Oral misoprostol alone, compared with oral misoprostol followed by oxytocin, in women induced for hypertension of pregnancy: A multicentre randomised trial.

OBJECTIVE: To assess whether, in those requiring continuing uterine stimulation after cervical ripening with oral misoprostol and membrane rupture, augmentation with low-dose oral misoprostol is superior to intravenous oxytocin. DESIGN: Open-label, superiority randomised trial. SETTING: Government hospitals in India. POPULATION: Women who were induced for hypertensive disease in pregnancy and had undergone cervical ripening with oral misoprostol, but required continuing stimulation after artificial membrane rupture. METHODS: Participants received misoprostol (25 micrograms, orally, 2-hourly) or titrated oxytocin through an infusion pump. All women had one-to-one care; fetal monitoring was conducted using a mixture of intermittent and continuous electronic fetal monitoring. MAIN OUTCOME MEASURES: Caesarean birth. RESULTS: A total of 520 women were randomised and the baseline characteristics were comparable between the groups. The caesarean section rate was not reduced with the use of misoprostol (misoprostol, 84/260, 32.3%, vs oxytocin, 71/260, 27.3%; aOR 1.23; 95% CI 0.81-1.85; P = 0.33). The interval from randomisation to birth was somewhat longer with misoprostol (225 min, 207-244 min, vs 194 min, 179-210 min; aOR 1.137; 95% CI 1.023-1.264; P = 0.017). There were no cases of hyperstimulation in either arm. The rates of fetal heart rate abnormalities and maternal side effects were similar. Fewer babies in the misoprostol arm were admitted to the special care unit (10 vs 21 in the oxytocin group; aOR 0.463; 95% CI 0.203-1.058; P = 0.068) and there were no neonatal deaths in the misoprostol group, compared with three neonatal deaths in the oxytocin arm. Women's acceptability ratings were high in both study groups. CONCLUSIONS: Following cervical preparation with oral misoprostol and membrane rupture, the use of continuing oral misoprostol for augmentation did not significantly reduce caesarean rates, compared with the use of oxytocin. There were no hyperstimulation or significant adverse events in either arm of the trial.

Is epidural analgesia non-inferior to intrathecal fentanyl as initiation for neuraxial analgesia in early non-spontaneous labour?

BACKGROUND AND AIM: Intrathecal fentanyl, using the combined spinal-epidural (CSE) technique, provides rapid analgesia during early labour. Because of the technique's more complex and invasive nature, as its replacement we assessed the use of epidural analgesia in primiparous parturients with induced labour. The study was registered at www. CLINICALTRIALS: gov (NCT04645823). The aim was to compare the efficacy, duration of analgesia and maternal satisfaction. The primary outcome was the difference in pain visual analogue scale (VAS) between the interventions at 20 min after the analgesia administration. METHODS: Sixty volunteering parturients were randomly allocated in 1:1 ratio to receive either intrathecal fentanyl 20 µg or epidural analgesia (fentanyl 100 µg and lidocaine 80 mg). Contraction pain and maternal satisfaction were assessed by 0-100 mm VAS for 30 min, respectively. Foetal heart rate abnormalities, the time to first epidural dose and the incidence of pruritus were recorded. Non-inferiority margin for mean (95% CI) VAS after epidural analgesia was set at 20 mm above the VAS value for intrathecal fentanyl at 20 min. RESULTS: The contraction pain VAS fell from (median [interquartile range, IQR]) 82 (14) to 13 (20) mm and 76 (17) to 12 (27) mm in 20 min following the intrathecal fentanyl and epidural analgesia, respectively. The absolute mean difference (epidural-intrathecal fentanyl) in the VAS values was 3.3(-0.06 to 6.66) mm indicating non-inferiority. The median time to reach VAS <30 mm was 10 min in both groups. The duration until request for supplemental analgesia was 82(69-95) and 91(75-106) min after intrathecal fentanyl and epidural analgesia, respectively. The difference for the duration (epidural-intrathecal fentanyl) was 9 (6-12) min and for satisfaction-VAS 0.3 (-3.0 to 3.7) mm. There were no differences between the groups in the incidence of foetal heart rate abnormalities, while pruritus was more common after intrathecal fentanyl. CONCLUSION: After 20 min, epidural analgesia by lidocaine and fentanyl was within the non-inferior threshold compared with intrathecal fentanyl in efficacy. The duration of action was not shorter than that of intrathecal fentanyl and maternal satisfaction was also similar.

Obesity at term: What to consider? How to deliver?

Obesity presents significant challenges during pregnancy, increasing the risk of complications and adverse outcomes for both mother and baby. With the rising prevalence of obesity among pregnant women, questions arise regarding optimal management, including timing of delivery and choice of delivery mode. Labour induction in obese women may require a combination of mechanical and pharmacological methods due to increased risk of failed induction. Caesarean section in obese women presents unique challenges, requiring comprehensive perioperative planning and specialized care to optimize outcomes. However, specific guidelines tailored to obese patients undergoing caesarean sections are lacking. Postpartum care should include vigilant monitoring for complications. Addressing obesity in pregnancy necessitates a multidisciplinary approach and specialized care to ensure the best outcomes.

A nationwide, prospective, cohort study on exogenous oxytocin and delays in early child development: the Japan environment and children's study.

Although it remains debatable, exogenous oxytocin, commonly used for labour induction and augmentation, reportedly increases risks of neurodevelopment delay, attention-deficit/hyperactivity disorder, and autism spectrum disorder among children prenatally exposed to exogenous oxytocin. However, only few studies have objectively examined exogenous oxytocin's impact on early childhood development through scoring evaluations. This study investigated the association between exogenous oxytocin exposure and neurodevelopment in 3-year-old children using the Ages and Stages Questionnaires, Third Edition. In this nationwide prospective cohort study, we extracted data from 104,062 foetal records regarding exogenous oxytocin use during labour from the Japan Environment and Children's Study. Participants completed questionnaires throughout the pregnancy and postpartum periods. Outcomes comprised the developmental status less than each cut-off value for the five domains of the Ages and Stages Questionnaire, Third Edition. We conducted multivariable logistic regression analyses on the data of 55,400 children after controlling for confounders. Among the 55,400 included women, 19.0% (n = 10,506) used exogenous oxytocin during labour and 81.0% (n = 44,894) did not. Children exposed to exogenous oxytocin showed no significantly increased risk of developmental delay in any domain (communication: odds ratio [OR] 1.04, 95% confidence interval [CI] 0.92-1.16; gross motor: OR 0.97, 95% CI 0.87-1.08; fine motor: OR 1.00, 95% CI 0.92-1.09; problem-solving: OR 1.02, 95% CI 0.94-1.11; personal-social: OR 0.91, 95% CI 0.80-1.03).   Conclusion: Exogenous oxytocin for labour induction did not adversely affect early childhood development. Further studies accounting for the degree of exogenous oxytocin exposure are required to confirm these results. What is Known: • In developed countries, labour is induced in 20-25% of all pregnancies, for which oxytocin is commonly used. • Studies have associated risks of neurodevelopment delay, attention-deficit/hyperactivity disorder, and autism spectrum disorder with exposure to exogenous oxytocin. What is New: • Evaluation with the Ages and Stages Questionnaire, Third Edition, revealed that exogenous oxytocin use did not adversely affect early childhood development. • This prospective study reinforced the lack of evidence of an association between exogenous oxytocin use and early childhood development after adjustment for confounding and rigorous bias elimination.

Comparison of transvaginal sonographic cervical length measurement and Bishop score for predicting labour induction outcomes.

OBJECTIVES: Induction of labour (IOL) is of increasing prevalence worldwide and reliable prediction of its successful outcome is important. Traditional clinical methods for predicting successful IOL outcomes have been supplemented with newer technologies. The aim of this study was to compare transvaginal sonographic (TVS) cervical length measurement with Bishop score in predicting labour induction outcomes. METHODS: This study included pregnant women with term pregnancy, indication for IOL and unfavourable cervix (Bishop score >6) who had TVS performed prior to IOL. Exclusion critetia were regular contractions, ruptured membranes, non-cephalic presentation, uterine scar and pregnancy complications potentially influencing study outcomes. Outcomes measured were successful IOL defined as achievement of active phase of labour and vaginal delivery. Receiver operating characteristic (ROC) curves were used to determine diagnostic accuracy and sensitivity, specificity, positive and negative predictive values. Statistical significance was defined as p<0.05. RESULTS: Among 112 studied participants, IOL was successful in 101 (90.2%) pregnant women. AUC for Bishop score >2 was 0.831 (95% CI, 0.744-0.917, p<0.001) and for cervical length <30 mm 0.679 (95% CI 0.514-0.844, p<0.052). A total of 81 (72.3%) pregnant women delivered vaginally; AUC for Bishop score >2 was 0.754 (95% CI 0.648-0.861, p<0.001) and for cervical length <30 mm 0.602 (95% CI 0.484-0.720, p=0.092) which was the only insignificant predictor. CONCLUSIONS: Bishop score >2 is a better predictor for both successful IOL and vaginal delivery among induced women with term pregnancy and unfavourable cervix compared to cervical length <30 mm.

Labour induction for termination of pregnancy with severe fetal anomalies after 24 weeks' gestation: a case series and systematic review of the literature.

PURPOSE: Under some circumstances, individuals choose to undergo pregnancy termination for foetal anomalies in the second half of pregnancy. This report provides objective information on the clinical management of such cases and a systematic review of the literature on labour induction outcomes for third-trimester abortion using mifepristone-misoprostol. MATERIALS AND METHODS: The study is a case series describing outcomes for labour induction abortion for foetal anomalies, at gestational age 24 weeks and beyond. A systematic review was performed, searching PubMed, Embase, and Cochrane databases. Two independent authors reviewed and quality assessed the data from the articles. RESULTS: During a two-year period, 15 patients met inclusion criteria. Fourteen patients received mifepristone and misoprostol, and one received oxytocin. All delivered vaginally. Thirteen patients delivered within 24 hours of the first misoprostol dose, and half delivered within 12 hours. The average interval from misoprostol initiation to foetal expulsion was 15.5 hours in our series. The systematic review identified nine articles for inclusion, all retrospective studies. Labour induction protocols for mifepristone-misoprostol, reporting of gestational age, and key comparisons varied greatly. CONCLUSIONS: The case series illustrates successful termination of pregnancy primarily using combined mifepristone-misoprostol. Certainty of current evidence is low, based on the GRADE framework. Future research is necessary on third-trimester outcomes with mifepristone-misoprostol.

Effectiveness and safety of membrane sweeping in the prevention of post-term pregnancy: a randomised controlled trial.

There is a rising concern with increasing rates of pharmacologically induced labour and its complications. Membrane sweeping is a simple and less invasive means of initiating spontaneous labour onset. We compared the safety and efficacy of membrane sweeping. A total of 186 women (62 in each arm) were recruited at the antenatal clinic at 39 weeks. The intervention groups had membrane sweeping once and twice weekly respectively while the control arm had no membrane sweeping. They were all monitored and followed up till delivery. The trial was registered with the South Africa registry www.pactr.org (PACTR202112841108933) The incidence of prolonged pregnancy was 32.3%, 19.4% and 11.7% among the control, once-weekly, and twice-weekly groups respectively. The sweeping to the delivery interval was significantly shorter for the twice-weekly group (7.4 days) compared to once weekly (8.8 days) and the control group (10.6 days). There were significantly higher odds of spontaneous labour onset in the twice-weekly group (HR 1.53, p = .029) compared to the control group (HR 0.65, p = .033) and the once-weekly group using once weekly as reference. Membrane sweeping is a safe and effective means of preventing prolonged pregnancy. Twice-weekly sweeping of foetal membranes is more effective than once-weekly or no sweeping without added adverse feto-maternal outcomes.IMPACT STATEMENTWhat is already known about the subject? There is no evidence supporting any increase in maternal or foetal morbidity suggesting that membrane sweeping is a safe procedure to offer to all low-risk pregnant women so as to initiate spontaneous labour onset.What do the results of the study add? Membrane sweeping twice weekly after 39weeks for low-risk pregnant women is more effective than once weekly or no sweep with no added adverse maternal or perinatal risks.What are the implications of these findings for clinical practice and or further research? Twice-weekly membrane sweeping is encouraged in selected patients to reduce the risks associated with post-term pregnancy.

Titrated oral misoprostol versus static regimen of oral misoprostol for induction of labour: a systematic review and meta-analysis.

We aimed to conduct a systematic review and meta-analysis to compare the efficacy and safety of titrated oral misoprostol versus static oral misoprostol for labour induction. We searched for the available randomised clinical trials (RCTs) in the Cochrane Library, PubMed, ISI web of science, Scopus, and ClinicalTrials.gov. We included RCTs compared titrated oral misoprostol versus static regimen of oral misoprostol during labour induction. Our main outcomes were vaginal and caesarean delivery rates, uterine tachysystole, misoprostol side effects, and neonatal adverse events. Three RCTs met our inclusion criteria with a total number of 360 patients. The vaginal delivery rate did not significantly differ between both groups (p = 0.49). Titrated oral misoprostol was associated with significant increase in the caesarean delivery rate compared to static oral misoprostol (p = 0.04). Moreover, titrated oral misoprostol led to significant increase in the uterine tachysystole and misoprostol side effects (p = 0.01 & p = 0.003, respectively). There were no differences among both groups regarding different neonatal adverse events. In conclusion, titrated oral misoprostol increases the incidence of caesarean delivery, uterine tachysystole, and misoprostol side effects with a similar vaginal delivery rate compared to static dose misoprostol. Thus, static oral misoprostol should be used instead of titrated oral misoprostol during labour induction. Impact StatementWhat is already known on this subject? Different studies have evaluated titrated oral misoprostol administration for induction of labour and proved their efficacy in comparison with other induction methods. However, there is controversy among the published studies between titrated oral misoprostol and static oral misoprostol during induction of labour. A recent study concluded that hourly titrated misoprostol and static oral misoprostol are equally safe and effective when utilised for induction of labour with no fear of any adverse events. However, another study recommended static oral misoprostol administration for labour induction as it was linked to a lower caesarean section incidence, fewer drug side effects, and decline in complication rates in comparison with titrated oral misoprostol.What the results of this study add? Titrated oral misoprostol increases the incidence of caesarean delivery, uterine tachysystole, and misoprostol side effects with a similar vaginal delivery rate compared to static dose misoprostol.What the implications are of these findings for clinical practice and/or further research? Static oral misoprostol should be used instead of titrated oral misoprostol during labour induction. More future trials are required to confirm our findings.

Effect of vaginal pH on efficacy of dinoprostone gel for labour induction: a cross-sectional study.

The purpose of this study was to assess the effect of vaginal pH on efficacy of intracervical dinoprostone gel (PGE2) for labour induction, progression and induction delivery interval. A cross-sectional study was done among 150 term pregnant women planned for induction with unfavourable Bishop's score ≤5. Women were categorised into two groups based on vaginal pH >4.5 and ≤4.5. Induction was done with maximum of three doses of PGE2 based on Bishop's score, followed by oxytocin administration. Failed induction rate was 14.5%. There was no significant association between vaginal pH and Bishop's score change after first gel application. There was no significant difference in failed induction rates, time from induction to active labour as well as induction delivery interval between two groups. Similarly, there was no significant association between oxytocin requirement and mode of delivery with vaginal pH. Intracervical PGE2 is an ideal route, unaffected by vaginal pH.Impact StatementWhat is already known on this subject? Prostaglandins are organic acids that have diminished solubility in aqueous solution with a low pH. The release of the drug could be altered by the acidity of vagina and this could result in variable clinical response. Vaginal pH may alter the efficacy of intravaginally administered prostaglandins through several potential mechanisms.What the results of this study add? There was no significant effect of change in vaginal pH on effectiveness of intracervical administered PGE2. There was no significant association between vaginal pH and time from induction to time women is entering into active labour as well as time from induction to delivery. Similarly, there was no significant association between mode of delivery and oxytocin usage with vaginal pH in labour. Intracervical PGE2 is an ideal route, unaffected by vaginal pH.What the implications are of these findings for clinical practice and/or further research? Further randomised studies are required comparing both vaginally administered PG inserts and intracervical PGE2 gels with vaginal and cervical pH, to directly compare their effectiveness in labour induction.

Effect of dexamethasone on labour induction and cervical ripening in term pregnancies: a systematic review and meta-analysis.

This study assessed the effect of dexamethasone on labour induction, Bishop Score, mean intervals from induction of labour to the active phase and delivery, duration of first and second stages of labour and caesarean section frequency. A search was carried out in PubMed, Cochrane Library, Embase, Ovid, Scopus, ClinicalTrials.gov, Google Scholar and Persian databases. The quality of studies was evaluated using Cochrane handbook and the meta-analysis was conducted in RevMan 5.3. The heterogeneity of the studies was assessed using I2, T2 and Chi2. Subgroup analysis was used based on the routes of drug administration. Quality of evidence was assessed using the GRADE approach. 10 studies were included. The results showed significant differences between dexamethasone and control groups in terms of the mean interval from induction of labour to the active phase (MD = -1.55), Bishop score (MD = 2.40), duration of second stage of labour (MD = -8.61) and interval from induction of labour to delivery (MD = -2.83). There were no significant differences in duration of first stage of labour (MD= -0.69) and caesarean section frequency (RR = 1.09). Dexamethasone reduces the time interval between induction and delivery and also accelerates labour through cervical ripening and Bishop Score improvements.IMPACT STATEMENTWhat is already known on this subject? Labour induction is a common obstetrics procedure. The desirable condition of the cervix, measured by the Bishop score, is a key to the successful induction. Several mechanical and biomechanical methods are used to achieve desirable cervical ripeness. The role of corticosteroids in the delivery process has not been well demonstrated.What do the results of this study add? The meta-analysis results showed significant differences between dexamethasone and control groups in terms of the mean interval from induction of labour to the active phase.What are the implications of these findings for clinical practice and/or future research? According to the evidences, dexamethasone can be used to reduce the interval between induction to active phase.

Prevalence and risk factors for caesarean delivery following labor induction at a tertiary hospital in North Tanzania: a retrospective cohort study (2000-2015).

BACKGROUND: Labor induction is among the common and widely practiced obstetric interventions aiming at achieving vaginal delivery. However, cesarean section (CS) delivery incidences have been reported following its use. This study aimed at determining the prevalence and risk factors for caesarean delivery following labor induction among women who gave birth at a tertiary hospital in north-Tanzania. METHODS: A hospital-based retrospective cohort study was designed using maternally-linked data from Kilimanjaro Christian Medical Centre (KCMC) birth registry among women who gave birth to singleton babies from the year 2000 to 2015. All induced deliveries done in this period were studied. Women with multiple pregnancy, missing information on delivery mode and those with history of CS delivery were excluded. Relative risk and 95% Confidence Interval for risk factors for CS delivery following labor induction were estimated using log-binomial regression models. Robust variance estimation was used to account for repeated deliveries from the same subject. RESULTS: A total of 1088 deliveries were analysed. The prevalence of CS following labour induction was 26.75%. Independent risk factors for CS delivery were; primiparity (RR = 1.46; 95% CI: 1.18-1.81), high birthweight (RR =1.28; 95% CI: 1.02-1.61), post-term pregnancy (RR = 1.45; 95% CI: 1.09-1.93), and urban residence (RR =1.29; 95%CI: 1.05-1.58). CONCLUSION: In patients undergoing labor induction, primiparity, high birthweight, post dates and urban residence were found to associate with an elevated risk of caesarean delivery. Assessment of these factors prior to labor induction intervention is warranted to reduce adverse pregnancy outcomes associated with emergency caesarean delivery.

Socioeconomic risk factors for labour induction in the United Kingdom.

BACKGROUND: Labour induction is a childbirth intervention experienced by a growing number of women globally each year. While the maternal and socioeconomic indicators of labour induction are well documented in countries like the United States, considerably less research has been done into which women have a higher likelihood of labour induction in the United Kingdom. This paper explores the relationship between labour induction and maternal demographic, socioeconomic, and health indicators by parity in the United Kingdom. METHOD: Logistic regression analyses were conducted using the first sweep of the Millennium Cohort Study, including a wide range of socioeconomic factors such as maternal educational attainment, marital status, and electoral ward deprivation, in addition to maternal and infant health indicators. RESULTS: In fully adjusted models, nulliparous and multiparous women with fewer educational qualifications and those living in disadvantaged places had a greater likelihood of labour induction than women with higher qualifications and women in advantaged electoral wards. CONCLUSIONS: This paper highlights which UK women are at higher risk of labour induction and how this risk varies by socioeconomic status, demonstrating that less advantaged women are more likely to experience labour induction. This evidence could help health care professionals identify which patients may be at higher risk of childbirth intervention.

The Edmonton Obesity Staging System Predicts Mode of Delivery After Labour Induction.

OBJECTIVE: This study sought to evaluate the use of the Edmonton Obesity Staging System (EOSS) in predicting cesarean delivery among term, nulliparous, singleton pregnancies in women with overweight or obesity who are undergoing an induction of labour. METHODS: A prospective cohort study was performed in Edmonton, Alberta. Women undergoing an induction of labour at term were recruited to either a sample cohort, including women with a body mass index of ≥25 kg/m2 at first antenatal visit, or a control cohort with a body mass index of 18.5 to 24.9 kg/m2. Participating women provided a self-reported health history and consented to review of their medical records allowing allocation into EOSS categories. The primary outcome was the rate of cesarean delivery based on EOSS category. Secondary outcomes consisted of a summary score of adverse maternal, delivery, and neonatal events (Canadian Task Force Classification II-2). RESULTS: Overall, 345 women were recruited, with a participation rate of 93.7%. The sample cohort consisted of 276 women with overweight or obesity, whereas the control cohort included 69 normal-weight women. The overall rate of cesarean delivery was 30.4% for the control cohort and 35.8%, 29.9%, 43.2%, and 90.5% for women assigned an EOSS category 0, 1, 2, and 3, respectively (P < 0.001). A summary score was not indicative of overall rate of adverse maternal, delivery, and neonatal events (P = 0.22). CONCLUSION: The EOSS may help predict the chance of cesarean delivery in a high-risk group of nulliparous women with overweight or obesity who are undergoing an induction of labour at term.

Effect of premature rupture of membranes on time to delivery and outcomes in full-term pregnancies with vaginal dinoprostone-induced labour.

OBJECTIVE: The aim of this study was to assess the effect of premature rupture of membranes (PROM) in full-term pregnancies with dinoprostone-induced labour. PATIENTS AND METHODS: This historical cohort study analysed 2166 full-term pregnancies with dinoprostone-induced labour between 1 August 2016 and 30 April 2018. A group that underwent induction of labour for PROM (PROM group) was compared to a group that underwent labour induction for other indications (no-PROM group). Time to delivery and perinatal outcome were compared between the two groups. RESULTS: A total of 2166 pregnancies (662 PROM and 1504 no-PROM) were included. The two groups demonstrated no significant differences except in biparietal diameter and gestational age (P < 0.001). The caesarean section delivery rate in the PROM group was significantly lower than in the non-PROM group (26.89 vs. 33.58%, P < 0.0001). In the PROM group, the induction-to-delivery time was shorter (P < 0.0001) and the rates of vaginal birth within 24 h (P < 0.0001) and 48 h (P < 0.0001) were higher than those in the control group. The incidence rate of amniotic fluid contamination in the PROM group was significantly lower than that in the non-PROM group (19.18 vs. 25.20%, P = 0.002). CONCLUSION: PROM significantly affects perinatal outcome in Chinese women who undergo dinoprostone-induced labour, especially the caesarean delivery rate and the induction-to-delivery time.

Efficacy comparison of titrated oral solution of misoprostol and intravenous oxytocin on labour induction in women with full-term pregnancy.

A double-blind randomised trial was conducted on women with gestational age of 40-42 weeks of pregnancy and Bishop score of more than 5. The first group received oxytocin infusion and the second group received a titrated oral solution of misoprostol. Then, the two groups were compared by the primary outcome (the number of deliveries in the first 24 hours of intervention). The two groups did not have any significant difference in maternal and gestational age at the time of intervention, primary Bishop score, parity and neonatal weight. The number of deliveries in the first 24 hours was greater in the misoprostol group. Duration of onset of intervention to proper contractions was longer in the misoprostol group. However, the number of deliveries between 6-12 hours, 12-18 hours and 18-24 hours after induction was greater in the misoprostol group. The incidence of tachysystole and meconium was greater in the misoprostol group.Impact statementWhat is already known on this subject? Labour induction is widely used where the continuation of pregnancy might be dangerous for the mother or the baby. Of the various methods used for induction, misoprostol which is a prostaglandin E1 analogue has been reviewed more in recent years. Misoprostol has various routes of administration but in most studies only vaginal administration has been evaluated, leaving us with limited data about oral administration.What do the results of this study add? Oral misoprostol is a suitable method for labour induction and can be used as an alternative to oxytocin.What are the implications of these findings for clinical practice and/or further research? Misoprostol is not expensive, has a long shelf life, accessible in underdeveloped countries and rural areas and has several routes of administrations such as oral, sublingual and vaginal. Despite the fact that the oral route of misoprostol has a fast absorption and easier administration, there are relatively few studies assessing the the use of the oral route of misoprostol. Misoprostol is a suitable method for Labour induction and it has the potentials of being used as an alternative for oxytocin, however, the optimum dosages, the preferred route of administration, the maximum dose, the maximum time for administration, and maternal and neonatal safety should be studied more.

Double- versus single-balloon catheters for labour induction and cervical ripening: a meta-analysis.

BACKGROUND: The induction of labour is an increasingly common procedure in the obstetrics field. Various methods have been used to induce labour, among which balloon catheters play an important role. Whether the specifically designed double-balloon catheter is better than the single-balloon device in terms of efficacy, efficiency, safety and patient satisfaction remains controversial. Identifying even small differences between these two devices could be useful to guide clinical practices, to further explore their mechanisms, and to promote a better understanding of the optimal methods for inducing labour. METHODS: Using the population, intervention, comparison, outcomes and study designs (PICOS) principle, we searched the PubMed, EMBASE, OVID, SCI, CENTRAL, ClinicalTrial.gov , and CDSR databases to identify relevant randomised controlled trials (RCTs) from inception through February 14, 2018. The primary outcome was the caesarean delivery rate, and the secondary outcomes focused on efficacy, efficiency, safety, and patient satisfaction. The relative risks or mean differences, including their 95% confidence intervals, were calculated using fixed-effects or random-effects models. All statistical analyses were completed with RevMan version 5.3. RESULTS: From a total of 1326 articles, 7 RCTs involving 1159 women were included. There were no significant differences in primary outcomes (RR, 0.88 [0.65, 1.2]; p-value, 0.43) or secondary outcomes identified between single- and double-balloon catheters. However, heterogeneity existed for some aspects. CONCLUSION: Both kinds of balloon catheter have similar levels of efficacy, efficiency, safety and patient satisfaction; however, the single-balloon method is considered to be more cost-effective.

Comparing birth experience and birth outcome of vaginal births between induced and spontaneous onset of labour: a prospective study.

PURPOSE: In developed countries, around 25% of all births involve labour induction. Studies have indicated that labour induction negatively influences the birth experience as well as the birth process. However, the impact of labour induction when only considering vaginal deliveries has not been studied yet, which was the purpose of the present study. METHODS: 186 women who gave birth vaginally took part in this prospective study. 95 women gave birth after spontaneous onset of labour (SL-group) and 91 women received a labour induction (LI-group). Eight to 72 h after birth, the women filled in the revised version of the standardised Childbirth Experience Questionnaire, which examines the birth experience in four dimensions (Own Capacity, Perceived Safety, Participation and Professional Support). Medical details regarding birth and fetal outcomes were taken from the medical records. RESULTS: Birth outcomes (the number of epidural anaesthesia, the duration of birth, birth risks and childbirth injuries) as well as fetal outcomes (APGAR after 1 and 5 min and arterial cord pH) did not differ between the groups. Regarding the subjective birth experience, the LI-group indicated significantly lower values for Perceived Safety and Participation compared to the SL-group, while there were no differences for the dimensions Own Capacity and Professional Support. DISCUSSION: Successful labour induction resulting in a vaginal birth did not negatively influence birth and fetal outcomes and only partly affected the women's birth experience. The negative impact of labour induction on the dimensions Perceived Safety and Participation should sensitize midwives in order to provide optimal support.

Obesity, gestational diabetes and macrosomia are associated with increasing rates of early-term induction of labour at The Canberra Hospital.

BACKGROUND: Early-term delivery is an important cause of short-term neonatal morbidity and associated high healthcare costs, with possible additional long-term developmental ramifications. As a form of 'iatrogenic' delivery, induction of labour (IOL) is a potentially modifiable contributor to this burden. AIMS: To determine patterns of, and primary indication for, early-term IOL, as well as temporal trends in this primary indication and differences from other modes of delivery with respect to maternal factors and maternal/neonatal outcomes. MATERIALS AND METHODS: The Canberra Hospital births database (2012-2016) was queried; patients who underwent IOL were included in the analysis. RESULTS: Total deliveries and the proportion of early-term IOL procedures rose markedly over the time period. Gestational diabetes mellitus (GDM) was the most frequent and an increasing main indication for IOL. GDM was associated with significantly higher body mass index, an increased proportion of obesity, and a greater incidence of labour complications related to macrosomia. Birthweight of neonates of diabetic mothers was significantly higher, which was associated with decreased rates of admission to the special care nursery/neonatal intensive care unit (SCN/NICU) compared to all other babies. GDM increased relative risk of early-term IOL in obese women by 1.8 times. CONCLUSIONS: The burden of GDM and early-term IOL have increased at The Canberra Hospital although adverse short-term neonatal outcomes have not, possibly suggesting appropriate management of these patients. Nonetheless, effort should be made to identify patients who can safely continue pregnancy to full term, given the higher proportion of SCN/NICU admissions among early-term neonates.

Foley catheter silicone versus latex for term outpatient induction of labour: A randomised trial.

BACKGROUND: Both silicone and latex single-balloon Foley catheters are available for cervical ripening but no literature exists to compare them. Local experience suggested more frequent insertion-related accidental rupture of the membranes (acROM) with silicone. AIMS: To compare the performance of silicone versus latex catheters with respect to acROM and other outcomes. MATERIALS AND METHODS: Women undergoing outpatient Foley catheter cervical ripening were randomised to a silicone or latex catheter. Data were collected on the primary outcome, acROM, and secondary outcomes including catheter insertion failure, unplanned hospital admission and patient-reported discomfort, together with intrapartum fever and antibiotics for suspected chorioamnionitis along with general obstetric and neonatal outcomes. RESULTS: Among 534 recruited women, acROM was significantly more common with a silicone compared to a latex catheter at 7.2% (19/265) versus 1.5% (4/269) (relative risk (RR) 4.8; 95% CI 1.7-14.0). Insertion failure was significantly less common with silicone than latex at 2.6% (7/265) versus 9.3% (25/269) (RR 0.3; 95% CI 0.1-0.6). However, when the alternative catheter was subsequently tried, the final failure rates were 1.9% silicone (5/265) versus 2.6% latex (7/269). Insertion-related hospital admission was higher with silicone at 9.4% (25/265) than latex at 4.8% (13/269) (RR 2.1; 95% CI 1.1-4.1). All other obstetric outcomes were similar between the groups. CONCLUSION: When used for cervical ripening, a silicone Foley catheter is associated with a higher rate of acROM than a latex catheter but a lower rate of insertion failure. It may, therefore, be reasonable to attempt insertion with a latex catheter initially and manage insertion failures with a silicone catheter.

Accuracy of the Manipal Cervical Scoring System for predicting successful induction of labour.

The Manipal Cervical Scoring System is an accurate and objective sonographic score that predicts the outcome of induced labour. The aim of the current study was to compare the performance of the Manipal Cervical Scoring System against the Bishop Score. A prospective study was conducted on 105 women underwent labour induction in Ain Shams University Hospital, Cairo, Egypt. Both scores were assessed pre-induction. Successful induction occurred in 78.09% of the cases. The area under the ROC curve (AUC) was of 0.940 (95% CI = 0.876 to 0.977; p value <.0001) for the Manipal Score and 0.863 (95% CI = 0.783-0.923; p value <.0001) for the Bishop Score. The Manipal Score >5 had a sensitivity of 91.5% and a specificity of 91.3%. While the Bishop score >4 had a sensitivity of 98.8% and specificity of 69.6% to predict the outcome of induced labour. The Manipal Cervical Scoring system is a better objective tool to predict the outcome of labour induction compared to the Bishop Score. However, other female and fetal characteristics, including body mass index (BMI) at gestation, gestational weight gain, occiput position and parity should be taken into consideration when performing labour induction. Impact statement What is already known on this subject? The ultimate fate of 20% of women having an induction of labour (IOL) is a Caesarean delivery. Thus, predicting the possible response to IOL before starting induction could guide clinicians to determine the efficacy of starting and/or continuing the induction process and in counselling women regarding the possible response to IOL. The main predictor for IOL outcome is based on the pre-induction cervical status which has been traditionally assessed by the Bishop Score. However, the Bishop Score remains subjective, thereby, associated with high rates of bias and several studies have demonstrated its poor predictive value for the outcome of induction. What do the results of this study add? Proposed use of ultrasound parameters that are equivalent to Bishop Score will be objective, reliable and reproducible method. It allows for patient re-evaluation by other obstetricians without the need for re-examination (thus decreasing exposing the patient to pain and anxiety). What are the implications of these findings for clinical practice and/or further research? According to WHO and FIGO, oral misoprostol (25 µg, 2-hourly) is recommended for induction of labour. This helps to decrease the discomfort of repeated vaginal examination and increases the women satisfaction with labour process, especially in women at higher risk of infection. Thus evaluating cervical status using an ultrasound cervical scoring system can similarly increase women's satisfaction with labour process. Our goal in the upcoming trial is to perform RCT comparing ultrasound versus Bishop in women undergoing IOL using oral misopristol regarding measures of satisfaction during labour in the parturient women.