Indications and results of labour induction in nulliparous women: an interview among obstetricians, residents and clinical midwives.

OBJECTIVE: To investigate which clinical factors are important in management decisions that clinicians make in the process of labour induction, and which clinical factors they estimate as predictive of labour outcome after induction. STUDY DESIGN: A written interview was conducted among obstetricians, residents and clinical midwives in five teaching hospitals in the south of the Netherlands. Sixteen fictive vignettes were constructed of pregnant nulliparous women who were candidates for induction of labour. The vignettes differed on eight clinical variables: maternal age, BMI, gestational age, indication for induction (maternal request vs mild pre-eclampsia), dilation, position, consistency and effacement of the cervix. For each case presentation, the inclination to induce labour was calculated for the three groups, and their estimates of the probability of a spontaneous vaginal delivery or a caesarean delivery were analyzed. RESULTS: Of the 80 questionnaires sent, 60 (75%) were completed. Mild pre-eclampsia and post-term pregnancy were the most important clinical factors for the decision to induce or not in all three groups. Gestational age, effacement and dilation of the cervix were considered as the most important predictors of labour outcome after induction. CONCLUSIONS: In this interview, obstetricians, residents and clinical midwives based their decision-making whether or not to induce labour predominantly on medical indications. Outcome of labour after induction was estimated to depend on gestational age and cervical status at the start of induction.

Which factors play a role in clinical decision-making in external cephalic version?

OBJECTIVE: To assess the clinical factors that influence the estimates of clinicians of the success of an external cephalic version(ECV), and the subsequent management decisions made by clinicians. DESIGN: We constructed 16 fictional vignettes of women with a term fetus in breech position eligible for ECV. Setting. Secondary and tertiary clinics in The Netherlands. POPULATION: Thirty-seven gynaecologists, residents and midwifes. METHODS: Sixteen case summaries concerning a hypothetical patient eligible for ECV. Potential prognostic factors that varied between the cases were parity, maternal body mass index, engagement of the fetus, amniotic fluid, fetal growth, fetal presentation and placental localisation. For each case presentation, the clinicians were asked for their inclination to perform an ECV, and whether or not they would use tocolysis. RESULTS: The estimated probabilities of success varied between 20 and 60%. The number of clinicians that would attempt an ECV varied per case between 32 and 97%. Amniotic fluid and engagement contributed 80% of the variation in the decision to perform ECV. In the case of oligohydramnios or an engaged breech, the clinicians tended not to perform an ECV. CONCLUSION: Amniotic fluid and engagement seem to be the main factors in the clinical decision-making of clinicians in ECV.This decision-making is probably experience based. Systematic knowledge of clinical prognosticators and subsequent assessment of their prognostic capacity is needed.