Failed Induction Of Labor Research Articles

Incidence of and Risk Factors for Failed Induction of Labor Using a Contemporary Definition.

To estimate the incidence of failed induction of labor and the associated patient risk factors. We performed a case-control study from a cohort of nulliparous women who delivered between 39 and 41 weeks of gestation after an induction of labor in one of seven hospitals. Cases of failed induction were defined using the Obstetric Care Consensus criteria (ie, cesarean delivery performed in early labor [less than 6 cm dilatation] after at least 12 hours of oxytocin administration from membrane rupture). For each case of failed induction, the next four women who did not meet the criteria for failed induction of labor were selected for the control group, matched by hospital. We identified characteristics associated with failed induction of labor using a multivariable conditional logistic regression that was constructed with backward stepwise method for variable selection. Across the hospitals, 4,123 of 10,175 nulliparous women were induced (40.5%), of whom 82 had a failed induction of labor (2.0%). A total of 328 women were selected for the matched control group. Baseline characteristics were similar between the groups. Compared with women in the control group, women with a failed induction were more likely to have a delivery body mass index (BMI) of 40 or higher (28.0 vs 8.2%, P<.001), shorter height (mean 63.9 vs 64.8 inches, P=.01), and closed cervix on admission (41.5 vs 24.1%, P=.002). Factors significantly associated with induction failure in the multivariable model included: 1) delivery BMI (adjusted odds ratio [aOR] 7.93, 95% CI 3.48-18.09, for BMI 40 or higher relative to BMI lower than 30, 2) height in inches (aOR 0.89, 95% CI 0.80-0.98), and 3) number of centimeters dilated on admission 2 or more (aOR 0.30, 95% CI 0.14-0.65). Failed induction of labor occurs infrequently. Risk factors include shorter height, BMI 40 or higher, and cervical dilatation of less than 2 cm on admission. Even so, most women with these risk factors will not experience failed labor induction.

Dinoprostone vaginal insert vs the Foley catheter in labor induction. Observational study

Background: A common practice used prior to induction of labor (IOL) is cervical ripening. Currently, there is no consensus from world scientific societies on the method of first choice. One of the most popular method is prostaglandin PGE2 (dinoprostone) usage. It is used in different doses and pharmaceutical forms. Methods: In our analysis we compared the obstetrical outcome of IOL using a dinoprostone vaginal insert (DVI) with 10 mg of dinoprostone, which released 0.3 mg/h of dinoprostone for 24 hours (Cervidil®, Ferring Pharmaceutical Poland) with an intracervical Foley catheter (20 F, 50–60 mL balloon). A total of 456 patients (100-DVI, 356-Foley catheter) were included in the study. All patients were in term, singleton pregnancy with intact fetal membranes. Results: In the DVI group, oxytocin was used less frequently during IOL (OR = 0.35, 95% CI 0.23–0.57) and meconium stained amniotic fluid was recorded less often (OR = 0.38, 95% CI = 0.15–0.99). Other obstetric outcomes such as percentage of cesarean deliveries, vaginal operative deliveries, incidence of postpartum haemorrhage, failed labour induction, unreassuring CTG trace did not differ between groups. Clinical condition of newborns and cord blood pH did not differ between groups. In the group of patients pre-induced with a Foley catheter, the need for labor augmentation with oxytocin is more common (62% vs 37%, P &lt; 0.01). Conclusion: Necessity of labor augumentation with oxytocin is more frequent in patients pre-induced with the intracervical Foley catheter compered to DVI usage. There is no difference between groups in obstetrical and neonatological outcomes.

Contributing Factors to Failed Oxytocin Induction among Women Giving Birth at Referral Hospitals of Amhara Regional State, Ethiopia, in 2018: A Case-control Study

Background & aim: Failed oxytocin induction of labor increases the rate of cesarean section and associated complications. The present study aimed to identify contributing factors to failed oxytocin induction among women who gave birth at the referral hospitals of Amhara regional state, Ethiopia, in 2018. Methods: This unmatched case-control study was conducted on a total of 336 parturient women (112 cases and 224 controls) at the referral hospitals of Amhara regional state, Ethiopia, within March 19 to May 18, 2018. Systematic and consecutive sampling methods were applied for the selection of controls and cases, respectively. Both the interviewer-administered questionnaire and medical chart review were utilized as tools for data collection. The validity of the tools was determined by content validity, and Cronbach’s alpha coefficient as a measure of tool reliability was rendered at 0.82. Data analysis was carried out by SPSS software (version 23) using multivariable logistic regression analysis. Results: According to the obtained results, primiparity (AOR=6.24; 95% CI: 3.32-11.73), intermediate Bishop score (AOR=11.77; 95% CI: 5.19-26.71), emergency oxytocin induction (AOR=2.47; 95% CI: 1.31-4.68), and age of ≤ 30 years (AOR=2.16; 95% CI: 1.13-4.16) were considered the determinants of failed oxytocin induction. Conclusion: Considering the factors of primiparity, intermediate Bishop score (5-8) and the age of ≤ 30 years as determinants of failed oxytocin induction, it is recommended to use oxytocin induction after obtaining a favorable Bishop score.

Nėščiųjų nutukimo įtaka gimdymo sužadinimo rezultatams ir jų baigtims

Tyrimo tikslas. Įvertinti nutukimo įtaką gimdymo sužadinimui ir baigtims. Tyrimo metodai. Altiktas retrospektyvusis atvejo – kontrolės tyrimas, į kurį įtrauktos iš Gimdymų registro atrinktos 509 moterys, kurios 2018 m. gimdė Lietuvos sveikatos mokslų universiteto ligoninės Kauno klinikose (Kauno klinikos) ir jų gimdymai buvo sužadinti: 114 nutukusios ir 395 kontrolės grupėsmoterų, kurių kūnomasė buvo normali. Analizuotimoterų sociodemografiniai rodikliai, gimdymų sužadinimo būdai, dažniausia nėštumo patologija, gimdymo sužadinimo indikacijos, gimdymo eigos savitumai bei duomenys apie naujagimių svorį ir būklę po gimimo. Rezultatai. Nėščiųjų diabetas nutukusių moterų grupėje diagnozuotas 51,8 proc., o normalaus KMI grupėje – 17,5 proc., p&lt;0,001. Nutukusioms moterims gimdymo sužadinimas dažnesnis nei turinčioms normalią kūno masę dėl preeklampsijos (18,4 ir 6,6 proc.), p&lt;0,001, nėščiųjų diabeto (30,7 ir 16,2 proc.), p=0,001, nėščiųjų hipertenzinių būklių (14,9 ir 4,0 proc.), p&lt;0,001 bei nestabilios vaisiaus būklės (5,3 ir 1,5 proc.), p=0,031. Dėl užsitęsusio nėštumo normalios kūno masės moterims gimdymas sužadintas 29,9 proc., nutukusioms – 14,9 proc., p=0,001, dėl vaisiaus augimo sulėtėjimo – 9,9 ir 2,6 proc., p=0,013 ir priešlaikinio vaisiaus vandenų nutekėjimo – 7,1 ir 0,9 proc., p=0,012. Gimdymą sužadinant prostaglandinais, normalios kūno masės moterų gimdos kaklelio Bishop balų vidurkis 3,4 (SN 1,13), nutukusių – 4,28 (SN 1,07), p&lt;0,001. II gimdymo laikotarpis normalios kūnomasėsmoterų truko 65,5 (SN 69,87)min., nutukusių 41,0 (SN 54,18)min., p&lt;0,001.Gimdymą sužadinant prostaglandinais, normalios kūnomasėsmoterų I gimdymo laikotarpis truko 555,2min. (SN 343,57), nutukusių – 442,4min. (SN 353,57), p=0,035, II gimdymo laikotarpis – 79,3min. (SN 76,92) ir 53,5min. (SN 72,29), atitinkamai, p=0,007. Gimdymą sužadinant atliekant amniotomiją, normalios kūno masės nėščiųjų II gimdymo laikotarpis truko 58,8min. (SN 64,18), nutukusių – 32,4 (SN 41,19) min., p=0,004. Gimdymo sužadinimas oksitocinu, nutukusiųmoterų I gimdymo laikotarpis truko 548,0min. (SN 248,94), normalios kūnomasėsmoterų – 346,4min. (SN 183,29) , p=0,037. Cezario pjūvio operacija dėl nepavykusio gimdymo sužadinimo atlikta 66,7 proc. nutukusių ir 13,6 proc. normalios kūno masės moterų, p&lt;0,001, dėl nestabilios vaisiaus būklės – 16,7 ir 30,5 proc., p&lt;0,001, dėl kliniškai siauro dubens – 16,7 ir 42,4 proc., p&lt;0,001 ir dėl neprogresuojančio gimdymo – 0 ir 13,6 proc., p&lt;0,001. Nutukusių moterų naujagimių Apgar balųmediana po 1 min. 9,0 (6–10), normalų KMI turinčių moterų – 9,0 (3–10), p=0,001, po 5 min. – 10,0 (7–10) ir 10,0 (7–10), atitinkamai, p=0,03. Nutukusių moterų naujagimių svoris 3605,9 (SN 516,40), normalios kūno masės moterų – 3492,8 (SN 527,25), p=0,027. Per didelis pagal nėštumo laiką vaisius gimė 20,2 proc. nutukusių ir 11,4 proc. normalios kūno masės moterims, p=0,015. Išvados. Nutukusių moterų gimdymo sužadinimai buvo reikšmingai dažnesni dėl nėščiųjų diabeto, nėščiųjų hipertenzinių būklių ir nestabilios vaisiaus būklės,cezario pjūvio operacija dažniau atlikta dėl nepavykusio gimdymo sužadinimo. Sužadinant gimdymą oksitocinu, ilgiau truko nutukusių moterų I gimdymo laikotarpis. Didesnio svorio ir žemesniais balais pagal Apgar įvertinti naujagimiai dažniau gimė sužadinus gimdymą nutukusioms moterims.

Mifepristone for cervical ripening and induction of labour

Objective: To study the efficacy of oral mifepristone in pre induction cervical ripening and induction of labour in term pregnancy. Materials and Methods: This is a single blind randomised control trial. 200 women with term pregnancy and bishop score < 6 were recruited and randomly allocated into two groups. Women who received tablet mifepristone 400 mg were assigned to study group (n=100) and who received placebo orally were assigned to control group (n=100). At the end of 48 hours, change in the bishop was assessed and accordingly induction/ augmentation of labour was done. Analysis regarding safety and efficacy of the drug was done with regards to maternal and perinatal outcome. Results: Among 200 women, 100 received mifepristone and 100 received placebo. In mifepristone group, 75% patients entered into labour within 48 hours of induction as compared to 48% in placebo group. The mean time interval between induction to start of labour pains was 28 hours 54 min in group A and 42 hours 18 min in group B. This difference was statistically significant. (p=0.000). In the study group 70% patients delivered within 48 hours of treatment as compared to 38% patients in control group. Mean induction delivery interval was 35 hours 38 min in study group and 49 hours 52 min in control group (p=0.000). There were fewer caesareans in the mifepristone treated group (10%) than placebo group (20%) particularly for failed induction (2 versus 6) and non progress of labour (2 versus 5). There was no statistically significant different in perinatal outcome between two groups. Conclusion: Mifepristone has modest affect on cervical repining when given 48 hour prior to labour induction and appears to reduce need for further induction compared to placebo. Mifepristone is a simple and effective method of inducing labour in women with term pregnancy and unripe cervix. The use of Mifepristone provides an interesting new alternative to classic uterotonic agents when induction of labour is neces

Non-adherence to labor guidelines in cesarean sections done for failed induction and arrest of dilation.

In 2014, the American College of Obstetrics and Gynecology published guidelines for diagnosing failed induction of labor (FIOL) and arrest of dilation (AOD) to prevent cesarean delivery (CD). The objectives of this study were to determine the rate of adherence to these guidelines and to compare the association of guideline adherence with physician CD rates and obstetric/neonatal outcomes. Retrospective cohort review of singleton primary cesarean deliveries for FIOL and AOD at a single academic institution from 2014 to 2016. Univariate and multivariate analyses were used to compare adherence to the guidelines with physician CD rates and obstetric/neonatal outcomes. Of the 591 cesarean deliveries in the study, 263 were for failed induction, 328 for AOD and 79% (468/591) were not adherent to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (ACOG/SMFM) guidelines. Of the failed inductions, 82% (215/263) and of the AODs 77% (253/328) were not adherent. There was no difference between adherent and non-adherent CDs with regard to maternal characteristics, or obstetric/neonatal outcomes. Duration of oxytocin use after rupture of membranes, dilation at time of CD, and birth weight were statistically higher in adherent CDs. On multivariate linear regression, physician CD rates were inversely correlated with adherence to ACOG/SMFM guidelines (p<0.0001), gestational age (p=0.007), and parity (p=0.003). Our study shows that physician non-compliance with ACOG guidelines was high. Adherence to these guidelines was associated with lower physician CD rates, without an increase in obstetric or neonatal complications.

Rare case of Bicornuate Uterus with Fetal Death in a Multipara woman

Congenital uterine anomalies result from defect in unification of the müllerian duct during intrauterine fetal life. Pregnancy in such abnormalities associated with poor outcome including rudimentary horn rupture, miscarriage, hemorrhage and death. The diagnosis is also difficult in lower resource settings and case management requires good skills in surgery. We present a case with failed labour induction and misdiagnosis of pregnancy in rudimentary horn of bicornuate uterus. This case has tremendously delay in diagnosis and management, however the final decision of conducting surgery was implicit successful.

Incidence of cesarean delivery after induction of labor with intravenous oxytocin drip among women undergoing induction of labor at Dessie referral hospital, Northeast Ethiopia, 2017

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The number of delivering women undergoing an induction of labor is greater than 20% and continues to rise. Simultaneously, the cesarean delivery rate continues to increase as well. This increase has resulted from evidence-based recommendations on how to handle certain conditions. Labor induction has been associated with increased likelihood of cesarean birth for some groups of women.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Institutional based retrospective cross sectional study was conducted on 319 women medical chard who undergone induction of labor with oxytocin infusion at Dessie referral hospital. Systematic sampling techniques was used to select the samples. The data was cleaned, edited, coded, and entered in to EPI INFO version 3.5 and exported and analyzed by SPSS with windows version 20.0. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; A total of 319 delivery records were reviewed. Out of this 256 (80.3%) was successful induction of labor. Incidence of cesarean section after induction of labor with oxytocin infusion among women at Dessie referral hospital was 136 (42.6%). The most frequent cause of induction of labor was due to hypertensive disorder 133 (41.7%) followed by pre labor rupture of membrane 111 (34.8%). Cesarean section was done due to failed induction of labor 63 (19.7%) followed by fetal distress 40 (12.5%).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; In present study incidence of cesarean delivery after induction of labor was 42.6%. Most frequent cause of induction of labor was due to hypertensive disorder followed by pre-labor rupture of membrane. Cesarean section was done due to failed induction of labor followed by fetal distress.&lt;/p&gt;

Preventing the Primary Cesarean: Adherence to SMFM/ACOG Guidelines by Use of Intrauterine Pressure Catheter [29P

INTRODUCTION: In order to reduce the primary Cesarean delivery (CD) rate, SMFM and ACOG offer guidelines for diagnosing arrest of dilation (AOD) and failed induction of labor (FIOL). At our institution, adherence to these guidelines is low, at 28%, but there is limited understanding of contributing factors. The intrauterine pressure catheter (IUPC) is a recognized, helpful component of labor induction protocols, but few studies have examined whether its use is related to CD rates and adherence to labor guidelines. The objective of this study is to evaluate IUPC utilization and its relationship to SMFM/ACOG guideline adherence rates. METHODS: A retrospective cohort analysis was conducted at our institution of all singleton primary CDs performed for AOD or FIOL between March 1st 2014 and July 3rd 2018. Cases were defined as being adherent or non-adherent to published guidelines. A chi square test was used to compare the association of guideline adherence to IUPC use. RESULTS: Baseline characteristics were similar between adherent and non-adherent groups. For CDs that were non-adherent to ACOG guidelines, IUPCs were utilized in 208/767 cases (27.1%). For CDs that were adherent to ACOG guidelines, IUPCs were utilized in 123/295 cases (41.7%) (P less than 0.001). CONCLUSION: We observed a significantly greater rate of IUPC use in CDs that were adherent to SMFM/ACOG guidelines. Overall, adherent physicians performed fewer CDs. This finding suggests that IUPC utilization may be a helpful adjunct for improving labor management and lowering primary CD rates. Interventions around physician education are needed to increase appropriate IUPC use.

Implementation of Pre-cesarean Checklist for Labor Arrest and Failed Induction [16P

INTRODUCTION: National and Stamford Hospital cesarean delivery (CD) rates, at 32% and 40.4% respectively, remain high. A large contributor to the primary CD rate is labor arrest, including failed induction of labor (IOL). Use of new guidelines for diagnosing these conditions have been shown to decrease the CD rate. This study aims to assess adherence to new definitions and the impact of a pre-cesarean checklist at our institution. METHODS: A retrospective chart review for primary CD in nulliparous, singleton, term, vertex (NSTV) pregnancies performed for labor arrest, including failed IOL, from January 2018 to August 2019. In January 2019 a paper pre-cesarean checklist, adapted from a previously published checklist was introduced to labor and delivery to allow physicians to review labor arrest criteria. Calculated primary CD rates for labor arrest pre and post implementation were compared using chi square analysis. RESULTS: The primary cesarean delivery (pCD) rate in NSTV pregnancies for labor arrest was 14.1% in 2018 and 12.5% in 2019 (P=.5). Of the 55 pCD for labor arrest in 2019, 17 (30.9%) filled out the pre-cesarean checklist. Only 18 (32.79%) met criteria for labor arrest/failed IOL. CONCLUSION: At our institution, CD in NSTV pregnancies for labor arrest or failed IOL do not meet contemporary definitions. Introduction of a paper pre-cesarean checklist to evaluate labor arrest has not affected the CD rate. However, use of the checklist was limited, thus there remains significant room for a decrease in the cesarean rate if adherence can be improved.

Preventing the Primary Cesarean Delivery—Adherence to Labor Arrest Guidelines [28P

INTRODUCTION: The ACOG/SMFM Safe Prevention of Primary Cesarean Delivery guidelines suggest minimum criteria at which cesarean should be performed for labor arrest with the goal of reducing primary cesarean delivery rates. This study evaluates current adherence to these criteria at an academic medical center with two different campuses in order to quantify variation in the modifiable proportion of the cesarean rate and to target quality improvement initiatives. METHODS: We analyzed cesareans deliveries performed for arrest of dilation, arrest of descent and failed induction among singleton, term, cephalic live births at a large academic center with two campuses from September 2018 to August 2019. Using the ACOG/SMFM guidelines, the labor course for each cesarean was examined to determine if minimum criteria were met. RESULTS: During the study period, there were 1716 cesarean deliveries with 286 performed for labor arrest disorders: 94 for arrest of dilation, 120 for arrest of descent, and 72 for failed induction of labor. At campus A, 27% met criteria for arrest of dilation, 46% for arrest of descent, and 45% for failed induction; at campus B, 95% met criteria for arrest of dilation, 61% for arrest of descent, and 60% for failed induction. Over the study period, the primary cesarean rates at campus A and B were 19.4% and 13.4%, respectively. CONCLUSION: The adherence to criteria for arrest disorders was suboptimal and varied significantly across campuses. Quality improvement initiatives targeted to improve adherence to criteria for labor arrest disorders have the potential to impact primary cesarean delivery rates.

Association Between Time of Day and the Decision for an Intrapartum Cesarean Delivery.

To examine whether the decision and indications for performing intrapartum cesarean delivery vary by time of day. We conducted a secondary analysis of a multicenter observational cohort of 115,502 deliveries (2008-2011), including nulliparous women with term, singleton, nonanomalous live gestations in vertex presentation who were attempting labor. Those who attempted home birth, or underwent cesarean delivery scheduled or decided less than 30 minutes after admission were excluded. Time of day was defined as cesarean delivery decision time among those who delivered by cesarean and delivery time among those who delivered vaginally, categorized by each hour of a 24-hour day. Primary outcomes were decision to perform cesarean delivery and the indications for cesarean delivery (labor dystocia, nonreassuring fetal status, or other indications). Secondary outcomes included whether a dystocia indication adhered to standards promoted to reduce cesarean delivery rates. Bivariate analyses were performed using χ and Kruskal-Wallis tests for categorical and continuous outcomes, respectively, and generalized additive models with smoothing splines explored nonlinear associations without adjustment for other factors. Seven thousand nine hundred fifty-six (22.1%) of 36,014 eligible women underwent cesarean delivery. Decision for cesarean delivery (P<.001) decreased from midnight (21.2%) to morning, reaching a nadir at 10:00 (17.9%) and subsequently rising to peak at 21:00 (26.2%). The frequency of cesarean delivery for dystocia also was significantly associated with time of day (P<.001) in a pattern mirroring overall cesarean delivery. Among cesarean deliveries for dystocia (n=5,274), decision for cesarean delivery at less than 5 cm dilation (P<.001), median duration from 5 cm dilation to cesarean delivery decision (P=.003), and median duration from complete dilation to cesarean delivery decision (P=.014) all significantly differed with time of day. The frequency of nonreassuring fetal status and "other" indications were not significantly associated with time of day (P>.05). Among nulliparous women who were attempting labor at term, the decision to perform cesarean delivery, particularly for dystocia, varied with time of day. Some of these differences correlate with labor management differences, given the changing frequency of latent phase cesarean delivery and median time in active phase.

Risk factors for failed induction of labor among pregnant women with Class III obesity.

Our aim was to identify risk factors for failed induction in morbidly obese patients undergoing the induction of labor at term. This was a retrospective multicenter study on a cohort of 235 patients with a body mass index greater than 40kg/m2 and giving birth to a singleton in cephalic presentation, who had an induction of labor from 38weeks of amenorrhea. Scheduled cesareans and spontaneous vaginal deliveries were excluded. Maternal, peri-partum and neonatal characteristics were analyzed according to the delivery route. In all, 235 patients were included. Of these, 62.5% patients delivered vaginally and 37.5% by cesarean section. The frequency of nulliparity was greater in patients who had a cesarean section (56 [interquartile range, IQR, 38.1] vs 56 [IQR 63.6], P<.001). In multivariate analysis, nulliparity (odds ratio [OR] 2.81, 95% confidence interval [CI] 1.58-4.97], P<.001), low Bishop's score (OR .794, 95% CI .70-.90, P<.001) and weight gain (OR 1.04, 95% CI 1.01-1.08, P=.033) were independent risk factors for failed induction. Umbilical cord pH at birth lower than 7 (0 vs 7 [IQR 8.0], P<.001) and lower than 7.20 (36 [IQR 24.5] vs 35 [IQR 39.8], P=.014) as well as the Apgar at 1minute (14 [IQR 9.5] vs 17 [IQR 19.3], P=.032) was significantly higher in infants born by cesarean section. In this cohort, 63% of women with Class III obesity had successful inductions of labor; risk factors for failed induction include nulliparity and unfavorable Bishop score.

366: Incidence of and characteristics associated with failed induction of labor

366: Incidence of and characteristics associated with failed induction of labor

283: Labor induction at term and cesarean delivery rates – Earlier rather than later?

Mechanisms involved in parturition evolve throughout pregnancy, and therefore might be insufficiently mature for medically indicated induction of labor (IOL) during the different stages of pregnancy. We investigated labor induction failure rates (i.e. leading to cesarean delivery-CD) during the different stages of pregnancy. A population-based retrospective cohort analysis was performed, including all labor induction cases occurring at 32 to 44 gestational weeks, between 1991-2017, at a regional tertiary medical center. Congenital malformations, antepartum fetal demise, and multiple pregnancies were excluded. Rates of CD following IOL were assessed at different gestational weeks (GW). Term deliveries (≥37 weeks) following IOL were subdivided into separate GW. All post-term deliveries (≥42 weeks) following IOL were grouped together. A multivariable analysis was performed, assessing the independent association between IOL gestational age (within term) and failure rates, while adjusting for confounders. T The study population included 26,722 pregnancies involving IOL, 25,392 (95%) of which occurred at term. The trendline of CD rates according to gestational week demonstrated an "inverted J” shape, with a gradual decrease in CD rates as GA increased from 32 to 41 weeks (Figure, p< 0.001). A subsequent increase in CD rates was observed from 41 weeks and on. Among term pregnancies involving IOL, 73% were induced mechanically and the rest using prostaglandins, with a total CD rate of 16.8%. In the multivariate analysis, post-term IOL was independently associated with a higher CD rate (18.8%) as compared to IOL performed at 39 weeks’ gestation (17.4%, aHR 1.15, p=0.05, 95%CI 1.00-1.32, Table) while controlling for maternal age, IOL indication, previous CD, IOL method (mechanical vs. pharmacological) and birthweight. In this large cohort of IOL cases, CD rates are relatively low, and decrease as GA increases. Post-term deliveries involving IOL are independently associated with a higher CD risk as compared to deliveries following IOL at 39 weeks' gestation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Maternal morbidity of induction of labor compared to planned cesarean delivery in twin gestations

Objective To compare maternal morbidity associated with induction of labor (IOL) with planned cesarean delivery (CD) in twin gestations. Methods This was a retrospective cohort study of vertex-presenting twin pregnancies ≥24-week gestation delivering at our institution from 2016 to 2017. We compared patients undergoing IOL with patients undergoing planned CD. Demographic and pregnancy outcome data were abstracted from the medical record. Our primary outcome was composite maternal morbidity including severe postpartum hemorrhage (PPH) (EBL >1500 cc), hysterectomy, transfusion, ICU admission, use of ≥2 uterotonic medications or maternal death. These morbidities were also assessed independently. Secondary analyses of maternal morbidity among unplanned CD versus planned CD and successful IOL versus planned CD was also performed. Chi-square, Mann–Whitney U and multivariate logistic regression were used in statistical analysis. Results Of 211 twin gestations included, 70.6% were nulliparous, the median age was 35.5 years [32–38], and the median gestational age at delivery was 37 weeks [35–38]. One hundred and five underwent IOL and 106 had a planned CD. Composite morbidity was higher in the IOL group versus planned CD group (30.5 versus 11.3%, p = .001). In the IOL group, 64 (61.0%) achieved a vaginal delivery. Patients in the planned CD group were more likely to be >35 years of age (62.3 versus 48.6%, p = .045), nulliparous (80.2 versus 61.0%, p = .002) and deliver preterm (53.8 versus 38.1%, p = .022). Patients with a planned CD had a significantly lower risk of composite morbidity compared to those who had CD after failed IOL (11.3 versus 48.8%, p ≤ .001) and there was no significant difference in composite morbidity in the successful IOL compared to the planned CD group (18.8 versus 11.3%, p = .18). There were four peri-partum hysterectomies, all within the IOL group. Conclusion Labor induction in twins was associated with increased maternal morbidity compared to planned CD. The increase in adverse maternal outcomes was due to those who underwent an IOL and ultimately required CD.

A comparison between labor induction with only Dilapan-S and a combination of mifepristone and Dilapan-S in nulliparous women: a prospective pilot study

Objective The aim of our study was to determine whether the combination of mifepristone and the osmotic dilator Dilapan-S improves the labor induction outcomes as compared to Dilapan-S alone. Methods This prospective comparative study included 127 eligible women, of whom 58 underwent cervical ripening with Dilapan-S (12-h exposure, the control group) and 69 with Dilapan-S, with a concurrent pretreatment of 200 mg oral mifepristone (the study group), 8 h before Dilapan-S insertion. Results The vaginal delivery rate in the control group and the study group was 60.3 and 76.8% (p = .045), respectively; the induction to delivery interval was 22.74 ± 3.01 h and 19,890 ± 2.42 h (p < .001), respectively; and the number of births within 24 h was 43.1 and 73.9% (p < .001), respectively. There was no difference in the rate of failed labor induction (6.9 versus 8.7%, p = .939). The Bishop’s score improved significantly after the combined treatment as compared to with Dilapan alone (3.10 ± 0.58 versus 4.03 ± 1.35, p < .001). Moreover, in the study group, labor started earlier and proceeded faster with a lower additional oxytocin usage for labor induction or augmentation. There were no differences in the operative delivery rate and the perinatal outcomes. There were no adverse side effects of both mifepristone and Dilapan-S. Conclusion Our study is the first one to show that in comparison to labor induction using only osmotic dilators Dilapan-S, the combination of mifepristone and Dilapan-S is more efficient in terms of improving cervical ripening and vaginal delivery rate and reducing labor duration and frequency of oxytocin augmentation. The results revealed that this combined method is safe and has no immediate adverse effects on newborns. More studies are needed to evaluate what clinical cases are the most appropriate for the application of this combined method, considering the parity, degree of cervical ripening, and indication for labor induction.

Predictive Model for Failed Induction of Labor Among Obese Women

To evaluate antenatal risk factors associated with failed induction of labor among obese women to develop a predictive model for induction of labor outcome. We conducted a population-based cohort study of all obese (body mass index higher than 30.0) women with singleton live births who underwent attempted induction of labor between 37 and 44 weeks of gestation in the United States from 2012 to 2016 using de-identified U.S live birth records. The primary objective was to build a predictive model for the probability of induction of labor failure using antenatal factors. Multivariable logistic regression estimated the association of these factors on risk of failed induction of labor. We performed k-fold cross-validation for internal validation and then externally validated the model using a separate live birth cohort from 2017 (n=197,982). An online calculator was developed after validation, and calibration was performed. The 10 variables selected for inclusion in the model in order of significance were prior vaginal delivery, prior cesarean delivery, maternal height, age, weight at delivery, parity, gestational weight gain, Medicaid insurance, pregestational diabetes, and chronic hypertension. Among 19,844,580 live births in the United States between 2012 and 2016, 1,098,981 obese women with singleton pregnancies underwent induction of labor, of which 273,184 (24.9%) were unsuccessful. The receiver operator characteristic curve for the 10 variable model achieved an area under the curve (AUC) of 0.79 (95% CI 0.78-0.79). External validation demonstrated a consistent measure of discrimination, with an AUC curve of 0.77 (95% CI 0.76-0.77). This model provides valuable estimation as to the cumulative effect of multiple factors on the risk of failed induction of labor among obese parturients. The predictive model identifies women at increased or decreased risk (ie, greater than 75% vs less than 20%) for cesarean delivery. This risk calculator may be a useful tool for practitioners in the counseling, triaging, risk stratifying, and delivery planning for obese women before attempted induction of labor.

Ultrasound Evaluation of the Cervix to Predict Failed Labor Induction.

Labor induction does not always result in vaginal delivery, and can expose both the mother and the fetus to the risks inherent to the induction procedure or a possible cesarean section. Transvaginal sonography (TVS) of the cervix is a useful tool to predict prematurity; in the present study, this tool was used to evaluate postterm induction. We evaluated the ultrasound characteristics of the cervix (cervical length, cervical funneling, internal os dilation, the presence or absence of the cervical gland area [CGA], and the morphological changes of the cervix as a result of applying fundal pressure) before the onset of labor induction among women with postterm pregnancy to identify the possible predictors of failed labor induction. The Bishop score (BS) was used for comparison purposes. Three groups were evaluated: successful versus unsuccessful induction; vaginal delivery versus cesarean delivery (excluding cases of acute fetal distress [AFD]); and vaginal delivery versus cesarean delivery (including cases of AFD). A fourth group including only the primiparous women from the three previous groups was also evaluated. Based on the studied characteristics and combinations of variables, a cervical length ≥ 3.0 cm and a BS ≤ 2 were the best predictors of induction failure. Although TVS is useful for screening for induction failure, this tool should not be used as an indication for cesarean section.

In Vivo Measurement of Cervical Elasticity on Pregnant Women by Torsional Wave Technique: A Preliminary Study.

A torsional wave (TW) sensor prototype was employed to quantify stiffness of the cervix in pregnant women. A cross-sectional study in a total of 18 women between 16 weeks and 35 weeks + 5 days of gestation was performed. The potential of TW technique to assess cervical ripening was evaluated by the measurement of stiffness related to gestational age and cervical length. Statistically significant correlations were found between cervical stiffness and gestational age (, , using 1 kHz waves and , , using 1.5 kHz waves). A uniform decrease in stiffness of the cervical tissue was confirmed to happen during the complete gestation. There was no significant correlation between stiffness and cervical length. A stronger association between gestational age and cervical stiffness was found compared to gestational age and cervical length correlation. As a conclusion, TW technique is a feasible approach to objectively quantify the decrease of cervical stiffness related to gestational age. Further research is required to evaluate the application of TW technique in obstetric evaluations, such as prediction of preterm delivery and labor induction failure.