Immediate Induction Of Labor Research Articles

Diagnosis and Management of Preterm Prelabor Rupture of Membranes: A Comprehensive Review of Major Guidelines.

Preterm prelabor rupture of membranes (PPROM) represents a significant contributor of maternal and neonatal morbidity complicating a significant proportion of pregnancies worldwide. The aim of this review was to summarize and compare the most recently published guidelines on the diagnosis and management of this critical pregnancy complication. A comparative review of 3 recently updated national guidelines from the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynaecologists, and the Society of Obstetricians and Gynaecologists of Canada on PPROM was conducted. There is an overall agreement that the diagnosis of PPROM should be mainly based on sterile speculum examination and patient's history, followed by additional tests in equivocal cases, although the accuracy and contribution of both ultrasound and amniotic proteins tests in the diagnosis remain debatable. Following PPROM confirmation, all guidelines recommend the performance of vaginal and rectal swabs, the evaluation of fetal and maternal status, the administration of antibiotics and corticosteroids, and the immediate induction of labor, if severe complications are identified. Expectant management from viability until late preterm period is universally recommended; nevertheless, there are discrepancies on the optimal timing of delivery. Magnesium sulfate should be administered in case of imminent preterm delivery; however, there is no consensus on the upper gestational age limit. Recommendations on inpatient and outpatient management of PPROM are also inconsistent. Moreover, there is no common guidance on the use of tocolysis or antibiotic regimens. Finally, all medical societies agree that closer surveillance of future pregnancies is required. PPROM remains the most common identifiable risk factor of preterm delivery, despite constant improvement in prenatal provision of care. Thus, the establishment of consistent international practice protocols for the timely and accurate diagnosis and the optimal management of this complication seems of vital importance and will hopefully lead to significant reduction of the associated adverse outcomes.

Study protocol for a randomized trial on timely delivery versus expectant management in late preterm small for gestational age pregnancies with an abnormal umbilicocerebral ratio (UCR): the DRIGITAT study

BackgroundThe clinical inability to correctly identify late fetal growth restriction (FGR) within a group of fetuses who are identified as small for gestational age (SGA) is an everyday problem for all obstetrician-gynecologists. This leads to substantial overtreatment of healthy small fetuses but also inadequate detection of the growth-restricted fetuses that may benefit from timely delivery. Redistribution of the fetal circulation, signaled by an abnormal ratio of the Doppler velocity flow profiles of the umbilical artery and the middle cerebral artery, more specifically an increased umbilicocerebral ratio (UCR) (or its inverse: a decreased cerebroplacental ratio (CPR)), is an adaptation to chronic hypoxemia and nutritional scarcity with long-term consequences in survivors. The relevance of an abnormal UCR has been signaled extensively, and there is a general consensus that it is a signal of FGR, independent of size, with a strong association with poor outcomes. Yet, in the current literature, no comparisons of a monitoring-delivery strategy based on unfavorable UCR have been published. The objective of the Doppler Ratio In fetal Growth restriction Intervention Trial At (near) Term (DRIGITAT) is to evaluate if the timing of the delivery based on an abnormal UCR in late preterm fetuses identified as SGA improves neurodevelopmental outcomes at 2 years of age.MethodsThe DRIGITAT study is a national multicenter cohort study of women with singleton pregnancies between 32 and 37 weeks of gestation identified as SGA, with a nested randomized controlled trial (RCT) in case of an abnormal UCR (> 0.8). Recruiting centers are in The Netherlands. In the nested RCT, women are randomized to either immediate induction of labor or expectant management from 34 weeks in case of severely abnormal size (EFW or FAC < p3) and from 36 weeks in case of mildly abnormal size (EFW or FAC p3–p10). The primary outcome measure is the 7-point average difference in the composite cognitive score (CCS) and composite motor score (CMS) on the Bayley-3 at 2 years. Secondary outcome measures include a composite outcome of neonatal morbidity, perinatal mortality, mode of delivery, maternal quality of life, costs, and predictive value of serum biomarkers. Analyses will be by intention to treat. The required sample size is determined for the nested RCT as 185 patients.DiscussionThis study will provide insight into the diagnostic efficacy of UCR measurement in the evaluation of SGA fetuses in order to differentiate the healthy SGA fetus from the growth-restricted fetus and to determine if a fetus with abnormal UCR benefits from early delivery.Trial registrationHealthcare Evaluation Netherlands NTR6663. Registered on 14 August 2017.

Prelabor rupture of membranes at term: A possible hematological triage in addition to vagino-rectal beta-hemolytic streptococcus screening for early labor induction.

IntroductionA potential complication of term prelabor rupture of membranes (term PROM) is chorioamnionitis with an increased burden on neonatal outcomes of chronic lung disease and cerebral palsy. The purpose of the study was to analyze the efficacy of a standing clinical protocol designed to identify women with term PROM at low risk for chorioamnionitis, who may benefit from expectant management, and those at a higher risk for chorioamnionitis, who may benefit from early induction.Material and methodsThis retrospective study enrolled all consecutive singleton pregnant women with term PROM. Subjects included women with at least one of the following factors: white blood cell count ≥ 15×100/μL, C-reactive protein ≥ 1.5 mg/dL, or positive vaginal swab for beta-hemolytic streptococcus. These women comprised the high risk (HR) group and underwent immediate induction of labor by the administration of intravaginal dinoprostone. Women with none of the above factors and those with a low risk for chorioamnionitis waited for up to 24 hours for spontaneous onset of labor and comprised the low-risk (LR) group.ResultsOf the 884 consecutive patients recruited, 65 fulfilled the criteria for HR chorioamnionitis and underwent immediate induction, while 819 were admitted for expectant management. Chorioamnionitis and Cesarean section rates were not significantly different between the HR and LR groups. However, the prevalence of maternal fever (7.7% vs. 2.9%; p = 0.04) and meconium-stained amniotic fluid was significantly higher in the HR group than in LR group (6.1% vs. 2.2%; p = 0.04). This study found an overall incidence of 4.2% for chorioamnionitis, 10.9% for Cesarean section, 0.5% for umbilical artery blood pH < 7.10, and 1.9% for admission to the neonatal intensive care unit. Furthermore, no confirmed cases of neonatal sepsis were encountered.ConclusionsA clinical protocol designed to manage, by immediate induction, only those women with term PROM who presented with High Risk factors for infection/inflammation achieved similar maternal and perinatal outcomes between such women and women without any risks who received expectant management. This reduced the need for universal induction of term PROM patients, thereby reducing the incidence of maternal and fetal complications without increasing the rate of Cesarean sections.

Outcomes of Expectant Management of Term Prelabor Rupture of Membranes

ObjectiveTo assess rates of induction/augmentation of labor, maternal infection, neonatal outcomes, and time to birth when women were expectantly managed after term prelabor rupture of membranes (PROM) at home or in the hospital. DesignRetrospective, descriptive study based on a review of data from a hospital midwifery service database and chart review. SettingA large Midwest hospital with 4,700 births annually. ParticipantsWe used the cases of women who received midwifery care, experienced term PROM, and had singleton fetuses in the vertex position. MethodsWe conducted an analysis of maternal and neonatal outcomes with term PROM using data from a midwifery service quality improvement database. We compared characteristics and outcomes between management plans (immediate induction, expectant hospital, and expectant home) using chi-square, analysis of variance, and independent t-tests. ResultsPROM occurred in 281 (12%) of the 2,357 women cared for by the midwifery service between January 2016 and December 2018. One hundred fifty women (53.3%) opted to wait for labor onset at home, 102 (36.3%) were expectantly managed in the hospital, 21 (7.5%) were admitted for immediate induction of labor, and 8 (2.8%) were admitted for immediate cesarean birth. The rate of spontaneous labor onset was not significantly different between the two expectant management groups or between nulliparous and multiparous women. A total of 88 (34.9%) women who were expectantly managed ultimately had their labors induced. Rates of chorioamnionitis and endometritis were not significantly different between the expectant management groups in this study or compared with national averages. There was no difference in NICU admissions or Apgar scores below 7. The mean time from PROM to birth was significantly shorter in the expectant management in hospital group (27.3 hours) than in the expectant management at home group (33.5 hours). ConclusionExpectant management at home or in the hospital is appropriate for low-risk pregnant women with term PROM. Women for whom this option is appropriate include those with term singleton fetuses in vertex presentation with reassuring fetal heart rates and confirmed clear amniotic fluid. Acceptable time frames for home management include up to 24 hours for women with negative group B streptococcus cultures and up to 12 hours for those with positive cultures.

Cervical maturation using mifepristone in women with normal pregnancies at or beyond term

ObjectiveThe aim of our study was to evaluate the efficacy and safety of oral mifepristone use for cervical ripening and the initiation of labor in women with normal pregnancies at or beyond term. Study designWe conducted a monocentric, prospective, comparative study on the induction of labor in women with an unfavorable cervix after 37 or more weeks of gestation in the Franck Joly Hospital, French Guiana.The immediate induction of labor by mifepristone was compared to expectant management and the induction of labor with routine cervical ripening agents during two consecutive periods. During the first period, patients received mifepristone (600 mg orally at the moment of enrollment) and were evaluated after 48 h. In the second period, patients did not receive any drugs and were evaluated after 48 h of expectant management. Primary outcomesSpontaneous labor or a Bishop Score ≥6 within 48 h of mifepristone administration. Secondary outcomesenrollment-induction to delivery interval, rate of failed induction, doses of prostaglandin used, mode of delivery, requirement of oxytocin augmentation, and neonatal outcomes. ResultsThis study enrolled 231 women, 108 in the first and 123 in the second period undergoing induced labor at term caused by various obstetric conditions. There were no significant differences between groups for age, body mass index, gravida, parity, the initial Bishop Score, scarred uterus, or post-term pregnancy.There were statistically significant differences between the two groups concerning spontaneous labor and/ or a Bishop Score ≥6 within 48 h (p < 10-3) and received doses of misoprostol (p = 0.01). Patients receiving mifepristone were 10 times more likely to be in labor after 48 h of inclusion (RR = 9.98, CI 95 % = [4.47–22.29]).The enrollment-induction to delivery interval was significantly shorter for the mifepristone group (p < 0.001). There were no other differences in mode of delivery, placenta abnormalities or neonatal outcomes. ConclusionMifepristone efficiently induced cervical ripening and labor initiation in women with normal pregnancies at or beyond term. It may offer an alternative method to the classic induction especially for patients seeking spontaneous labor.

Induction of labor compared to expectant management in term nulliparas with a latent phase of labor of more than 8\u2009hours: a randomized trial

BackgroundProlonged latent phase of labor is associated with adverse maternal and neonatal outcomes. Preliminary data indicate that labor induction for prolonged latent phase may reduce cesarean delivery. We performed a study powered to Cesarean delivery to evaluate labor induction compared to expectant management in full term nulliparas hospitalized for persistent contractions but non-progressive to established labor after an overnight stay.MethodsFrom 2015 and 2017, nulliparas, ≥ 39 weeks’ gestation with prolonged latent phase of labor (persistent contractions after overnight hospitalization > 8 h), cervical dilation ≤3 cm, intact membranes and reassuring cardiotocogram were recruited. Participants were randomized to immediate induction of labor (with vaginal dinoprostone or amniotomy or oxytocin as appropriate) or expectant management (await labor for at least 24 h unless indicated intervention as directed by care provider). Primary outcome measure was Cesarean delivery.ResultsThree hundred eighteen women were randomized (159 to each arm). Data from 308 participants were analyzed. Cesarean delivery rate was 24.2% (36/149) vs. 23.3%, (37/159) RR 1.0 95% CI 0.7–1.6; P = 0.96 in induction of labor vs. expectant arms. Interval from intervention to delivery was 17.1 ± 9.9 vs. 40.1 ± 19.8 h; P < 0.001, intervention to active labor 9.6 ± 10.2 vs. 29.6 ± 18.5 h; P < 0.001, active labor to delivery 7.6 ± 3.6 vs. 10.5 ± 7.2 h; P < 0.001, intervention to hospital discharge 2.4 ± 1.2 vs. 2.9 ± 1.4 days; P < 0.001 and dinoprostone use was 19.5% (29/149) vs. 8.2% (13/159) RR 2.4 95% CI 1.3–4.4; P = 0.01 in IOL compared with expectant arms respectively. Intrapartum oxytocin use, epidural analgesia and uterine hyperstimulation syndrome, postpartum hemorrhage, patient satisfaction on allocated intervention, during labor and delivery and baby outcome were not significantly different across trial arms.ConclusionsInduction of labor did not reduce Cesarean delivery rates but intervention to delivery and to hospital discharge durations are shorter. Patient satisfaction scores were similar. Induction of labor for prolonged latent phase of labor can be performed without apparent detriment to expedite delivery.Trial registrationRegistered in Malaysia National Medical Research Register (NMRR-15-16-23,886) on 6 January 2015 and the International Standard Randomised Controlled Trials Number registry, registration number ISRCTN14099170 on 5 Nov 2015.

To Determine the Effects of Labor Induction on Maternal and Fetal Outcome in Postterm Pregnancies (41 Weeks Plus)

Background: Pregnancies progressing postterm are associated with a higher perinatal morbidity and mortality rates than those delivered at term. In a United Kingdom study, the rate of stillbirth increased from 0.35 in 1000 live births in pregnancies of 37 weeks to 2.12 in 1000 live births in pregnancies of 43 weeks gestation. Morbidities associated with postterm births include an increased risk of fetal distress, intrauterine growth restriction, dysfunctional labor, shoulder dystocia, obstetric trauma (relative risk 1.09 - 1.68) and an increase in perinatal complications, such as aspiration of meconium and asphyxia, peripheral nerve injury, greenstick bone fractures, pneumonia and septicemia (adjusted odds ratio 1.4 - 2.0). Antenatal surveillance and induction of labor may decrease the risks of an adverse outcome. In a recent review of term and postterm pregnancies in Norway, we found that there were adverse outcomes associated with both postterm pregnancy and induction of labor independently. On comparison of the two, a randomized controlled trial showed no difference in their neonatal outcome, but demonstrated a reduction in the cesarean delivery rate when labor was induced at 41 weeks. Aim of the Work: The aim of this study was to determine the effect of labor induction on maternal and fetal outcome in postterm pregnancies. Subjects and Methods: This study was carried out on 150 pregnant women who had completed 41 weeks of gestation between Jun. 1, 2012 up to Dec. 31, 2012 at Department of Obstetrics & Gynecology, Faculty of Medicine, Benghazi University, and were scheduled for induction of labor after cardiotocography (CTG) and ultrasonography (USS) have been done and Bishop’s score assessed, to determine the effects of labor induction on maternal and fetal outcome in postterm pregnancies (41 weeks plus). Results: Regarding the relationship between a history of (H/O) postdatism and fetal distress, it was found that there was no significant relationship between them. There was a significant relationship between a history of macrosomia and fetal distress. There was a significant relationship between instrumental delivery and fetal distress. The majority of the fetal distress had an indication for Caesarean section (CS) (fetal distress (FD) and fetal distress meconium (FDM) more than those without fetal distress. All fetuses that had APGAR scores of 8 were distressed. There was a significant relationship between the APGAR score at 10 minutes with fetal distress. All fetuses that had meconium aspiration had fetal distress. There was a significant increase in the amount of oxytocin in unit in distressed cases than the non-distressed ones. The total duration of induction was also significantly increased in stressed fetuses than the non-stressed ones. There was a significant increase in the weight of distressed fetuses than the non-distressed. Conclusions: In conclusion, there was no difference in the neonatal outcome or mode of delivery for postterm pregnancies managed either by immediate induction of labor or expectantly with serial antenatal surveillance. The outcomes were generally good, and neonatal morbidity, cesarean section, and operative vaginal delivery rates were low. If pregnancy is uncomplicated and continued surveillance is possible, women’s own wishes may guide the decision to induce or monitor a pregnancy beyond 41 weeks.

Major changes in diagnosis and management of preeclampsia.

Preeclampsia and eclampsia continue to be major contributors to maternal mortality and morbidity. Lack of appreciation for the multi-organ involvement of preeclampsia, combined with overly rigid criteria for diagnosis, may hinder early diagnosis and appropriate management. Recently, the American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy evaluated the evidence and formulated new recommendations for diagnosis and management. This article reviews some of these recommended changes, including the new classification of the hypertensive diseases of pregnancy. Systolic blood pressure has been shown to be as important as diastolic blood pressure in the diagnosis of preeclampsia. Changes in proteinuria are not predictive of disease severity or maternal or fetal complications; therefore, the magnitude of proteinuria or changes in the amount should not dictate diagnosis or management. Instead, symptoms of cerebral involvement, such as headache and visual changes or signs of end-organ involvement including abnormal laboratory tests (elevated serum creatinine or liver function tests, low platelet count), are evidence of preeclampsia with severe features. Immediate induction of labor is recommended for women with gestational hypertension or preeclampsia at 37 weeks' gestation or later. Pregnant and postpartum women need to know important warning signs and symptoms of preeclampsia. Prompt diagnosis of preeclampsia and appropriate management will improve the quality of care for women.

Orally administered misoprostol for induction of labor with prelabor rupture of membranes at term.

Prelabor rupture of membranes (PROM) occurs in approximately 8% to 10% of women with term pregnancies. The management of PROM continues to be controversial. Approaches include expectant management and immediate induction of labor. The use of orally administered misoprostol for the management of women with PROM may provide significant advantages when they choose immediate induction of labor. This literature review presents current evidence that supports the use of oral misoprostol for women with PROM, including the benefits of a decreased interval time from PROM to vaginal birth, good safety profile, and reductions in the use of oxytocin augmentation and epidural anesthesia. In addition to clinically proven benefits to women of oral misoprostol for PROM, it also has the potential to reduce chorioamnionitis by reducing the number of sterile vaginal examinations performed thereby reducing the risk of ascending bacteria. Women have also reported acceptability and satisfaction when using oral misoprostol for immediate induction of labor. This review of literature discusses what is known about the use of orally administered misoprostol for the management of term PROM and makes recommendations for clinical use.

Women's experiences and attitudes towards expectant management and induction of labor for post‐term pregnancy

Clinical guidelines for post-term management differ, and studies on women's attitudes are lacking. We aimed to assess the experiences and attitudes among women managed with serial antenatal monitoring or induction of labor, and the effects of post-term pregnancy on self-reports of quality of life. Women were randomized at 41 weeks to immediate induction of labor or antenatal fetal surveillance every third day. At inclusion women answered a questionnaire about their attitudes towards post-term pregnancy and health-related quality of life. This was repeated in a follow-up phone interview 6 months later, including questions about their experiences of labor and perspective on future deliveries. A total of 508 women entered the study. At 41 weeks 74% of all women preferred to be induced. Women reported good general and mental health, but physical health and vitality scores were low. In the induction group, 74% of women said they would prefer the same management in future pregnancies; only 38% of women who had serial antenatal monitoring would prefer this option again (p<0.001). In the induction group, contractions were reported as more intense (n=157 versus n=118, p<0.01) and frequent (n=116 versus n=87, p<0.01) compared to the monitored group. The majority (84%) reported a positive labor induction experience. Women preferred induction of labor to serial antenatal monitoring beyond 41 weeks. Labors were shorter and contractions were reported to be more frequent and intense in the induction group compared with the monitored group. However, their experience with labor induction was positive.

Prospective randomized clinical trial of immediate induction of labor with oral misoprostol for prelabor rupture of the membranes in women with unfavorable cervix at term

Prospective randomized clinical trial of immediate induction of labor with oral misoprostol for prelabor rupture of the membranes in women with unfavorable cervix at term

Prelabor rupture of the membranes at term: when to induce labor?

Objectives: To determine the significant predictors of clinical chorioamionitis and neonatal infection in patients with prelabor rupture of the membranes at term, and to apply this information to determination of optimal timing of labor induction. Study design: A retrospective case control series of women at ≥37 weeks’ with prelabor rupture of the membranes. The study group consisted of women with evidence of maternal or neonatal infection. Controls had no evidence of infection. Three types of management were compared. (1) Immediate induction of labor, (2) expectant management up to 24 h followed by induction of labor if still necessary, or (3) expectant management for over 24 h. Univariate and multivariate analyses were performed by stepwise logistic regression (SPSS software package). The size of the study and the control groups was calculated for a 90% power with two sided P value of 0.05 in order to demonstrate an odds ratio of 2 for expectant management (two groups: early and late) versus immediate induction of labor (132 and 279 women in the study and the control groups, respectively). Results: The rate of expectant management for over 24 h versus expectant management until 24 h followed by induction of labor when still necessary, was higher among cases than among controls (OR=1.84; P<0.017; 95% CI, 1.127–3.003). Conversely, the rate of immediate induction of labor versus expectant management until 24 h followed by induction of labor when still necessary, was also higher among cases (OR=2.66; P<0.001; 95% CI, 0.222–0.644). Conclusion: In women with prelabor rupture of the membranes at term, the best approach is to induce labor if spontaneous labor has not begun after 24 h.

Postterm with favorable cervix: is induction necessary?

Objective: To study the cesarean rate between expectant management and immediate induction in the otherwise uncomplicated postterm pregnancy with favorable cervix. Study design: A total of 249 women with uncomplicated pregnancies at 41 weeks plus 3 days (290 days) with favorable cervix (Bishop score ≥6) were randomized to either expectant management ( n=125) or immediate induction of labor ( n=124). The women in the induction group were sent to labor ward for induction by artificial rupture of membranes (ARM) and/or oxytocin infusion. The women with expectant management had nonstress test (NST) and amniotic fluid index (AFI) performed once a week and twice a week after 43 weeks of gestation until spontaneous labor. Results: The cesarean rate was not different between expectant management and immediate induction (21.6% versus 26.6%; P=0.36). Ninety-five percent of the expectant group delivered within 1 week after enrollment, and all of them delivered within 9 days after randomization. Maternal and fetal complications in both groups were not different. There was also no difference in the mean birth weight ( P=0.24) and the frequency of macrosomia (birth weight ≥4000 g) between the two groups ( P=0.23). Conclusion: Cesarean section rate between expectant management and immediate induction in the otherwise uncomplicated postterm pregnancy with favorable cervix was not different. Due to the very low adverse perinatal outcome, both expectant management and immediate induction are acceptable.

Clinical amnionitis and endometritis in patients with premature rupture of membranes: Endocervical prostaglandin E 2 gel versus oxytocin for induction of labor

To compare the rates of clinical amnionitis and endometritis in patients with premature rupture of membranes (PROM), using endocervical prostaglandin E2 (PGE2) gel for induction of labor versus immediate oxytocin induction of labor. We randomized 118 patients to receive either endocervical 0.5 mg of PGE2 gel (study group) or immediate oxytocin induction of labor (control group). If labor was not established in the group receiving PGE2 gel in 24 hours, intravenous oxytocin was given in incremental doses. The rates of clinical amnionitis and endometritis in the two groups were analyzed. Also compared were hours of labor, duration of rupture of membranes and number of vaginal examinations. Student t test, chi 2, or Wilcoxon rank-sum test were used for statistical analysis, as appropriate. P < .05 was considered significant. The rates of clinical amnionitis were 5.3% in the PGE2 group and 8% in the control group. Endometritis developed in 1.7% of PGE2 patients and 3.2% of controls. These differences in maternal infection rates were not statistically significant. The two groups were comparable with respect to age, parity, and antepartum group B streptococcal colonization. No significant differences in hours of labor, duration of ruptured membranes, or vaginal examinations were observed. Neonatal outcome data (mean birth weight, Apgar scores at 1 and 5 minutes, Apgar score less than 7 at 5 minutes) were not statistically significant. Endocervical placement of 0.5 mg of PGE2 gel does not increase the incidence of clinical amnionitis and endometritis in patients with PROM at term when compared with immediate induction of labor with oxytocin.

Mode of delivery following external cephalic version and induction of labor at term.

External cephalic version should be followed by fetal and maternal surveillance until delivery. To shorten this period of surveillance, a protocol of version at term, followed by immediate induction of labor, was adopted. The aim of the present study was to evaluate the effect of this protocol on the subsequent mode of delivery. Two hundred and ninety-one singleton breech pregnancies were included in this study. Of these, 74 cases underwent version, 75% of which were successful. Success of version compared to failed version was associated with statistically significant (p < 0.001) lower rate of cesarean sections (9% and 67%, respectively). The overall rate of abdominal deliveries in the version group (74 cases) was statistically significantly lower compared with two other groups: one composed of breech pregnancies that did not undergo versions, but would have been qualified for it, had they been referred on time (121 cases), and the other (96 cases) that did not have versions done because of contraindications to its performance (cesarean rates, 23%, 54%, and 79%, respectively; p < 0.001). It may be concluded that a policy of external cephalic version at term is effective in lowering the incidence of cesarean deliveries, and the added intervention of induction of labor does not negate this effect.

A clinical trial of induction of labor versus expectant management in postterm pregnancy

OBJECTIVE: Management of the uncomplicated pregnancy prolonged beyond the estimated date of confinement is controversial, particularly when the cervix is unfavorable for induction. The benefit of reducing potential fetal risk with induction of labor must be balanced against the morbidity associated with this procedure. The objective of this study was to compare two strategies for managing postterm pregnancy (i.e., immediate induction and expectant mangement). STUDY DESIGN: Four hundred forty patients with uncomplicated pregnancies at 41 weeks' gestation were randomized to either immediate induction of labor (n = 265) or expectant management (n = 175). Patients with expectant management underwent nonstress testing and amnioic fluid volume assessment twice per week. Patients in the induction group underwent induction within 24 hours of randomization. To evaluate the efficacy of intracervical prostaglandin E2 gel, patients in the induction group were randomized in a 2:1 scheme to receive either 0.5 mg prostaglandin E2 gel or placebo gel intracervically 12 hours before induction of labor with oxytocin. RESULTS: The incidence of adverse perinatal outcome (neonatal seizures, intracranial hemorrhage, the need for mechanical ventilation, or nerve injury) was 1.5% in the induction group and 1% in the expectant management group (p > 0.05). There were no fetal deaths in either group. There were no differences in mean birth weight or the frequency of macrosomia (birth weight ≥ 4000 gm) between the two groups (p > 0.05). Regardless of parity, prostaglandin E2 intracervical gel was not more effective than placebo in ripening the cervix. The cesarean delivery rate was not significantly different in the expectant (18%), prostaglandin E2 gel (23%), or placebo gel (18%) groups. CONCLUSIONS: Adverse perinatal outcome in otherwise uncomplicated pregnancies of ≥41 weeks is very low with either of the management schemes described. Thus from the perspective of perinatal morbidity or mortality either management scheme is acceptable. (AM J OBSTET GYNECOL 1994;170:716-23.)

Induction versus expectant management in premature rupture of the membranes with mature amniotic fluid at 32 to 36 weeks: A randomized trial

Our objective was to compare maternal and perinatal outcomes between two management schemes for women with preterm premature rupture of the membranes and documented fetal pulmonary maturity. Of 164 women with preterm premature rupture of the membranes at 32 weeks to 36 weeks 6 days' gestation, 93 eligible and consenting women were randomly selected for either induction of labor (n = 46) or expectant management (n = 47). Expectant management included hospitalization, assessment for fetal heart rate abnormalities, chorioamnionitis, and labor. Digital cervical examinations were prohibited until progressive labor occurred. Follow-up was also done for the 71 women who did not participate. The women in the induction of labor and expectant management groups had similar demographic characteristics and gestational ages (34.1 vs 34.3 weeks). Expectant management was associated with prolonged latencies to labor, delivery, and maternal hospitalization (p < 0.001), as well as increased hospitalization of infants at 2 to 5 days after delivery (p < 0.05). These patients had increased chorioamnionitis and fetal heart rate abnormalities before labor (p = 0.01, 0.03). Infants received more frequent (p < 0.001) and prolonged antimicrobial therapy after expectant management (p = 0.003) with no reduction in proven sepsis (6.8% vs 4.4%). These latter differences were influenced by the neonatologist's concern over potential neonatal infection. Among women with preterm premature rupture of the membranes at 32 to 36 weeks with mature surfactant profiles, immediate induction of labor reduces the duration of hospitalization and infection in both mothers and neonates.

No Benefit From Conservative Management in Nulliparous Women with Premature Rupture of the Membranes (PROM) at Term: A Randomized Study

To compare maternal and fetal outcome in pregnancies with premature rupture of the membranes (PROM) at term with either early induction of labor or conservative management awaiting spontaneous labor. A prospective randomized trial. The University Hospital of Lund, Sweden. Altogether 369 women with singleton pregnancy, cephalic presentation, gestational duration 36-41 weeks, were randomized either to induction of labor (n = 139) or conservative management up to 3 days (n = 138). Those eligible but not participating in the study totalled 92. MAIN OBSTETRIC MEASURES: Obstetric intervention rate (cesarean section or instrumental delivery) and short-term neonatal morbidity. No difference was found in the rate of obstetric intervention between the induction of labor group and the group with conservative management (12.2 vs. 18.8%; chi 2 = 2.3, p greater than 0.05). A slightly increased rate of neonatal infections was seen in the latter group (0.7 vs. 4.3%; chi 2 = 3.2, p less than 0.05). We found no benefit from conservative management for up to 3 days in women with PROM at term, compared with immediate induction of labor. There was no difference in the number of obstetric interventions during labor. The neonatal infectious morbidity was slightly higher in conservatively managed cases.

Oxytocic effects of intravenously administered hypertonic sodium chloride in human pregnancy at term

1.1. Administration of hypertonic sodium chloride to 14 pregnant women resulted in antidiuresis in all cases.2.2. The oxytocic response varied. In 5 cases there was definite induction or enhancement of labor, in 4 cases there was demonstrable increase in uterine contractility without immediate induction of labor, while in 3 cases there was only mild transient increase in the intensity and/or frequency of the contractions. In the remaining 2 subjects there was no demonstrated alteration in contractility by the methods then available for measurement.3.3. In one subject, the oxytocic effect was equivalent to the effect produced by infusion of 2 to 4 mU per minute of synthetic oxytocin.4.4. Whether the oxytocic effect of hypertonic solutions is due to ADH or some combination of ADH and oxytocin in unknown at this time.