Full-term induction of labor vs expectant management and cesarean delivery in women with obesity: systematic review and meta-analysis.

OBJECTIVE: This study aimed to review the literature comparing full-term induction of labor with expectant management in women with obesity on the risk of cesarean delivery and other adverse outcomes. DATA SOURCES: A literature search was performed on PubMed, EMBASE, Scopus, ClinicalTrials.gov, and the Cochrane Library. This study had no time, language, or geographic restriction. STUDY ELIGIBILITY CRITERIA: Studies were eligible if (1) they were cohort or randomized controlled trials, (2) they compared induction of labor at early or late term with expectant management, and (3) they included women with a body mass index of ≥30 kg/m2. Studies restricted to women with multiple pregnancy, premature rupture of membranes, or noncephalic presentation were excluded. The primary outcome was cesarean delivery. The secondary outcomes included maternal and neonatal mortality and morbidities and were evaluated. METHODS: The risk of bias was assessed by 2 authors using the Risk of Bias In Non-Randomized Studies of Interventions tool. Only studies assessed with low or moderate risk of bias contributed to the meta-analysis. Data were combined to pooled relative risks and 95% confidence intervals using random effects models. The quality of evidence was assessed for selected outcomes. RESULTS: Of the 232 studies identified, 13 were aligned with the inclusion criteria, and 4 cohort studies, including 216,318 women with induction of labor and 1,122,769 women managed expectantly, were included in the meta-analysis for the primary outcome. In women with obesity, full-term induction of labor was associated with a lower risk of cesarean delivery than expectant management (19.7% vs 24.5%; relative risk, 0.71; 95% confidence interval, 0.63-0.81). Moreover, this study found the same direction of the association for other selected outcomes: severe perineal lacerations (relative risk, 0.65; 95% confidence interval, 0.48-0.89), maternal infection (relative risk, 0.42; 95% confidence interval, 0.21-0.84), perinatal mortality (relative risk, 0.41; 95% confidence interval, 0.18-0.90), low Apgar score (relative risk, 0.48; 95% confidence interval, 0.26-0.91), meconium aspiration syndrome (relative risk, 0.40; 95% confidence interval, 0.28-0.56), and macrosomia (relative risk, 0.57; 95% confidence interval, 0.43-0.75). Conversely, induction of labor was associated with an increased risk of instrumental vaginal delivery (relative risk, 1.12; 95% confidence interval, 1.02-1.22). The quality of evidence ranged from low to very low. CONCLUSION: Full-term induction of labor in women with obesity may reduce the risk of cesarean delivery compared with expectant management, but the quality of the evidence is low.

Induction of labour at 39 weeks versus expectant management in low-risk obese women: study protocol for a randomised controlled study.

INTRODUCTION: Obesity is associated with many pregnancy complications, including both fetal macrosomia and prolonged labour. As a result, there is often also an increased risk of caesarean section. In other settings, labour induction near to term reduces adverse outcomes such as stillbirth and birth injury, without causing more caesarean deliveries. It has been suggested that induction will reduce adverse events in this setting too, but there have been no trials and the effect on caesarean section is unknown. The objective of this study is to compare induction of labour in gestational week 39 with expectant management on the risk of caesarean section in women with body mass index ≥30 kg/m2. METHODS AND ANALYSIS: An open label randomised controlled multicentre trial are conducted at Danish delivery departments with an in-house neonatal intensive care unit. Recruitment started October 2020. A total of 1900 women with a prepregnancy body mass index ≥30 kg/m2 are randomised in a 1:1 ratio to either labour induction at 39 weeks and 0 to 3 days of gestation or to expectant management; that is, waiting for spontaneous labour onset or induction if medically indicated. The primary outcome is caesarean section. Data will be analysed according to intention-to-treat. ETHICS AND DISSEMINATION: The Central Denmark Region Committee on Biomedical Research Ethics approved the study. The study is conducted in accordance with the ethical principles outlined in the latest version of the 'Declaration of Helsinki' and the 'Guideline for Good Clinical Practice' related to experiments on humans. The trial findings will be disseminated to participants, clinicians, commissioning groups and via peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT04603859.

Major Differences in the Use of Protocols for Dispatcher-Assisted Cardiopulmonary Resuscitation Among ILCOR Member Countries.

INTRODUCTION AND PURPOSE: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) increases the rate of bystander cardiopulmonary resuscitation (CPR). DA-CPR is recommended by resuscitation councils globally and it has been shown that the general public expects to receive pre-arrival instructions while waiting for help. A scientific advisory from the American Heart Association identifies standardized and structured DA-CPR protocols as important to increase bystander CPR rates. This study aims to investigate whether different International Liaison Committee on Resuscitation (ILCOR) member countries use DA-CPR protocols and to compare protocol contents between countries. METHODS: All resuscitation councils forming ILCOR were inquired by email to provide a copy of their DA-CPR protocol, and to state whether this protocol was used by all emergency dispatch centers in their country. The collected protocols were translated into English, and content was compared. RESULTS: A total of 60 countries were contacted (response rate: 83%). Of these, 46% stated to have a nationwide protocol, 30% reported to use local protocols, and 24% did not use a protocol. Overall, 54% provided a copy of their protocol. All translated protocols asked the rescuer to check for responsiveness and breathing, 35% to activate phone speaker function, half contained notes about agonal breathing and 59% included notes about integrating an automated external defibrillator. CONCLUSION: Almost one quarter of ILCOR member countries did not use a protocol for DA-CPR. Half of the protocols included notes about agonal breathing. Activation of phone speaker function and protocolled encouragements during CPR were rarely included.

Three-Month Retention of Basic Life Support with an Automated External Defibrillator Using a Two-Stage versus Four-Stage Teaching Technique.

INTRODUCTION: Resuscitation training increases bystander's ability to perform basic life support (BLS) with an automated external defibrillator (AED) immediately after training. However, several studies indicate that resuscitation skills decay rapidly. METHODS: This study evaluates retention of BLS/AED skills three months after an initial study comparing acquisition of BLS/AED skills among laypersons immediately after training with a two-stage versus four-stage teaching technique. RESULTS: There was no difference in retention of BLS/AED skills (pass rate 10.8% versus 10.9%, respectively, p=1) three months after training. Total average number of skills adequately performed (of 17) was 13.3 versus 13.7 among laypersons trained with a two-stage and a four-stage technique, respectively. No difference was found in quality of chest compressions and rescue breaths between the two groups. CONCLUSION: Three months after training, this study found no difference in retention of BLS/AED skills among laypersons taught using a two-stage compared to a four-stage teaching technique.

In a bed or on the floor? - The effect of realistic hospital resuscitation training: A randomised controlled trial.

INTRODUCTION: In-hospital cardiac arrest has a poor prognosis and often occurs in patients lying in a hospital bed. A bed mattress is a soft compressible surface that may decrease cardiopulmonary resuscitation (CPR) quality. Often hospital CPR training is performed with a manikin on the floor. AIM: To study CPR quality following realistic CPR training with a manikin in a bed compared with one on the floor. METHODS: We conducted a randomised controlled study. Healthcare professionals were randomised to CPR training with a manikin in a hospital bed or one on the floor. Data on CPR quality was collected from manikins. The primary outcome measure was chest compression depth. RESULTS: In total, 108 healthcare professionals (age: 40years, female: 94%) were included. The mean chest compression depth was 39mm (standard deviation (SD): 10), for the bed group compared with 38mm (SD: 9) for the floor group, p=0.49. A post hoc analysis showed that regardless of the training method, the participants who optimised their working position by jumping onto the bed or lowering the bed had a median chest compression depth of 39mm (25th-75th percentiles: 33-45) compared with 29mm (25th-75th percentiles: 23-41) for participants who did neither, p=0.04. CONCLUSION: There was no significant difference in chest compression depth between healthcare professionals who trained CPR on a manikin in a hospital bed compared with one on the floor. Chest compression depth was too shallow in both groups. Irrespective of the training method, participants who optimised their working position performed deeper chest compressions.

A novel protocol for dispatcher assisted CPR improves CPR quality and motivation among rescuers-A randomized controlled simulation study.

BACKGROUND: Emergency dispatchers use protocols to instruct bystanders in cardiopulmonary resuscitation (CPR). Studies changing one element in the dispatcher's protocol report improved CPR quality. Whether several changes interact is unknown and the effect of combining multiple changes previously reported to improve CPR quality into one protocol remains to be investigated. We hypothesize that a novel dispatch protocol, combining multiple beneficial elements improves CPR quality compared with a standard protocol. METHODS: A novel dispatch protocol was designed including wording on chest compressions, using a metronome, regular encouragements and a 10-s rest each minute. In a simulated cardiac arrest scenario, laypersons were randomized to perform single-rescuer CPR guided with the novel or the standard protocol. PRIMARY OUTCOME: a composite endpoint of time to first compression, hand position, compression depth and rate and hands-off time (maximum score: 22 points). Afterwards participants answered a questionnaire evaluating the dispatcher assistance. RESULTS: The novel protocol (n=61) improved CPR quality score compared with the standard protocol (n=64) (mean (SD): 18.6 (1.4)) points vs. 17.5 (1.7) points, p<0.001. The novel protocol resulted in deeper chest compressions (mean (SD): 58 (12)mm vs. 52 (13)mm, p=0.02) and improved rate of correct hand position (61% vs. 36%, p=0.01) compared with the standard protocol. In both protocols hands-off time was short. The novel protocol improved motivation among rescuers compared with the standard protocol (p=0.002). CONCLUSIONS: Participants guided with a standard dispatch protocol performed high quality CPR. A novel bundle of care protocol improved CPR quality score and motivation among rescuers.

E-learning in pediatric basic life support: a randomized controlled non-inferiority study.

OBJECTIVE: Dissemination of pediatric basic life support (PBLS) skills is recommended. E-learning is accessible and cost-effective, but it is currently unknown whether laypersons can learn PBLS through e-learning. The hypothesis of this study was to investigate whether e-learning PBLS is non-inferior to instructor-led training. STUDY DESIGN: Participants were recruited among child-minders and parents of children aged 0-6 years. Participants were randomized to either 2-h instructor-led training or e-learning using an e-learning program (duration 17 min) including an inflatable manikin. After training, participants were assessed in a simulated pediatric cardiac arrest scenario. Tests were video recorded and PBLS skills were assessed independently by two assessors blinded to training method. Primary outcome was the pass rate of the PBLS test (≥8 of 15 skills adequately performed) with a pre-specified non-inferiority margin of 20%. RESULTS: In total 160 participants were randomized 1:1. E-learning was non-inferior to instructor-led training (difference in pass rate -4%; 95% CI -9:0.5). Pass rates were 100% among instructor-led trained (n=67) and 96% among e-learned (n=71). E-learners median time spent on the e-learning program was 30 min (range: 15-120 min) and the median number of log-ons was 2 (range: 1-5). After the study, all participants felt that their skills had improved. CONCLUSION: E-learning PBLS is non-inferior to instructor-led training among child-minders and parents with children aged 0-6 years, although the pass rate was 4% (95% CI -9:0.5) lower with e-learning.