Recommendations for strain elastography of the uterine cervix.

PURPOSE: Conventional vaginal strain ultrasound elastography, not based on shear-wave elastography imaging, can assess the biomechanical properties of the uterine cervix. This assessment may inform the risks of preterm birth and failed induction of labor. However, there is considerable variation in the approaches to strain elastography, including the placement of the region of interest (ROI). Therefore, our aim was to provide recommendations for cervical elastography. METHODS: We conducted a literature review on (1) elastography principles, and (2) the cervical anatomy. Subsequently, we performed elastography scanning using a Voluson™ E10 Expert scanner with the BT18 software of (3) polyacrylamide hydrogel simulators, and (4) pregnant women. RESULTS: Increasing the distance between the ROI and probe led to a decrease in the obtained strain value; a 53% decrease was observed at 17.5 mm. Similarly, an increased angle between the ROI and probe-centerline resulted in a 59% decrease for 40° angle. Interposition of soft tissue (e.g., cervical canal) between the ROI and the probe induced an artifact with values from the posterior lip being 54% lower than those from the anterior lip, even after adjusting for probe-ROI distance. Equipment and the recording conductance significantly influenced the results. CONCLUSION: Our findings inform recommendations for future studies on strain cervical elastography.

The REDUCED trial: a cluster randomized trial for REDucing the utilization of CEsarean delivery for dystocia.

BACKGROUND: To reduce cesarean delivery rates in nulliparous women, guidelines for diagnosing nonprogressive labor have been developed by the National Institute of Child Health and Human Development, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine. These are mainly based on data from the Consortium for Safe Labor study. The guidelines have not been tested in a clinical trial, so the efficacy and safety of this new approach is uncertain. OBJECTIVE: This study aimed to assess whether adoption of new guidelines for diagnosing nonprogressing labor would reduce cesarean delivery rates. STUDY DESIGN: We conducted a cluster randomized controlled trial of a knowledge translation program of the guidelines in 26 Canadian hospitals (13 control sites and 13 intervention sites). The sites included all intrapartum care sites in Alberta that perform cesarean delivery and deliver at least 70 nulliparous women annually. The baseline period started on January 1, 2015. The intervention was initiated at the first intervention site in January 2017. The follow-up period began at the first intervention site in February 2017 and lasted till February 2020. The primary outcome was the rate of cesarean delivery in nulliparous women with vertex presentation in labor at term. The secondary outcomes included spontaneous vaginal birth and maternal and neonatal safety. The main data source for the primary and secondary outcomes was the Alberta Perinatal Health Program database. The cesarean delivery rates were assessed using repeated measures mixed effects logistic regression applied to individual births. RESULTS: The analysis was based on 45,193 deliveries at intervention sites and 43,725 deliveries at control sites. There was no evidence of a decrease in the rate of cesarean delivery in association with the intervention (baseline-adjusted odds ratio, 0.94; 95% confidence interval [0.85-1.05]; P=.259). The rate of spontaneous vaginal delivery increased slightly (baseline-adjusted odds ratio, 1.10; 95% confidence interval, [1.01-1.18]; P=.024). We did not observe any differences in adverse maternal or neonatal outcomes. CONCLUSION: Cesarean delivery rates in nulliparous women were not reduced by the application of recent guidelines for the diagnosis of nonprogressive labor. Spontaneous vaginal delivery-a secondary outcome-was increased in the intervention group. The intervention appears to be safe.

Adverse neonatal outcomes and associated factors among mothers who gave birth through induced and spontaneous labor in public hospitals of Awi zone, Northwest Ethiopia: a comparative cross-sectional study.

BACKGROUND: Adverse neonatal outcomes are one of the most common causes of neonatal mortality and morbidity. Empirical evidence across the world shows that induction of labor potentiates adverse neonatal outcomes. In Ethiopia, there has been limited data that compares the frequency of adverse neonatal outcomes between induced and spontaneous labor. OBJECTIVES: To compare the prevalence of adverse neonatal outcomes between induced and spontaneous labor and to determine associated factors among women who gave birth in public hospitals of Awi Zone, Northwest Ethiopia. METHODS: A comparative cross-sectional study was conducted at Awi Zone public hospitals from May 1 to June 30, 2022. A simple random sampling technique was employed to select 788 (260 induced and 528 spontaneous) women. The collected data were analyzed using statistical package for social science (SPSS) software version 26. The Chi-square test and an independent t-test were used for categorical and continuous variables, respectively. A binary logistic regression was used to assess the association between the outcome and explanatory variables. In the bivariate analysis, a p-value ≤ 0.2 at a 95% confidence interval was used to consider the variables in the multivariate analysis. Finally, statistical significance was stated at a p-value of less than 0.05. RESULT: The adverse neonatal outcomes among women who gave birth through induced labor were 41.1%, whereas spontaneous labor was 10.3%. The odds of adverse neonatal outcomes in induced labor were nearly two times higher than in spontaneous labor (AOR = 1.89, 95% CI: 1.11-3.22). No education (AOR = 2.00, 95% CI: 1.56, 6.44), chronic disease (AOR = 3.99, 95% CI: 1.87, 8.52), male involvement (AOR = 2.23, 95% CI: 1.23, 4.06), preterm birth (AOR = 9.83, 95% CI: 8.74, 76.37), operative delivery (AOR = 8.60, 95% CI: 4.63, 15.90), cesarean section (AOR = 4.17, 95% CI: 1.94, 8.95), and labor complications (AOR = 5.16, 95% CI: 2.90, 9.18) were significantly associated factors with adverse neonatal outcomes. CONCLUSION AND RECOMMENDATION: Adverse neonatal outcomes in the study area were higher. Composite adverse neonatal outcomes were significantly higher in induced labor compared to spontaneous labor. Therefore, it is important to anticipate the possible adverse neonatal outcomes and plan management strategies while conducting every labor induction.

Predictors of vaginal delivery following balloon catheter for labor induction in women with one previous cesarean.

BACKGROUND: The aim of this study was to estimate predictors for vaginal birth following balloon catheter induction of labor (IOL) in women with one previous cesarean section (CS) and an unfavorable cervix. METHODS: This 4-year retrospective cohort study was conducted in Longhua District Central Hospital in Shenzhen China, between January 2015 and December 2018. Patients with one previous CS and a current singleton-term pregnancy who underwent balloon catheter cervical ripening and IOL were enrolled. Univariate analysis was used to identify predictive factors associated with vaginal birth after cesarean section (VBAC). Binary logistic regression was further used to identify which factors were independently associated with the outcome measure. The primary outcome was VBAC, which was a successful trial of labor after cesarean delivery (TOLAC) following IOL. RESULTS: A total of 69.57% (208/299) of the women who planned for IOL had VBAC. In the final binary logistic regression equation, lower fetal weight (< 4000 g) (odds ratio [OR]5.26; 95% confidence interval [CI] 2.09,13.27), lower body mass index (BMI,<30 kg/m2) (OR 2.27; CI 1.21, 4.26), Bishop score after cervical ripening > 6 (OR 1.94; CI 1.37, 2.76) remained independently associated with an increased chance of VBAC. CONCLUSIONS: The influencing factors of VBAC following IOL were fetal weight, BMI, and Bishop score after cervical ripening. Adequate individualized management and assessment of the IOL may help improve the VBAC rate.

Effects of the Oxytocin Hormone on Pelvic Floor Muscles in Pregnant Rats.

Background and Objectives: Oxytocin induction is a known risk factor for pelvic floor disorders (PFDs). The aim of the study was to investigate the effects of oxytocin induction on pelvic floor muscles in pregnant rats. Methods: Thirty-two female Wistar rats were included and divided into four groups (n = 8). The groups were as follows: virgin group (group I)-from which muscles were dissected at the beginning of the experiment; spontaneous vaginal delivery (group II) which has delivery spontaneously; saline control group (group III) and oxytocin group (group IV). In groups III and IV, pregnancy was induced on d 21 of pregnancy, with 2.5 mU saline solution or iv oxytocin, respectively, delivered by the intravenous (iv) route in pulses at 10-min intervals for 8 h. Then, the rats were euthanized, the m. coccygeus, m. iliocaudalis and m. pubocaudalis muscles were excised and tissue samples were taken. After histological processing, the vertical and horizontal dimensions of the muscles were analyzed under a light microscope. Results: In group IV; the measurement of the horizontal dimension of the m. pubocaudalis muscles was 50.1 ± 5.4 µm and it was significantly higher than other groups (p < 0.001). In group III; the mean value of the horizontal dimension of m. coccygeus muscle was found to be 49.5 ± 10.9 µm and it was significantly higher than other groups (p < 0.009). Between-group comparisons revealed no difference in mean m. iliocaudalis muscle dimension (p > 0.05). Conclusions: As a result of our study it can say that whether oxytocin induced or not, vaginal birth is a process that affects the pelvic muscles.

Spontaneous and induced labor: association with maternal well-being three months after childbirth.

A woman's first childbirth represents a moment of elevated maternal emotional vulnerability. Indeed, there is a prevalence of anxiety and depression symptomatology in primiparas during the postpartum period that negatively influences the well-being of the woman, of her newborn, and of the quality of their attachment bond. Much attention has been paid to the possible risk factors involved in the onset of mood disturbance in the postpartum. However, knowledge is still limited regarding the role played by the specific clinical aspects linked to labor. Therefore, the aim of the present study was to explore whether spontaneous or elective induction labor is linked to the level of postnatal depression and anxiety three months after birth. One hundred and sixty-one women (Mage = 31.63; SD = 4.88) were recruited, using the following inclusion criteria: native Italian women; age > 18 years; physically and psychologically healthy nulliparous with singleton no-risk pregnancy; no previous abortion or interruption of pregnancy; no previous psychopathological diagnoses. Exclusion criteria: twin pregnancy, fetal pathologies, and planned elective cesarean. Data was collected at two different times: T1 (day of childbirth) clinical data of labor (spontaneous or induced) from hospital records; T2 (three months after birth) level of mother's depression and anxiety. In order to explore if the level of depression and anxiety three months after childbirth differ in women according to the type of labor, spontaneous or induced, two univariate analyses of variance (ANOVA) were conducted. Results showed that women who had a spontaneous labor reported lower levels of anxiety and depression than women who had an induced labor. Our results highlight the significant implications that the mode of labor has on the emotional well-being of mothers, underlining the need to support women throughout all their transition to motherhood, including the childbirth experience.

The Impact of Mouse Preterm Birth Induction by RU-486 on Microglial Activation and Subsequent Hypomyelination.

Preterm birth (PTB) represents 15 million births every year worldwide and is frequently associated with maternal/fetal infections and inflammation, inducing neuroinflammation. This neuroinflammation is mediated by microglial cells, which are brain-resident macrophages that release cytotoxic molecules that block oligodendrocyte differentiation, leading to hypomyelination. Some preterm survivors can face lifetime motor and/or cognitive disabilities linked to periventricular white matter injuries (PWMIs). There is currently no recommendation concerning the mode of delivery in the case of PTB and its impact on brain development. Many animal models of induced-PTB based on LPS injections exist, but with a low survival rate. There is a lack of information regarding clinically used pharmacological substances to induce PTB and their consequences on brain development. Mifepristone (RU-486) is a drug used clinically to induce preterm labor. This study aims to elaborate and characterize a new model of induced-PTB and PWMIs by the gestational injection of RU-486 and the perinatal injection of pups with IL-1beta. A RU-486 single subcutaneous (s.c.) injection at embryonic day (E)18.5 induced PTB at E19.5 in pregnant OF1 mice. All pups were born alive and were adopted directly after birth. IL-1beta was injected intraperitoneally from postnatal day (P)1 to P5. Animals exposed to both RU-486 and IL-1beta demonstrated microglial reactivity and subsequent PWMIs. In conclusion, the s.c. administration of RU-486 induced labor within 24 h with a high survival rate for pups. In the context of perinatal inflammation, RU-486 labor induction significantly decreases microglial reactivity in vivo but did not prevent subsequent PWMIs.

Is the increase in postpartum hemorrhage after vaginal birth because of altered clinical practice?: A register-based cohort study.

BACKGROUND: To identify risk factors for severe postpartum hemorrhage (PPH) ≥1000 ml in women giving birth vaginally. METHOD: A register-based cohort study including women with singleton pregnancies giving birth vaginally at term to a live-born child at Aarhus University Hospital, Denmark, from January 1, 2004, to December 31, 2012. Logistic multivariable regression was used to analyze data. RESULTS: In 31 837 births, 1832 women (5.7%) experienced severe PPH. Maternal age, smoking during pregnancy, and prepregnancy body mass index did not increase the risk of severe PPH. However, nulliparous and multiparous women with a previous cesarean birth had an increased risk of severe PPH. Antepartum and intrapartum risk factors for severe PPH included gestational age >40 weeks, induction of labor, augmentation of labor, irregular fetal position, instrumental birth, and birthweight >4000 g. In particular, the combination of induction and augmentation of labor doubled the risk of severe PPH. Among genital tract tears, vaginal tears >3 cm were associated with the highest risk of severe PPH. CONCLUSIONS: Maternal characteristics did not increase the risk of severe PPH, except for nulliparous and multiparous women with a previous cesarean birth. Obstetric interventions such as induction of labor, augmentation of labor, and a birthweight higher than 4000 g increased the risk of severe PPH. Larger vaginal tears presented the highest risk of severe PPH. Clinical practice with rigorous indications for obstetric interventions and timely identification and management of genital tract tears may reduce risk of severe PPH.

Target populations to reduce cesarean rates after induced labor: A national population-based cohort study.

INTRODUCTION: Great variations in cesarean rates after induction of labor exist and reasons for these disparities remain unclear. They may be explained by individual characteristics or obstetric practices. Ten-group classification systems have proved their utility to monitor cesarean rates in general population. We aimed to identify groups of women that account for most cesareans after induction of labor using the Nippita reproducible 10-group classification, specifically designed for induced population. MATERIAL AND METHODS: A prospective population-based cohort study was performed in 94 French maternity units, including 3042 women undergoing induction of labor. Women were sorted according to 10 mutually exclusive groups based on parity, weeks of gestation, number of fetuses, fetal presentation and previous cesarean delivery. Relative size, cesarean delivery rate and contribution to the overall cesarean rate were described for each group. Cesarean rates were compared according to the Bishop score at the onset of labor induction. Indications for cesarean delivery were also described in the groups that contributed most to the overall cesarean rate. The MEDIP protocol was registered in ClinicalTrial (NCT02477085). RESULTS: The overall cesarean rate was 21.0% among this population of induced women. Nulliparous women with a term singleton cephalic fetus (groups 1, 2 and 3; at 37-38, 39-40 and ≥41 weeks of gestation, respectively) accounted for two-thirds of the overall cesarean rate because they were the largest group (relative size of 10.6, 16.6 and 18.1%, respectively) and had higher cesarean rates (27.2, 30.9 and 33.0%, respectively). When the Bishop score was <6 (n = 2270/3042), cesarean delivery rates were higher (24.1 vs 10.7% if Bishop score ≥6, P < 0.01), in particular for group 1 (29.1 vs 12.5%, P = 0.02), and group 2 (33.3 vs 19.3%, P = 0.01). In groups 1, 2 and 3, which contributed most to the overall cesarean rate, a significant part of the cesareans were performed before 6 cm of cervical dilation for dystocia only (40.0, 16.7 and 17.6%, respectively). CONCLUSIONS: Nulliparous women with a term singleton cephalic fetus and an unfavorable cervix represent the population to target for auditing induction practices. Specific actions could be implemented among this population to weigh the benefits and risks of induction and improve the management of labor induction.

Oxytocin induced labor causes region and sex-specific transient oligodendrocyte cell death in neonatal mouse brain.

AIM: Previous reports showed associations between oxytocin induced labor and mental disorders in offspring. However, those reports are restricted in epidemiological analyses and its mechanism remains unclear. In this study, we hypothesized that induced labor directly causes brain damage in newborns and results in the development of mental disorders. Therefore we aimed to investigate this hypothesis with animal model. METHODS: The animal model of induced labor was established by subcutaneous oxytocin administration to term-pregnant C57BL/6J mice. We investigated the neonatal brain damage with evaluating immediate early gene expression (c-Fos, c-Jun and JunB) by quantitative polymerase reaction and TdT-mediated dUTP nick end labeling staining. To investigate the injured brain cell types, we performed double-immunostaining with TdT-mediated dUTP nick end labeling staining and each brain component specific protein, such as Oligo2, NeuN, GFAP and Iba1. RESULTS: Brain damage during induced labor led to cell death in specific brain regions, which are implicated in mental disorders, in only male offspring at P0. Furthermore, oligodendrocyte precursors were selectively vulnerable compared to the other cell types. This oligodendrocyte-specific impairment during the perinatal period led to an increased numbers of Olig2-positive cells at P5. Expression levels of oxytocin and Oxtr in the fetal brain were not affected by the oxytocin administered to mothers during induced labor. CONCLUSION: Oligodendrocyte cell death in specific brain regions, which was unrelated to the oxytocin itself, was caused by induced labor in only male offspring. This may be an underlying mechanism explaining the human epidemiological data suggesting an association between induced labor and mental disorders.

Predicting labor induction success by cervical funneling in uncomplicated pregnancies.

AIM: Predictive accuracy of cervical funneling for successful vaginal delivery prior to labor induction was compared to that of conventional methods such as Bishop score and cervical length. METHODS: Prospective observational study was conducted on nulliparous women at 38 gestational weeks or more with intact membranes who delivered vaginally following labor induction. Transvaginal ultrasound was performed prior to labor induction to evaluate the cervix, to determine the cervical length and to check for the presence of funneling. Following pelvic examinations, the Bishop score was calculated. Predictive accuracy of the three different methods, namely cervical funneling, cervical length and Bishop, were compared. RESULTS: A total of 235 nulliparous women with intact membranes were recruited. Of these, 194 women (82.6%) had successful vaginal deliveries following induction. Cervical funneling was observed in 105 women (44.7%). The rate of successful vaginal delivery was significantly higher in women with cervical funneling than in those without funneling (90.5% vs 76.2%, P < 0.004). Multivariable analysis showed that cervical funneling, similar to traditional measures such as the Bishop score and cervical length, was an independent predictor of successful vaginal delivery following labor induction (odds ratio = 2.95; 95% confidence interval: 1.38-6.47; P = 0.007). CONCLUSIONS: Similar to the conventional methods of cervical evaluation, such as the Bishop score and cervical length, cervical funneling may serve as a useful and valid predictor of successful vaginal deliveries prior to labor induction.

The risk of cesarean delivery after labor induction among women with prior pregnancy complications: a subgroup analysis of the AFFIRM study.

BACKGROUND: To determine the risk of cesarean delivery after labor induction among patients with prior placenta-mediated pregnancy complications (pre-eclampsia, late pregnancy loss, placental abruption or intrauterine growth restriction). METHODS: The AFFIRM database includes patient level data from 9 randomized controlled trials that evaluated the role of LMWH versus no LMWH during pregnancy to prevent recurrent placenta-mediated pregnancy complications. The primary outcome of this sub-study was the proportion of women who had an unplanned cesarean delivery after induction of labor compared to after spontaneous labor. RESULTS: There were 512 patients from 7 randomized trials included in our sub-study. There was no difference in the risk of cesarean delivery between women with labor induction (21/148, 14.2%) and spontaneous labor (79/364, 21.7%) (odds ratio (OR) 0.60, 95% CI, 0.35-1.01; p = 0.052). Among 274 women who used LMWH prophylaxis during pregnancy, the risk of cesarean delivery was lower among those that underwent labor induction (9.8%) compared to spontaneous labor (22.4%) (OR 0.38, 95% CI, 0.17-0.84; p = 0.01). CONCLUSIONS: The risk of cesarean delivery is not increased after labor induction among a higher risk patient population with prior pregnancy complications. Our results suggest that women who receive LMWH during pregnancy might benefit from labor induction.

Low-dose vaginal misoprostol vs vaginal dinoprostone insert for induction of labor beyond 41st week: A randomized trial.

INTRODUCTION: The aim of this study was to compare the efficacy and safety of a low-dose protocol of vaginal misoprostol and vaginal dinoprostone insert for induction of labor in women with post-term pregnancies. MATERIAL AND METHODS: We designed a prospective, randomized, open-labeled trial with evaluators blinded to the end-point, including women of at least 41 weeks of gestational age with uncomplicated singleton pregnancies and a Bishop score <6. They were randomized into dinoprostone or misoprostol groups in a 1:1 ratio. Baseline maternal data and perinatal outcomes were recorded for statistical analysis. Successful vaginal delivery within 24 hours was the primary outcome variable. A P value <0.05 was considered statistically significant. This study was registered in ClinicalTrials.gov (number NTC03744364). RESULTS: We included 198 women for analysis (99 women in each group). Vaginal birth rate within 24 hours did not differ between groups (49.5% vs 42.4%; P = 0.412). When the Bishop score was <4, dinoprostone insert showed a higher probability of vaginal delivery within 12 hours (17.8% vs 4%; P = 0.012). In the dinoprostone group, removal of the insert was more likely to be due to an adverse event (5.1% vs 14.1%; P = 0.051) and an abnormal fetal heart rate pattern during active labor (44.4% vs 58.6%; P = 0.047). Both groups were similar in neonatal outcomes including Apgar score, umbilical cord pH and neonatal intensive care unit admission. CONCLUSIONS: Low-dose vaginal misoprostol and vaginal dinoprostone insert seem to be equally effective and safe for induction of labor in pregnant women with a gestational age beyond 41 weeks.

Midwifery presence in United States medical centers and labor care and birth outcomes among low-risk nulliparous women: A Consortium on Safe Labor study.

BACKGROUND: The presence of midwives in a health system may affect perinatal outcomes but has been inadequately described in United States settings. Our objective was to compare labor processes and outcomes for low-risk nulliparous women birthing in United States medical centers with interprofessional care (midwives and physicians) versus noninterprofessional care (physicians only). METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk nulliparous women who birthed in interprofessional (n = 7393) or noninterprofessional centers (n = 6982). Unadjusted, adjusted (age, race, health insurance type), propensity-adjusted, and propensity-matched logistic regression models were used to compare outcomes. RESULTS: There was concordance across logistic regression models, the most restrictive and conservative of which were propensity-matched models. With this approach, women at interprofessional medical centers, compared with women at noninterprofessional centers, were 74% less likely to undergo labor induction (risk ratio [RR] 0.26; 95% CI 0.24-0.29) and 75% less likely to have oxytocin augmentation (RR 0.25; 95% CI 0.22-0.29). The cesarean birth rate was 12% lower at interprofessional centers (RR 0.88; 95% CI 0.79-0.98). Adverse neonatal outcomes occurred in only 0.3% of births and were thus too rare to be modeled. CONCLUSIONS: The care processes and birth outcomes at interprofessional and noninterprofessional medical centers differed significantly. Nulliparous women receiving care at interprofessional centers were less likely to experience induction, oxytocin augmentation, and cesarean than women at noninterprofessional centers. Labor care and birth outcome differences between interprofessional and noninterprofessional centers may be the result of the presence of midwives and interprofessional collaboration, organizational culture, or both.

Influence of midwifery presence in United States centers on labor care and outcomes of low-risk parous women: A Consortium on Safe Labor study.

BACKGROUND: Sixty percent of United States births are to multiparous women. Hospital-level policies and culture may influence intrapartum care and birth outcomes for this large population, yet have been poorly explored using a large, diverse sample. We sought to use national United States data to analyze the association between midwifery presence in maternity care teams and the birth processes and outcomes of low-risk parous women. METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk parous women in either interprofessional care (n = 12 125) or noninterprofessional care centers (n = 8996). Unadjusted, adjusted (age, race, health insurance type), propensity-adjusted, and propensity-matched logistic regression models were used to assess processes and outcomes. RESULTS: There was concordance in outcome differences across regression models. With propensity score matching, women at interprofessional centers, compared with women at noninterprofessional centers, were 85% less likely to have labor induced (risk ratio [RR] 0.15; 95% CI 0.14-0.17). The risk for primary cesarean birth among low-risk parous women was 36% lower at interprofessional centers (RR 0.64; 95% CI 00.52-0.79), whereas the likelihood of vaginal birth after cesarean for this population was 31% higher (RR 1.31; 95% CI 1.10-1.56). There were no significant differences in neonatal outcomes. CONCLUSIONS: Parous women have significantly higher rates of vaginal birth, including vaginal birth after cesarean, and lower likelihood of labor induction when cared for in centers with midwives. Our findings are consistent with smaller analyses of midwifery practice and support integrated, team-based models of perinatal care to improve maternal outcomes.

[Contrast study of double-balloon catheter with and without oxytocin for cervical ripening].

Objective: To evaluate the efficacy and related issues for cervical ripening by double-balloon catheter with and without oxytocin. Methods: The prospective non-randomly control research was conducted from March 2015 to June 2017 in Yuquan Hospital of Tsinghua University. The primipara with induced labor indications and balloon placement conditions were divided into two groups. Seventy-eight cases were in the balloon with oxytocin group, in which oxytocin was used if there were no contraction 1 hour after balloon placement. Meanwhile, 220 cases were in the single balloon group. Before and after balloon placement, the changes of cervical Bishop Scores and delivery outcome were compared between the groups. Results: The effective rate of cervical ripening in the balloon with oxytocin group was higher than that in the balloon group[92.3% (72/78) vs 82.7% (182/220), P<0.05], the proportion of parturiency within 12 hours was as well[15.4% (12/78) vs 7.3% (16/220), P<0.05]. The effective rate of cervical Bishop score 4-5 points was further improved in the balloon with oxytocin group[95.7%(66/69) vs 85.1% (165/194), P<0.05]. Taken out balloon, the cervical Bishop scores (8.1±1.1) points in the balloon with oxytocin group were higher than (6.5±1.2) points in the balloon group (P<0.05). For the maternal without parturiency in the balloon with oxytocin group, the cervical Bishop score reduced from (7.7±0.9) points to (6.6±0.6) points after removal balloon for 12 hours (P<0.05). The cesarean section proportion for intrauterine infection in the balloon with oxytocin group was higher than that of the balloon group ( P<0.05), but the placental pathological diagnosis proportion was no significant difference ( P>0.05). In the two groups, the cesarean section rate, the first labor stage, the episiotomy rate, the postpartum hemorrhage rate, neonatal weight, the neonatal asphyxia and referral rate showed no significant differences (P>0.05, respectively). Conclusions: The double-balloon catheter with oxytocin can further improve the efficiency of patients with cervical Bishop score 4-5 points for cervical ripening , and increase the chance of labor in 12 hours.

Decline in stillbirths and perinatal mortality after implementation of a more aggressive induction policy in post-date pregnancies: a nationwide register study.

INTRODUCTION: In 2011 Danish national guidelines were changed towards a more aggressive induction and fetal surveillance policy from (1) induction of labor at gestational age (GA) of 42+0  weeks and (2) no fetal surveillance after 40+0  weeks to (1) induction of labor between 41+2 and 41+6  weeks, (2) earlier induction at 41+0  weeks in the case of maternal age >40 years or body mass index (BMI) >35 kg/m2 and (3) fetal surveillance at GA 41+0  weeks. MATERIAL AND METHODS: This national cohort study included all pregnancies that reached 41+0  weeks of gestation in 2008-2014 (n = 102 167). Multivariate logistic regression analyses were used to estimate risks in the years after (2012-2014) vs. before (2008-2010) new national guidelines, adjusted for maternal age, BMI, and parity. RESULTS: We observed a decline in stillbirths from 0.9‰ to 0.5‰ [odds ratio (OR)adjusted 0.50, 95% CI 0.29-0.89, p = 0.018]. Furthermore, a decline in perinatal deaths from 1.3‰ to 0.8‰ (ORadjusted 0.62, 95% CI 0.39-0.96, p = 0.033) and vacuum extraction (ORadjusted 0.86, 95% CI 0.82-0.90, p = 0.007) was observed. The risk of cesarean section (ORadjusted 0.98, 95% CI 0.94-1.02, p = 0.251), Apgar score below 7 at five minutes (ORadjusted 0.96, 95% CI 0.81-1.14, p = 0.0.678) and admissions to the neonatal department (ORadjusted 1.04, 95% CI 1.00-1.14, p = 0.064) did not change, whereas induction of labor increased from 28.2 to 42.6% (ORadjusted 1.89, 95% CI 1.84-1.95, p < 0.001). CONCLUSIONS: This study showed a decline in stillbirths and perinatal mortality after implementation of new Danish guidelines for post-date pregnancies. The risk of interventions as cesarean section and vacuum extraction remained stable despite an increase in labor inductions.

The SaTH risk-assessment tool for the prediction of emergency cesarean section in women having induction of labor for all indications: a large-cohort based study.

PURPOSE: To develop a risk-assessment model for the prediction of emergency cesarean section (CS) in women having induction of labor (IOL). METHODS: This was an observational cohort study of women with IOL for any indication between 2007 and 2013. Women induced for stillbirths and with multiple pregnancies were excluded. The primary objective was to identify risk factors associated with CS delivery and to construct a risk-prediction tool. RESULTS: 6169 women were identified with mean age of 28.9 years. Primiparity involved 47.1 %, CS rate was 13.3 % and post-date pregnancies were 32.4 %. Risk factors for CS were: age >30 years, BMI >25 kg/m2, primiparity, black-ethnicity, non post-date pregnancy, meconium-stained liquor, epidural analgesia, and male fetal gender. Each factor was assigned a score and with increasing scores the CS rate increased. The CS rate was 5.4 % for a score <11, while for a score ≥11 it increased to 25.0 %. The model had a sensitivity, specificity, negative predictive value and positive predictive value of 75.8, 65.1, 93.8 and 25.0 %, respectively. CONCLUSION: We have constructed a risk-prediction tool for CS delivery in women with IOL. The risk-assessment tool for the prediction of emergency CS in induced labor has a high negative-predictive value and can provide reassurance to presumed low-risk women.

Contemporary epidemiology and novel predictors of uterine rupture: a nationwide population-based study.

PURPOSE: In spite of several policies aiming to decrease cesarean rates and related complications such as uterine rupture, data show that uterine rupture and associated morbidity are increasing along the years. Whether previously unidentified risk factors are currently playing an important role on these trends is unknown. We analyze current risks of uterine rupture and main preceding factors from more recent years compared to former data. METHODS: All uterine rupture cases in the US from 2011-2012 were selected, with matched non-uterine rupture cases selected as controls. Variables considered for analysis included demographics, maternal morbidity, and obstetric complications. Likelihood forward selection was used to identify main risk factors of uterine rupture. Medians of main factors identified were used to simulate groups at risk and calculate odds ratios of uterine rupture. RESULTS: From ~8 million births, 1925 presented uterine rupture. In patients with no prior cesarean delivery, multiple gestation, chronic hypertension and chorioamnionitis presented the highest odds of uterine rupture, with the combination of these factors increasing the odds of rupture 59 times (~1%). In women with prior cesarean delivery, induction/augmentation and chorioamnionitis were the most significant predictors, with the combination increasing the odds 33 times (~3%). CONCLUSIONS: Despite policies implemented and changes in clinical practice, uterine rupture remains an important issue. Previously unidentified risk factors are playing now an important role, information that should be considered during patient counseling and clinical practice. Combinations of some of these factors may increase the risk of uterine rupture significantly enough to modify clinical care.

Induced Labor in Sweden, 1999-2012: A Population-Based Cohort Study.

BACKGROUND: Previous studies show contradictory results about the impact of induced labor on the cesarean delivery rate and few studies have investigated the risk of vacuum extraction subsequent to induced labor. The aims of the present study were to describe the rate of induced labor in Sweden from 1999 to 2012, and to assess the risk of unplanned cesarean delivery and vacuum extraction after induced labor in relation to medical complications and length of gestation. METHODS: A register-based cohort study was conducted, including 1,078,536 women with spontaneous or induced onset of labor who gave birth by noninstrumental vaginal delivery, unplanned cesarean delivery, or vacuum extraction in gestational week 37 + 0 to 41 + 6. Logistic regression was used to study the association between induced labor and instrumental delivery. RESULTS: The rate of induced labor increased from 7.7 to 12.9 percent among primiparous and from 7.5 to 11.8 percent among multiparous women. Induced labor was associated with 2-3 times greater risk of unplanned cesarean delivery among all women, except multiparas in gestational week 37-38, and with a 20-50 percent higher risk of vacuum extraction after the adjustment for confounding factors. Among women without a recognized medical complication, induced labor was associated with a threefold increased risk of cesarean delivery in gestational week 39-41 and a 40 percent increase in gestational week 37-38 compared with women with spontaneous onset of labor. CONCLUSIONS: The proportion of induced labors increased substantially during the 14-year study period and was associated with an increased risk of both cesarean delivery and vacuum extraction, even in women without a documented medical complication. The increased risk of instrumental delivery should be taken into account when counseling about the risks and benefits of induced labor.