Induction of labour at 41 weeks or expectant management until 42 weeks: A systematic review and an individual participant data meta-analysis of randomised trials.

BACKGROUND: The risk of perinatal death and severe neonatal morbidity increases gradually after 41 weeks of pregnancy. Several randomised controlled trials (RCTs) have assessed if induction of labour (IOL) in uncomplicated pregnancies at 41 weeks will improve perinatal outcomes. We performed an individual participant data meta-analysis (IPD-MA) on this subject. METHODS AND FINDINGS: We searched PubMed, Excerpta Medica dataBASE (Embase), The Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and PsycINFO on February 21, 2020 for RCTs comparing IOL at 41 weeks with expectant management until 42 weeks in women with uncomplicated pregnancies. Individual participant data (IPD) were sought from eligible RCTs. Primary outcome was a composite of severe adverse perinatal outcomes: mortality and severe neonatal morbidity. Additional outcomes included neonatal admission, mode of delivery, perineal lacerations, and postpartum haemorrhage. Prespecified subgroup analyses were conducted for parity (nulliparous/multiparous), maternal age (<35/≥35 years), and body mass index (BMI) (<30/≥30). Aggregate data meta-analysis (MA) was performed to include data from RCTs for which IPD was not available. From 89 full-text articles, we identified three eligible RCTs (n = 5,161), and two contributed with IPD (n = 4,561). Baseline characteristics were similar between the groups regarding age, parity, BMI, and higher level of education. IOL resulted overall in a decrease of severe adverse perinatal outcome (0.4% [10/2,281] versus 1.0% [23/2,280]; relative risk [RR] 0.43 [95% confidence interval [CI] 0.21 to 0.91], p-value 0.027, risk difference [RD] -57/10,000 [95% CI -106/10,000 to -8/10,000], I2 0%). The number needed to treat (NNT) was 175 (95% CI 94 to 1,267). Perinatal deaths occurred in one (<0.1%) versus eight (0.4%) pregnancies (Peto odds ratio [OR] 0.21 [95% CI 0.06 to 0.78], p-value 0.019, RD -31/10,000, [95% CI -56/10,000 to -5/10,000], I2 0%, NNT 326, [95% CI 177 to 2,014]) and admission to a neonatal care unit ≥4 days occurred in 1.1% (24/2,280) versus 1.9% (46/2,273), (RR 0.52 [95% CI 0.32 to 0.85], p-value 0.009, RD -97/10,000 [95% CI -169/10,000 to -26/10,000], I2 0%, NNT 103 [95% CI 59 to 385]). There was no difference in the rate of cesarean delivery (10.5% versus 10.7%; RR 0.98, [95% CI 0.83 to 1.16], p-value 0.81) nor in other important perinatal, delivery, and maternal outcomes. MA on aggregate data showed similar results. Prespecified subgroup analyses for the primary outcome showed a significant difference in the treatment effect (p = 0.01 for interaction) for parity, but not for maternal age or BMI. The risk of severe adverse perinatal outcome was decreased for nulliparous women in the IOL group (0.3% [4/1,219] versus 1.6% [20/1,264]; RR 0.20 [95% CI 0.07 to 0.60], p-value 0.004, RD -127/10,000, [95% CI -204/10,000 to -50/10,000], I2 0%, NNT 79 [95% CI 49 to 201]) but not for multiparous women (0.6% [6/1,219] versus 0.3% [3/1,264]; RR 1.59 [95% CI 0.15 to 17.30], p-value 0.35, RD 27/10,000, [95% CI -29/10,000 to 84/10,000], I2 55%). A limitation of this IPD-MA was the risk of overestimation of the effect on perinatal mortality due to early stopping of the largest included trial for safety reasons after the advice of the Data and Safety Monitoring Board. Furthermore, only two RCTs were eligible for the IPD-MA; thus, the possibility to assess severe adverse neonatal outcomes with few events was limited. CONCLUSIONS: In this study, we found that, overall, IOL at 41 weeks improved perinatal outcome compared with expectant management until 42 weeks without increasing the cesarean delivery rate. This benefit is shown only in nulliparous women, whereas for multiparous women, the incidence of mortality and morbidity was too low to demonstrate any effect. The magnitude of risk reduction of perinatal mortality remains uncertain. Women with pregnancies approaching 41 weeks should be informed on the risk differences according to parity so that they are able to make an informed choice for IOL at 41 weeks or expectant management until 42 weeks. Study Registration: PROSPERO CRD42020163174.

Which level of risk justifies routine induction of labor for healthy women?

Although induction of labor can be crucial for preventing morbidity and mortality, more and more women (and their offspring) are being exposed to the disadvantages of this intervention while the benefit is at best small or even uncertain. Characteristics such as an advanced maternal age, a non-native ethnicity, a high Body Mass Index, an artificially assisted conception, and even nulliparity are increasingly considered an indication for induction of labor. Because induction of labor has many disadvantages, a debate is urgently needed on which level of risk justifies routine induction of labor for healthy women, only based on characteristics that are associated with statistically significant small absolute risk differences, compared to others without these characteristics. This commentary contributes to this debate by arguing why induction of labour should not routinely be offered to all women where there is a small increase in absolute risk, and no any other medical risks or complications during pregnancy. To underpin our statement, national data from the Netherlands were used reporting stillbirth rates in groups of women based on their characteristics, for each gestational week from 37 weeks of gestation onwards.

Does induction of labour in nulliparous hypertensive women result in vaginal birth? - A descriptive study utilising birth registry data.

BACKGROUND: Induction of labour (IOL) is a common procedure yet we have little information on the efficacy of the process for women with a hypertensive disorder of pregnancy (HDP). OBJECTIVE: To describe the birth type and associated factors in nulliparous HDP women undergoing an induction of labour. STUDY DESIGN: Statutorily collected datasets on every birth and hospital admission which occurred in the state of NSW Australia between the years 2000-2011 were analysed. Hypertensive women were compared to normotensive women. RESULTS: Of the nulliparous women, 9.9% had a HDP. IOL for HDP women were 56.2% in a cohort of 447 558 women. The AOR for a woman with a HDP undergoing an IOL resulting in a vaginal delivery when compared to a normotensive woman is 0.86 (95% CI 0.83-0.88). Prior to 33 weeks, the lowest perinatal mortality rates (PMR) are seen in women who undergo elective caesarean section (C/S). For women with preeclampsia (PE), lower PMR are seen in women who undergo IOL. CONCLUSION: For women with PE and SPE, IOL resulted in lower rates of vaginal delivery than spontaneous labour when compared to normotensive women who also underwent IOL. Women with PE at ≥33 weeks who underwent IOL had the lowest PMR.

Women's Voices in Maternity Care: The Triad of Shared Decision Making, Informed Consent, and Evidence-Based Practices.

The United States is the only industrialized nation that has experienced dramatic increases in the use of maternity interventions resulting in poor birth outcomes. It is speculated that the increased rates of maternal mortality and other outcomes are attributed to the current maternity model of care focused on the overuse of interventions, such as induction of labor, in otherwise healthy pregnant women. The overuse of induction of labor to artificially speed up the birth process has been linked to an increase in preterm and cesarean births. The cost of these interventions and poor outcomes has been substantial. The purpose of this article is to present concepts that demonstrate the challenges and value of informed, shared decision making, informed consent, and women's use of evidence within the context of maternity care. To highlight these important concepts, this article presents original findings from a secondary analysis of data on induction of labor. Findings from this analysis further highlight the importance of including women as part of informed, shared decision making in models of maternity care.

Nationwide population-based cohort study of uterine rupture in Belgium: results from the Belgian Obstetric Surveillance System.

OBJECTIVES: We aimed to assess the prevalence of uterine rupture in Belgium and to evaluate risk factors, management and outcomes for mother and child. DESIGN: Nationwide population-based prospective cohort study. SETTING: Emergency obstetric care. Participation of 97% of maternity units covering 98.6% of the deliveries in Belgium. PARTICIPANTS: All women with uterine rupture in Belgium between January 2012 and December 2013. 8 women were excluded because data collection forms were not returned. RESULTS: Data on 90 cases of confirmed uterine rupture were obtained, of which 73 had a previous Caesarean section (CS), representing an estimated prevalence of 3.6 (95% CI 2.9 to 4.4) per 10 000 deliveries overall and of 27 (95% CI 21 to 33) and 0.7 (95% CI 0.4 to 1.2) per 10 000 deliveries in women with and without previous CS, respectively. Rupture occurred during trial of labour after caesarean section (TOLAC) in 57 women (81.4%, 95% CI 68% to 88%), with a high rate of augmented (38.5%) and induced (29.8%) labour. All patients who underwent induction of labour had an unfavourable cervix at start of induction (Bishop Score ≤7 in 100%). Other uterine surgery was reported in the history of 22 cases (24%, 95% CI 17% to 34%), including 1 case of myomectomy, 3 cases of salpingectomy and 2 cases of hysteroscopic resection of a uterine septum. 14 cases ruptured in the absence of labour (15.6%, 95% CI 9.5% to 24.7%). No mothers died; 8 required hysterectomy (8.9%, 95% CI 4.6% to 16.6%). There were 10 perinatal deaths (perinatal mortality rate 117/1000 births, 95% CI 60 to 203) and perinatal asphyxia was observed in 29 infants (34.5%, 95% CI 25.2% to 45.1%). CONCLUSIONS: The prevalence of uterine rupture in Belgium is similar to that in other Western countries. There is scope for improvement through the implementation of nationally adopted guidelines on TOLAC, to prevent use of unsafe procedures, and thereby reduce avoidable morbidity and mortality.

Timing of induction of labor.

Determining the optimal timing for induction of labor is critical in minimizing the risks to maternal and fetal health. While data are available to guide us in some clinical situations, such as hypertension and diabetes, many gaps in knowledge still exist in others, including cholestasis of pregnancy, fetal anomalies, and placental abruption. This review of the currently available literature assesses the risks and benefits of preterm and early term induction in a wide variety of maternal and fetal conditions.

Impact of change in delivery practice on neonatal and maternal outcomes in cases of significant congenital heart disease.

OBJECTIVE: Because of data published in 2009 demonstrating improved outcomes among early- vs. late-term infants,practice shifted toward delivering infants at later gestational ages. We examined the effects of this change on neonates with congenital heart disease. DESIGN: This was a retrospective cohort study. Neonates with congenital heart disease born between 2004 and 2008 were compared with those born in 2010. Patients born in 2009, considered to be a transitional year, were excluded. SETTING: Our study was conducted at a tertiary care level 4 neonatal intensive care unit with comprehensive cardiac service. PATIENTS: Study subjects consisted of neonates with significant congenital heart disease admitted between 2004 and 2010. OUTCOME MEASURES: Outcomes measures consisted of mode of delivery, length of stay, neonatal morbidity, and mortality. RESULTS: There were 878 infants with congenital heart disease born in 2004-2008 and 124 in 2010. The mean gestational age was higher in 2010 than in 2004-2008 (38.4 ± 1.9 vs. 37.8 ± 2.3 weeks, P = .001), and there were fewer preterm births in 2010 compared with 2004-2008 (P = .003, odds ratio [OR] = 0.4). Mean birth weight was also higher in 2010 (3134 ± 675 vs. 2975 ± 599 g, P = .008). In 2010, less than half as many infants were born via scheduled induction (P < .001, OR = 0.2) or scheduled cesarean delivery (P = .002, OR = 0.4) as in 2004-2008. However, in 2010, there were more urgent inductions (P = .002, OR = 3.1), cesarean deliveries after labor (P = .01, OR = 2.2),and unplanned cesarean deliveries in general (P = .02, OR = 1.7) compared with 2004-2008. In 2010, neonates were less likely to require preoperative vasopressors (P = .002), but there were no differences in 5 minutes APGAR,antibiotic administration, preoperative intubation, median length of stay, or mortality compared with 2004-2008.Conclusions. Despite increased gestational age and birth weight following the shift in delivery practice, there was no difference in length of stay, neonatal morbidity, or mortality in infants with congenital heart disease. The resultant increase in urgent cesarean delivery and urgent inductions may confer additional maternal morbidity.

[Increased risk of stillbirth in older mothers--a rationale for induction of labour before term?]. / Erhöhtes Risiko für Totgeburt bei älteren Müttern - Rationale für Geburtseinleitung vor dem Termin?

The average age of childbearing has risen markedly in Germany and other high-income countries during the past 2 decades. Women aged 35 years or older have an increase in pregnancy complications and in preexisting medical conditions including obesity, diabetes and hypertension as well as a significant increase in the gestational age-related rate of stillbirth compared to younger mothers. Additional individual risk factors for stillbirth are primiparity, body mass index>30 and smoking. After exclusion of risk factors the absolute risk of stillbirth in women aged≥40 years old is 2-fold higher (1 in 503 maternities) at 39/40 weeks of gestation compared to women aged<35 years (1 in 1 020 maternities) at the same gestational age. Women aged 40 years or older have a similar stillbirth risk at 39 weeks of gestation to 25-29-year-olds at 41 weeks gestation. The underlying mechanism for the excess risk of stillbirth in women of advanced maternal age after exclusion of congenital anomalies is unknown. Independent of maternal age the cumulative probability of perinatal death increases from 1.8/1 000 deliveries at 38 weeks of gestation to 9.3/1 000 deliveries at 42 weeks of gestation. Whether on the basis of these data induction of labour at 39 weeks of gestation should be recommended in women of advanced maternal age has recently been discussed in a Scientific Impact Paper of the Royal College of Obstetricians and Gynaecologists. In this context it should be taken into account that the rate of Caesarean sections in women aged 40 years or over is 40%, and, in particular, older nulliparous may request elective Caesaran section rather than elective induction of labour. Recent metaanalyses have shown that elective induction of labour before or after term is not associated with an increase of the Caesarean section rate compared to expectant management. Up to now no randomised controlled trials exist and consequently no -recommendations from current guidelines regarding induction of labour in women of advanced maternal age can be given. In any case, a careful consultation and an individual risk-benefit analysis regarding the obstetric management is mandatory, and the final decision should be made in agreement between the pregnant women and the obstetrician. Currently a randomised controlled trial in the U.K. comparing induction of labour at 39 weeks of gestation with expectant management in nulliparous women aged over 35 years is recruiting, with the aim to determine intrapartum complications and perinatal morbidity and mortality in both managements.

Effects of induction of labour versus expectant management in women with impending post-term pregnancies: the 41 week - 42 week dilemma.

BACKGROUND: Post-term pregnancy, a pregnancy exceeding 294 days or 42 completed weeks, is associated with increased perinatal morbidity and mortality and is considered a high-risk condition which requires specialist surveillance and induction of labour. However, there is uncertainty on the policy concerning the timing of induction for post-term pregnancy or impending post-term pregnancy, leading to practice variation between caregivers. Previous studies on induction at or beyond 41 weeks versus expectant management showed different results on perinatal outcome though conclusions in meta-analyses show a preference for induction at 41 weeks. However, interpretation of the results is hampered by the limited sample size of most trials and the heterogeneity in design. Most control groups had a policy of awaiting spontaneous onset of labour that went far beyond 42 weeks, which does not reflect usual care in The Netherlands where induction of labour at 42 weeks is the regular policy. Thus leaving the question unanswered if induction at 41 weeks results in better perinatal outcomes than expectant management until 42 weeks. METHODS/DESIGN: In this study we compare a policy of labour induction at 41 + 0/+1 weeks with a policy of expectant management until 42 weeks in obstetrical low risk women without contra-indications for expectant management until 42 weeks and a singleton pregnancy in cephalic position. We will perform a multicenter randomised controlled clinical trial. Our primary outcome will be a composite outcome of perinatal mortality and neonatal morbidity. Secondary outcomes will be maternal outcomes as mode of delivery (operative vaginal delivery and Caesarean section), need for analgesia and postpartum haemorrhage (≥1000 ml). Maternal preferences, satisfaction, wellbeing, pain and anxiety will be assessed alongside the trial. DISCUSSION: This study will provide evidence for the management of pregnant women reaching a gestational age of 41 weeks. TRIAL REGISTRATION: Dutch Trial Register (Nederlands Trial Register): NTR3431. Registered: 14 May 2012.

Elective birth at 37 weeks of gestation versus standard care for women with an uncomplicated twin pregnancy at term: the Twins Timing of Birth Randomised Trial.

OBJECTIVE: To evaluate whether for women with an uncomplicated twin pregnancy, elective birth at 37 weeks of gestation was associated with reduced risk of death or serious outcomes for babies, without increasing harm. DESIGN: Randomised controlled trial. SETTING: Maternity hospitals across Australia, New Zealand and Italy. POPULATION: A total of 235 women with an uncomplicated twin pregnancy at 36(+6) weeks of gestation, with no contraindication to continuing their pregnancy. METHODS: Using a computer-generated, central telephone randomisation service, 235 women were randomised to Elective Birth (birth at 37 weeks; n=116) or Standard Care (continued expectant management, with birth planned from 38 weeks; n=119). Outcome assessors were masked to treatment allocation. MAIN OUTCOME MEASURE: A composite of serious adverse outcome for the infant. RESULTS: For women with an uncomplicated twin pregnancy, elective birth at 37 weeks of gestation was associated with a significant reduction in risk of serious adverse outcome for the infant (Elective Birth 11/232 [4.7%] versus Standard Care 29/238 [12.2%]; risk ratio [RR] 0.39; 95% CI 0.20-0.75; P=0.005), reflecting a reduction in birthweight less than the third centile using singleton gestational age-specific charts (Elective Birth 7/232 [3.0%] versus Standard Care 24/238 [10.1%]; RR 0.30; 95% CI 0.13-0.67; P=0.004). In a post hoc analysis using twin gestational age-specific charts, there was evidence of a trend towards a reduction in the primary composite of serious adverse infant outcome (Elective Birth Group 4/232 [1.7%] versus Standard Care Group 12/238 [5.0%]; RR 0.34; 95% CI 0.11 to 1.05; P=0.06). CONCLUSION: The findings of our study support recommendations for women with an uncomplicated twin pregnancy to birth at 37 weeks of gestation.

Impact of Doppler sonography on intrauterine management and neonatal outcome in preterm fetuses with intrauterine growth restriction.

OBJECTIVES: To test the hypothesis that earlier delivery may be warranted to improve neonatal outcome of fetuses with intrauterine growth restriction (IUGR) with abnormal Doppler parameters. METHODS: This was a retrospective cohort study of 110 fetuses with an antenatal diagnosis of IUGR due to placental insufficiency which had a very low birth weight (< 1500 g), delivered at the Department of Fetomaternal Medicine of the Medical University of Vienna, Austria, between January 1999 and July 2009. Doppler results before delivery were classified as follows: Group 1: abnormal umbilical artery (UA) pulsatility index (PI) more than 2 SD above the mean for normal reference data, or absent UA end-diastolic flow, both with normal middle cerebral artery (MCA) PI (mean ± 2 SD); Group 2: abnormal UA-PI > mean + 2 SD, or absent or reversed UA end-diastolic flow, with abnormal MCA-PI (< mean - 2 SD) and normal ductus venosus (DV) PI (mean ± 2 SD); Group 3: absent or reversed UA end-diastolic flow, with abnormal MCA-PI (< mean - 2 SD) and abnormal DV-PI (> mean + 2 SD) and/or absent or reversed end-diastolic DV flow. Pregnancy outcome was analyzed according to Doppler results. RESULTS: Due to very poor prognosis, 19 fetuses underwent expectant management and died in utero. These were excluded from further analyses. Of the remaining 91 cases, 17 were in Doppler Group 1, 44 in Group 2 and 30 in Group 3. Within 4 weeks after delivery, 0/17 (0%) infants in Group 1 died, 2/44 (4.5%) infants in Group 2 died and 7/30 (23.3%) infants in Group 3 died (P = 0.019). None of the 42 Group 2 cases that delivered at or after 28 completed gestational weeks died within 4 weeks after delivery, in contrast to 4/20 (20.0%) Group 3 cases (P = 0.009). In comparison, among infants delivered before 27 completed gestational weeks, 2/2 (100%) Group 2 cases died and 3/10 (30.0%) Group 3 cases died; P = 0.152). CONCLUSIONS: Doppler examinations are highly predictive in assessing the outcome of IUGR fetuses. From 28 completed gestational weeks, early delivery before the onset of fetal cardiac decompensation might be beneficial.

Optimal timing of delivery in pregnancies with pre-existing hypertension.

OBJECTIVE: To determine the optimal timing of delivery in pregnancies with pre-existing (chronic) hypertension by quantifying the gestational age-specific risks of stillbirth associated with ongoing pregnancy and the gestational age-specific risks of neonatal mortality or serious neonatal morbidity following the induction of labour. DESIGN: Population-based cohort study. SETTING: USA. POPULATION: A total of 171 669 singleton births to women with pre-existing hypertension between 1995 and 2005. Pregnancies additionally complicated by diabetes mellitus, cardiac, pulmonary or renal disease were excluded. METHODS: The week-specific risks of stillbirth between 36 and 41 completed weeks of gestation were contrasted with the week-specific risks of neonatal mortality or serious neonatal morbidity among births following induction of labour in women with pre-existing hypertension. MAIN OUTCOME MEASURES: Stillbirth, neonatal mortality or serious neonatal morbidity (defined as a composite outcome which included any of the following: neonatal seizures, severe respiratory morbidity or 5-minute Apgar score ≤3). RESULTS: The risk of stillbirth in women with pre-existing hypertension remained stable at 1.0-1.1 per 1000 ongoing pregnancies until 38 weeks, before rising steadily to 3.5 per 1000 [95% confidence interval (CI): 2.4, 5.0] at 41 weeks. The risk of serious neonatal morbidity/neonatal mortality decreased sharply between 36 and 38 weeks from 137 [95% CI: 127, 146] to 26 [95% CI: 24, 29] per 1000 induced births, before stabilising beyond 39 weeks. CONCLUSIONS: Among women with otherwise uncomplicated pre-existing hypertension, delivery at 38 or 39 weeks appears to provide the optimal trade-off between the risk of adverse fetal and adverse neonatal outcomes.

Is dinoprostone safe? A report of three maternal deaths.

We report three maternal deaths which might be in possible association with the use of intravaginal dinoprostone for cervical ripening and induction of labor. All cases occurred at our institution between January 2006 and December 2007. Uterine atony and profuse bleeding followed by disseminated intravascular coagulation (DIC), characterized by severe hypofibrinogenemia developed shortly after delivery of the first two patients. The third patient developed respiratory symptoms in the active labor followed by hemodynamic changes manifested by tetanic uterine contractions and fetal heart rate decelerations. Cardiac arrest developed in all patients shortly after the occurrence of symptoms with no response to any medical intervention. The pharmacologic induction of labor with dinoprostone may be in association with increased risk of maternal death because of increased risk of postpartum DIC and amnionic fluid embolism. Further investigations seem to be needed.

How to avoid iatrogenic morbidity and mortality while increasing availability of oxytocin and misoprostol for PPH prevention?

OBJECTIVE: Increased availability of oxytocin and misoprostol is needed to reduce the risk of postpartum hemorrhage. This review compiles rates and risks of adverse maternal and perinatal outcomes associated with use of these medications for labor induction and augmentation in low-income countries. Recommendations are proposed based on the findings. METHODS: We did a structured literature review using 5 databases followed by analysis of induction and augmentation rates from existing data. RESULTS: Combined induction and augmentation rates were documented in up to 50% of hospital-based deliveries identified in the databases. Data are sparse but suggest associations between induction/augmentation and stillbirth, neonatal resuscitation, and uterine rupture, and inappropriate administration of oxytocin and misoprostol both outside and inside healthcare systems in low-income countries. CONCLUSIONS: Guidelines for labor induction/augmentation are needed specifically for low resourced settings. Rigorous studies should be pursued to quantify the magnitude and effect of inappropriate induction and augmentation on maternal and perinatal morbidity and mortality. Programs are needed to ensure community-wide awareness of the adverse effects of the improper use of these drugs on mothers and babies, especially in out-of-hospital settings.

[Management of postterm pregnancies]. / Prise en charge du dépassement de terme.

The classic pregnancy term is between 37 and 42 weeks of gestation and the perinatal mortality and morbidity rates increasing progressively during this period, it is difficult to decide of an "ideal" term above which a medical intervention (induction of labour) brings more benefits than risks linked to the natural evolution of pregnancy. There is a good scientific evidence for the induction of labour from 41 weeks of gestation, defined like "postdating" term, when the cervical conditions are favourable (Bishop score>5) and systematically from 42 weeks (significative reduction of perinatal mortality rate and not increased rate of cesarean delivery compared with expectant management). An intensive antenatal surveillance involving a nonstress test and an evaluation of amniotic fluid volume is an efficient alternative when the conditions of delivery are unfavourable between 41 and 42 weeks of gestation or when the woman does not wish induction.

Spontaneous versus induced labor after a previous cesarean delivery.

OBJECTIVE: To compare maternal and neonatal outcomes in spontaneous versus induced labor after one previous cesarean delivery. METHODS: Women with one previous cesarean delivery who had spontaneous labor between January 1992 and January 2000 were compared with those whose labor was induced. RESULTS: Three thousand seven hundred forty-six patients had a trial of labor (2943 spontaneous, 803 induced). Those induced had more frequent early postpartum hemorrhage (7.3% versus 5.0%; odds ratio [OR] 1.66; 95% confidence interval [CI] 1.18, 2.32), cesarean delivery (37.5% versus 24.2%; OR 1.84; 95% CI 1.51, 2.25), and neonatal intensive care unit (NICU) admission (13.3% versus 9.4%; OR 1.69; 95% CI 1.25, 2.29). There was a trend toward higher uterine rupture rates in those with induced versus spontaneous labor (0.7% versus 0.3%, P =.128) and for patients undergoing dinoprostone (prostaglandin E(2)) induction versus other methods (1.1% versus 0.6%, P =.62), although neither difference achieved statistical significance. CONCLUSION: Induced labor is associated with an increased rate of early postpartum hemorrhage, cesarean delivery, and neonatal ICU admission. The higher rate of uterine rupture in those who had labor induced was not statistically significant.

[Parturient and puerperal mortality in preterm labor]. / Smertnost' rozhenits i rodil'nits pri prezhdevremennykh rodakh.

The peculiarities of mortality patterns in preterm labour are overviewed, including early and late, induced and spontaneous labour. The revealed drawbacks in the management of future mothers, both in counseling centers and maternity clinics, are discussed.