Elective Induction Research Articles

Cost Analysis of Elective cesarean versus induction in nulliparous patients with super-morbid obesity

Cost Analysis of Elective cesarean versus induction in nulliparous patients with super-morbid obesity

Elective induction of labor versus expectant management after one prior cesarean delivery

Elective induction of labor versus expectant management after one prior cesarean delivery

Elective induction of trial of labor after cesarean at 39 weeks: is it risk reducing?

After the ARRIVE trial, induction of labor (IOL) at 39 weeks became ubiquitous. We aim to determine whether patients with a prior cesarean should undergo risk reducing induction of labor at 39 weeks or be expectantly managed beyond 39 weeks. We created a decision analytic model to compare two management strategies in patients with a prior cesarean: 1) IOL at 39 weeks, 2) expectant management beyond 39 weeks. Patients expectantly managed beyond 39 weeks could: experience stillbirth, undergo indicated induction, or reach 40 weeks. At 40 weeks, patients could be induced or expectantly managed. We assumed all patients would be induced if they reached 41 weeks. We further assumed that all patients would attempt a trial of labor after cesarean (TOLAC) and all patients undergoing TOLAC were at risk for uterine rupture; the risk of uterine rupture was varied by IOL versus spontaneous labor and gestational age. Adverse maternal outcomes considered were maternal death, hysterectomy, operative injury (bowel or bladder injury). Neonatal outcomes considered were stillbirth, neonatal death, and hypoxic ischemic encephalopathy. Baseline risk estimates for uterine rupture, adverse events associated with uterine rupture, failed TOLAC, and successful TOLAC were obtained from the literature. One-way and multi-way sensitivity analyses were performed to address uncertainties in baseline assumptions. Within baseline assumptions, the model identified that IOL at 39 weeks resulted in fewer adverse maternal or neonatal events compared to expectant management and more vaginal deliveries (Table). The model is sensitive to the risk of uterine rupture associated with IOL at 39 weeks; if the incidence of uterine rupture exceeds 1.42% in those undergoing IOL at 39 weeks, the model favors expectant management. In Monte Carlo simulations, induction of labor was selected in 91.7% of simulations. Risk-reducing IOL at 39 weeks should not be withheld from women undergoing TOLAC and, depending on the risk of uterine rupture, may be associated with more favorable outcomes than expectant management.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The ARRIVE Trial: Impact of Elective Induction on Subsequent Pregnancy Occurrence and Mode of Delivery

The ARRIVE Trial: Impact of Elective Induction on Subsequent Pregnancy Occurrence and Mode of Delivery

Maternal and Neonatal Outcomes of Elective Induction of Labor at 39 or More Weeks: A Prospective, Observational Study.

The purpose of our study is to compare the maternal and neonatal outcomes of induction of labor (IOL) versus expectant management at 39 weeks of gestation. We conducted a single-centered, prospective, observational study of nulliparous singleton women at 39 weeks or more. We compared the maternal and perinatal outcomes. Of 408 nulliparous women, 132 women were IOL group and 276 women were expectant management group. IOL and expectant group had similar cesarean delivery rate (18.2% vs. 15.9%, p = 0.570). The delivery time from admission was longer in IOL group (834 ± 527 vs. 717 ± 469 min, p = 0.040). The IOL group was less likely to have Apgar score at 5 min < 7 than in expectant group (0.8% vs. 5.4%, p = 0.023). Multivariate analysis showed that IOL at 39 weeks was not an independent risk factor for cesarean delivery (relative risk 0.64, 95% confidence interval: 0.28−1.45, p = 0.280). Maternal and neonatal adverse outcomes, including cesarean delivery rate, were similar to women in IOL at 39 weeks of gestation compared to expectant management in nulliparous women. IOL at 39 weeks of gestation could be recommended even when the indication of IOL is not definite.

Outpatient Foley Catheter for Induction of Labor in Obese Nulliparous Patients: A Secondary Analysis of OFFSITE II Randomized Controlled Trial.

In the OFFSITE II randomized controlled trial, outpatient cervical ripening with a Foley catheter (CF) in nulliparous patients undergoing elective induction of labor (eIOL) shortened the time from admission to delivery. Given that patients with obesity have protracted labor and higher rates of failed IOL, we sought to determine if outpatient ripening with a CF may be even more beneficial for this high-risk group. We performed a secondary analysis of the OFFSITE II randomized controlled trial. For this analysis, all patients from the primary trial were classified by their intervention assignment (inpatient vs. outpatient) and also by their admission body mass index (BMI) class (BMI ≥ 30 and BMI < 30 kg/m2). The primary outcome was time from labor and delivery (L&D) admission to delivery. Secondary outcomes included cesarean delivery, time from admission to hospital discharge, and rates of clinically diagnosed chorioamnionitis and endometritis. In patients with BMI ≥ 30, the primary outcome, time from admission to delivery, (18.0 [13.5-20.9] vs. 20.4 [16.6-31.3] hours, p = 0.01), as well as total hospitalization length (3.2 [2.5-3.3] vs. 3.4 [3.1-4.3] days, p = 0.02) were shorter in the outpatient group. There were no differences in rates of chorioamnionitis or endometritis in outpatient compared with inpatient CF. Furthermore, in those with a BMI ≥ 30, the cesarean rate was significantly lower with outpatient CF (19.4% vs. 44.7%, p = 0.03); it was not statistically different in patients with BMI < 30. In this exploratory retrospective secondary analysis of the OFFSITE II randomized control trial, we found that in patients with BMI ≥ 30 undergoing eIOL, outpatient CF was associated with a lower time from L&D admission until delivery. This was also associated with a shorter time of total hospital duration and decreased the rate of cesarean, a benefit not detected in the overall analysis presented in the primary study. In nulliparas undergoing induction of labor, ripening with outpatient cervical Foley may even more significantly reduce labor duration, total hospital duration, and the rate of cesarean in patients with obesity. · Outpatient CF was associated with a lower time from L&D admission until delivery in obese nulliparas.. · Outpatient CF was associated with a shorter time of total hospital duration in obese nulliparas.. · Outpatient CF was associated with a decreased rate of cesarean birth in obese nulliparas..

Failed Induction of Labor and Associated Factors Among Women Who Undergone Induction of Labor in Jimma Medical Center, Ethiopia: A Hospital-Based Cross-Sectional Study

BACKGROUNDAlthough induction of labor is intended to achieve a safe vaginal delivery, its process is not always successful. Failed induction of labor leads to an increased risk of complication for both mother and fetus. Thus, this study aimed to assess the proportion of failed induction of labor and associated factors among women who undergone induction of labor from September 1, 2019 to August 31, 2020 in Jimma Medical Center (JMC), southwest Ethiopia.METHODSA hospital-based retrospective cross-sectional study was conducted on 243 charts of women who had induction of labor in JMC selected by a simple random sampling method from January 10 to 30, 2021. The collected data were entered into Epi-data version 4.2 and analyzed by SPSS version 23. Bivariate and multivariable logistic regression analyses were done to test the association. Adjusted odds ratio at 95% confidence interval (CI) andP-value &lt;.05 was used to ascertain statistical significance.RESULTSThe proportion of failed induction of labor in JMC was 16.9%. Maternal age ≥ 30 years (AOR 7.57; 95%CI = 2.88, 19.9) at (P-value = .000), elective induction (AOR .39; 95% CI = .16, .98) at (P-value = .045), and unfavorable bishop score (AOR 6.94; 95%CI = 2.35, 20.4) at (P-value = .000) were factors statistically significantly associated with failed induction of labor.CONCLUSIONSThe proportion of failed induction of labor was relatively low in the study area. Advanced maternal age, elective induction, and unfavorable bishop score were associated with failed induction of labor. Thus, the hospital should strictly follow the protocol for induction of labor, and candidates of emergency induction of labor should be counseled thoroughly so as to be well prepared psychologically for the labor thereby reducing the risk of failed induction.

Analytical approaches to evaluating hypertensive disorders of pregnancy

Data from the A Randomized Trial of Induction Versus Expectant Management study suggested that low-risk pregnant patients randomized to expectant management at term had a higher risk for developing hypertensive disorders of pregnancy than pregnant patients randomized to elective induction at 39 weeks. In addition, hypertensive disorders of pregnancy were reported to decrease with advancing gestational age when comparing outcomes by gestational age at delivery. This study aimed to verify these contrasting findings by evaluating the relationship between hypertensive disorders of pregnancy at term and gestational age at delivery. This was a secondary analysis of a multicenter, prospective cohort study of nulliparous pregnant patients with singleton gestations (from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be). Pregnant patients who delivered ≥37+0 weeks' gestation were included. Patients were excluded if they did not provide consent for data release in subsequent studies or if they had missing outcome data. The primary outcome was hypertensive disorders of pregnancy, defined as gestational hypertension or preeclampsia with or without severe features according to the American College of Obstetricians and Gynecologists guidelines. Descriptive statistics were used to evaluate hypertensive disorders of pregnancy in the following 2 ways: analysis (1), incidence of hypertensive disorders of pregnancy by gestational age week among all ongoing pregnancies and analysis (2), the incidence of hypertensive disorders of pregnancy by gestational age week among deliveries at that gestational age week. It was assumed that hypertensive disorders of pregnancy were not expectantly managed at term. Of the 8011 pregnant patients included in this analysis, 1003 (12.5%) had hypertensive disorders of pregnancy: 162 (24.5%) delivered at 37+0 to 37+6 weeks' gestation, 232 (18%) delivered at 38+0 to 38+6 weeks, 310 (12.1%) delivered at 39+0 to 39+6 weeks, 207 (8.7%) delivered at 40+0 to 40+6 weeks, and 92 (8.1%) delivered at ≥41+0 weeks. In analysis 1, the incidence of hypertensive disorders of pregnancy increased with advancing gestational age among all ongoing pregnancies with a hypertensive disorder of pregnancy (2.0% at 37 weeks and 8.1% at 41 weeks). In analysis 2, the incidence of hypertensive disorders of pregnancy decreased with advancing gestational age among deliveries at that gestational age week alone (24.5% at 37 weeks and 8.1% at 41 weeks). Our results confirm the findings from the A Randomized Trial of Induction Versus Expectant Management study showing that the risk for hypertensive disorders of pregnancy increases with advancing gestational age, but hypertensive disorders of pregnancy is more common among deliveries at earlier gestational ages. These key differences illustrate how important the study design and analytical approach are to accurately interpret results and apply findings clinically.

Is gestational age at term a risk factor for ongoing pregnancies in nulliparous women: A prospective cohort study

The results of American observational studies and 1 large, randomized trial show that elective induction of labor among nulliparous women can reduce cesarean delivery rates and suggest that gestational age at delivery may be a risk factor for cesarean delivery in pregnancies managed expectantly. However, data on the risk of cesarean delivery at term in ongoing pregnancies are sparse, especially in high-income countries, and further information is needed to explore the external validity of these previous studies. This study aimed to evaluate the risk of cesarean delivery for each gestational week of ongoing pregnancy in nulliparous women with a singleton fetus in the cephalic presentation at term in a French population. This retrospective study was conducted in a perinatal network of 10 maternity units from January 1, 2016, to December 31, 2017, and included all nulliparous women with a singleton fetus in the cephalic presentation who gave birth at term (≥37 0/7 weeks of gestation). From the start of term (37 completed weeks) and at the start of each subsequent week of completed gestation (each week + 0 days), ongoing pregnancy was defined as that of a woman who was still pregnant and who gave birth at any time after that date. For each week of gestation for these ongoing pregnancies, the cesarean delivery rate was defined as the number of cesarean deliveries performed in each ongoing pregnancy group divided by the number of women in this group. Separate models for each week of gestation, adjusted by maternal characteristics and hospital status, were used to compare the cesarean delivery risk between ongoing pregnancies and those delivered the preceding week. The same methods were applied to subgroups defined according to the mode of labor onset. Odds ratios were calculated after adjusting for maternal age and educational level, presence of severe preeclampsia, and maternity unit status. The study included 11,308 nulliparous women, 2544 (22.5%) of whom had a cesarean delivery. These rates remained stable for ongoing pregnancies at 37 0/7, 38 0/7, and 39 0/7 weeks of gestation; the rates were 22.5% (95% confidence interval, 21.7-23.2), 22.6% (95% confidence interval, 21.8-23.3); and 22.7% (95% confidence interval, 21.9-23.6), respectively. The risk of cesarean delivery started to increase in ongoing pregnancies at 40 0/7 weeks of gestation (24.3%; 95% confidence interval, 23.1-25.4) and especially at 41 0/7 weeks of gestation (30.7%; 95% confidence interval, 28.9-32.5). Similar trends were also shown for all modes of labor onset and in every maternity unit. In univariate and multivariate analyses, ongoing pregnancy at or beyond 40 0/7 weeks of gestation was associated with a higher risk of cesarean delivery than pregnancy delivered the previous week: 24.3% of ongoing pregnancies at 40 0/7 weeks of gestation vs 19.9% of deliveries between 39 0/7 weeks of gestation and 39 6/7 weeks of gestation. The odds ratios were 1.28 (95% confidence interval, 1.15-1.44) or 30.4% of ongoing pregnancies at 41 0/7 weeks of gestation vs 1.73 (95% confidence interval, 1.51-1.96) or 19.6% of deliveries between 40 0/7 weeks of gestation and 40 6/7 weeks of gestation. Cesarean delivery rates increased starting at 40 0/7 weeks of gestation in ongoing pregnancies regardless of the mode of labor onset.

Elective induction of labour and expectant management in late-term pregnancy: A prospective cohort study alongside the INDEX randomised controlled trial.

ObjectiveTo assess adverse perinatal outcomes and caesarean section of low-risk women receiving elective induction of labour at 41 weeks or expectant management until 42 weeks according to their preferred and actual management strategy.DesignMulticentre prospective cohort study alongside RCT.Setting90 midwifery practices and 12 hospitals in the Netherlands.Population3642 low-risk women with uncomplicated singleton late-term pregnancy.Main outcome measuresComposite adverse outcome (perinatal death, Apgar score 5′ < 7, NICU admission, meconium aspiration syndrome), composite severe adverse perinatal outcome (all above with Apgar score 5′ < 4 instead of < 7) and caesarean section.ResultsFrom 2012–2016, 3642 women out of 6088 eligible women for the INDEX RCT, participated in the cohort study for observational data collection (induction of labour n = 372; expectant management n = 2174; unknown preference/management strategy n = 1096).Adverse perinatal outcome occurred in 1.1 % (4/372) in the induction group versus 1.9 % (42/2174) in the expectant group (adjRR 0.56; 95 %CI: 0.17–1.79), with severe adverse perinatal outcome occurring in 0.3 % (1/372) versus 1.0 % (22/2174), respectively (adjRR 0.39; 95 % CI: 0.05–2.88). There were no stillbirths among all 3642 women; one neonatal death occurred in the unknown preference/management group. Caesarean section rates were 10.5 % (39/372) after induction and 8.9 % (193/2174) after expectant management (adjRR 1.32; 95 % CI: 0.95–1.84).A higher incidence of adverse perinatal outcome was observed in nulliparous compared to multiparous women. Nulliparous 1.8 % (3/170) in the induction group versus 2.6 % (30/1134) in the expectant management group (adjRR 0.58; 95 % CI 0.14–2.41), multiparous 0.5 % (1/201) versus 1.1 % (11/1039) (adjRR 0.54; 95 % CI 0.07–24.19). One maternal death due to amniotic fluid embolism occurred after elective induction at 41 weeks + 6 days.ConclusionIn this cohort study among low-risk women receiving the policy of their preference in late-term pregnancy, a non-significant difference was found between induction of labour at 41 weeks and expectant management until 42 weeks in absolute risks of composite adverse (1.1 % versus 1.9 %) and severe adverse (0.3 % versus 1.0 %) perinatal outcome. The risks in this cohort study were lower than in the trial setting. There were no stillbirths among all 3642 women. Caesarean section rates were comparable.

Relation between perinatal outcome and gestational duration in term primiparous pregnancies stratified by body mass index.

There is growing evidence that induction of labor at 41 completed weeks improves neonatal outcome, at least among primiparous women. This study was performed to investigate whether maternal body mass index (BMI) should be considered when deciding on timing of intervention in term pregnancies. The study design was a historical cohort study using data from the Swedish Medical Birth Register, singletons in cephalic presentation with births 39+0 to 41+6 weeks, with available information on maternal BMI 2005-2017 (n= 352 567). Modified Poisson regression analyses were used to investigate the association between gestational duration and stillbirth or death before 45 postmenstrual weeks (primary outcome) and Apgar score <7 at 5 minutes (secondary outcome) by BMI, respectively. Adjustments were made for maternal age, smoking, country of birth and educational level. The adjusted relative risk (ARR) of stillbirth or death before 45 weeks among infants born at 41+0 to 41+6 vs 40+0 to 40+6 weeks, was 1.26 with a 95% confidence interval (CI) of 1.07-1.48. Among women with BMI≥30, the offspring mortality risk in pregnancies lasting 39+0 to 39+2 weeks was significantly above the corresponding risk among women of normal BMI who delivered at 41+0 to 41+2 weeks (ARR=1.95; 95% CI 1.07-3.56) but no statistically significant heterogeneity was found regarding the magnitude of the association between gestational duration and offspring mortality. The ARR, for Apgar <7 at 5minutes (41+0 to 41+6 vs 40+0 to 40+6 weeks, regardless of BMI), was 1.36 (95% CI 1.27-1.45). The risk for low Apgar score at 41+0 weeks was 1.5% among all children regardless of maternal BMI. Among children to women with BMI≥30, this magnitude of risk was found already at 39+3 weeks. In primiparous women with obesity the risk of stillbirth or death before 45 postmenstrual weeks were increased throughout all full-term gestational age categories, compared with women with overweight or normal BMI. Children to obese women had the same risk for Apgar scores <7 at 5minutes compared with women overall at earlier gestational age. The results suggest that maternal BMI needs to be considered when discussing timing of elective induction in term healthy pregnancies of primiparous women.

Elective Induction of Labour at 39 Weeks Compared With Expectant Management in Nulliparous Persons Delivering in a Community Hospital

ObjectiveTo determine the impact of offering elective labour induction at 39 weeks gestation on perinatal and maternal outcomes in nulliparous people with low-risk pregnancies. MethodsThe charts of all pregnant people who delivered at Brockville General Hospital between September 2018 and December 2021 were retrospectively reviewed. Perinatal and maternal outcomes of low-risk nulliparous pregnant people who underwent elective induction at 39 weeks and over were extracted and compared with those of low-risk nulliparous pregnant people who underwent expectant management. Exclusion criteria included multiparous people, high-risk pregnancies, multiple gestations, deliveries at less than 39 weeks gestation, and elective cesarean deliveries. Univariate and multivariate analysis was performed. ResultsA total of 174 patients were included. Of these patients, 56 (32.2%) underwent elective induction of labour between 390 and 396 weeks gestation over the period of June 2020 to December 2021, whereas 118 (67.8%) were expectantly managed from 390 weeks gestation over the period of September 2018 to March 2020. Compared with expectant management, those in the 39+ weeks induction group had a significantly lower risk of cesarean delivery (odds ratio [OR] 0.39; 95% confidence interval [CI] 0.15–0.99), composite adverse maternal outcomes (OR 0.34; 95% CI 0.12–0.97), and composite adverse perinatal outcomes (OR 0.26; 95% CI 0.074–0.92). ConclusionOur results suggest that elective induction of labour at 39 weeks gestation and over in low-risk nulliparous people is associated with lower risks of cesarean delivery, composite adverse maternal outcomes, and composite adverse perinatal outcomes than expectant management.

Outcomes of Elective Induction of Labor Versus Expectant Management

Summary Context: Both medical and nonmedical interventions to hasten labour and delivery are on the rise. Whether or not elective induction of labour improves outcomes or merely leads to additional complications and healthcare expenditures is a contentious topic in the scientific literature. Purpose: Choosing to induce labour artificially vs waiting for the baby to come naturally is the focus of this research. Data Sources: Internet, previous systematic reviews, and databases including MEDLINE (2022), Web of Science (2022), CINAHL (2022), and the Cochrane Central Register of Controlled Trials (2022). Data Extraction: Structure, patient characteristics, quality standards, and outcomes like as caesarean section and maternal and neonatal morbidity were abstracted by two writers. Data Synthesis: In all, more than a hundred publications were considered, but only 36 were included (11 RCTs and 25 observational studies). In a non-significant trend, women who were treated as if they were about to give birth (OR, 1.21 [CI, 1.01 to 1.46]) had a higher chance of having a caesarean section than women who were treated as though they were still in the early stages of pregnancy (OR, 1.73 [CI, 0.67 to 4.5]). Amniotic fluid was more likely to be meconium-stained in women who were expectantly managed than to those who had chosen to be induced (OR, 2.04 [CI, 1.34 to 3.09]). Exponential likelihood ratio = 2.04 [95% confidence interval = 1.34 to 3.09]). Conclusion: RCTs imply that inducing labor at 41 weeks or later reduces the risk of caesarean birth and meconium-stained amniotic fluid. Future research should evaluate elective induction of labor where most obstetric care is offered.

Elective Induction of Labor and Postpartum Hemorrhage in Females Presenting for Normal Vaginal Delivery at Term

Background: Labor induction is the process or treatment that stimulates childbirth and delivery. Induction of labor without a medical indication is termed elective induction of labor and appears to be increasing even more rapidly than induction of labor as a whole. Postpartum hemorrhage (PPH) leads to prominent causes of maternal death. Uterine massage is a simple first line treatment as it helps the uterus to contract to reduce bleeding. Objectives: To determine the frequency of elective induction of labor in females undergoing normal vaginal delivery at term and to compare the frequency of postpartum hemorrhage with spontaneous versus elective induced labor in females presenting for normal vaginal delivery at term. Study Design: Descriptive case series study Place and Duration of Study: Department of Obstetrics &amp; Gynecology, Shaikh Zayed Women Hospital, Larkana from 1st October 2021 to 31st March 2022. Methodology: Two hundred females were enrolled. They were divided in two groups; elective induction or spontaneous delivery. Females who had active labour without oxytocin with no membrane rupture before labour, labeled as having spontaneous labour otherwise. Results: The induced delivery was noted in 35(17.50%) females and spontaneous type of delivery was noted in 165(82.50%) females, the postpartum hemorrhage was noted among 23(11.50%) females. The postpartum hemorrhage is not associated with type of delivery (p=0.249). Conclusion: The elective induction of labor in females undergoing normal vaginal delivery at term was 17.50% patients and postpartum hemorrhage was 11.50% patients. Keywords: Postpartum hemorrhage, Postpartum hemorrhage (PPH), Spontaneous, Induced, Labour, Delivery

Reducing pelvic floor injury by induction of labor.

Introduction and hypothesisWe hypothesized that elective induction of labor (eIOL) at 39 weeks is protective of levator ani muscle injury (LAMI) and is associated with decreased pelvic symptoms at 6 weeks postpartum compared to expectant management of labor.MethodsProspective cohort pilot study of uncomplicated, primiparous women with a singleton, vertex gestation enrolled immediately post-vaginal delivery (VD). Subjects were dichotomized into two groups based on labor management: eIOL without complication defined by the ARRIVE trial versus spontaneous VD between 39 weeks0/7 and 42 weeks5/7 or no indication for IOL prior to 40 weeks5/7. The primary outcome was LAMI at 6 weeks postpartum as evidenced by any of the following ultrasound measures: (1) increased levator hiatal area (LHA) > 2500 mm2, (2) increased elasticity index (EI, > 75th quartile) or (3) levator enthesis avulsion.ResultsAnalysis represents 45/102 consented women from July 2019–October 2020 (eIOL n = 22 and spontaneous VD, n = 23). Neither maternal, clinical, sociodemographic characteristics nor pelvic symptoms differed between groups. Fewer women had LAMI as defined by the primary outcome with eIOL (n = 5, 23.8%) compared to spontaneous VD (n = 15, 65.2%), p = 0.008. Levator enthesis was more deformable (increased EI) with spontaneous VD as compared to the eIOL [10.66 (8.99) vs. 5.68 (2.93), p = 0.046]. On univariate logistic regression women undergoing spontaneous VD had unadjusted OR of 6.0 (1.6–22.5, p = 0.008) of sustaining LAMI compared to those undergoing eIOL.ConclusionsComposite measures of LAMI though not pelvic floor symptoms were markedly increased in women undergoing spontaneous VD compared to those undergoing eIOL at 39 weeks.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00192-022-05296-1.

Evolución del conocimiento sobre la fisiología ovárica y su contribución a la aplicación de las biotecnologías reproductivas en Sudamérica

As our understanding of ovarian function in cattle has improved, our ability to control it has also increased. Luteal function in cattle has been studied in detail, and prostaglandin F2α has been used for several years for elective induction of luteal regression. More recently, follicular wave dynamics have been studied and protocols have been designed to induce follicular wave emergence and ovulation, and the need to detect oestrus has even been eliminated. The addition of progesterone, estradiol, GnRH and equine chorionic gonadotropin (eCG) releasing devices has provided opportunities for fixed-time AI (IATF) and possibilities for achieving higher pregnancy rates. In embryo transfer programs, these same treatments have eliminated the need to detect oestrus, allowing fixed-time embryo transfer (TETF) and the initiation of superstimulatory treatments regardless of the day of the estrous cycle. Taken together, the new protocols have facilitated the application of assisted reproductive technologies, and this is especially true in South America. Over the past 20 years, the use of AI in South America has increased, due in large part to the use of the IATF. The use of the IATF has been multiplied by more than 10 times in Brazil, with more than 11 million treatments in 2016, which represents 85% of all AI. Similar trends are occurring in Argentina and Uruguay. In vivo embryo production produced by superovulation (DIV) has remained relatively stable over the years, but in vitro embryo production (PIV) has increased dramatically in the last 10 to 15 years, especially in Brazil, where More than 300,000 PIV embryos were produced in 2010. Worldwide, over 990,000 bovine PIV embryos were produced in 2017, of which more than% were produced in South America. The use of assisted reproductive technologies has facilitated the spread of genetic improvements and increased reproductive performance; These practices are spreading to many South American countries.

Prediction of spontaneous onset of labor at term (PREDICT study): Research protocol.

Recent studies have shown that elective induction of labor versus expectant management after 39 weeks of pregnancy result in lower incidence of perinatal complications, while the proportion of cesarean deliveries remains stable, or even decreases. Still, evidence regarding collateral consequences of the potential increase of induction of labor procedures is still lacking. Also, the results of these studies must be carefully interpreted and thoroughly counter-balanced with women's thoughts and opinions regarding the active management of the last weeks of pregnancy. Therefore, it may be useful to develop a tool that aids in the decision-making process by differentiating women who will spontaneously go into labor from those who will require induction. To develop a predictive model to calculate the probability of spontaneous onset of labor at term. We designed a prospective national multicentric observational study including women enrolled at 39 weeks of gestation, carrying singleton pregnancies. After signing an informed consent form, several clinical, ultrasonographic, biophysical and biochemical variables will be collected by trained staff. If delivery has not occurred at 40 weeks of pregnancy, a second visit and evaluation will be performed. Prenatal care will be continued according to current hospital guidelines. Once recruitment is completed, the information gathered will be used to develop a logistic regression-based predictive model of spontaneous onset of labor between 39 and 41 weeks of gestation. A secondary exploration of the data collected at 40 weeks, as well as a survival analysis regarding time-to-delivery outcomes will also be performed. A total sample of 429 participants is needed for the expected number of events. This study aims to develop a model which may help in the decision-making process during follow-up of the last weeks of pregnancy. NCT05109247 (clinicaltrials.gov).

Outcomes In Elective Induction Of Labour With μg Intravaginal Misoprostol In Postdate Singleton Live Pregnancy At Korle-Bu Teaching Hospital

Background: Induction of labour is indicated when the risk associated with expectant management of labour is higher. The most common indication for labour induction is postdate pregnancy and induction for this indication has been shown to reduce perinatal death. Misoprostol is the most commonly used drug for labour induction at the Korle-Bu Teaching, the leading national referral centre in Ghana. Method: To assess the outcomes in Elective Induction of Labour using 50 μg of intravaginal misoprostol in postdate singleton live pregnancies at Korle-Bu Teaching Hospital. This was a prospective cohort study carried out to measure the rates of vaginal deliveries and factors affecting vaginal deliveries during labour induction. One hundred and sixteen pregnant women of at least 41 weeks gestation. Women were included and followed up from the first insertion of misoprostol to delivery.Results: Eighty-six patients (74.1%) had vaginal delivery and 30 (25.9%) were delivered by caesarean section. Among those who delivered vaginally, 77 (89.5%) delivered within 24 hours. There was a significant association between mode of delivery and Bishop Score (P=0.002). The highest Apgar score at the first minute was 7 in 55 babies (47.4%) and the lowest was 3 in 2 babies (1.7%).Conclusions: The high rate of vaginal delivery and absence of induction related perinatal mortality confirmed the effectiveness and safety of misoprostol in postdate singleton live pregnancy at Korle-Bu Teaching Hospital.

Comparing Vaginal and Oral Administration of Misoprostol for Cervical Ripening and Induction of Labour in Prolonged Pregnancies

Background: Dinoprostone (prostaglandin E2), is presently used as the approved standard protocol for cervical ripening and labour induction. In search for a cheaper alternative, misoprostol (prostaglandin E1) has been found to be a good substitute. The ideal dose, route and frequency of administration of misoprostol are, however, still under investigation. Although, vaginal application of misoprostol has been validated as a reasonable means of induction, there is patient resistance to digital vaginal examination and there is a risk of ascending infection. For these reasons, oral administration of misoprostol for cervical ripening and labour induction has been tried.Objective: The efficacy and safety of oral and vaginal misoprostol for the elective induction of labour with prolonged pregnancy and unfavourable cervix was compared through a prospective study over a period of one year at the Military Hospital, Accra. Methods: A prospective, non-blinded randomised study of 148 women with prolonged pregnancy. Data was collected using a prepared structured case record form (data profoma). The study population was randomized into two groups and given 50 μg misoprostol orally in one group and 50 μg vaginally in the other. The main outcomes were measured as induction to delivery time,vaginal delivery achieved within 24 hours and the incidence of uterine hyperstimulation with fetal heart rate (FHR) changes. Results: The mean induction to delivery interval was shorter in vaginal group than oral group but the differences did not reach statistical significance (12.9hrs vs 14.3hrs; mean difference -1.42, P value = 0.24). The shorter duration of vaginal misoprostol, however, was significant for nulliparous women (13.4hrs vs 17.9hrs; mean difference 4.53, p&lt;0.05). There was less failure to achieve vaginal delivery within 24 hours of induction in the vaginal route group, but the differences did not reach statistical significance (6.1% vs. 6.8%; p = 0.81). Fewer women needed oxytocin augmentation in the vaginal group (24.2% vs.17.4%, p = 0.11). There was a higher incidence of uterine hyperstimulation in the vaginal group but not significant (14.7% vs 6.1%, p = 0.10). APGAR scores at 5 minutes showed no difference between the two groups (1.49% vs. 2.99%, p =0.42).Conclusions: Compared with oral misoprostol, vaginal misoprostol for induction of labour at term resulted in a shorter induction-to-delivery time and a lesser need of oxytocin for women to deliver within 24 hours of induction. Both maternal and neonatal safety outcome were comparable in both groups. However, the more frequent occurrence of hyperstimulation in the vaginal group could lessen its preference to the oral route. More trials are needed to determine the right oral dosage that combines efficacy with safety.

Outcome of Spontaneous Vaginal Delivery and Elective Induction of Labour in Postdated Pregnancy

Background: Postdated pregnancies are associated with increased perinatal morbidity and mortality. The risk increases when pregnancy continues beyond 41 wks. So, the Induction of labor conducted at or beyond 41 wks could help prevent these complications. But there are certain risks associated with Induction of labor. Again, Induction success varies widely and depends on some modifiable and nonmodifiable factors. Objective: To assess the feto-maternal outcome and analyze the factors affecting the outcome of electively induced labour in postdated pregnancy with a low bishop score compared to spontaneous onset labour in a secondary level hospital. Materials and methods: Prospective analytical study involving 220 participants divided into induction (study) and spontaneous labour (control) groups. Data collected on socio-demographic data, characteristics of the study population, causes of failed Induction, maternal complications and neonatal outcomes. Results: Among electively induced postdated pregnancy (study group) vaginal delivery was 45.45% with caesarean section 54.54% compared to 80% and 20% respectively in the spontaneous labour (control group). Cervical dystocia was the commonest indication for caesarean section (P=0.001). Among maternal complications control group had significant perineal lacerations (P=0.016) and study group had a longer duration of hospital stay (P&lt;0.001). The neonatal outcome didn’t show significant difference. Conclusion: The present study showed routine Induction of labor in prolonged pregnancy may encourage higher caesarean section rate with prolonged hospital stay but judicious Induction even in poor bishop score is not associated with any major feto-maternal complication. Further multicentric study with a larger sample size is recommended. J Bangladesh Coll Phys Surg 2022; 40: 175-182