Routine vaginal examination to assess labor progress at 8 compared to 4 hours after early amniotomy following Foley balloon ripening in the labor induction of multiparas: a randomized trial.

BACKGROUND: Vaginal examination to monitor labor progress is recommended at least every 4 hours, but it can cause pain and embarrassment to women. Trial data are limited on the best intensity for vaginal examination. Vaginal examination is not needed for oxytocin dose titration after an amniotomy has been performed and oxytocin infusion started. The Foley balloon commonly ripens the cervix without strong contractions. Amniotomy and oxytocin infusion are usually required to drive labor. OBJECTIVE: This study aimed to evaluate the first vaginal examination at 8 vs 4 hours after amniotomy-oxytocin after Foley ripening in multiparous labor induction. STUDY DESIGN: A randomized controlled trial was conducted from October 2021 to September 2022 at the University Malaya Medical Center, Kuala Lumpur, Malaysia. Multiparas at term were recruited at admission for labor induction. Participants were randomized to a first routine vaginal examination at 8 or 4 hours after Foley balloon ripening and amniotomy. Titrated oxytocin infusion was routinely commenced after amniotomy to initiate contractions. The 2 primary outcomes were the time from amniotomy to delivery (noninferiority hypothesis) and maternal satisfaction (superiority hypothesis). Data were analyzed using the Student t test, Mann-Whitney U test, and chi-square test (or Fisher exact test), as suitable for the data. RESULTS: A total of 204 women were randomized, 102 to each arm. Amniotomy to birth intervals were 4.97±2.47 hours in the 8-hour arm and 5.79±3.17 hours in the 4-hour arm (mean difference, -0.82; 97.5% confidence interval, -1.72 to 0.08; P=.041; Bonferroni correction), which were noninferior within the prespecified 2-hour upper margin, and the maternal satisfaction scores (11-point 0-10 numerical rating scale) with allocated labor care were 9 (interquartile range, 8-9) in the 8-hour arm and 8 (interquartile range, 7-9) in the 4-hour arm (P=.814). In addition, oxytocin infusion to birth interval difference was noninferior within the 97.5% confidence interval (-1.59 to 0.23) margin of 1.3 hours. Of the maternal outcomes, the amniotomy to first vaginal examination intervals were 3.9±1.8 hours in the 8-hour arm and 3.4±1.3 hours in the 4-hour arm (P=.026), and the numbers of vaginal examinations were 2.00 (interquartile range, 2.00-3.00) in the 8-hour arm and 3.00 (interquratile range, 2.00-3.25) in the 4-hour arm (P<.001). For the 8-hour arm, the first vaginal examination was less likely to be as scheduled and more likely to be indicated by sensation to bear down (P<.001), and the epidural analgesia rates were lower (13/102 participants [12.7%] in the 8-hour arm vs 28/102 participants [27.5%] in the 4-hour arm; relative risk, 0.46; 95% confidence interval, 0.26-0.84; P=.009). Other outcomes of the mode of delivery, indications for cesarean delivery, and delivery blood loss were not different. Neonatal outcomes were not different. CONCLUSION: Routine first vaginal examination at 8 hours compared with that at 4 hours was noninferior for the time to birth but did not improve maternal satisfaction.

Early vs delayed amniotomy following transcervical Foley balloon in the induction of labor: a randomized clinical trial.

BACKGROUND: The optimal timing of amniotomy during labor induction is a topic of ongoing debate due to the potential risks associated with both amniotomy and prolonged labor. As such, individuals in the field of obstetrics and gynecology must carefully evaluate the associated benefits and drawbacks of this procedure. While amniotomy can expedite the labor process, it may also lead to complications such as umbilical cord prolapse, fetal distress, and infection. Therefore, a careful and thorough examination of the risks and benefits of amniotomy during labor induction is essential in making an informed decision regarding the optimal timing of this procedure. OBJECTIVE: This study aimed to determine if an amniotomy within 2 hours after Foley balloon removal reduced the duration of active labor and time taken to achieve vaginal delivery when compared with an amniotomy ≥4 hours after balloon removal among term pregnant women who underwent labor induction. STUDY DESIGN: This was an open-label, randomized controlled trial that was conducted at a single academic center from October 2020 to March 2023. Term participants who were eligible for preinduction cervical ripening with a Foley balloon were randomized into 2 groups, namely the early amniotomy (rupture of membranes within 2 hours after Foley balloon removal) and delayed amniotomy (rupture of membranes performed more than 4 hours after Foley balloon removal) groups. Randomization was stratified by parity. The primary outcome was time from Foley balloon insertion to active phase of labor. Secondary outcomes, including time to delivery, cesarean delivery rates, and maternal and neonatal complications, were analyzed using intention-to-treat and per-protocol analyses. RESULTS: Of the 150 participants who consented and were enrolled, 149 were included in the analysis. In the intention-to-treat population, an early amniotomy did not significantly shorten the time between Foley balloon insertion and active labor when compared with a delayed amniotomy (885 vs 975 minutes; P=.08). An early amniotomy was associated with a significantly shorter time from Foley balloon placement to active labor in nulliparous individuals (1211; 584-2340 vs 1585; 683-2760; P=.02). When evaluating the secondary outcomes, an early amniotomy was associated with a significantly shorter time to active labor onset (312.5 vs 442.5 minutes; P=.02) and delivery (484 vs 587 minutes; P=.03) from Foley balloon removal with a higher rate of delivery within 36 hours (96% vs 85%; P=.03). Individuals in the early amniotomy group reached active labor 1.5 times faster after Foley balloon insertion than those in the delayed group (hazard ratio, 1.5; 95% confidence interval, 1.1-2.2; P=.02). Those with an early amniotomy also reached vaginal delivery 1.5 times faster after Foley balloon removal than those in the delayed group (hazard ratio, 1.5; 95% confidence interval, 1-2.2; P=.03). A delayed amniotomy was associated with a higher rate of postpartum hemorrhage (0% vs 9.5%; P=.01). No significant differences were observed in the cesarean delivery rates, length of hospital stay, maternal infection, or neonatal outcomes. CONCLUSION: Although an early amniotomy does not shorten the time from Foley balloon insertion to active labor, it shortens time from Foley balloon removal to active labor and delivery without increasing complications. The increased postpartum hemorrhage rate in the delayed amniotomy group suggests increased risks with delayed amniotomy.

Maternal and Neonatal Outcomes Associated with Amniotomy among Nulliparous Women Undergoing Labor Induction at Term.

OBJECTIVE: The aim of the study is to evaluate the association between amniotomy at various time points during labor induction and maternal and neonatal outcomes among term, nulliparous women. STUDY DESIGN: Secondary analysis of a randomized trial of term labor induction versus expectant management in low-risk, nulliparous women (2014-2017) was conducted. Women met inclusion criteria if they underwent induction ≥38 weeks' gestation using oxytocin with documented time and type of membrane rupture. Women with antepartum stillbirth or fetal anomaly were excluded. The primary outcome was cesarean delivery. Secondary outcomes included maternal and neonatal complications. Maternal and neonatal outcomes were compared among women with amniotomy versus women with intact membranes and no amniotomy at six 2-hour time intervals: before oxytocin initiation, 0 to <2 hours after oxytocin, 2 to <4 hours after, 4 to <6 hours after, 6 to <8 hours after, and 8 to <10 hours after. Multivariable logistic regression adjusted for maternal age, body mass index, race/ethnicity, modified Bishop score on admission, treatment group, and hospital (as a random effect). RESULTS: Of 6,106 women in the parent trial, 2,854 (46.7%) women met inclusion criteria. Of these 2,340 (82.0%) underwent amniotomy, and majority of the women had amniotomy performed between 2 and <6 hours after oxytocin. Cesarean delivery was less frequent among women with amniotomy 6 to <8 hours after oxytocin compared with women without amniotomy (21.9 vs. 29.7%; adjusted odds ratio 0.61, 95% confidence interval 0.42-0.89). Amniotomy at time intervals ≥4 hours after oxytocin was associated with lower odds of labor duration >24 hours. Amniotomy at time intervals ≥2 hours and <8 hours after oxytocin was associated with lower odds of maternal hospitalization >3 days. Amniotomy was not associated with postpartum or neonatal complications. CONCLUSION: Among a contemporary cohort of nulliparous women undergoing term labor induction, amniotomy was associated with either lower or similar odds of cesarean delivery and other adverse outcomes, compared with no amniotomy.

The association between delayed amniotomy and adverse outcomes in labor induction.

OBJECTIVE: To assess if delayed amniotomy during labor induction is associated with adverse delivery outcomes. STUDY DESIGN: Retrospective cohort study of women with a viable, singleton gestation who underwent labor induction at a tertiary-care hospital (4/2014-3/2017). Women were excluded if oxytocin was not used or if spontaneous rupture of membranes (ROM) occurred ≤8 h after oxytocin initiation. The primary outcome was cesarean delivery, and secondary outcomes included postpartum hemorrhage, maternal infectious morbidity, neonatal 5-min Apgar score <7, and neonatal intensive care unit admission. Women were compared by timing of amniotomy: delayed (ROM > 8 h after oxytocin initiation) versus not delayed. Multivariable logistic regression was used to estimate the association between delayed amniotomy and study outcomes. RESULTS: Of 2081 women who met inclusion criteria, 1125 (before 54%) had delayed amniotomy. Women with delayed amniotomy had ROM 12.7 h (IQR 10.0, 17.9) after oxytocin versus 5.0 h (IQR 3.7, 6.5) without delayed amniotomy. In multivariable regression, delayed amniotomy was associated with increasingly higher odds of cesarean as maternal obesity severity increased (aOR 1.58, 95 %CI 1.24-2.03 at BMI 30 kg/m2; aOR 2.15, 95 %CI 1.45-3.21 at BMI 40 kg/m2; aOR 2.93, 95 %CI 1.54-5.57 at BMI 50 kg/m2). CONCLUSION: Delayed amniotomy >8 h after starting oxytocin for labor induction was associated with higher odds of cesarean delivery. Significant delay in ROM should be avoided during labor induction.

Labor augmentation strategies: What's the evidence?

Labor augmentation is a commonly used strategy in obstetrics to make labor more efficient or to increase the chance of achieving a vaginal delivery. Intravenous infusion of synthetic oxytocin and early amniotomy are the most widely used methods, but there is considerable variation in how they are used in clinical practice. There remain significant differences in the timing, dosing, and administration of synthetic oxytocin across institutions. The use and timing of amniotomy is similarly controversial. Much of the clinical variation in augmentation practices stem from the significant heterogeneity that exists in the literature, as well as the lack of an optimal strategy that has been subjected to the scientific scrutiny needed to prove its superiority in both efficacy and safety. Further research is needed to allow for better standardized care of women presenting in spontaneous labor.

Vaginal assessment and expedited amniotomy in oral misoprostol labor induction in nulliparas: a randomized trial.

BACKGROUND: Labor is induced in 20-30% of maternities, with an increasing trend of use. Labor induction with oral misoprostol is associated with reduced risk of cesarean deliveries and has a safety and effectiveness profile comparable to those of mechanical methods such as Foley catheter use. Labor induction in nulliparous women continues to be challenging, with the process often quite protracted. The eventual cesarean delivery rate is high, particularly when the cervix is unfavorable and ripening is required. Vaginal examination can cause discomfort and emotional distress particularly to nulliparous women, and plausibly can affect patient satisfaction with the induction and birth process. OBJECTIVE: The aim of this study was to evaluate regular (4-hourly prior to each oral misoprostol dose with amniotomy when feasible) compared with restricted (only if indicated) vaginal assessments during labor induction with oral misoprostol in term nulliparous women MATERIALS AND METHODS: We performed a randomized trial between November 2016 and September 2017 in a university hospital in Malaysia. Our oral misoprostol labor induction regimen comprised 50 µg of misoprostol administered 4 hourly for up to 3 doses in the first 24 hours. Participants assigned to regular assessment had vaginal examinations before each 4-hourly misoprostol dose with a view to amniotomy as soon as it was feasible. Participants in the restricted arm had vaginal examinations only if indicated. Primary outcomes were patient satisfaction with the birth process (using an 11-point visual numerical rating scale), induction to vaginal delivery interval, and vaginal delivery rate at 24 hours. RESULTS: Data from 204 participants (101 regular, 103 restricted) were analyzed. The patient satisfaction score with the birth process was as follows (median [interquartile range]): 7 [6-9] vs 8 [6-10], P = .15. The interval of induction to vaginal delivery (mean ± standard deviation) was 24.3 ± 12.8 vs 31.1 ± 15.0 hours (P = .013). The vaginal delivery rate at 24 hours was 27.7% vs 20.4%; (relative risk [RR], 1.4; 95% confidence interval [CI], 0.8-2.3; P = .14) for the regular vs restricted arms, respectively. The cesarean delivery rate was 50% vs 43% (RR, 1.1; 95% CI, 0.9-1.5; P = .36). When assessed after delivery, participants' fidelity to their assigned vaginal examination schedule in a future labor induction was 45% vs 88% (RR, 0.5; 95% CI, 0.4-0.7; P < .001), and they would recommend their assigned schedule to a friend (47% vs 87%; RR, 0.6; 95% CI, 0.5-0.7; P < .001) in the regular compared with the restricted arms, respectively. CONCLUSION: Despite a shorter induction to vaginal delivery interval with regular vaginal examination and a similar vaginal delivery rate at 24 hours and birth process satisfaction score, women expressed a higher preference for the restricted examination schedule and were more likely to recommend such a schedule to a friend.

Vía de finalización en pacientes con segunda inducción al trabajo de parto en el Hospital Nacional prof. A. Posadas / Postterm pregnancy in patients with second labour induction - Author's experience

The labour induction is an intervention to initiate artificially the uterine contractions to produce the effacement and dilatation of the uterine cervix until the child-birth is achieved. It is indicated when the benefit of the termination of the pregnancy for the mother and the child is greater than its continuation. It is perfored in more or less the 20 % of the women. In our institution the rate oscillates in around the 9 % of the cases. It is understand as an successful induction the termination of the labour through the vaginal delivery. The methods for labour induction more commonly used at present are mechanical and pharmacological. Between the first group we can find the Hamilton maneuver and the amniotomy. And between the pharmacologicals we find the oxytocine. These elements are considered in the article

Maternity Care Update: Labor and Delivery.

Labor is defined as contractions with cervical change and active labor starts when the cervix is dilated 6 cm. Updated labor curves and definitions should be used to define labor dystocia. Oxytocin and amniotomy have important roles in the management of labor dystocia. Structured intermittent fetal monitoring should be considered for women with low-risk pregnancies but continuous electronic fetal monitoring still is used most commonly. Moderate fetal heart rate variability is the most reliable marker of fetal well-being. Epidural analgesia is used in more than half of all births in the United States. It is not associated with an increase in the rate of cesarean deliveries but is associated with a longer second stage of labor. Interventions that may reduce the need for cesarean delivery include use of the new definitions of labor dystocia, a trial of manual rotation of occiput posterior presentations, use of cervical ripening agents for induction of labor with an unfavorable cervix, and encouragement of women with previous cesarean deliveries to attempt vaginal delivery.

Does Early Artificial Rupture of Membranes Speed Labor in Preterm Inductions?

OBJECTIVE: In full-term patients, early artificial rupture of membranes (AROMs) decreases time in labor. We assessed the impact of early AROM in preterm patients undergoing indicated induction of labor. STUDY DESIGN: We conducted a retrospective cohort study of all patients undergoing indicated preterm induction (23-34 weeks) at a single tertiary care center from 2011 to 2014. Early AROM was defined as <4 cm and late AROM was defined as ≥4 cm. The primary outcomes evaluated were cesarean delivery and time in labor. Secondary outcomes were chorioamnionitis and a composite of maternal and neonatal adverse outcomes. RESULTS: Of the 149 women included, 65 (43.6%) had early AROM. Early AROM was associated with an increased time from the start of induction to delivery (25.7 ± 13.0 vs. 19.0 ± 10.3 hours, p < 0.01) and with an increase in the risk of cesarean (53.4 vs. 22.6%, adjusted odds ratio: 3.5, 95% confidence interval: 1.60-7.74). Early AROM was not associated with an increased risk of chorioamnionitis or adverse maternal or fetal outcomes. CONCLUSION: In this observational cohort, early AROM was associated with an increased risk of cesarean. A randomized controlled trial is necessary to determine the optimal timing of AROM in preterm patients requiring delivery.

The effect of induction method in twin pregnancies: a secondary analysis for the twin birth study.

BACKGROUND: This secondary analysis for the Twin Birth Study, an international, multicenter trial, aimed to compare the cesarean section rates and safety between methods of induction of labor in twin pregnancies. METHODS: Women with twin pregnancies where the first twin was in a cephalic presentation and who presented for labor induction, were non-randomly assigned to receive prostaglandin or amniotomy and/or oxytocin. Main outcome measures were the rates of unplanned cesarean section and neonatal and maternal mortality or serious morbidity. RESULTS: 153 (41.5%) were induced by prostaglandin (prostaglandin group) and 215 (58.5%) were induced by amniotomy and/or oxytocin alone (no prostaglandin group). Induction using prostaglandin was more common in countries with a low perinatal mortality rate <10/1000 (45.7 versus 32.5%, p = 0.02). Cesarean section rates were similar in the two groups: 62/153 (40.5%) in the prostaglandin group and 87/215 (40.5%) in the no prostaglandin group (odds ratio 1, 95% CI 0.65-1.5). Nulliparity, late maternal age, non-cephalic presentation of twin B and high country's perinatal mortality rate were found to be independently associated with the induction to end with an unplanned cesarean section. There were no significant differences between groups with respect to maternal or neonatal adverse outcomes. CONCLUSIONS: The need for cervical ripening by prostaglandin had no effect on the incidence of cesarean delivery or an abnormal outcome. There is a significant risk of unplanned cesarean section independent of chosen induction method. TRIAL REGISTRATION: This trial was registered at the International Standard Randomized Controlled Trial Register (identifier ISRCTN74420086 ; December 9, 2003) and retrospectively registered at the www.clinicaltrials.gov (identifier NCT 00187369 ; September 12, 2005).

Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis.

BACKGROUND: More than 150,000 pregnant women in England and Wales have their labour induced each year. Multiple pharmacological, mechanical and complementary methods are available to induce labour. OBJECTIVE: To assess the relative effectiveness, safety and cost-effectiveness of labour induction methods and, data permitting, effects in different clinical subgroups. METHODS: We carried out a systematic review using Cochrane methods. The Cochrane Pregnancy and Childbirth Group's Trials Register was searched (March 2014). This contains over 22,000 reports of controlled trials (published from 1923 onwards) retrieved from weekly searches of OVID MEDLINE (1966 to current); Cochrane Central Register of Controlled Trials (The Cochrane Library); EMBASE (1982 to current); Cumulative Index to Nursing and Allied Health Literature (1984 to current); ClinicalTrials.gov; the World Health Organization International Clinical Trials Registry Portal; and hand-searching of relevant conference proceedings and journals. We included randomised controlled trials examining interventions to induce labour compared with placebo, no treatment or other interventions in women eligible for third-trimester induction. We included outcomes relating to efficacy, safety and acceptability to women. In addition, for the economic analysis we searched the Database of Abstracts of Reviews of Effects, and Economic Evaluations Databases, NHS Economic Evaluation Database and the Health Technology Assessment database. We carried out a network meta-analysis (NMA) using all of the available evidence, both direct and indirect, to produce estimates of the relative effects of each treatment compared with others in a network. We developed a de novo decision tree model to estimate the cost-effectiveness of various methods. The costs included were the intervention and other hospital costs incurred (price year 2012-13). We reviewed the literature to identify preference-based utilities for the health-related outcomes in the model. We calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit. We represent uncertainty in the optimal intervention using cost-effectiveness acceptability curves. RESULTS: We identified 1190 studies; 611 were eligible for inclusion. The interventions most likely to achieve vaginal delivery (VD) within 24 hours were intravenous oxytocin with amniotomy [posterior rank 2; 95% credible intervals (CrIs) 1 to 9] and higher-dose (≥ 50 µg) vaginal misoprostol (rank 3; 95% CrI 1 to 6). Compared with placebo, several treatments reduced the odds of caesarean section, but we observed considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 µg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed 'best'. Few studies collected information on women's views. Owing to incomplete reporting of the VD within 24 hours outcome, the cost-effectiveness analysis could compare only 20 interventions. The analysis suggested that most interventions have similar utility and differ mainly in cost. With a caveat of considerable uncertainty, titrated (low-dose) misoprostol solution and buccal/sublingual misoprostol had the highest likelihood of being cost-effective. LIMITATIONS: There was considerable uncertainty in findings and there were insufficient data for some planned subgroup analyses. CONCLUSIONS: Overall, misoprostol and oxytocin with amniotomy (for women with favourable cervix) is more successful than other agents in achieving VD within 24 hours. The ranking according to safety of different methods was less clear. The cost-effectiveness analysis suggested that titrated (low-dose) oral misoprostol solution resulted in the highest utility, whereas buccal/sublingual misoprostol had the lowest cost. There was a high degree of uncertainty as to the most cost-effective intervention. FUTURE WORK: Future trials should be powered to detect a method that is more cost-effective than misoprostol solution and report outcomes included in this NMA. STUDY REGISTRATION: This study is registered as PROSPERO CRD42013005116. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Caracterização da assistência ao parto em adolescentes primigestas no município de cuiabá-mt / Caracterización de la atención al parto en adolescentes primigestas en el municipio de cuiabá-mt / Characterization of pregnancy labor assistance of primigravida adolescents in the city of cuiabá-mt

RESUMO O objetivo foi analisar a assistência ao parto de adolescentes primigestas no contexto do Sistema Único de Saúde (SUS) no município de Cuiabá, Mato Grosso. Estudo transversal, descritivo e documental com amostragem aleatória simples composta por 164 prontuários de puérperas adolescentes coletados por meio de ficha estruturada durante os meses de dezembro de 2012 a maio de 2013. Foi realizada análise descritiva simples dos dados. Os resultados indicaram que o parto cesáreo apresentou taxa de 37,2%, a amniotomia foi adotada em 62,1%, a ocitocina em 53,4% e a episiotomia em 82,4%. A desproporção céfalo-pélvica representou 27,9% das indicações de cesariana e dentre as complicações maternas, a hemorragia destacou-se em ambos os tipos de parto. Conclui-se a existência de uma forte influência do modelo tecnicista sobre os resultados maternos na assistência obstétrica de adolescentes primigestas e que o fato do desconhecimento atrelado à vulnerabilidade deste grupo populacional evidencia a soberania do profissional em relação às decisões obstétricas.

RESUMEN El objetivo ha sido analizar la atención al parto de adolescentes primigestas en el contexto del Sistema Único de Salud (SUS) en el municipio de Cuiabá, Mato Grosso. Estudio transversal, descriptivo y documental con muestreo aleatorio simple compuesto de 164 registros médicos de puérperas adolescentes recogidos a través del formulario estructurado durante los meses de diciembre de 2012 hasta mayo de 2013. Fue realizado el análisis descriptivo simple de los datos. Los resultados indicaron que el parto por cesárea ha presentado tasa de 37,2%, la amniotomía fue adoptada en 62,1%, la oxitocina en 53,4% y la episiotomía en 82,4%. La desproporción cefalopélvica ha representado 27,9% de las indicaciones de la cesárea y entre las complicaciones maternas, la hemorragia se ha destacado en ambos tipos de parto. Se concluye que existe una fuerte influencia del modelo técnico sobre los resultados maternos en la atención obstétrica a las adolescentes primigestas y que el hecho del desconocimiento relacionado a la vulnerabilidad de este grupo poblacional evidencia la soberanía del profesional en relación a las decisiones obstétricas.

ABSTRACT It aimed to analyze labor assistance for primigravida adolescents in the context of the Unified Health System (SUS) in the city of Cuiabá, Mato Grosso. Cross-sectional, descriptive and documental study with a random sample composed of 164 medical records of postpartum adolescent collected through structured file during the months of December 2012 to May 2013. Data were analyzed through simple descriptive analysis. The results indicated that cesarean section showed rate of 37.2%, amniotomy was adopted in 62.1%, oxytocin 53.4% and 82.4% in the episiotomy. Cephalopelvic disproportion represented 27.9% of cesarean section indications and among maternal complications, hemorrhage stood out in both types of delivery. It is concluded that there is a strong influence of the technicist model on maternal outcomes in obstetric care to pregnant adolescents and that the lack of knowledge linked to the vulnerability of this group shows the professional sovereignty in relation to obstetric decisions.