Labor induction at 41+0 gestational weeks or expectant management for the nulliparous woman: The Finnish randomized controlled multicenter trial.

INTRODUCTION: Neonatal and maternal risks increase in term pregnancy as gestational age advances and become increasingly evident post-term. Management practices of late- and post-term pregnancies vary, and the optimal time point for intervention by labor induction is yet to be determined. MATERIAL AND METHODS: This randomized controlled trial of 381 nulliparous women with unripe cervices compared labor induction at 41+0 gestational weeks (early induction) with expectant management and labor induction at 41+5 to 42+1 gestational weeks (expectant management). This multicenter study included all five university hospitals and the largest central hospital in Finland. The study period was 2018-2022. Participants were randomized to either early induction (48.8%, n = 186) or expectant management (51.2%, n = 195) with equal randomization ratios of 1:1. This was a superiority trial, and the primary outcomes were rates of cesarean section (CS) and composite of adverse neonatal outcomes. The trial was registered at the ISRCTN registry (ISRCTN83219789, https://doi.org/10.1186/ISRCTN83219789). RESULTS: The rates of CS (16.7% [n = 31] vs. 24.1% [n = 47], RR 0.7 [95% CI: 0.5-1.0], p = 0.07) and a composite of adverse neonatal outcomes (9.7% [n = 18] vs. 14.4% [n = 28], RR 0.7 [95% CI: 0.4-1.2] p = 0.16) did not significantly differ between the groups, but the operative delivery rate was lower in the early induction group than in the expectant management group (30.6% [n = 57] vs. 45.6% [n = 89], p = 0.003). The rates of hemorrhage ≥1000 mL and neonatal weight ≥4000 g were also lower in the early induction group, as was the vacuum extraction rate in women with vaginal delivery. Of the women with expectant management, 45.6% (n = 89) had spontaneous onset of labor. No perinatal deaths occurred, but one case of eclampsia appeared in the expectant management group. CONCLUSIONS: Offering labor induction to nulliparous women at 41+0 gestational weeks may decrease the probability of operative delivery, postpartum hemorrhage, and neonatal weight ≥4000 g. However, this study was underpowered to affirm the trends of rising rates of CS and adverse neonatal outcomes in the expectant management group. Thus, expectant management could remain an option for some, as one in two women with expectant management had a spontaneous onset of labor.

Women's subjective perceptions and background factors associated with poor maternal childbirth experience among induced and spontaneous onset of labour: a two-year tertiary hospital cohort study.

BACKGROUND: Women undergoing induction of labour (IOL) more often have poor childbirth experience compared to women with spontaneous onset of labour (SOL). For understanding and optimizing childbirth experience in IOL, we investigated the subjective maternal reasons and perceptions leading to poor childbirth experience in IOL compared to SOL, as well as the background factors and delivery outcomes associated with the poor experience. METHODS: Two-year retrospective cohort study included 836/19442 deliveries (4.3%) with poor childbirth experience in induced or spontaneous onset at term in Helsinki University Hospital. Poor childbirth experience occurred in 389/5290 (7.4%) cases of IOL and in 447/14152 (3.2%) of SOL. Childbirth experience was measured after delivery using Visual Analog Scale (VAS) score, with poor experience defined as VAS < 5. The primary outcome of the study were the maternal reasons for poor childbirth experience. The parameters were collected in the hospital database and statistical analyses were performed by using Mann-Whitney U-test and t-test. RESULTS: The subjective maternal reasons for poor childbirth experience were pain (n = 529, 63.3%), long labour (n = 209, 25.0%), lack of support by care givers (n = 108, 12.9%), and unplanned caesarean section (CS) (n = 104, 12.4%). The methods of labour analgesia were similar among the women who expressed pain as the main reason compared with those who didn't. When comparing the reasons according to the onset of labour, IOL group more often reported unplanned CS (17.2% vs. 8.3%; p < 0.001) and lack of support by the care givers (15.4% vs. 10.7%; p = 0.04), while SOL group more often named pain (68.7% vs. 57.1%; p = 0.001) and rapid labour (6.9% vs. 2.8%; p = 0.007). In multivariable logistic regression model, IOL was associated with lower risk for pain compared to SOL (adjusted OR 0.6, 95%CI 0.5-0.8; p < 0.01). Primiparas more often reported long labour (29.3% vs. 14.3%; p < 0.001) and concern over own or baby's wellbeing (5.7% vs. 2.1%; p = 0.03) compared to multiparas. Women who feared childbirth more often reported lack of support compared to women with no fear (22.6% vs. 10.7%; p < 0.001). CONCLUSION: The main reasons for poor childbirth experience were pain, long labour, unplanned CS and the lack of support by care givers. The childbirth experience is complex and could be optimized by information, support and presence of care givers especially in induced labour.

Planned vaginal and planned cesarean delivery outcomes in pregnancies complicated with pregestational type 1 diabetes - A three-year academic tertiary hospital cohort study.

BACKGROUND: Finland has the world's highest incidence of 62.5/100000 of diabetes mellitus type 1 (DM1) with approximately 400 (1%) DM1 pregnancies annually. Pregnancies complicated by DM1 are accompanied with increased risk for perinatal morbidity and mortality. Timing and mode of delivery are based on the risk of complications, yet the data on labor induction is limited. The aim of this study was to compare delivery outcomes in planned vaginal (VD) and planned cesarean deliveries (CD) in late preterm and term DM1 pregnancies, and to evaluate the feasibility of labor induction. MATERIALS AND METHODS: Pregnant women with DM1, live singleton fetus in cephalic presentation ≥34 gestational weeks delivering in Helsinki University Hospital between January 1st 2017 and December 31st 2019 were included. The primary outcome were the rates of adverse maternal and perinatal outcome. The study population was classified according to the 1980-revised White's classification. Statistical analyses were performed by IBM SPSS Statistics for Windows. RESULTS: Two hundred four women were included, 59.8% (n = 122) had planned VD. The rate of adverse maternal outcome was 27.5% (n = 56), similar between the planned modes of delivery and White classes. The rate of perinatal adverse outcome was 38.7% (n = 79), higher in planned CD (52.4% vs. 29.5%;p = 0.001). The most common adverse perinatal event was respiratory distress (48.8% vs. 23.0%;p <  0.001). The rate of adverse perinatal outcome was higher in White class D + Vascular compared to B + C (45.0% vs. 25.0%, OR after adjustment by gestational age 2.34 [95% CI 1.20-4.50];p = 0.01). The total rate of CD was 63.7% (n = 130), and 39.3% (n = 48) in planned VD. Women with White class D + Vascular more often had emergency CD compared to White Class B + C (48.6% vs. 25.0%;p = 0.009). The rate of labor induction was 51%, being 85.2% in planned VD. The rate of VD in induced labor was 58.7% (n = 61) and the rate of failed induction was 14.1% (n = 15). CONCLUSION: Planned VD was associated with lower rate of adverse perinatal outcome compared to planned CS, with no difference in the rates of adverse maternal outcome. Induction of labor may be feasible option but should be carefully considered in this high-risk population.

Comparison of primiparous women's childbirth experience in labor induction with cervical ripening by balloon catheter or oral misoprostol - a prospective study using a validated childbirth experience questionnaire (CEQ) and visual analogue scale (VAS).

INTRODUCTION: Primiparity and labor induction, especially when cervical ripening is required, are risk factors for a negative childbirth experience. Our aim was to compare childbirth experience in primiparous women with cervical ripening by balloon catheter or oral misoprostol using the validated Childbirth Experience Questionnaire (CEQ). We also wanted to compare assessment of a negative childbirth experience by visual analogue scale (VAS) and CEQ. MATERIAL AND METHODS: This is a prospective study of 362 primiparous women undergoing cervical ripening and labor induction by balloon catheter (67.4%) or oral misoprostol (32.6%) at Helsinki University Hospital, Finland, between January 1, 2019 and January 31, 2020. After delivery, the women assessed their childbirth experience using the CEQ, and patient records provided the patient characteristics, delivery outcomes and VAS ratings. We analyzed the results using IBM SPSS Statistics. RESULTS: Overall, the women experienced their labor and delivery rather positively, with a mean CEQ score of 2.9 (SD 0.6) (scale 1-4), and no differences were detectable when comparing women with cervical ripening by balloon catheter or misoprostol. However, women with balloon catheter were more often satisfied with the method chosen for them and would choose the same method in a future pregnancy. Compared with CEQ, VAS seems mainly to reflect the women's perception of their own capacity to give birth and the safety of the hospital setting, not the level of professional support or participation in decision-making. According to our results, CEQ and VAS are comparable, but the usability of the CEQ is limited by its inability to distinguish the most negative and the most positive experiences, and the VAS is limited by its simplicity. CONCLUSIONS: Women with cervical ripening by balloon catheter or oral misoprostol experienced their childbirth rather positively, results being similar in both groups. However, women with cervical ripening by balloon catheter were more content with their labor induction. The CEQ and VAS can both be used to assess the childbirth experience of primiparous women undergoing labor induction, but both methods have limitations.

Vaginal streptococcus B colonization is not associated with increased infectious morbidity in labor induction.

INTRODUCTION: Labor induction rates are increasing and, in Finland today, one of three labors is induced. Group B streptococcus (GBS) is a bacterium found in 10%-30% of pregnant women and it can be transmitted to the neonate during vaginal delivery. Although GBS is rarely harmful in the general population, it is the leading cause of severe neonatal infections such as sepsis, pneumonia, and meningitis. In addition, GBS can cause maternal morbidity. Labor induction in GBS-positive women has not yet been investigated but concerns of infectious morbidity associated with balloon catheters have been raised. MATERIAL AND METHODS: A historical cohort study of 1959 women undergoing labor induction by balloon catheter in Helsinki University Hospital, Finland, between January 1, 2014 and December 31, 2017. Women with viable singleton term pregnancy in cephalic presentation, unfavorable cervix (Bishop score <6), and intact amniotic membranes were included. GBS was screened by rapid qualitative in vitro test (XPert® GBS) from vaginal and perineal culture upon admission for labor induction. All women testing positive received prophylactic antibiotics. RESULTS: Of the women, 469 (23.9%) were GBS-positive. The rate of maternal intrapartum infection was 7.4%, being lower in the GBS-positive group compared with the GBS-negative group (4.7% vs 8.3%; p = 0.01). The rate of maternal postpartum infection was 3.9%, and the rate of neonatal infection was 3.3%, both being similar between the groups. Also, no difference in the rates of other adverse neonatal outcomes was seen. No GBS sepses occurred in the study. In multivariable logistic regression, rupture of membranes to delivery interval ≥12 hours was associated with maternal intrapartum and postpartum infection, as well as neonatal infection. Other risk factors for maternal intrapartum infection were GBS-negativity, nulliparity, prolonged pregnancy (≥41 weeks), and Bishop score <3 at the start of induction. Cesarean section was associated with postpartum endometritis, while nulliparity, gestational diabetes, and maternal intrapartum infection were associated with neonatal infection. CONCLUSIONS: Regarding maternal and neonatal infectious morbidity, labor induction with balloon catheter appears safe in women colonized with GBS when prophylactic antibiotics are administered at the onset of labor or at membrane rupture.

Maternal childbirth experience in induced and spontaneous labour measured in a visual analog scale and the factors influencing it; a two-year cohort study.

BACKGROUND: Poor maternal childbirth experience plays a role in family planning and subsequent pregnancies. The aim of this study was to compare childbirth experiences in induced and spontaneous labor and to investigate the factors influencing the childbirth experience. METHODS: This two-year cohort study included all women with term singleton pregnancies in cephalic presentation aiming for vaginal delivery at Helsinki University Hospital between January 2017 and December 2018. Maternal satisfaction in the childbirth experience was measured after delivery using a Visual Analog Scale (VAS) score. A low childbirth experience score was defined as VAS < 5. The characteristics and delivery outcomes of the study population were collected in the hospital database and analyzed by SPSS. RESULTS: A total of 18,396 deliveries were included in the study, of which 28.9% (n = 5322) were induced and 71.1% (n = 13 074) were of spontaneous onset. The total caesarean delivery rate was 9.3% (n = 1727). Overall, 4.5% (n = 819) of the women had a low childbirth experience VAS score. The women who underwent labor induction were less satisfied with their birth experience compared to women with spontaneous onset of labor [7.5% (n = 399) vs. 3.2% (n = 420); p < 0.001]. Poor childbirth experience was associated with primiparity [OR 2.0 (95% CI 1.6-2.4)], labor induction [OR 1.6 (95% CI 1.4-1.9)], caesarean delivery [OR 4.5 (95% CI 3.7-5.5)], operative vaginal delivery [OR 3.3 (95% CI 2.7-4.0)], post-partum hemorrhage [OR 1.3 (95% CI 1.1-1.6)], and maternal infections [OR 1.7 (95% CI 1.3-2.4)]. CONCLUSIONS: Poor childbirth experience was associated with labor induction, primiparity, operative delivery, and labor complications, such as post-partum hemorrhage and maternal infections. These results highlight the aspects of care for which patient experience may be improved by additional support and counselling.

Balloon catheter use for cervical ripening in women with term pre-labor rupture of membranes: A 5-year cohort study.

INTRODUCTION: To investigate the safety of balloon catheter for cervical ripening in women with term pre-labor rupture of membranes (PROM) and to compare the incidence of maternal and neonatal infections in women with PROM and women with intact membranes undergoing cervical ripening with a balloon catheter. MATERIAL AND METHODS: This retrospective cohort study of 1923 women with term singleton pregnancy and an unfavorable cervix undergoing cervical ripening with a balloon catheter was conducted in Helsinki University Hospital between January 2014 and December 2018. For each case of PROM, two controls were assigned. The main outcome measures were the rates of maternal and neonatal infections. Statistical analyses were performed by SPSS. RESULTS: In all, 641 (33.3%) women following PROM and 1282 (66.6%) women with intact amniotic membranes underwent labor induction. The rates of intrapartum infection (3.7% vs 7.7%; P = .001) and neonatal infection (1.7% vs 3.8%; P = .01) were not increased in women induced by balloon catheter following PROM. Intrapartum infections were associated with nulliparity (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.6-6.5), history of previous cesarean section (OR 2.8, 95% CI 1.2-6.4), extended gestational age ≥41 weeks (OR 1.9, 95% CI 1.2-3.0) and an induction to delivery interval of 48 hours or more (OR 2.0, 95% CI 1.2-3.3). The risk of neonatal infection was associated with nulliparity (OR 3.3, 95% CI 1.4-8.0), gestational age ≥41 weeks (OR 1.9, 95% CI 1.09-3.36) and induction to delivery interval of 48 hours or more (OR 3.4, 95% CI 1.9-6.0). CONCLUSIONS: Use of balloon catheter in women with term PROM appears safe and was not associated with increased maternal or neonatal infectious morbidity.

Success of trial of labor in women with a history of previous cesarean section for failed labor induction or labor dystocia: a retrospective cohort study.

BACKGROUND: The rates of cesarean section (CS) are increasing worldwide leading to an increased risk for maternal and neonatal complications in the subsequent pregnancy and labor. Previous studies have demonstrated that successful trial of labor after cesarean (TOLAC) is associated with the least maternal morbidity, but the risks of unsuccessful TOLAC exceed the risks of scheduled repeat CS. However, prediction of successful TOLAC is difficult, and only limited data on TOLAC in women with previous failed labor induction or labor dystocia exists. Our aim was to evaluate the success of TOLAC in women with a history of failed labor induction or labor dystocia, to compare the delivery outcomes according to stage of labor at time of previous CS, and to assess the risk factors for recurrent failed labor induction or labor dystocia. METHODS: This retrospective cohort study of 660 women with a prior CS for failed labor induction or labor dystocia undergoing TOLAC was carried out in Helsinki University Hospital, Finland, between 2013 and 2015. Data on the study population was obtained from the hospital database and analyzed using SPSS. RESULTS: The rate of vaginal delivery was 72.9% and the rate of repeat CS for failed induction or labor dystocia was 17.7%. The rate of successful TOLAC was 75.6% in women with a history of labor arrest in the first stage of labor, 73.1% in women with a history of labor arrest in the second stage of labor, and 59.0% in women with previous failed induction. The adjusted risk factors for recurrent failed induction or labor dystocia were maternal height < 160 cm (OR 1.9 95% CI 1.1-3.1), no prior vaginal delivery (OR 8.3 95% CI 3.5-19.8), type 1 or gestational diabetes (OR 1.8 95% CI 1.0-3.0), IOL for suspected non-diabetic fetal macrosomia (OR 10.8 95% CI 2.1-55.9) and birthweight ≥4500 g (OR 3.3 95% CI 1.3-7.9). CONCLUSIONS: TOLAC is a feasible option to scheduled repeat CS in women with a history of failed induction or labor dystocia. However, women with no previous vaginal delivery, maternal height < 160 cm, diabetes or suspected neonatal macrosomia (≥4500 g) may be at increased risk for failed TOLAC.

The efficacy of misoprostol vaginal insert compared with oral misoprostol in the induction of labor of nulliparous women: A randomized national multicenter trial.

INTRODUCTION: Our objective was to compare the efficacy of a 200-µg misoprostol vaginal insert vs oral misoprostol regarding the cesarean section rate and the time interval to vaginal delivery in nulliparous women with unfavorable cervix. MATERIAL AND METHODS: In this prospective multicenter trial, 283 nulliparous women at term with Bishop score <6 were randomized to induction of labor with either a misoprostol vaginal insert (n = 140) or oral misoprostol (n = 143). In the oral misoprostol group, a 50-µg dose of oral misoprostol was administered every 4 hours up to three times during the first day; during the second day, the dose was increased to 100-µg every 4 hours up to three times during the first day, if necessary. Primary outcome was the cesarean section rate. Secondary outcomes were the time from induction of labor to vaginal delivery, the rate of other induction methods needed, labor augmentation with oxytocin and/or amniotomy, use of tocolytics and adverse neonatal and maternal events. RESULTS: In the misoprostol vaginal insert group, median time to vaginal delivery was shorter (24.5 hours vs 44.2 hours, P < 0.001), whereas no difference was found in the cesarean section rate (33.8% vs 29.6%, odds ratio [OR] 1.21, 95% confidence interval [CI] 0.66-1.91, P = 0.67). Other induction methods and labor augmentation with oxytocin and/or amniotomy were less frequent in the misoprostol vaginal insert group (OR 0.32, 95% CI 0.18-0.59 and OR 0.56, 95% CI 0.32-0.99, respectively). Need for tocolysis and meconium-stained amniotic fluid were more common in the misoprostol vaginal insert group (OR 3.63, 95% CI 1.12-11.79 and OR 2.38, 95% CI 1.32-4.29, respectively). Maternal and neonatal adverse events did not differ between groups. CONCLUSIONS: Misoprostol vaginal insert proved to shorten the time to vaginal delivery and to reduce the use of other methods of labor induction and augmentation, but it did not reduce the cesarean section rate compared with oral misoprostol. The benefit of more rapid delivery associated with misoprostol vaginal insert should be weighed against the greater risks for uterine hyperstimulation and meconium-stained amniotic fluid.

Cervical and Amniotic Fluid Matrix Metalloproteinase-8 and Interleukin-6 Concentrations in Preterm Pregnancies with or without Preterm Premature Rupture of Membranes.

INTRODUCTION: Intra-amniotic inflammation is defined by elevated inflammatory biomarkers in the amniotic fluid (AF), either due to microbial invasion of the amniotic cavity (MIAC) or sterile inflammation. Amniocentesis being an invasive procedure, we wanted to investigate whether elevated matrix metalloproteinase-8 (MMP-8) or interleukin-6 (IL-6) concentrations could be detected from cervical fluid samples. MATERIALS AND METHODS: This prospective study included 67 women with singleton nondiabetic pregnancies with or without preterm premature rupture of membranes (PPROM) between 22+0 and 37+0 weeks of gestation. Simultaneous AF and cervical samples were obtained. RESULTS: In women without PPROM, cervical MMP-8 concentrations correlated with AF MMP-8 concentrations (rS = 0.466, p = 0.002), but cervical IL-6 did not correlate with AF IL-6 (rS = 0.277, p = 0.076). In PPROM cases no correlations were found. Women with MIAC had higher concentrations of AF MMP-8 and AF IL-6 compared to women without MIAC regardless of membrane status. However, only women without PPROM had higher concentrations of cervical MMP-8 in proven MIAC. CONCLUSION: In women without PPROM, cervical MMP-8 concentration reflects the magnitude of AF MMP-8, thus potentially guiding the selection of patients benefitting from amniocentesis.

Cervical biomarkers as predictors of successful induction of labour by Foley catheter.

The prediction of successful labour induction is difficult, indicating a need for a biomarker test. Little is known about the effect of Foley catheter (FC) induction on biochemical mediators in the cervix, such as the insulin-like growth factor binding protein-1 (IGFBP-1), matrix metalloproteinases (MMP) and their inhibitors (TIMP). We enrolled 35 nulliparous women with singleton pregnancies, intact amniotic membranes and cephalic presentation ≥40 gestational weeks scheduled for labour induction by FC. Serial cervical swab samples were collected at FC insertion and expulsion. The concentrations of IGFBP-1, PhIGFBP-1, MMP-8, MMP-2, MMP-9, TIMP-1 and TIMP-2 were analysed. The IGFBP-1 and phIGFBP-1 concentrations increased during the FC-induced cervical ripening. In contrast, MMP-8 and MMP-9 concentrations decreased. However, these changes did not predict the outcome of the labour induction, thus appearing not suitable for clinical use. Impact statement What is already known on this subject? During cervical ripening, various constituents interact in a complex network. Insulin-like growth factor binding protein-1 (IGFBP-1), matrix metalloproteinases (MMP) and their tissue inhibitors (TIMP) appear to play a role in cervical ripening. The mechanism of Foley catheter on cervical ripening consists of direct mechanical stretching of the cervix and lower uterine segment, and the stimulation of local secretion of endogenous prostaglandins. What do the results of this study add? This study investigated the role of cervical biochemical mediators during Foley catheter-induced cervical ripening, and their predictive value in a successful labour induction and vaginal delivery. The IGFBP-1 and phosphorylated IGFBP-1 concentrations increased, whereas MMP-8 and MMP-9 concentrations decreased during the Foley catheter-induced cervical ripening in nulliparous women. However, these changes did not predict the outcome of labour induction, thus appearing not suitable for clinical use. What are the implications of these findings for clinical practice and/or further research? Prediction of a successful labour induction is difficult, indicating a need for a biomarker test. Future studies with larger data are needed for investigating the role of these cervical biomarkers in successful labour induction, and in developing a future bedside a screening tool for clinical use.

Foley Catheter or Oral Misoprostol for Induction of Labor in Women with Term Premature Rupture of Membranes: A Randomized Multicenter Trial.

Objectives To compare the Foley catheter and misoprostol for induction of labor in term women with premature rupture of membranes. Study Design A randomized controlled trial was performed in three university hospitals in Finland between March 2012 and September 2014. A total of 202 term women with ruptured membranes >18 hours, singleton pregnancies in cephalic presentation, unfavorable cervix, and no prior cesarean section were enrolled. Participants were randomly allocated to induction of labor by Foley catheter or oral misoprostol in a 1:1 ratio. All women received prophylactic antibiotics. The main outcomes were cesarean section and maternal and neonatal infections. Results Labor induction by Foley catheter or misoprostol showed no difference in cesarean delivery rates (23.6 vs. 18.2%; odds ratio [OR], 1.39; 95% confidence interval [CI], 0.69-2.82; p = 0.36), maternal intrapartum infections (2.2 vs. 2%; OR, 1.12; 95% CI, 0.15-8.9; p = 1.00), postpartum infections (1.1 vs. 2.0%; OR, 0.55; 95% CI, 0.05-6.18; p = 1.00), or neonatal infections (1.1 vs. 5.1%; OR, 0.21; 95% CI, 0.24-1.87; p = 0.22). The total time from induction to delivery was similar (1,311 vs. 1,435 minutes; p = 0.31) in the two groups. Conclusions Foley catheter or misoprostol can both be used for induction of labor in women with term premature rupture of membranes.

Management of Foley catheter induction among nulliparous women: a retrospective study.

BACKGROUND: Induction of labour is associated with increased risk for caesarean delivery among nulliparous women. The aims of this study were to evaluate the risk factors for caesarean delivery and to investigate the risk of maternal and neonatal infections in nulliparous women undergoing induction of labour by Foley catheter. METHODS: This clinical retrospective study of 432 nulliparous women with singleton pregnancy and intact amniotic membranes at or beyond 37 gestational weeks scheduled for induction of labour by Foley catheter was conducted over the course of one year, between January 2012 and January 2013, in Helsinki University Hospital. The main outcome measures were caesarean section rate and maternal and neonatal infections. Univariate and multivariate logistic regressions were used to estimate relative risks by odds ratios with 95% confidence intervals. RESULTS: The caesarean section rate was 39.1% (n = 169). In multivariate regression analysis, the factors associated with caesarean section were the need for oxytocin for labour induction [OR 2.9 (95% CI 1.8-4.5) p < 0.001] and early epidural analgesia [OR 9.9 (95% CI 2.1-47.5), p = 0.004]. The maternal intrapartum infection rate was 6.3%, and the clinical neonatal infection rate was 2.8%. In multivariate analysis, gestational diabetes was associated with maternal intrapartum infection [OR 4.3 (95% CI 1.7-11.0, p = 0.002] and early epidural analgesia with neonatal clinical sepsis [OR 10.5 (95% CI 1.4-76), p = 0.02]. CONCLUSIONS: Oxytocin induction and early epidural analgesia were associated with caesarean delivery. Gestational diabetes and early epidural analgesia were associated with infectious morbidity. Since the first caesarean delivery has a major impact on subsequent pregnancies, optimising labour induction among nulliparous women is important.

Management of prolonged pregnancy by induction with a Foley catheter.

OBJECTIVES: To describe labor outcomes in women with prolonged pregnancy and induction of labor with a Foley catheter, as compared with women with spontaneous onset of labor. DESIGN: Retrospective study. SETTING: Helsinki University Hospital. SAMPLE: 553 women with uncomplicated prolonged pregnancies between January 2011 and January 2012, divided into 303 women (54.8%) with Foley catheter induction and 250 (45.2%) with spontaneous labor. METHODS: Maternal and neonatal characteristics of women with uncomplicated singleton pregnancy of ≥41(+5) weeks of gestation were analyzed. MAIN OUTCOME MEASURES: Cesarean delivery rates, maternal and neonatal morbidity. RESULTS: The cesarean delivery rate was 30.7% (n = 93/303) in women with labor induction and 4.8% (12/250) in women with spontaneous onset of labor (p < 0.001). The cesarean delivery rate was 37.3% (91/244) among nulliparous women with labor induction and 8.7% (11/126) among women with spontaneous labor, a sixfold increased risk (odds ratio 6.2). Among parous women, cesarean section rates were low and not significantly different (3.4% vs. 0.8%, p = 0.2). There were no differences in maternal intrapartum or postpartum infection rates or adverse neonatal outcomes between the groups. CONCLUSIONS: Foley catheter induction of labor in prolonged pregnancy did not increase maternal or perinatal morbidity compared with spontaneous onset of labor but was associated with a considerably increased cesarean section rate, particularly among nulliparous women.

Comparison of delivery outcomes in low-dose and high-dose oxytocin regimens for induction of labor following cervical ripening with a balloon catheter: A retrospective observational cohort study.

A variety of oxytocin regimens are used for labor induction and augmentation. Considering the increasing rates of labor induction, it is important to assess the most optimal oxytocin regimen without compromising maternal and fetal safety. The aim of this study was to compare delivery outcomes of low-dose and high-dose oxytocin induction protocols. This retrospective cohort study of 487 women comparing low-dose oxytocin protocol (n = 280) and high-dose oxytocin protocol (n = 207) in labor induction following cervical ripening by balloon catheter was performed in Helsinki University Hospital after implementation of a new oxytocin induction protocol. The study included two six-month cohorts from 2016 and 2019. Women with vital singleton pregnancies ≥37 gestational weeks, cephalic presentation, and intact amniotic membranes were included. The primary outcome was the rate of vaginal delivery. The secondary outcomes were the rates of maternal and neonatal infections, postpartum hemorrhage, umbilical artery blood pH-value, admission to neonatal intensive care, and induction-to-delivery interval. Statistical analyses were performed by using IBM SPSS Statistics for Windows (Armonk, NY, USA). The rate of vaginal delivery was higher [69.9% (n = 144) vs. 47.9% (n = 134); p<0.004] and the rates of maternal and neonatal infection were lower during the new high-dose oxytocin protocol [maternal infections 13.6% (n = 28) vs. 22.1% (n = 62); p = 0.02 and neonatal infection 2.9% (n = 6) vs. 14.6% (n = 41); p<0.001, respectively]. The rates of post-partum hemorrhage, umbilical artery blood pH-value <7.05 or neonatal intensive care admissions did not differ between the cohorts. The median induction-to-delivery interval was shorter in the new protocol [32.0 h (IQR 18.5-42.7) vs. 37.9 h (IQR 27.8-52.8); p<0.001]. In conclusion, implementation of the new continuous high-dose oxytocin protocol resulted in higher rate of vaginal delivery and lower rate of maternal and neonatal infections. Our experience supports the use of high-dose continuous oxytocin induction regimen with a practice of stopping oxytocin once active labor is achieved, and a 15-18-hour maximum duration for oxytocin induction in the latent phase of labor following cervical ripening with a balloon catheter.

Breaking the myth: the association between the increasing incidence of labour induction and the rate of caesarean delivery in Finland - a nationwide Medical Birth Register study.

OBJECTIVES: To determine the association between the rate of labour induction and caesarean delivery. DESIGN: Medical Birth Register-based study. We used data from the nationwide Medical Birth Register collecting data on delivery outcomes on all births from 22+0 weeks and/or birth weight of at least 500 g. SETTING: Finland. PARTICIPANTS: 663 024 live births in Finland from 2008 to 2019. MAIN OUTCOME MEASURES: The rates of labour induction and caesarean delivery. RESULTS: The rate of labour induction increased from 17.8% to 30.3%; p<0.001, during the study. The total caesarean delivery rate was 16.5% (n=109 178). An increase of approximately 0.5% in the caesarean delivery rate occurred during the study period. The rate of caesarean delivery following labour induction slightly decreased (15.41% vs 15.35%; p<0.001). In multivariate logistic regression analysis, induction of labour was associated with a reduced risk for caesarean delivery (OR 0.72, 95% CI 0.71 to 0.74). The frequency of advanced maternal age (18.0% vs 23.5%; p<0.001), obesity (11.4% vs 15.1%; p<0.001) and gestational diabetes (9.8% vs 23.3%; p<0.001) increased during the study. CONCLUSIONS: The 70% increase in the rate of labour induction in Finland has not led to a significant increase in the rate of caesarean delivery, which has remained one of the lowest in the world. Pregnant women in Finland are more frequently obese, older and diagnosed with gestational diabetes, which may partly explain the increase in the rate of labour induction.

Childbirth experience in induced labor: A prospective study using a validated childbirth experience questionnaire (CEQ) with a focus on the first birth.

OBJECTIVE: First birth and labor induction are risk factors for negative childbirth experiences. As labor inductions are increasing, research into this high-risk group's childbirth experiences is important. We aimed to investigate whether nulliparity or factors related to labor induction, labor, and delivery explain the association. METHODS: This was a prospective study of 711 women undergoing labor induction at Helsinki University Hospital, Finland, between January 1, 2019, and January 31, 2020. The participants answered the Childbirth Experience Questionnaire (CEQ) after delivery (response rate 69.4%). The patient characteristics and delivery outcomes were collected from patient records. We analyzed the results for nulliparous and parous women. RESULTS: The mean CEQ scores were 2.9 (SD 0.5) for nulliparous women (n = 408) and 3.2 (SD 0.5) for parous women (n = 303), on a scale of 1-4; higher scores represent more positive experiences. However, 7.3% of the women had negative childbirth experiences (8.8% nulliparous; 5.3% parous, p = 0.08). Negative experiences were associated with a cesarean section (OR 6.7, 95% CI 1.8-9.3, p < 0.001) and a hemorrhage ≥ 1500 ml in vaginal delivery (OR 2.8, 95% CI 1.1-7.5, p = 0.03). In the separate CEQ domains analyses, nulliparity was associated with negative experiences in the "Own Capacity" domain (OR 1.6, 95% CI 1.0-2.4, p = 0.03). Cervical ripening, oxytocin use, and daytime delivery were associated with negative experiences in at least one domain, whereas epidural or spinal analgesia was regarded positively in two domains and negatively in one. CONCLUSIONS: Nulliparous women undergoing labor induction risk negative childbirth experiences mainly due to labor and delivery-related factors, similar to parous women. Their perceptions of their capacity and preparedness for labor and delivery should be enhanced antenatally. An effective labor induction protocol promoting as high a rate of vaginal delivery as possible and preparedness to promptly respond to postpartum hemorrhage are key for avoiding negative childbirth experiences.