Differences In Cesarean Rates Research Articles

Differences in Cesarean Rates for Nulliparous, Term, Singleton, Vertex Births Among Racial and Ethnic Groups and States Before and After Stay-at-Home Orders During the COVID-19 Pandemic, United States, 2017-2021.

Evidence is limited on differences in cesarean rates for nulliparous, term, singleton, vertex (NTSV) births across racial and ethnic groups at the national and state level during the COVID-19 pandemic. We assessed changes in levels and trends of NTSV cesarean rates before and after stay-at-home orders (SAHOs) were implemented in the United States (1) overall, (2) by racial and ethnic groups, and (3) by 50 US states from January 2017 through December 2021. We used birth certificate data from 2017 through 2021, restricted to hospital births, to calculate monthly NTSV cesarean rates for the United States and for racial and ethnic groups and to calculate quarterly NTSV cesarean rates for the 50 states. We used interrupted time-series analysis to measure changes in NTSV cesarean rates before and after implementation of SAHOs (March 1 through May 31, 2020). Of 6 022 552 NTSV hospital births, 1 579 645 (26.2%) were cesarean births. Before implementation of SAHOs, NTSV cesarean rates were declining in the United States overall; were declining among births to non-Hispanic Asian, non-Hispanic Black, Hispanic, and non-Hispanic White women; and were declining in 6 states. During the first month of implementation of SAHOs in May 2020, monthly NTSV rates increased in the United States by 0.55%. Monthly NTSV rates increased by 1.20% among non-Hispanic Black women, 0.90% among Hispanic women, and 0.28% among non-Hispanic White women; quarterly NTSV rates increased in 6 states. In addition to emergency preparedness planning, hospital monitoring, and reporting of NTSV cesarean rates to increase provider awareness, reallocation and prioritization of resources may help to identify potential strains on health care systems during public health emergencies such as the COVID-19 pandemic.

Racial Disparities in Caesarean Delivery Among Nulliparous Women That Delivered at Term: Cross-Sectional Decomposition Analysis of Nebraska Birth Records From 2005–2014

ObjectivesPrevious studies suggest higher rates of caesarean section among women who identify as racial/ethnic minorities. The objective of this study was to understand factors contributing to differences in caesarean rates across racial and ethnic groups.MethodsData was collected from 2005–2014 Nebraska birth records on nulliparous, singleton births occurring on or after 37 weeks gestation (n = 87,908). Risk ratios (RR) and 95% confidence intervals (CI) for caesarean were calculated for different racial and ethnic categories, adjusting for maternal age, marital status, county of residence, education, insurance status, pre-pregnancy BMI, and smoking status. Fairlie decomposition technique was utilized to quantify the contribution of individual variables to the observed differences in caesarean.ResultsIn the adjusted analysis, relative to non-Hispanic (NH) White race, both Asian-NH (RR 1.21, 95% CI 1.14, 1.28) and Black-NH races (RR 1.13, 95% CI 1.08, 1.19) were associated with a significantly higher risk for caesarean. The decomposition analysis showed that among the variables assessed, maternal age, education, and pre-pregnancy BMI contributed the most to the observed differences in caesarean rates across racial/ethnic groups.ConclusionsThis analysis quantified the effect of social and demographic factors on racial differences in caesarean delivery, which may guide public health interventions aimed towards reducing racial disparities in caesarean rates. Interventions targeted towards modifying maternal characteristics, such as reducing pre-pregnancy BMI or increasing maternal education, may narrow the gap in caesarean rates across racial and ethnic groups. Future studies should determine the contribution of physician characteristics, hospital characteristics, and structural determinants of health towards racial disparities in caesarean rates.Funding SourcesN/A.

Hospital differences in rates of cesarean deliveries in the Sardinian region: An observational study

Background: The rates of cesarean deliveries have been increasing steadily in several European countries in recent decades, with Italy having the second-highest rate (38% in 2010), causing concern and debate about the appropriateness of many interventions. Moreover, some recent studies suggest that rates of common obstetric interventions are not homogeneous across hospitals, maybe not only because of patient case mix but also possibly because of different hospital practices and cultures. Thus, it is important to investigate whether the variation in rates of cesarean sections can be traced back to patient characteristics or whether it depends upon context variables at the hospital level.
 Objective and method: Using official hospital abstracts on deliveries that occurred in Sardinia over a two-year period, we implement multilevel logistic regression models in order to assess whether the observed differences in cesarean rates across hospitals can be justified by case-mix differences across hospitals.
 Results: The between-hospital variation in rates of cesarean delivery is estimated to be 0.388 in the model with only the intercept and 0.382 in the model controlling for the mother’s clinical and sociodemographic characteristics.
 Conclusions: The results show that taking into account the individual characteristics of delivered mothers is not enough to justify the observed variation across hospital rates, suggesting the important role of unobserved variables at the hospital level in determining cesarean section rates.

Racial disparities in caesarean delivery among nulliparous women that delivered at term: cross-sectional decomposition analysis of Nebraska birth records from 2005-2014

BackgroundPrevious studies suggest higher rates of caesarean section among women who identify as racial/ethnic minorities. The objective of this study was to understand factors contributing to differences in caesarean rates across racial and ethnic groups.MethodsData was collected from 2005 to 2014 Nebraska birth records on nulliparous, singleton births occurring on or after 37 weeks gestation (n = 87,908). Risk ratios (RR) and 95% confidence intervals (CI) for caesarean were calculated for different racial and ethnic categories, adjusting for maternal age, marital status, county of residence, education, insurance status, pre-pregnancy BMI, and smoking status. Fairlie decomposition technique was utilized to quantify the contribution of individual variables to the observed differences in caesarean.ResultsIn the adjusted analysis, relative to non-Hispanic (NH) White race, both Asian-NH (RR 1.21, 95% CI 1.14, 1.28) and Black-NH races (RR 1.13, 95% CI 1.08, 1.19) were associated with a significantly higher risk for caesarean. The decomposition analysis showed that among the variables assessed, maternal age, education, and pre-pregnancy BMI contributed the most to the observed differences in caesarean rates across racial/ethnic groups.ConclusionThis analysis quantified the effect of social and demographic factors on racial differences in caesarean delivery, which may guide public health interventions aimed towards reducing racial disparities in caesarean rates. Interventions targeted towards modifying maternal characteristics, such as reducing pre-pregnancy BMI or increasing maternal education, may narrow the gap in caesarean rates across racial and ethnic groups. Future studies should determine the contribution of physician characteristics, hospital characteristics, and structural determinants of health towards racial disparities in caesarean rates.

A Multistate Decomposition Analysis of Cesarean Rate Variations, Associated Health Outcomes, and Financial Implications in the United States.

Cesarean rates vary widely across the U.S. states; however, little is known about the causes and implications associated with these variations. The objectives of this study were to quantify the contribution of the clinical and nonclinical factors in explaining the difference in cesarean rates across states and to investigate the associated health outcome of cesarean variations. Using the Hospital Cost and Utilization Project State Inpatient Databases, this retrospective study included all nonfederal hospital births from Wisconsin, Florida, and New York. A nonlinear extension of the Oaxaca-Blinder method was used to decompose the contributions of differences in characteristics to cesarean variations between these states. The risk factors for cesarean delivery were identified using separate multivariable logistic regression analysis for each State. The difference in clinical and nonclinical factors explained a substantial (~46.57-65.45%) proportion of cesarean variations between U.S. states. The major contributors of variation were patient demographics, previous cesareans, hospital markup ratios, and social determinants of health. Cesarean delivery was significantly associated with higher postpartum readmissions and unplanned emergency department visits, greater lengths of stay, and hospital costs across all states. Although a proportion of variations in cesarean rates can be explained by the differences in risk factors, the remaining unexplained variations suggest differences in practice patterns and imply potential quality concerns. Since nonclinical factors are likely to play an important role in cesarean variation, we recommend targeted initiatives increasing access to maternal care and improving maternal health literacy. · Cesarean rates vary widely almost two folds within U.S. states.. · The difference in risk factors explained substantial (~46.57-65.45%) of the cesarean variations.. · Mother race, hospital factors, and social determinants comprised major proportion of explained variation.. · Adverse outcomes and increased expenditures were associated with cesarean than vaginal delivery.. · Significant potential cost savings for Medicaid if the unnecessary cesarean deliveries are reduced..

Differential rates of cesarean delivery by maternal geographical origin: a cohort study in France

BackgroundIn many Western countries, higher rates of cesarean have been described among migrant women compared to natives of receiving countries. We aimed to estimate this difference comparing women originating from France and Sub-Saharan Africa (SSA), identify the clinical situations explaining most of this difference and assess whether maternal origin was independently associated with cesarean risk.MethodsThe PreCARE prospective multicenter cohort study was conducted in 2010–2012 in the north Paris area. Our sample was restricted to 1500 women originating from Sub-Saharan Africa and 2206 from France. Profiles of cesarean section by maternal origin were described by the Robson classification. Independent associations between maternal origin and 1) cesarean before labor versus trial of labor, then 2) intrapartum cesarean versus vaginal delivery were assessed by logistic regression models to adjust for other maternal and pregnancy characteristics.ResultsRates of cesarean for women originating from France and SSA were 17 and 31%. The Robson 5A category “unique uterine scar, single cephalic ≥37 weeks” was the main contributor to this difference. Within this category, SSA origin was associated with cesarean before labor after adjustment for medical risk factors (adjusted odds ratio [aOR] = 2.30 [1.12–4.71]) but no more significant when adjusting on social deprivation (aOR = 1.45 [0.63–3.31]). SSA origin was associated with cesarean during labor after adjustment for both medical and social factors (aOR = 2.95 [1.35–6.44]).ConclusionsThe wide difference in cesarean rates between SSA and French native women is mainly explained by the Robson 5A category. Within this group, medical factors alone do not explain the increased risk of cesarean in SSA women.

Differences in caesarean rates across women's socio-economic status by diverse obstetric indications: Cross-sectional study.

The existing inconsistent association between the caesarean rate and maternal socio-economic status (SES) may be the result of a failure to examine the association across indications for caesarean. This study examined the variation in caesarean rates by maternal SES across diverse obstetric-indications. Data on demographics, education, insurance status, medical-conditions, and obstetric characteristics needed to classify deliveries according to Robson's 10 obstetric-groups were extracted from the 2015 US birth certificate data (n=3988733). Multivariable log-binomial regression was used to analyse the data adjusting for confounders. The caesarean rate was 34.1% for women with high SES and 26.8% for those with low SES. After adjustment for confounders, the rate was similar between women with graduate degrees and those who did not complete high school (relative risk (RR) 1.0, 95% confidence interval (CI) 0.9, 1.1). However, different rates of caesareans across SES were observed for particular obstetric-indications. Notably, women with graduate education compared to those who did not complete high school were more likely to have a caesarean (RR 3.0, 95% CI 2.9, 3.1) for a low-risk condition (group 1: nulliparous women with single, cephalic, ≥37 gestational weeks, and spontaneous labour). Women with private insurance were more likely to have a caesarean in almost all obstetric groups, compared to those without private insurance or Medicaid. Examining the overall caesarean rate obscures the relationship between SES and the use of caesarean for particular obstetric-indications. The unequal utilisation of caesareans across SES highlights overuse and potential underuse of the caesareans among American women.

Length of residence and caesarean section in migrant women in Sweden: a population-based study.

Prior studies have reported substantial differences in caesarean rates between migrant and non-migrant women. In this study we investigate whether the association between maternal country of birth and caesarean section is modified by length of residence in Sweden. Population-based register study. A total of 106 760 migrant and 473 881 Swedish-born women having singleton, first births were studied using multinomial multiple regression models to estimate odds ratios (OR) and 95% confidence intervals for mode of birth. Random effect meta-analyses were conducted to assess true heterogeneity between categories of length of residence. Longer duration of residence was associated with an increased overall risk of both unplanned and planned caesarean section among migrant women. This pattern was more pronounced among countries grouped as having higher prevalence (compared to Swedes) of unplanned: OR≤1=1.41 (1.32-1.50); OR>1-<6=1.49 (1.42-1.57); OR6-<10=1.61 (1.50-1.72); OR≥10=1.71 (1.64-1.79) and planned caesarean section [OR≤1=1.14 (0.95-1.36); OR>1-<6=1.30 (1.13-1.51); OR6-<10=1.97 (1.64-2.37]; OR≥10=1.82 (1.67-1.98)]. The results were robust to social, obstetric and health adjustments. There were some country-of-origin-specific findings. The fact that the risk of unplanned and planned caesarean section tended to increase with length of residence, even with adjustment for social, obstetric and health factors, suggests that receiving country-specific factors are playing an important role in caesarean section.

Institutional setting and wealth gradients in cesarean delivery rates: Evidence from six developing countries.

The influence of the type of institutional setting on cesarean delivery is well documented. However, the traditional boundaries between public and private providers have become increasingly blurred with the commercialization of the state health sector that allows providers to tailor the quantity and quality of care according to patients' ability to pay. This study examined wealth-related variations in cesarean rates in six lower- and upper-middle income countries: the Dominican Republic, Egypt, Guatemala, Jordan, Pakistan, and the Philippines. Demographic and Health Survey data and a hierarchical regression model were used to assess wealth-related variations in cesarean rates in government and private hospitals while controlling for a wide range of women's socioeconomic and risk profiles. The odds of undergoing a cesarean delivery were greater in private facilities than government hospitals by 58% in Jordan, 129% in Guatemala, and 262% and 279% in the Dominican Republic and Egypt, respectively. Additional analysis involving interactions between the type of facility and wealth quintiles indicated that wealthier women were more likely to undergo a cesarean birth in government hospitals than poorer women in all countries but the Dominican Republic and Guatemala. Moreover, in both Egypt and Jordan, differences in cesarean rates between government and private hospitals were smaller for the wealthier strata than for the nonwealthy. Large wealth-related variations in the mode of delivery across government and private hospitals suggest the need for well-developed guidelines and standards to achieve a more appropriate selection of cases for cesarean delivery.

Impact of a prenatally diagnosed nuchal cord on obstetrical outcome in an unselected population

Objective: Evaluate the outcome of prenatally diagnosed nuchal cord.Methods: A retrospective study on all cases of prenatally diagnosed nuchal cord. Study end points were gestational age at delivery, intrapartum fetal heart rate (FHR) abnormalities, mode of delivery, intrauterine fetal growth retardation (IUGR), intrauterine fetal demise (IUFD), and the rate of labor induction.Results: This study included 44 cases; 86% were diagnosed at second trimester scan, confirmed by Color Doppler and 3D ultrasound. Mean gestational age at delivery was 39 weeks.18/44 cases (41%) underwent labor induction mostly as a result of parental anxiety. Primary cesarean rate was 34% (15/44), and 16% (7/44) had intrapartum FHR abnormalities with no impact for induction of labor. Instrumental vaginal delivery was used in 5 cases. IUGR was present in 7% (3/44), and none had IUFD. Nuchal cord was confirmed at birth in all cases. Correct prenatal diagnosis was in only one case of the 5/44 (11%) with multiple loops.Conclusion: Prenatal diagnosis of nuchal cord is feasible with difficulty in determining multiple loops. Outcome is favorable, but parental anxiety is common and may increase induction rates, without leading to difference in cesarean rates or FHR abnormalities.

Intra-vaginal prostaglandin E2 versus double-balloon catheter for labor induction in term oligohydramnios.

Compare mechanical and pharmacological ripening for patients with oligohydramnios at term. Fifty-two patients with oligohydramnios ⩽ 5 cm and Bishop score ⩽ 6 were randomized for labor induction with a vaginal insert containing 10 mg timed-release dinoprostone (PGE2) or double-balloon catheter. The primary outcome was time from induction to active labor. Time to labor, neonatal outcomes and maternal satisfaction were also compared. Baseline characteristics were similar. Time from induction to active labor (13 with PGE2 vs 19.5 h with double-balloon catheter; P = 0.243) was comparable, with no differences in cesarean rates (15.4 vs 7.7%; P = 0.668) or neonatal outcomes. The PGE2 group had higher incidence of early device removal (76.9 vs 26.9%; P = 0.0001), mostly because of active labor or non-reassuring fetal heart rate. Fewer PGE2 patients required oxytocin augmentation for labor induction (53.8 vs 84.6% P = 0.034). Time to delivery was significantly shorter with PGE2 (16 vs 20.5 h; P = 0. 045). Intravaginal PGE2 and double-balloon catheter are comparable methods for cervical ripening in term pregnancies with oligohydramnios.

Preterm birth risk at high altitude in Peru

High altitude has been implicated in a variety of adverse pregnancy outcomes including preeclampsia and stillbirth. Smaller studies show conflicting data on the association between high altitude and preterm birth (PTB). The objective of this study was to assess the association between altitude and PTB. A retrospective cohort study was performed using data from the Perinatal Information System, which includes deliveries from 43 hospitals in Peru from 2000 through 2010. Altitude was classified into the following categories: low (0-1999 m), moderate (2000-2900 m), and high (3000-4340 m). The primary outcome was PTB (delivery <37 weeks). Secondary outcomes were cesarean delivery and small for gestational age (SGA). Deliveries less than 23 weeks are not included in the database. χ(2) analyses were performed to compare categorical variables, and a logistic regression was used to calculate the odds ratios and control for confounders. Clustering by hospital was accounted for using generalized estimating equations. A total of 550,166 women were included (68% low, 15% moderate, 17% high altitude). The overall PTB rate was 5.9%, with no difference in the PTB rate among the 3 altitudes (5.6%, 6.2%, 6.8%, P = .13). There was a significant difference in cesarean rates (28.0%, 26.6%, 20.6%, P < .001) with a 34% decreased risk at high vs low altitude adjusted for confounders (adjusted odds ratio, 0.66; 95% confidence interval, 0.51-0.85). There was a difference in SGA (3.3%, 3.6%, 5.0%, P = .02) with a 51% increased risk at high vs low altitude adjusted for confounders (adjusted odds ratio, 1.49; 95% confidence interval, 1.14-1.93). High altitude is not associated with PTB. At high altitude, the cesarean rate was reduced and the SGA rate was increased.

Improving Maternal and Infant Health through CenteringPregnancy: Results of a 2‐Year Retrospective Chart Review Using a Matched Comparison Design

ObjectiveHealthy People 2020 goals include reducing infant mortality and morbidity associated with pregnancy. CenteringPregnancy is a model of health care delivery that unifies health assessment, education, and support into a group setting that has been shown to improve prenatal care compliance, prenatal health knowledge, and prematurity.Research QuestionIs there a difference in select maternal health indicators and pregnancy outcomes between women participating in CenteringPregnancy and traditional care?MethodsAn analysis was conducted comparing CenteringPregnancy participants with a matched comparison group (traditional care). Data were collected through retrospective records review. Institutional review board approval was obtained from Western Michigan University and Borgess Medical Center prior to data collection. For the period of data collection (January 2010 through April 2012), 173 CenteringPregnancy participants were identified and a comparison group of 170 traditional certified nurse‐midwife (CNM) care clients were selected matched on race, age, and insurance status. Additional maternal data collected included prior pregnancies, height, and prepregnancy weight. Prenatal variables included number and timing of prenatal care visits, weight gain, and smoking status. Intrapartum variables included mode of birth and gestational age. Postpartum data were collected regarding attendance at a 6‐week postpartum visit and breastfeeding.ResultsThere was a significant between‐groups difference in gestation at first prenatal visit (11.8 weeks for traditional care vs 10.3 for CenteringPregnancy, P = .031). There was not a significant difference in mean number of prenatal visits (14.2 for CenteringPregnancy vs 13.4 for traditional care, P = .266). There was not a significant difference in rates of smoking at pregnancy diagnosis (26% [n = 45] of CenteringPregnancy vs 30% [n = 49] of traditional care); however, 69% (n = 31) of the women in the CenteringPregnancy group quit with pregnancy diagnosis versus 18% (n = 9) of the traditional care group (P &lt; .001). Additionally, 50% (n = 7) of those still smoking quit during CenteringPregnancy versus only 8% (n = 3) during traditional care (P &lt; .001). There was no difference in pre‐pregnancy weights or weight gain between groups, with only 28% of traditional care and 25% of CenteringPregnancy participants gaining the optimal amount of weight. There was no difference in mean gestational age at birth (39.3 weeks for CenteringPregnancy vs 39.5 weeks for traditional care) or rates of preterm births (5.8% in CenteringPregnancy vs 5.9% in traditional care). There were no differences in cesarean rates (17% for CenteringPregnancy vs 14% for traditional care, P = .443). Both groups had high rates of attendance at their 6‐week postpartum visit (92% for CenteringPregnancy vs 88% for traditional care, P = .243). CenteringPregnancy participants were more likely to initiate breastfeeding (79% vs 60% for traditional care, P &lt; .001) and more likely to still be breastfeeding at the 6‐week postpartum visit (65% vs 45% for traditional care, P &lt; .001).ConclusionIn this study, CenteringPregnancy demonstrated promise in reducing smoking rates during pregnancy and improving breastfeeding rates. This study also demonstrates that optimal weight gain guidelines must be addressed with women during pregnancy regardless of type of prenatal care. Findings from this study must be viewed in light of the self‐selection bias. Despite our attempts to control for variance by utilizing a matched comparison design, women who chose CenteringPregnancy initiated prenatal care earlier and also were more likely to quit smoking prior to onset of prenatal care than those who chose traditional care.

OP46 The Association Between Private Patient Status and Caesarean Delivery: A Retrospective Cohort Study of 403,642 Childbirth Hospitalisations

BackgroundThe increase in Caesarean delivery rates over the past decades has resulted in it becoming one of the most commonly performed in-hospital surgical procedures. While many Caesarean deliveries are clinically...

Foley Catheter Versus Vaginal Prostaglandin E2 Gel for Induction of Labor at Term (PROBAAT Trial)

Pharmacological methods (e.g., prostaglandins) are the primary means for induction of labor in women with an unfavorable cervix. However, mechanical methods are also used, most commonly a Foley catheter balloon. When used for induction, it has been demonstrated that the Foley catheter and prostaglandins have similar cesarean rates. However, it is unclear whether the rates of fetal distress, postpartum hemorrhage, or other complications differ between the 2 methods. Moreover, there are concerns that the use of the Foley catheter for induction may increase the risk of maternal and neonatal infection. This open-label randomized controlled trial compared the effectiveness and safety of a Foley catheter and vaginal prostaglandin E2 gel for induction of labor in women with an unfavorable cervix in a term pregnancy. The study was conducted in 12 hospitals in the Netherlands between 2009 and 2010. The participants were women with a term pregnancy, singleton gestation, cephalic presentation, intact membranes, an indication for induction, and no previous cesarean delivery. All were randomly assigned to either induction of labor with a Foley catheter (n = 412) or vaginal prostaglandin E2 gel (n = 412). The primary study outcome measure was the cesarean rate. Secondary outcomes included time from intervention to birth and maternal and neonatal morbidity. There was no significant difference in cesarean rates between the 2 groups (23% vs. 20%); the risk ratio was 1.13, with a 95% confidence interval of 0 · 87–1 · 47 (P = 0.38). Findings from a meta-analysis, including the results of this trial, confirmed that use of the Foley catheter for induction does not reduce the cesarean section rate compared with use of prostaglandin E2 gel. Use of the Foley catheter was associated with a lower rate of operative delivery for suspected fetal distress and fewer admissions of newborns to neonatal intensive care units. The only serious maternal adverse events—1 uterine perforation and 1 uterine rupture—occurred in the prostaglandin group. These findings indicate that induction of labor with the Foley catheter in term women with an unfavorable cervix has similar cesarean rates compared with vaginal prostaglandin E2 gel, with fewer side effects.

Does case mix explain regional differences in cesarean rates

Does case mix explain regional differences in cesarean rates

Safety and efficacy of misoprostol orally and vaginally: a randomized trial

Objective: To compare the safety and efficacy accompanying oral and vaginal misoprostol for cervical ripening. Methods: One thousand four women with medical or obstetric indications for labor induction and unripe cervices were randomly assigned to receive oral or vaginal misoprostol. Initial doses of 200 μg oral and 50 μg vaginal misoprostol were increased to 300 μg oral and 100 μg vaginal after two doses, to a maximum of six doses. Misoprostol was given every 6 hours in both groups. We anticipated that 11% of women treated vaginally would require intervention during the ripening process. Intervention was defined as interruption of the ripening process before labor or Bishop score of 7 or a lack of response to six misoprostol doses. Results: Five hundred three subjects were assigned to oral and 501 to vaginal administration. Oral misoprostol was associated with significantly higher frequencies of intervention (67 [13.3%] versus 42 [8.4%], P = .01), tachysystole (114 [23.6%] versus 85 [17.6%], P = .02), and hyperstimulation (90 [18.6%] versus 66 [13.7%], P = .04). There were no significant differences in cesarean rates (147 [29.2%] versus 120 [24.0%], P = .06), mean number of misoprostol doses used (1.5 versus 1.6, P = .18), or hours from drug administration to delivery (24.5 versus 25.4, P = .77) between the oral and vaginal groups, respectively. The numbers of deliveries between the groups within 24 hours was different (271 [56%] versus 290 [60%], P = .02), oral and vaginal, respectively. No adverse neonatal outcomes were noted. Conclusion: Oral misoprostol has similar efficacy as vaginal misoprostol but is associated with a higher frequency of excessive uterine contractility and intervention.

Extra-Amniotic Saline, Laminaria, or Prostaglandin E2 Gel for Labor Induction With Unfavorable Cervix

In Brief Objective To determine which of three methods of cervical ripening resulted in the lowest cesarean rate in women with unfavorable cervices and indications for labor induction. Methods Consenting women with singleton gestations, vertex presentations, and unfavorable cervices (dilatation under 2 cm and effacement under 75%) were randomly assigned to laminaria and standard intravenous oxytocin, serial doses of intracervical prostoglandin (PG) E2 gel (Prepidil, Pharmacia & Upjohn, Inc., Kalamazoo, MI) 0.5 μg every 6 hours for two doses followed by oxytocin if indicated, or extra-amniotic saline infusion and oxytocin. Results An interim analysis after recruitment of 321 subjects, 67% of the planned sample, found similar cesarean rates for the three groups (laminaria 36%; gel 33%; PGE2 saline infusion 29%; P = .59); however, the mean randomization-to-delivery interval was significantly longer in the PGE2 group. Stochastic curtailment, as part of the interim analysis, indicated a low likelihood of achieving a statistically significant difference in cesarean rates between PGE2 gel and the other two groups. Therefore, we completed the study with saline infusion and laminaria. The saline infusion and laminaria groups had similar preinduction characteristics. The cesarean rates were similar (saline infusion 25.4% versus laminaria 30.3%; P = .32), but the mean interval from randomization to delivery was shorter in the saline infusion group (18.0 versus 21.5 hours, P = .002). There were no significant differences in selected maternal and neonatal morbidities. Conclusion Cervical ripening with extra-amniotic saline infusion, PGE2, or laminaria resulted in comparable cesarean rates in women with an unfavorable cervix and indications for labor induction. Extra-amniotic saline infusion had the shortest randomization-to-delivery interval without increasing maternal or neonatal morbidity. Extra-amniotic saline infusion, laminaria, and intracervical prostaglandin gel are associated with similar cesarean rates in women with unfavorable cervices who have labor induction.

Extra-amniotic saline, laminaria, or prostaglandin E 2 gel for labor induction with unfavorable cervix: a randomized controlled trial

Objective: To determine which of three methods of cervical ripening resulted in the lowest cesarean rate in women with unfavorable cervices and indications for labor induction. Methods: Consenting women with singleton gestations, vertex presentations, and unfavorable cervices (dilatation under 2 cm and effacement under 75%) were randomly assigned to laminaria and standard intravenous oxytocin, serial doses of intracervical prostoglandin (PG) E 2 gel (Prepidil, Pharmacia & Upjohn, Inc., Kalamazoo, MI) 0.5 μg every 6 hours for two doses followed by oxytocin if indicated, or extra-amniotic saline infusion and oxytocin. Results: An interim analysis after recruitment of 321 subjects, 67% of the planned sample, found similar cesarean rates for the three groups (laminaria 36%; PGE 2 gel 33%; saline infusion 29%; P = .59); however, the mean randomization-to-delivery interval was significantly longer in the PGE 2 group. Stochastic curtailment, as part of the interim analysis, indicated a low likelihood of achieving a statistically significant difference in cesarean rates between PGE 2 gel and the other two groups. Therefore, we completed the study with saline infusion and laminaria. The saline infusion and laminaria groups had similar preinduction characteristics. The cesarean rates were similar (saline infusion 25.4% versus laminaria 30.3%; P = .32), but the mean interval from randomization to delivery was shorter in the saline infusion group (18.0 versus 21.5 hours, P = .002). There were no significant differences in selected maternal and neonatal morbidities. Conclusion: Cervical ripening with extra-amniotic saline infusion, PGE 2, or laminaria resulted in comparable cesarean rates in women with an unfavorable cervix and indications for labor induction. Extra-amniotic saline infusion had the shortest randomization-to-delivery interval without increasing maternal or neonatal morbidity.

Randomized controlled comparison of epidural bupivacaine versus pethidine for analgesia in labour

We compared the incidence of Caesarean delivery in nulliparous women randomized to receive epidural analgesia with those randomized to intramuscular (i.m.) pethidine. On admission to the delivery suite in established labour, 802 nulliparae had already agreed to be randomized with respect to their first analgesia. One hundred and eighty-eight women required either no analgesia or 50% nitrous oxide in oxygen (Entonox) only. Of the remaining 614 women, 310 were randomly allocated to receive i.m. pethidine up to 300 mg and 304 to receive epidural bupivacaine. Labour management was standardized according to the criteria for active management of labour. The intention-to-treat analysis showed similar Caesarean section rates in those randomized to epidural (12%) or pethidine analgesia (13%). The difference in Caesarean rate was -1.1% with 95% confidence intervals from -6.3% to +4.1%. The normal vaginal delivery rates were similar (epidural, 59%; pethidine, 61%).