was induced (adjusted odd ratio?=?1.90, 95% CI 1.45–2.48).

Conclusion.?Women with preeclampsia undergoing labor induction had higher cesarean delivery rates compared with non-preeclamptics regardless of parity or gestational age. However, the majority of women with preeclampsia still had successful vaginal deliveries.     

Term induction of labor and risk of cesarean delivery by parity

Abstract

Objective: To evaluate the risk of cesarean delivery among both nulliparous and multiparous women undergoing a term induction of labor compared to women that present in spontaneous labor at term.

Methods: We performed a retrospective cohort study of term (≥37 weeks) singleton pregnancies between 2005 and 2010 comparing women that had an induction to those that presented in spontaneous labor. Multiparity was defined as a prior delivery after 20 weeks’ gestation. Chi-square was used to compare categorical variables. Multivariable logistic regression was used to control for confounders. Analyses were stratified by parity.

Results: 863 women were included in the analysis. There were 605 inductions (cesarean rate 23%) and 257 spontaneous labor (cesarean rate 7%), OR 3.4, 95% CI [2.1–5.4]. Stratified by parity, nulliparas undergoing induction had an increased cesarean rate compared to spontaneous labor (27% versus 11%, OR 3.13, 95% CI [1.76–5.57]) as did multiparas (13% versus 3%, OR 4.04, 95% CI [1.36–11.94]). This increased risk for cesarean after induction remained in both nulliparous and multiparous women even after controlling for confounders (aOR 2.90, 95% CI [1.60–5.25] and aOR 3.47, 95% CI [1.12–10.67], respectively). Neither starting cervical exam nor indication for induction altered this increased risk.

Conclusions: The increased risk of cesarean in women undergoing an induction is present regardless of parity and indication for induction. This should be taken into account when counseling women regarding risks of induction, regardless of parity. Future studies should focus on other clinical characteristics of induction that may mitigate this risk.     

Single indication of labor induction with prostaglandins: is advanced maternal age a risk factor for cesarean section? A matched retrospective cohort study

Abstract

Objective: The aim of this study is to investigate if advance maternal age is an independent risk factor for cesarean section in women induced with prostaglandins. Only patients with a single indication for induction of labor were considered.

Methods: A matched retrospective cohort study was conducted. A study group of 112 women aged 35 or older was enrolled. The control group included 216 women aged 34 or younger. Multivariate logistical regression models were fitted for the prediction of the cesarean section.

Results: There were no statistically significant differences in characteristics of the patients in the study and control groups. However, a higher prevalence of nulliparous women was found in control group (p?=?0.002). The indications of labor induction were homogeneous in the two groups. No significant differences were found in the route of delivery. The median time of labor was significantly shorter in the study group (p?=?0.002), and the birth weight and the placental weight were significantly lower in the study group. Advanced maternal age and newborn weight were directly related, whereas time of labor, Bishop score and parity were inversely related to a higher cesarean rate.

Conclusions: When single indication of induction of labor with prostaglandins is considered, advanced maternal age represents a significant independent risk factor for cesarean delivery.     

Effects of acupressure at the Sanyinjiao point (SP6) on the process of active phase of labor in nulliparas women

Introduction.?The reduction of the duration and pain of the active phase of labor is a very important issue and therefore always under serious investigation.

Objective.?The purpose of the present study is to evaluate the effect of acupressure at the Sanyinjiao point (SP6) on the duration and pain of the active phase of labor in nulliparas women.

Method.?A single blind randomized clinical trial was performed on 120 eligible nulliparas women who were at the beginning of active phase of labor (3–4?cm dilatation of cervix plus proper uterine contractions). The women were randomly assigned into two groups. The case group (n?=?60), received acupressure at Sanyinjiao point (above the ankle), for 30?min during contractions. In the control group (n?=?60), simply a touch at this point without massage was performed. Two hours later a second pelvic examination was performed and in the absence of good forceful contractions oxytocin in the classical form was infused. Finally, duration of active phase, severity of pain (using the Visual Analogue Scale), the amount of necessary oxytocin and necessity to administer oxytocin and the route of delivery were compared between the two groups and statistical analyses were performed using SPSS 15.

Results.?The mean duration of active phase was shorter in the case group (252.37?±?108.50?min vs. 441.38?±?155.88, p?=?0.0001). Six patients (10%) in the case group and 25 patients (41.7%) in the control group delivered via cesarean section (p?=?0.0001). The severity of pain in the case group was less than the control group (5.87?±?1.77 vs. 6.79?±?1.52, p?=?0.003). Twenty-five women (41.7%) in the case group and 38 women (63.3%) in the control group needed oxytocin (p?=?0.017) The amount of necessary oxytocin in the case group was less than the control group (73.33?±?97.19?ml vs. 126.6?±?97.19?ml, p?=?0.003).

Conclusion.?Acupressure at Sanyinjiao point (SP6) reduced the duration and severity of pain of the active phase of labor, cesarean section rates, and necessity and amount of oxytocin.     

Models for the prediction of successful induction of labor based on pre-induction sonographic measurement of cervical length

Objective.?To examine the effect of pre-induction cervical length, parity, gestational age at induction, maternal age and body mass index (BMI) on the possibility of successful delivery in women undergoing induction of labor.

Methods.?In 822 singleton pregnancies, induction of labor was carried out at 35 to 42^?+?6 weeks of gestation. The cervical length was measured by transvaginal sonography before induction. The effect of cervical length, parity, gestational age, maternal age and BMI on the interval between induction and vaginal delivery within 24?hours was investigated using Cox's proportional hazard model. The likelihood of vaginal delivery within 24?hours and risk for cesarean section overall and for failure to progress was investigated using logistic regression analysis.

Results.?Successful vaginal delivery within 24?hours of induction occurred in 530 (64.5%) of the 822 women. Cesarean sections were performed in 161 (19.6%) cases, 70 for fetal distress and 91 for failure to progress. Cox's proportional hazard model indicated that significant prediction of the induction-to-delivery interval was provided by the pre-induction cervical length (HR?=?0.89, 95 % CI 0.88–0.90, p?<?0.0001), parity (HR?=?2.39, 95% CI 1.98–2.88, p?<?0.0001), gestational age (HR?=?1.13, 95% CI 1.07–1.2, p?= <?0.0001) and birth weight percentile (HR?=?0.995, 95% CI 0.99?– 0.995, p?=?0.001), but not by maternal age or BMI. Logistic regression analysis indicated that significant prediction of the likelihood of vaginal delivery within 24?hours was provided by pre-induction cervical length (OR?=?0.86, 95% CI 0.84–0.88, p?<?0.0001), parity (OR?=?3.59, 95% CI 2.47–5.22, p?<?0.0001) and gestational age (OR =?1.19, 95% CI 1.07–1.32, p?= <?0.0001) but not by BMI or maternal age. The risk of cesarean section overall was significantly associated with all the variables under consideration, i.e., pre-induction cervical length (OR?=?1.09, 95% CI 1.06–1.11, p?<?0.0001), parity (OR?=?0.25, 95% CI 0.17–0.38, p?<?0.0001), BMI (OR?=?1.85, 95% CI 1.24–2.74, p?=?0.0024), gestational age (OR?=?0.88, 95% CI 0.78–0.98, p?=?0.0215) and maternal age (OR?=?1.04, 95% CI 1.01–1.07, p?=?0.0192). The risk of cesarean section for failure to progress was also significantly associated with pre-induction cervical length (OR?=?1.11, 95% CI 1.07–1.14, p?<?0.0001), parity (OR?=?0.26, 95% CI 0.15–0.43, p?<?0.0001), gestational age (OR?=?0.83, 95% CI 0.73–0.96, p?=?0.0097) and BMI (OR?=?2.07, 95% CI 1.27–3.37, p?=?0.0036).

Conclusion.?In women undergoing induction of labor, pre-induction cervical length, parity, gestational age at induction, maternal age and BMI have a significant effect on the interval between induction and delivery within 24?hours, likelihood of vaginal delivery within 24?hours and the risk of cesarean section.     

Risk factors for post-operative wound infection in the setting of chorioamnionitis and cesarean delivery

Objective: The objective of this study was to identify factors associated with an increased risk of post-operative wound infection in women with chorioamnionitis who undergo cesarean delivery.

Methods: We conducted a retrospective cohort study of women with clinical chorioamnionitis who underwent cesarean delivery at a tertiary-care center between June 2010 and May 2013. Demographic data, labor and delivery details and post-operative outcomes were collected. Women with and without post-operative wound infections were compared.

Results: Of 213 women with clinical chorioamnionitis who underwent cesarean delivery, 32 (15%) developed wound infections. Women with wound infection were more likely to have a body mass index (BMI) greater than or equal to 40 (p?=?0.04), chronic hypertension (p?=?0.03), leukocytosis on presentation (p?=?0.046) or use tobacco (p?=?0.002). Women who received ertapenem postpartum were less likely to develop wound infection than those who did not receive antibiotics (p?=?0.02) or those that received ampicillin, gentamicin and clindamycin (p?=?0.005).

Conclusions: Elevated BMI, tobacco use, chronic hypertension and leukocytosis at admission were associated with an increased risk of wound infection. Ertapenem appeared to reduce the risk of post-operative wound infections in women who had chorioamnionitis and underwent cesarean delivery. This could be considered as a treatment option for this high-risk population.     

Pregnancy outcome and placental pathology in emergent cesarean deliveries for non-reassuring fetal heart rate in laboring versus non-laboring women

Objective: The objective of this study is to correlate between pregnancy outcome and placental pathology in emergent cesarean deliveries (ECD) for non-reassuring-fetal-heart-rate (NRFHR) performed in women in their active phase of labor versus those performed in non-laboring women.

Methods: A retrospective cohort study. Data were reviewed for all pregnancies necessitating ECD for NRFHR between January 2009 and December 2013. Maternal outcome, neonatal outcome, and placental pathology parameters were compared between ECDs performed during active phase of labor and those performed before the active phase of labor (non-labor group).

Results: During the study period, a total of 661 ECDs were performed due to NRFHR. Compared with the active labor group (n?=?335), the non-labor group (n?=?326) had more pre-eclampsia (p?=?0.033), small for gestational age (SGA) (p?=?0.016), and preterm labor (p?<?0.001). Worse composite neonatal outcome was observed in the non-labor group compared with the active labor group, p?<?0.001. By a stepwise logistic regression model, non-labor was independently associated with adverse neonatal outcome (1.88 OR CI; 1.19–2.96, p?=?0.007). Placental inflammatory lesions were more common in the active labor group (p=?0.043), and abnormal cord insertions were more common in the non-labor group (p?=?0.002) as well as placental weight?<10th% (p?=?0.019).

Conclusion: Higher rate of pregnancy complications, abnormal cord insertion, smaller placentas, and worse neonatal outcome are associated with ECD for NRFHR when performed before the phase of active labor.     

How much weight are women gaining during pregnancy? An Italian cohort study

Abstract

Introduction: The 2009 Institute of Medicine (IOM) guidelines define adequate gestational weight gain (GWG) in the attempt to prevent maternal and neonatal adverse outcomes. The aim of this study was to assess whether the IOM guidelines are met in pregnant women with different pre-gestational body mass index (BMI).

Methods: The study included 230 pregnant women recruited at the University Hospital of Pisa (Italy) at their screening visit (24–28 weeks of gestation) for gestational diabetes (GDM). GWG was determined at screening time and before delivery to be compared with GWG recommended by IOM for each pre-pregnancy BMI category.

Results: A total of 48% of women had a GWG exceeding IOM recommendations. The prevalence of GWG excess was higher in over-weight (OW, 63.2%) and obese (OB, 63.8%) women as compared to normal-weight (NW, 27.7%; p?<?0.0001) women. The upper limit of the recommended IOM weight gain range was already exceeded at screening time in 15.5% of women. The percentage increased 27% and 18% in OW and OB, respectively, compared with 1.5% in NW (p?<?0.001).

Conclusion: About half of pregnant women had a GWG greater than the IOM recommended. GWG excess is particularly evident in OW and OB women.     

Persistent pulmonary hypertension of the newborn following elective cesarean delivery at term

Objective.?To evaluate the frequency of persistent pulmonary hypertension of the newborn (PPHN) following elective cesarean at greater than 34 weeks' gestation in an academically affiliated community hospital.

Methods.?Retrospective cohort study involving chart review of 300 newborns with PPHN between 1999 and 2006. Infants less than 34 weeks' or with congenital anomalies were excluded. Subjects were divided into two groups: (1) intended vaginal delivery and (2) elective cesarean.

Results.?A total of 125 neonates were included. In all, 46 were delivered vaginally, 53 by cesarean after a trial of labor, and 26 by elective cesarean. No statistically significant differences were noted between groups in birth weight, gestational age, or length of stay. The crude relative risk (RR) of PPHN in cesareans prior to labor (elective cesareans) when compared to intended vaginal deliveries was 2.0 (95% CI 1.3–3.1). The RR of PPHN in elective cesareans when compared to spontaneous labor resulting in vaginal deliveries was 3.4 (95% CI 2.1–5.5). The adjusted RRs for these outcomes comparing the same delivery groups when considering gestational age at birth (less vs. equal to or more than 37 weeks') were 2.2 (95% CI 1.4–3.4) and 3.7 (95% CI 2.3–6.1), and birth weight (less vs. equal to or more than 2500 g) were 1.9 (95% 1.3–3.0) and 3.4 (95% CI 2.1–5.5), respectively. The incidence of PPHN in the elective cesarean group was 6.9 per 1000 deliveries. The number of cesareans to be avoided to prevent one case of PPHN in this cohort was 387 (number needed to harm, 95% CI 206.8–3003.1).

Conclusions.?Our findings include a high rate of PPHN following elective cesarean delivery, and suggest that physicians should consider this added morbidity when performing elective cesareans.     

Foley catheter with simultaneous oxytocin on labor induction: a meta-analysis of randomized controlled trials

Objective: It is unclear that whether Foley catheter with simultaneous oxytocin could improve the efficacy of induction outcome.

Method: To conduct a meta-analysis of randomized controlled trial (RCT) studies to evaluate the effect of Foley catheter with simultaneous oxytocin on labor induction. PubMed, Embase, and other databases were searched from their inception to July 2017. We included all RCTs comparing Foley catheter with simultaneous oxytocin (i.e. intervention group) with Foley catheter followed by oxytocin (i.e. control group) in the three kinds of women (nulliparas and multiparas/only nulliparas/only multiparas). We estimate summarized relative risk (RR) and 95% confidence intervals (CIs) for dichotomous outcomes, standard mean difference for continuous outcomes. Fixed- and random-effects models were used, depending on heterogeneity.

Results: After application of our inclusion and exclusion criteria, six RCTs with a total of 1133 participants were identified. We found that only nulliparas had significant RR of delivery within 24?h (RR?=?1.32, 95% CI: 1.12, 1.55, I²?=?46.5%). Meanwhile, there was no statistically significant difference between intervention and control groups in vaginal delivery in 24?h, cesarean delivery, time to delivery, and Apgar score at 5?min less than 7. Foley catheter with simultaneous oxytocin did not increase the risk of side effects, included chorioamnionitis, postpartum hemorrhage, uterine hyperstimulation, and neonatal intensive care unit admission.

Conclusion: The results seem to support the use of oxytocin to a Foley catheter at the initiation of labor induction, as it might lead to increases the rate of delivery within 24?h in nulliparas.     

Induction of labor with an unfavorable cervix: how does BMI affect success?‡

Objective: Obesity places women and their babies at risk for obstetric and perinatal morbidity including induction of labor and cesarean delivery. We sought to evaluate the impact of body mass index (BMI) on successful induction of labor using misoprostol at our institution. The primary outcome was time to delivery. Secondary outcomes were number of doses of misoprostol, duration of oxytocin and cesarean delivery.

Methods: A retrospective cohort over two years found 329 patients who were >?37 weeks of gestational age and had a Bishop score <?5 prior to beginning induction. Patients were divided into three categories based on their BMI: Group 1: BMI?≤?30 kg/m², Group 2: BMI 30 to 39.9 kg/m² and Group 3: BMI?≥?40 kg/m². Statistical analysis included the use of multivariate analysis, contingency tables and Chi-square tests for categorical data and Pearson’s correlation coefficient for numerical data.

Results: There were no significant differences among the groups when analyzed for gestational age, bishop score, median parity or race. Time to delivery increased significantly with increasing BMI (p?<?0.01). Furthermore, women with higher BMIs required more doses of misoprostol (p?<?0.01), longer duration of oxytocin administration prior to delivery (p?<?0.02) and increased risk of cesarean section (p?<?0.0006).

Conclusion: As BMI increases, obese patients undergoing induction with misoprostol have a longer time to delivery, require more doses of misoprostol, require a longer duration of oxytocin and have higher cesarean delivery rate.     

Pre-induction cervical ripening: comparing between two vaginal preparations of dinoprostone in women with an unfavorable cervix

Abstract

Objective: Prostaglandin E2 (PGE2-Dinoprostone) is accepted for both ripening of the cervix and induction of labor. As conflicting data exist concerning the efficiency and safety of different treatment modalities, we aimed to compare slow-release vaginal insert PGE2 with serial vaginal tablets of PGE2 for cervical ripening and induction of labor.

Methods: A retrospective cohort study comparing all pregnancies who underwent induction of labor by either a single slow-release vaginal insert of 10?mg PGE2 (study group) to a historical control group of women who were treated with serial administration of 3?mg vaginal PGE2 tablets in a 2:1 ratio, matched by parity.

Results: Overall, 639 women were enrolled (213 treated with PGE2 tablets and 426 with slow-release vaginal inserts). Vaginal insert was associated with shorter initiation-to-ripening interval (12.4?±?7.7 versus 18.6?±?15.2?h, p?<?0.001) and a higher rate of delivery within 24?h (61.5 versus 51.6%, p?=?0.018). Vaginal insert was associated with an increased rate of tachysystole (8.0 versus 3.1%, p?<?0.01); however, the rates of cesarean section or operative delivery due to non-reassuring fetal heart rate (NRFHR) were similar. On multivariable analysis, slow-release vaginal insert was independently associated with a higher rate of delivery within 24?h (OR 1.50, 95% CI 1.04–2.18).

Conclusion: Slow-release PGE2 vaginal insert achieves cervical ripening and subsequently delivery over a shorter time period than PGE2 tablets, without increasing uterine hyperstimulation rate.     

Comparing vaginal misoprostol versus Foley catheter plus vaginal isosorbide mononitrate for labor induction

Objective(S): To compare the effectiveness and safety of intra-cervical Foley catheter combined with intra-vaginal isosorbide mononitrate (IMN) versus intra-vaginal misoprostol for cervical ripening and labor induction in pregnant women with unripe cervices.

Methods: Open-labeled randomized controlled trial in Cairo university hospital, Cairo, Egypt during 2012–2014. Three hundred and ninety-five pregnant women at term or post-term with an indication for labor induction and unripe cervix were included in the study. The subjects were randomly divided into two groups. Vaginal misoprostol was used in group 1 (n?=?197) and intra-cervical Foley catheter plus vaginal IMN in group 2 (n?=?198). Our main outcome measure was cesarean section rate.

Results: Among the 395 included patients there were significantly lower duration of induction of labor (p?<?0.001) in group 1with lower cesarean section rates [22.8% in group 1versus 33.3% in group 2; RR 0.7 (0.6–0.9), (p?=?0.020)]. Whereas the uterine hyperstimulation (p?<?0.001) was significantly higher in group 1. There were no significant differences between both groups as regard patients’ demographic characteristics.

Conclusions(s): Vaginal misoprostol is more effective but less safe than Foley catheter combined with vaginal IMN for induction of labor in term and post-term pregnancy.     

Comparison of elective induction of labor with favorable Bishop scores versus expectant management: A randomized clinical trial

Objective.?To determine if elective induction (IND) increases the risk of cesarean delivery compared to expectant management (EM).

Methods.?A randomized clinical trial involving women ?39 weeks' gestation, according to strict dating criteria, with a Bishop score of 5 or more in nulliparous patients and 4 or more in multiparous patients. The control group was expectantly managed and delivered for obstetric indications, but not later than 42 weeks' gestation. The study had 80% power to detect a three-fold increase in cesarean delivery.

Results.?One-hundred-and-sixteen patients (45 nulliparous) were randomized to IND and 110 (58 nulliparous) to EM. Demographic characteristics were no different between the groups. The cesarean delivery rate in the IND group was 6.9% (8/116) compared to 7.3% (8/110) in the EM group (p?=?NS). Rates of cesarean delivery for nulliparous patients randomized to IND compared to EM were also not significantly different: 13.3% (6/45) versus 10.3% (6/58) respectively (p?=?NS). Neonates delivered of IND patients weighed less than those of the EM group (3459?±?347 versus 3604?±?438, p?=?0.006).

Conclusion.?In women with favorable Bishop scores, elective induction of labor resulted in no increase in cesarean delivery compared to expectant management.     

Adverse obstetrical and neonatal outcomes in elective and medically indicated inductions of labor at term

Abstract

Objective: To compare the adverse neonatal and maternal outcomes after medically indicated and elective labor induction. Both induction groups were also compared to women with spontaneous onset of labor.

Method: Retrospective cohort study of 13?971 women with live, cephalic singleton pregnancies who delivered at term (from 1997 to 2007). Adverse maternal and neonatal outcomes were compared between women who underwent an induction of labor in the presence and absence of standard medical indications.

Results: Among 5090 patients with induced labor, 2059 (40.5%) underwent elective labor inductions, defined as inductions without any medical or obstetrical indication. Risks of cesarean or instrumental delivery, postpartum hemorrhage >500?ml, prolonged maternal hospitalization >6 days, Apgar<7 at 5?min of life, arterial umbilical cord pH<7.1, admission in neonatal intensive care unit (NICU) and prolonged NICU hospitalization >7 days were similar between nulliparous who underwent elective and medical labor induction. Similar results were obtained for multiparous. All the above mentioned risks, but the Apgar<7 at 5?min of life, were significantly increased after induction in comparison to spontaneous labor.

Conclusion: Elective induction of labor carries similar obstetrical and neonatal risks as a medically indicated labor induction. Thus, elective induction of labor should be strongly discouraged.     

The effect of inflatable obstetric belts in nulliparous pregnant women receiving patient-controlled epidural analgesia during the second stage of labor

Abstract

Objective: The aim of this study was to evaluate the effect of inflatable obstetric belts on uterine fundal pressure in the management of the second stage of labor.

Method: Between July 2009 and December 2010, 188 nulliparous women with a singleton pregnancy at term were enrolled and only one dropped. The participants were randomized to receive either standard care (control group, n?=?91) or uterine fundal pressure by the Labor Assister? (Baidy M-520/Curexo, Inc., Seoul, Korea; active group, n?=?97) during the second stage of labor in addition to standard care. The Labor Assister is an inflatable obstetric belt that is synchronized to apply constant fundal pressure during a uterine contraction. The primary endpoint was duration of the second stage of labor in women who delivered vaginally (control, n?=?80 versus active, n?=?93). It was not analyzed in women who delivered by cesarean section (n?=?14) and delivered precipitously (n?=?1). The secondary outcomes are perinatal outcomes and perineal laceration. Participants received patient-controlled epidural analgesia.

Results: The 93 women in the active group spent less time in the second stage of labor when compared to the 80 women in the control group (46.51?±?28.01?min versus 75.02?±?37.48?min, p?<?0.001). There was no significant difference in perinatal outcomes and perineal laceration between the two groups.

Conclusion: The uterine fundal pressure exerted by the inflatable obstetric belt reduces the duration of the second stage of labor without complications in nulliparous women who receive patient-controlled epidural analgesia.     

Unsuccessful trial of labor in women with and without previous cesarean delivery

Objective.?To compare maternal and neonatal outcomes after unsuccessful labor in women with and those without prior cesarean delivery.

Methods.?This was a retrospective cohort study of all women in labor delivered by cesarean section (CS) from November 2004 through December 2006. The study population was dichotomized by previous CS and compared for various maternal and neonatal outcomes. Student t-test, χ² and Fisher exact tests were used for analysis.

Results.?There was a significantly higher rate of symptomatic uterine rupture [3/100 (3%) vs. 0/449 (0%), p?=?0.006], asymptomatic uterine scar dehiscence [6/100 (6%) vs. 0/449 (0%), p?=?0.0001], and bladder injury [2/100 (2%) vs. 0/100 (0%), p?=?0.001], among women with prior cesarean delivery compared to those without. The rate of respiratory distress syndrome [(6/100) (6%) vs. 10/449 (2.2%), p?=?0.05] and meconium aspiration [4/100 (4%) vs. 2/449 (0.4%), p?=?0.01] was also significantly higher among neonates of women with prior cesarean delivery. However, the rate of endomyometritis [3/100 (3%) vs. 50/449 (11.1%), p?=?0.009] and febrile morbidity [17/100 (17%) vs. 144/449 (32.1%), p =?0.003] was significantly lower among women with prior cesarean delivery compared to those without prior cesarean birth.

Conclusions.?Compared to laboring women without previous cesarean delivery, women with previous cesarean delivery have increased maternal and neonatal morbidity. Febrile morbidity was, however, lower among women with previous cesarean delivery. These differential findings should further inform our perinatal counseling of women contemplating trial of labor after a previous cesarean delivery.     

Does dystocia during labor pose a risk factor for another non-progressive labor during the subsequent delivery?

Objective: To establish whether failure to progress during labor poses a risk factor for another non-progressive labor (NPL) during the subsequent delivery.

Methods: A retrospective cohort study including singleton pregnancies that failed to progress during the previous labor and resulted in a cesarean section (CS) was conducted. Parturients were classified into three groups for both previous and subsequent labors: CS due to NPL stage I, stage II and an elective CS as a comparison group.

Results: Of 202?462 deliveries, 10?654 women met the inclusion criteria: 3068 women were operated due to NPL stage I and 1218 due to NPL stage II. The comparison group included 6368 women. Using a multivariable logistic regression models, NPL stage I during the previous delivery was found as an independent risk factor for another NPL stage I in the subsequent labor (adjusted odds ratio [OR]?=?2.9; 95% confidence interval [CI]?=?2.4–3.7; p?p?=?0.033; adjusted OR?=?5.3; 95% CI?=?3.7–7.5; p?Conclusion: A previous CS due to a NPL is an independent risk factor for another NPL in the subsequent pregnancy and for recurrent cesarean delivery.