Just Pop It: Early AROM After Cervical Ripening Reduces the Time to Delivery.

In pregnant patients at term undergoing induction of labor, early time-based artificial rupture of membranes (AROM) within 1 hour of Foley bulb expulsion results in a shorter duration of labor by nearly 9 hours with no significant difference in cesarean delivery rates or maternal or neonatal adverse outcomes.1.

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.

Amniotomy versus expectant management during the active phase of labor defined by the new WHO definition on the duration of labor: A randomized controlled trial.

OBJECTIVE: To compare the labor duration and other maternal and neonatal outcomes between hospitalized women with uncomplicated pregnancies receiving amniotomy at 5 cm cervical dilatation and those not receiving amniotomy. METHODS: This prospective, randomized controlled trial was conducted at a tertiary hospital between June 2020 and October 2021. The study included low-risk pregnant women with spontaneous onset of labor at term, carrying a single fetus in cephalic presentation and with intact amniotic membranes. When the cervical dilatation reached 5 cm, participants were randomly assigned to receive or not receive amniotomy. Maternal demographics, labor and delivery data, and neonatal outcomes were compared between the two groups. RESULTS: The amniotomy group had a significantly shorter duration of labor compared with the control group (mean difference 49.4 min, 95% confidence interval [CI] 16.8-81.9, P = 0.003). The following outcomes were not significantly different between the two groups: (1) the need for oxytocin to augment labor; (2) cesarean section rates; (3) the incidence rates of suspected fetal distress and instrumental delivery; and (4) neonatal outcomes. CONCLUSIONS: Compared with expectant management, amniotomy during the active phase of labor (as newly defined by WHO) can shorten the labor duration without an increased risk of cesarean delivery or other negative consequences. THAI CLINICAL TRIALS REGISTRY (TCTR) (TCTR20200522001): https://www.thaiclinicaltrials.org/show/TCTR20200522001.

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.

Incidence and risk factors for umbilical cord prolapse in labor when amniotomy is used and with spontaneous rupture of membranes: A Swedish nationwide register study.

INTRODUCTION: Umbilical cord prolapse (UCP) is a rare but severe obstetric complication in the presence of a rupture of the membranes. Although it is not possible to prevent a spontaneous rupture of the membranes (SROM), it is possible to prevent an amniotomy, which is a commonly used intervention in labor. This study aimed to explore the incidence and risk factors that are associated with UCP in labor when amniotomy is used vs SROM. MATERIAL AND METHODS: A retrospective nationwide register study was conducted of all births in Sweden from January 2014 to June 2020 that were included in the Swedish Pregnancy Register (n = 717 336). The main outcome, UCP, was identified in the data by the International Classification of Diseases (ICD-10) diagnosis code O69.0. Multiple binary logistic regression analysis was used to identify the risk factors. RESULTS: Amniotomy was performed in 230 699 (43.6%) of all pregnancies. A UCP occurred in 293 (0.13%) of these cases. SROM occurred in 298 192 (56.4%) of all cases, of which 352 (0.12%) were complicated by UCP. Risk factors that increased the odds of UCP for both amniotomy and SROM were: higher parity, non-cephalic presentation and an induction of labor. Greater gestational age reduced the odds of UCP. Risk factors associated with only amniotomy were previous cesarean section and the presence of polyhydramnios. Identified risk factors for UCP in labor with SROM were a higher maternal age and maternal origin outside of the EU. CONCLUSIONS: UCP is a rare complication in Sweden. Beyond confirming the previously recognized risk factors, this study found induction of labor and previous cesarean section to be risk factors in labor when amniotomy is used.

Birth plans: definitions, content, effects, and best practices.

The first written guide for birth plans was introduced in 1980 as a means for birthing people to document their choices in the child birthing experience. The birth plan offers an opportunity for the patient and the provider to discuss the birthing process and determine how to safely accommodate patient preferences. Patient satisfaction with birthing plans is variable and may depend on how many requests they have, how many of their plans are accomplished, route of delivery, and whether complications arise during or after delivery. Unmet expectations may lead to posttraumatic stress disorder, but following a birth plan may also be protective against it. Birthing people who use a birth plan may be less likely to use epidural anesthesia, have early amniotomy, or use oxytocin. The first stage of labor may be longer when a birth plan is used; however, there does not seem to be a decrease in the length of the second stage of labor among patients with a birth plan. Some providers believe that a disadvantage of birth plans is disappointment when birth plans are not able to be followed, and others consider that birth plans interfere with professional autonomy.

Early versus late amniotomy during induction of labor using oxytocin: A randomized controlled trial.

OBJECTIVE: To assess the effect of early amniotomy on labor duration, maternal and neonatal outcomes during induction of labor (IOL). METHODS: This was a randomized controlled trial, conducted over a period of eight months at a monocentric site. Singleton pregnancies in nulliparous and parous patients with cephalic presentation and Bishop score ≥ 6 were enrolled in the study. One hundred participants were randomized into two groups: early amniotomy (initiating IOL with amniotomy followed by oxytocin) versus late amniotomy (initiating IOL with oxytocin followed by amniotomy 4 hours later). The primary endpoint was the time to active phase (cervical dilation ≥ 5 cm) during IOL. Secondary outcomes were time to vaginal delivery, mode of delivery, and maternal and fetal outcomes. RESULTS: Early amniotomy reduced time to active phase by 2 hours and 46 minutes compared to the late amniotomy group (3 h 42 min vs. 6 h 28 min; p<0.0001). It also reduced time to vaginal delivery by 2 hours and 52 minutes (5 h 17 min vs. 8 h 9 min; p = 0.0003). The rate of cesarean section (CS) for failed IOL was significantly lower in the early amniotomy group (31.2% vs. 70.0%; p = 0.02), without any significant difference in the overall rate of cesarean section between the two groups (32.0% vs. 40.8%; p = 0.36). There was no significant difference in maternal or fetal outcomes. CONCLUSIONS: Early amniotomy in IOL significantly shortens the time to active phase as well as the overall duration of labor without compromising maternal and neonatal safety.

Early versus delayed amniotomy with immediate oxytocin after Foley catheter cervical ripening in multiparous women with labor induction: A randomized controlled trial.

OBJECTIVE: To evaluate immediate oxytocin and early amniotomy compared with delayed amniotomy after Foley catheter cervical ripening in multiparous women on intervention-to-delivery interval. METHODS: This randomized trial was conducted in Malaysia in 232 term multiparous women with balloon catheter-ripened cervixes (dilatation ≥3 cm), singleton fetus, cephalic presentation with intact membranes, and reassuring fetal heart rate tracing. They were randomized to immediate titrated intravenous oxytocin infusion and early amniotomy (116) or delayed amniotomy after 4 h of oxytocin (116). Primary outcome was intervention (oxytocin initiation)-to-delivery interval. RESULTS: Oxytocin-to-delivery intervals were a median of 4.99 h (interquartile range [IQR], 3.21-7.82 h) versus 6.23 h (IQR, 4.50-8.45 h) (P < 0.001) for the early versus delayed amniotomy arms, respectively. Delivery rate at 4 h and 6 h after oxytocin infusion were 40 of 116 (35%) versus 22 of 116 (19%) (relative risk [RR], 1.82 [95% confidence interval (CI), 1.16-2.86], P = 0.011) and 77 of 116 (66%) versus 54 of 116 (47%) (RR, 1.43 [95% CI, 1.13-1.80], P = 0.003) for the early versus delayed amniotomy arms, respectively. Maternal satisfaction on birth process were 7 (IQR, 6-8) versus 7 (IQR, 7-8) (P = 0.006), uterine hyperstimulation rates were 10 of 116 (9%) versus 14 of 116 (12%) (RR, 0.71 [95% CI, 0.33-1.54]) (P = 0.519), and Cesarean delivery rates were 17 of 116 (15%) versus 19 of 116 (16%) (RR, 0.90 [95% CI, 0.49-1.63], P = 0.856) for the early versus delayed amniotomy arms, respectively. CONCLUSION: In multiparas at term following cervical ripening by Foley catheter, immediate oxytocin and early amniotomy compared with a scheduled 4-h delay to amniotomy shortens the interval to birth and decreases uterine hyperactivity in labor but lowers maternal satisfaction. The cesarean delivery rate is not significantly reduced. CLINICAL TRIAL REGISTRATION: This study was registered with the International Standard Randomised Controlled Trial Number (ISRCTN) on September 29, 2020, with trial identification number: ISRCTN87066007 (https://doi.org/10.1186/ISRCTN87066007). The first participant was recruited on September 29, 2020, after ISRCTN registry confirmation was received.

Artificial rupture of membranes as a mode for induction of labor in women with a previous cesarean section- a retrospective cohort study.

BACKGROUND: Induction of labor in women with a previous cesarean section (CS) is associated with increased rates of uterine rupture and failed attempt for vaginal delivery. Prostaglandins use is contraindicated in this population, limiting available options for cervical ripening. OBJECTIVE: To evaluate the efficacy and safety of artificial rupture of membranes (AROM) as a mode of Induction of labor (IOL) in women with a previous cesarean section. METHODS: A retrospective cohort study conducted in a single tertiary care center between January 2015 and October 2020. Women with one previous cesarean section and a current singleton term pregnancy requiring IOL, with an unfavorable cervix, were included. The primary outcome was a successful vaginal delivery (VBAC); secondary outcomes were rates of chorioamnionitis, uterine rupture and low Apgar score (< 7). RESULTS: Of the 665 women who met the inclusion criteria, 492 (74%) did not receive subsequent oxytocin and 173 (26%) did. There were significant differences in the baseline characteristics between these two groups, including maternal age, cervical dilation at presentation, parity, and a history of a previous VBAC. Among women who were induced solely by AROM the rate of a successful TOLAC was higher (81.3% vs 73.9%), total time of IOL was shorter (mean 8.7 h vs.16.1 h) and the risk of chorioamnionitis was lower (7.3% vs 18.4%). When subdividing the women who received oxytocin into early (< 12 h after AROM) vs late (> 12 h after AROM) administration, there were no significant changes in the rates of successful VBAC or of chorioamnionitis. CONCLUSION: AROM as a single mode of IOL in women with a previous CS is a safe and efficient practice with high rates of successful VBAC. When spontaneous labor does not develop, there is no advantage to delay the administration of oxytocin.

Cervical Dilators Used Concurrently With Misoprostol to Shorten Labor in Second-Trimester Termination of Pregnancy: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the use of cervical dilators concurrently with misoprostol to shorten labor in second-trimester medical termination of pregnancy. METHODS: This multicenter randomized controlled trial compared the efficacy of cervical dilators inserted concurrently with misoprostol with that of misoprostol, alone, to shorten labor for women undergoing termination of pregnancy between 15 0/7 and 27 6/7 weeks of gestation. The primary outcome was the proportion of women with a duration of labor exceeding 12 hours. Secondary outcomes included median duration of labor, time to amniotomy, side effects, complications, NPRS (Numeric Pain Rating Scale) score, and women's distress as measured by the IES-R (Impact of Event Scale-Revised). These outcomes also were studied separately in the nulliparous subgroup. To demonstrate a reduction of 50% of the proportion of women with a duration of labor exceeding 12 hours in the dilator group, with a power of 80% and a 2-sided 0.05 significance level, a sample of 268 women (134 in each group) was required. RESULTS: Between December 2017 and September 2019, this study enrolled and analyzed 347 women: 174 in the dilator group and 173 in the control group, including 87 and 93 nulliparous patients, respectively. Sociodemographic and obstetric characteristics were similar between groups. The proportion of women with labor exceeding 12 hours was not different between groups (49/174 [28.2%] in the dilator group vs 53/173 [30.6%] in the control group [ P =.61] for the whole population, and 37/87 [42.5%] vs 42/93 [45.2%] [ P =.72], respectively, among nulliparous patients). Median duration of labor was 8.5 hours in the dilator group compared with 9.2 hours in the control group ( P =.65) for the whole population, and 10.5 hours compared with 11.8 hours, respectively, among nulliparous patients ( P =.33). Median time to amniotomy was 3.6 hours in the dilator group compared with 5.0 hours in the control group ( P =.08) for the whole population, and 3.5 hours compared with 6.7 hours, respectively, among nulliparous patients ( P =.003). Side effects, complications, NPRS score, and IES-R score were similar between groups. CONCLUSION: Cervical dilators inserted concurrently with misoprostol did not reduce the proportion of women whose labor exceeded 12 hours compared with misoprostol alone. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT03194230.

Early versus delayed amniotomy with immediate oxytocin after Foley catheter cervical ripening in nulliparous labor induction: A randomized trial.

OBJECTIVE: To evaluate immediate oxytocin and early amniotomy compared with delayed amniotomy after Foley catheter cervical ripening in nulliparous women on intervention-to-delivery interval. METHODS: A randomized trial was conducted from September 2020 to March 2021. A total of 140 term nulliparas (70 early amniotomy, 70 delayed amniotomy) with Foley catheter-ripened cervices (dilatation ≥3 cm achieved), singleton fetus, cephalic presentation with intact membranes, and reassuring fetal heart rate tracing were recruited. Women were randomized to immediate titrated intravenous oxytocin infusion and early amniotomy or delayed amniotomy (after 4 h of oxytocin). The primary outcome was intervention (oxytocin)-to-delivery interval (h). RESULTS: Intervention-to-delivery intervals (h) were mean ± standard deviation 9.0 ± 3.6 versus 10.6 ± 3.5 h (mean difference of 1.4 h) (P = 0.004) for the early versus delayed amniotomy arms, respectively. Birth rates at 6 h after oxytocin infusion were 19 of 70 (27.1%) versus 8 of 70 (11.4%) (relative risk, 2.38 [95% confidence interval (CI), 1.11-5.06]; number needed to treat: 7 [95% CI, 3.5-34.4]) (P = 0.03), cesarean delivery rates were 29 of 70 (41.4%) versus 33 of 70 (47.1%) (relative risk, 0.88; 95% CI, 0.61-1.28) (P = 0.50), and maternal satisfaction on birth process were a median of 7 (interquartile range, 7-8) versus 7 (interquartile range, 7-8) (P = 0.40) for the early versus delayed amniotomy arms, respectively. CONCLUSION: In term nulliparas with cervices ripened by Foley catheter, immediate oxytocin and early amniotomy compared with a planned 4-h delay to amniotomy shortened the intervention-to-delivery interval but did not significantly reduce the cesarean delivery rate.

Induction of labour involving an amniotomy: Waiting compared to immediate oxytocin.

During induction of labour (IOL), the optimal timing of oxytocin following amniotomy is unknown, with limited data to guide decision-making. This study aimed to see whether a 2-h delay after amniotomy before starting oxytocin during IOL reduced the use of oxytocin as well as other positive or negative impact. A propensity-score-matched cohort study assessed the maternal, neonatal and process outcomes of 1168 women (584 per group) comparing immediate oxytocin to a 2-h delay ('wait') after amniotomy. Women who waited were significantly less likely to receive oxytocin (61.2 vs 100%, P < 0.001) but more likely to receive antibiotics (14.7 vs 10.3%, P = 0.021), to be delivered by caesarean section (20.0 vs 14.6%, P = 0.013) and to be exclusively breastfeeding during discharge (77.2 vs 71.2%, P = 0.019). These findings provide further information for women and caregivers regarding the risks and benefits of a short delay before starting oxytocin.

Prevalence of amniotomy in Sweden: a nationwide register study.

BACKGROUND: Amniotomy is a commonly used labor intervention with uncertain evidence, and there are complications connected to the intervention. Yet, the Swedish prevalence of amniotomy is unknown. The aim of the study was therefore to describe the prevalence of amniotomy in Sweden. METHODS: This nationwide register-based study included 330,913 women giving birth in 2017-2020. Data were collected from the Swedish Pregnancy Register in which the majority of data is collected via direct transfer from medical records. Prevalence of amniotomy was described for all births, for nulliparous and multiparous women with spontaneous onset of labour, and at the hospital level. Descriptive statistics and chi-square test were used to analyse the data. RESULTS: For all births, the prevalence of amniotomy was 40.6%. More amniotomies were performed in Robson group 1 compared to Robson group 3; 41.1% vs 32.3% (p < 0.001). The prevalence for all births remained the same during the study period; however, a decrease from 37.5 to 34.1%, was seen in Robson group 1 and Robson group 3 (p < 0.001). Variations in the prevalence between hospitals were reported. The hospitals with the fewest number of births annually had the highest prevalence of amniotomy (45.0%), and the lowest prevalence was reported at the University hospitals (40.4%) (p < 0.001). CONCLUSIONS: Amniotomy is a common labor intervention in Sweden, given that almost half of the laboring women underwent the intervention. Our results, regarding variations in the prevalence between hospitals, could imply a potential for fewer amniotomies in Swedish childbirth care.

Early vs expectant artificial rupture of membranes following Foley catheter ripening: a randomized controlled trial.

BACKGROUND: Early amniotomy shortens the duration of spontaneous labor, yet there is no clear evidence on the optimal timing of amniotomy following cervical ripening. There are limited high-quality studies on the use of early amniotomy intervention following labor induction. OBJECTIVE: This study aimed to evaluate whether amniotomy within 1 hour of Foley catheter expulsion reduces the duration of labor among individuals undergoing combined misoprostol and Foley catheter labor induction at term. STUDY DESIGN: This was a randomized clinical trial conducted from November 2020 to May 2021 comparing amniotomy within 1 hour of Foley catheter expulsion (early artificial rupture of membranes) with expectant management. Randomization was stratified by parity. Labor management was standardized among participants. Individuals undergoing induction at ≥37 weeks with a singleton gestation and needing cervical ripening were eligible. Our primary outcome was time to delivery. Wilcoxon rank sum, Pearson chi-square, and Cox survival analyses with intent-to-treat principles were performed adjusting for age, body mass index, parity, mode of delivery, Bishop score, and the interaction between randomization group and parity. A sample size of 160 was planned to detect a 4-hour reduction in delivery time. RESULTS: A total of 160 patients (79 early artificial rupture of membranes, 81 expectant management) were randomized. Early artificial rupture of membranes achieved a faster median time to delivery than expectant management (early artificial rupture of membranes: 11.1 hours; interquartile range, 6.25-17.1 vs expectant management: 19.8 hours; interquartile range, 13.2-26.2; P<.001). A greater percentage of individuals in the early artificial rupture of membranes group delivered within 24 hours (86% vs 70%; P=.03). There was no difference in the cesarean delivery rate between the 2 groups (22% vs 31%; P=.25). Individuals delivered 2.3 times faster following early artificial rupture of membranes (hazard ratio, 2.3; 95% confidence interval, 1.5-3.4; P<.001). There were no significant differences in maternal and neonatal outcomes. CONCLUSION: Amniotomy within 1 hour of Foley catheter expulsion resulted in 2.3 times faster delivery than expectant management. Therefore, early artificial rupture of membranes should be considered in individuals undergoing mechanical cervical ripening at term.

Early versus delayed oxytocin infusion following amniotomy for induction of labor: a meta-analysis of randomized controlled trials.

BACKGROUND: Oxytocin infusion prior to confirmation of delay in labor is discouraged by the World Health Organization. However, evidence from the Cochrane library seems to support early amniotomy and oxytocin to reduce the rates of cesarean sections (CS). OBJECTIVES: To investigate differences in mode of delivery among parturient receiving early versus delayed oxytocin infusion following amniotomy as a mean for augmentation of labor. SEARCH STRATEGY: We searched Medline, Scopus, EMBASE, Cochrane Central Register of Controlled Trials and Google Scholar databases from inception till February 2020. Selection criteria: Randomized controlled trials. DATA COLLECTION AND ANALYSIS: Data were collected using a modified Cochrane data collection form for intervention reviews. Meta-analysis was performed using the meta function in RStudio. MAIN RESULTS: Five studies were included that involved 1.232 parturient. The meta-analysis did not reveal significant differences in the mode of delivery among women that were randomized to receive immediate oxytocin infusion and those that received delayed oxytocin infusion (operative vaginal delivery OR 1.14, 95% CI 0.48, 2.69) and CS OR 0.81, 95% CI 0.53, 1.25)). The interval from amniotomy to delivery was significantly smaller in the immediate oxytocin infusion group; however, prediction intervals were not significant. CONCLUSIONS: The results of our meta-analysis suggest that there is no difference in the mode of delivery and interval from amniotomy to delivery when oxytocin is delayed for at least one hour following amniotomy. Taking in mind this information as well as current recommendations drawn from the WHO physicians should consider withholding oxytocin infusion at least until protracted labor is confirmed.

Amniotomy and early oxytocin infusion vs amniotomy and delayed oxytocin infusion for labour augmentation amongst nulliparous women at term: A randomised controlled trial.

OBJECTIVE: to compare the effect of amniotomy with early vs delayed oxytocin infusion on successful vaginal delivery. DESIGN: randomised controlled trial of nulliparous women with spontaneous labour at term. SETTING: labour suite of a university teaching hospital in Kuala Lumpur, Malaysia. PARTICIPANTS: 240 women were included (120 randomised into two arms). INTERVENTIONS: the randomisation sequence was generated using a computer randomisation program in two blocks: oxytocin infused early following amniotomy; and oxytocin infused 2 h after amniotomy. MEASUREMENTS AND FINDINGS: labour duration, mode of delivery, oxytocin dosage used, uterine hyperstimulation, postpartum haemorrhage, Apgar score and admission to the neonatal intensive care unit were recorded. No differences in vaginal delivery rate (62.9% vs 70.9%; p = 0.248) and second-stage labour were found between the early and delayed oxytocin infusion groups (21.2 ± 18.3 min vs 25.5 ± 19.9 min; p = 0.220). The mean interval from amniotomy to vaginal delivery was significantly shorter for the early group (5.8 ± 1.7 h vs 7.0 ± 1.9 h; p = 0.001), and more women in the early group delivered during/before the planned review at 4 h after amniotomy (53.6% vs 10.6%; p<0.001). Maximum oxytocin usage was lower in the early group (5.6 ± 4.4 mL/hour vs 6.8 ± 5.3 mL/hour; p = 0.104). KEY CONCLUSIONS: early oxytocin augmentation following amniotomy could be employed in low-risk primigravida, given that it is associated with a shorter labour duration without jeopardising maternal or neonatal outcomes. IMPLICATIONS FOR PRACTICE: low-risk primigravida benefit from early oxytocin infusion following amniotomy, and this can be offered as an additional practice in labour room care.

Effect of Amniotomy on Outcome of Spontaneous Labour.

Intentional artificial rupture of the amniotic membranes during labour, called amniotomy or 'breaking of the water's, is one of the most commonly performed procedures in modern obstetric and midwifery practice. The primary aim of amniotomy is to speed up uterine contractions and therefore shorten the length of labour. However there are concerns regarding unintended adverse effects on the woman and baby. A prospective observational study was conducted to determine the effectiveness and safety of routine procedure of amniotomy to shorten the duration of labour (prolonged or not) in Mymensingh Medical College & Hospital, Mymensingh, Bangladesh from July 2011 to December 2011. One hundred low-risk women with spontaneous onset of labour at term with singleton fetus in cephalic presentation and intact amniotic membranes and a cervical dilatation between 4 and 5cm were conventionally assigned to have amniotomy during the course of labour. Maternal demographics, duration of labour (prolonged or not), maternal and perinatal outcome were considered as major outcome. Majority (49.0%) of the patients belonged to 21-25 years age group and primigravida was predominant and most of them had middle socio-economic conditions. More the three-fourth (89.0%) of the patients had head engaged. Rh-positive and negative were found 96.0% and 4.0% respectively. The primigravidae required 10.07±2.17 hours in 1st stage of labour and had 1.51±0.5 hours duration of 2nd stage of labour. In case of multi-gravidae it was 6.07±2.06 hours in 1st stage of and 1±0.5 hours in 2nd stage of labour. There was a marked reduction of amniotomy-delivery interval time in this study, which was 3 hours 40 minutes and whereas mean cervical dilatation was 4cm during amniotomy. Almost three fourth (72.0%) cases delivered vaginally among which, with episiotomy in 49.0% and without episiotomy in 23.0%. Instrumental delivery was in 9.0% of which 4.0% by forceps, 5.0% by vaccum extraction and 14.0% underwent LUCS. Still birth was found 2.0%, asphyxiated 3.0% and prenatal death 1.0%. In terms of referral to neonatal care unit it was found that 7.0% were asphyxiated. Asphyxia and low APGAR score was 4.0%, low birth weight 9.0%, instrumental delivery was 5.0%, Rh incompatibility was 2.0%. Only 1.0% babies needed admission to neonatal care unit and were intubated. So, Amniotomy significantly reduced the duration of the first stage of labour without affecting the oxytocin requirement, the rate of caesarean section and newborn outcome.

Early description of amniotomy in medieval Persia.

AIM: Artificial rupture of the amniotic membranes during the labor, which is called amniotomy, is a common procedure in modern obstetric and midwifery protocols. There is no definite agreement regarding the timing of amniotomy in a delayed labor. In this study, we have discussed the history of amniotomy in medieval Persia mentioning the Persian medicine recommendations in this regard. METHODS: We studied main Persian medicine textbooks such as Canon of Medicine by Avicenna to investigate the history of labor management and amniotomy indications. In addition, amniotomy in current literature was studied using PubMed and Google Scholar databases. RESULTS: Persian medicine has recommended artificial rupture of membranes for labor augmentation based on its own theories. Methods for facilitation of the labor have been divided into two groups: one group before and the other during the labor. Avicenna has carefully explained the indication of amniotomy. He has recommended artificial rupture of membranes in cases of intact membranes with cervical dilatation and fetal descent. A needle or a kind of surgical knife called Mabzaa had been introduced for this procedure. CONCLUSIONS: It seems that Iranian physicians are the first scholars who have introduced the amniotomy for labor management in the 11th century. Persian medicine recommendations for labor facilitation should be considered in future studies.

Comparison of dinoprostone, misoprostol and amniotomy in labor induction.

OBJECTIVE: Comparison of dinoprostone, misoprostol and amniotomy in labor induction. METHODS: The study group included a total of 437 women who underwent consecutive induction of labor after evaluation of the indication and Bishops score. The most common indications were: postmaturity, hypertensive disease, diabetes mellitus and fetal growth restriction. In 327 cases we chose to induce labor using vaginal tablets of dinoprostone at a dose of 0.75mg, in 36 cases dinoprostone at a dose of 3mg, in 16 cases we used a vaginal insert of misoprostol (200 µg), and in 58 cases amniotomy was performed. RESULTS: In the subgroup of dinoprostone (0.75mg) the rate of vaginal delivery (including extraction delivery) was 90.2%, in the subgroup of dinoprostone (3mg) it was 91.6%, in the subgroup of misoprostol it was 100% and in the subgroup of amniotomy it was 93.1%. The time period between onset of labor induction and delivery was an average of 15.75 hours in the dinoprostone (0.75mg) subgroup, 21.41 hours in the dinoprostone (3mg) subgroup, 17.41 hours in the misoprostol subgroup and 7.49 hours in the amniotomy subgroup. CONCLUSION: Subgroup of patients with misoprostol showed the highest rate of vaginal delivery after labor induction. In the subgroup with amniotomy, the shortest time period between onset of induction and delivery was reached.