Morning versus evening induction of labour for improving outcomes.

BACKGROUND: Induction of labour is a common intervention in obstetric practice. Traditionally, in most hospitals induction of labour with medication starts early in the morning, with the start of the working day for the day shift. In human and animal studies spontaneous onset of labour is proven to have a circadian rhythm with a preference for start of labour in the evening. Moreover, when spontaneous labour starts in the evening, the total duration of labour and delivery shortens and fewer obstetric interventions are needed. Based on these observations one might assume that starting induction of labour in the evening, in harmony with the circadian rhythm of natural birth, is more beneficial for both mother and child. OBJECTIVES: To assess whether induction of labour starting in the evening, coinciding with the endogenous circadian rhythm, improves the outcome of labour compared with induction of labour starting in the early morning, organised to coincide with office hours. SEARCH METHODS: We contacted the Trials Search Co-ordinator to search the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2012). In addition, we searched MEDLINE (1966 to 16 February 2012) and EMBASE (1980 to 16 February 2012). SELECTION CRITERIA: We included all published and unpublished randomised controlled trials. We excluded trials that employed quasi-random methods of treatment allocation. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias. Two review authors independently extracted data. Data were checked for accuracy. Where necessary, we contacted study authors for additional information. MAIN RESULTS: The search resulted in 2693 articles that we screened on title and abstract for eligibility.Thirteen studies were selected for full text assessment. We included three randomised trials involving 1150 women. Two trials compared the administration of prostaglandins in the morning versus the evening in women with an unfavourable cervix, and one trial compared induction of labour in the morning versus the evening in women with a favourable cervix and/or ruptured membranes with intravenous oxytocin. Because of the different mechanism, we have reported results for these two comparisons separately.In the two trials comparing prostaglandins in the morning versus the evening there were few clinically significant differences between study groups for maternal or neonatal outcomes. One study reported a statistically significant preference by women to start induction of labour with prostaglandins in the morning.In the trial examining induction of labour with intravenous oxytocin, the number of neonatal admissions was statistically significantly increased in the group of women that started induction in the morning. This finding was unexpected, and while the trial authors offered some possible explanations for this, it is important that any future trials examine neonatal outcomes. AUTHORS' CONCLUSIONS: Taking into account women's preferences that favoured administration of prostaglandins in the morning, we conclude that caregivers should preferably consider administering prostaglandins in the morning.There is no strong evidence that induction of labour with intravenous oxytocin in the evening is more or less effective than induction in the morning. Consideration may be given to start induction of labour with oxytocin in the evening when indicated.

Morning versus evening induction of labour for improving outcomes.

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess whether induction of labour starting in the evening, coinciding with the endogenous circadian rhythm, improves the outcome of labour compared to induction of labour starting in the early morning, organised to coincide with office hours.

Effectiveness of detection of intrauterine growth retardation by abdominal palpation as screening test in a low risk population: an observational study.

OBJECTIVE: To evaluate the performance of abdominal palpation as a screening test for intrauterine growth retardation (IUGR) in a low risk population, under standard practice conditions. STUDY DESIGN: Population based observational study of 6318 consecutive low risk singleton pregnancies. The Dutch obstetric system distinguishes low from high risk pregnancies. In the low risk group abdominal palpation as a screening test is performed by midwives. If a complication, like IUGR, during prenatal care is assessed, the women is referred to a consulted obstetrician. Ultrasound is performed by the consulted obstetrician. In case of sustained suspicion the women is selected as high risk. OUTCOME PARAMETERS: severe small for gestational age (SGA) birthweight below 2.3rd centile, all SGA birthweight below 10th centile, operative delivery, neonatal morbidity and perinatal mortality. Screening value of abdominal palpation, abdominal palpation combined with ultrasound, and the performance of high risk selection was assessed by conventional performance measures. RESULTS: Abdominal palpation as a screening test for IUGR is of limited value: the observed sensitivities were 28% for severe SGA and 21% for SGA p < or = 10, respectively. After ultrasound in case of sustained suspicion, the sensitivity in detection of severe SGA was 25% and positive predictive value (PPV) 16%. In detection of SGA p < or = 10 sensitivity was 15% and PPV 55%, which means 45% were false positives. The sensitivity of the Dutch obstetric system in selection of high risk pregnancies in detection of severe SGA was 53%, in detection of SGA p < or = 10 was 37%. Perinatal mortality was 0.9% (57/6318) and 32% of these cases were SGA. Six cases of fetal death were unrecognised during prenatal care (0.09%) and seem preventable. The prevalence of a 5 min Apgar Score < or = 7 was significantly higher in the SGA infants if SGA was defined as p < or = 10. CONCLUSIONS: The diagnostic performance of abdominal palpation as a screening test for IUGR detection in a low risk population is disappointing. However, various stratagems such as routine ultrasound do not improve detection rate or perinatal morbidity and mortality.

Postpartum haemorrhage in nulliparous women: incidence and risk factors in low and high risk women. A Dutch population-based cohort study on standard (> or = 500 ml) and severe (> or = 1000 ml) postpartum haemorrhage.

OBJECTIVE: To determine the incidence and risk factors for standard and severe postpartum haemorrhage (PPH) in vaginally delivering nulliparous women, before and after risk stratification. STUDY DESIGN: A population-based cohort study in an unselected cohort nulliparous women (N = 3464) in 'The Zaanstreek' district, The Netherlands. Risk stratification is part of routine care, where midwives cover all obstetrical care for women with low risk pregnancies. RESULTS: The incidence of standard PPH (> or = 500 ml) and severe PPH (> or = 1000 ml) were 19 and 4.2%, respectively. A retained placenta occurred in 1.8%. These data show consistently slightly higher values as compared to studies in literature. The most important risk factors for standard and severe PPH were related to an abnormal third stage of labour-third stage > or = 30 min and retained placenta (in severe PPH: odds ratio (OR) 14.1, 95% confidence interval (CI) 10.4-19.1). High birth weight and perineal damage were less important, but independent, significant risk factors. In the low risk group (N = 1416), incidence of severe PPH was 4.0%. Independent risk factors for severe PPH were third stage > or = 30 min (incidence 7.1%, OR 3.6) and retained placenta (incidence 1.2%, OR 21.6). In 25% of the women with a prolonged third stage (> or = 30 min), third stage was complicated due to retained placenta and/or severe PPH (1.8% of the low risk group). CONCLUSIONS: The incidence of PPH in nulliparous women in this cohort was on average higher than published data, while the most important risk factors for standard and severe PPH, even after risk stratification, were the same. A prolonged third stage of labour has to be considered as abnormal, requiring specific action.