Initial Cervical Dilation Research Articles

Maternal Morbidity Rates Relative to Length of Labor in a Multiethnic Patient Population [ID: 1337798

INTRODUCTION: Prolonged induction of labor is associated with increased morbid maternal outcomes. Induction of labor length varies by institution and labor management. The objective of this study was to determine the risk of morbid outcomes increasing hours of labor induction in a multiethnic tertiary care center. METHODS: We conducted a retrospective cohort study on patients undergoing scheduled induction of labor from June 2020 to May 2021 at a tertiary care center. Nulliparous singleton term pregnancies with intact membranes who had an initial cervical dilation less than 3 were included. Length of labor induction was defined as first intervention to birth. Morbid outcomes included suspected intraamniotic infection (IAI), postpartum hemorrhage (PPH), and cesarean birth. Multivariable logistic regressions were performed relative to the length of labor. RESULTS: Two hundred sixty-seven patients were included in our study, with 18.0% Asian American/Pacific Islander, 6.4% Black/non-Hispanic, 20.2% Hispanic, 32.6% White/non-Hispanic, 17.6% multiracial/other, and 5.2% unknown. The median labor length was 28.5 hours (interquartile range 21.2–38.5). The rates of IAI was 22%, PPH 12%, and cesarean birth 22%. For every hour of labor, there was 1.04 increased odds of IAI, 1.08 odds of cesarean birth, and 1.05 odds of PPH after adjusting for confounders (P<.01). When comparing White versus non-White patients, there were no differences in labor length (28.4 hours versus 28.6 hours, P=.46) and no differences in IAI, PPH, and cesarean. CONCLUSION: For each hour of labor, the risk of IAI, PPH, and cesarean birth increased by 4%, 8%, and 5%, respectively. Characteristics contributing to this association may be multifactorial and suggest labor management should aim for an expedient birth.

Mifepristone prior to osmotic dilators for dilation and evacuation cervical preparation: A randomized, double-blind, placebo-controlled pilot study

ObjectivesTo evaluate mifepristone impact on osmotic dilator placement and procedural outcomes when given 18 to 24 hours before dilator placement for dilation and evacuation (D&E) at 18 weeks 0 days to 23 weeks 6 days gestation. Study DesignWe performed a randomized, double-blind, placebo-controlled trial from April 2019 through February 2021, enrolling participants undergoing osmotic dilator (Dilapan) placement for a planned, next-day D&E. Participants took mifepristone 200 mg or placebo orally 18 to 24 hours before dilator placement. We used a gestational age-based protocol for minimum number of dilators. Our primary outcome was the proportion of participants for whom 2 or more additional dilators could be placed compared to the minimum gestational age-based standard. We secondarily evaluated cervical dilation after dilator removal in the operating room, subjective procedure ease, and complication rates (cervical laceration, uterine perforation, blood transfusion, infection, hospitalization, or extramural delivery). ResultsOf the planned 66 participants, we enrolled 44 (stopped due to coronavirus disease 2019-related obstacles), and 41 (19 mifepristone; 22 placebo) completed the study. We placed 2 or more additional dilators compared to standard in 7 (36.8%) and 3 (13.6%) participants after mifepristone and placebo, respectively (p = 0.14). We measured greater median initial cervical dilation in the mifepristone (3.2 cm[2.6−3.6]) compared to placebo (2.6 cm[2.2−3.0]) group, p = 0.03. Surgeon's perception of procedure being “easy” (8/19[42.1] vs 9/22[40.9], respectively, p = 1.00) and complication rate (3/19[15.8%] vs 3/22[13.6], respectively, p = 1.00) did not differ. ConclusionOur underpowered study did not demonstrate a difference in cervical dilator placement, but mifepristone 18 to 24 hours prior to dilators increases cervical dilation without increasing complications. ImplicationsMifepristone 18 to 24 hours prior to cervical dilator placement may be a useful adjunct to cervical dilators based on increased cervical dilation at time of procedure; however, logistical barriers, such as an additional visit, may preclude routine adoption without definite clinical benefit.

994 Concurrent use of prostaglandin E2 and acetaminophen is associated with longer duration of labor induction

Acetaminophen (APAP) is widely used for pain management during pregnancy with a mechanism known to selectively suppresses peripheral prostaglandin E2 (PGE2) release. Dinoprostone is a naturally occurring PGE2 used for induction of labor. This study sought to determine if acetaminophen's suppressive activity on peripheral PGE2 effects the efficacy of dinoprostone for induction of labor. We conducted a 5 year retrospective cohort study and reviewed charts on women who received dinoprostone for induction of labor at term. Term pregnancies were defined as pregnancies between 40-42 weeks gestational age without onset of labor and a bishop score of 6 or less. Patients were included in the study if there received dinoprostone vaginally in doses of 10mg every 12 hours as needed for induction for a late term pregnancy and received between 2000-4000mg of APAP per day over the course of their induction. Patients receiving magnesium sulfate in the context of preeclampsia with severe features excluded. The study included 631 patients, with 303 receiving at least 2000mg of acetaminophen and 328 who did not. Baseline characteristics were not significantly different between treatment groups. Patients receiving acetaminophen experienced a longer duration of induction of labor 9.2±0.9 (1.6-13.7) hours as compared with those not receiving acetaminophen 6.3±1.1 (0.8-10.3), p = 0.02. In crude analysis, compared to those not receiving acetaminophen, receiving acetaminophen was associated with a 32% increased risk of requiring a second dose of dinoprostone (RR 1.78, 95% CI 1.42-1.93, p = 0.04.) After adjusting for BMI, initial cervical dilation at presentation, bishop score, diabetes mellitus, gestational blood pressure >140/90, race, advanced maternal age ( >34 y), and parity, this risk remained significant. APAP use ranging between 2000-4000mg over the course of a patient's labor induction with vaginal dinoprostone appears to be associated with a longer duration of induction. In such cases, other methods of cervical ripening may be a more suitable choice.

Morbidity associated with the use of Foley balloon for cervical ripening in women with prior cesarean delivery

Objective We evaluated the morbidity of Foley balloon for cervical ripening in comparison to oxytocin alone in women with a prior cesarean delivery. Study design A four-hospital retrospective review of all women with viable singleton pregnancies and history of a single prior cesarean delivery presenting for cervical ripening between 1994 and 2015. Exposure groups were either Foley balloon or oxytocin, at the treating physician’s discretion. The primary outcome was defined as maternal morbidity, evaluated by a composite that included hemorrhage, and/or uterine infection, and/or uterine rupture. We defined two secondary outcomes: neonatal morbidity, and vaginal delivery rate. Neonatal morbidity was evaluated by a composite that included five-minute APGAR score <7 and/or NICU admission. We adjusted results for potential confounding variables, including hospital site, maternal age and race, initial cervical dilation, and gestational age at delivery. Results We identified 688 patients who received ripening, 276 by Foley balloon and 412 by oxytocin. There was no significant difference in the primary outcome of maternal morbidity between groups: 38 (13.8%) in the Foley balloon group and 79 (19.2%) in the oxytocin group (aOR 1.43; 95% CI, 0.90–2.27). There was no significant difference in the secondary outcome of neonatal morbidity: 31 (11.3%) in the Foley balloon group and 51 (12.4%) in the oxytocin group (aOR 1.02; 95% CI, 0.57–1.80). The rate of vaginal delivery was significantly less in the Foley balloon group compared to the oxytocin group: 56.2% vs 64.1%, p = .037. Conclusion When cervical ripening with either Foley balloon or oxytocin was utilized at the physician’s discretion in women with prior cesarean, there was no identified difference in maternal and neonatal morbidity, but the rate of successful vaginal delivery was lower.

The effect of transcutaneous electrical nerve stimulation (TENS) and cryotherapy in the relief of pain during labor

Background: The delivery pain is an unpleasant experience which may generate some insecurity for the woman. Thus, some methods of analgesia need to be studied in order to generate greater comfort for the woman during labor. Objective: to evaluate the effect of transcutaneous electrical nerve stimulation (TENS) and cryotherapy (CRYO) on labor pain. Method/Design: quasi experimental study, randomized sample in two groups: TENS and CRYO. Pregnant women were selected in the Carmela Dutra Maternity (Florianópolis (SC), Brazil) according to inclusion criteria: women which are pregnant for the first time, age (18-40 years) and initial cervical dilatation of 4-5cm. The Visual Analogue Scale (VAS) was used to evaluate pain before and after each intervention. Results: 24 parturient women were studied (TENS = 11, CRYO = 13). In the TENS group, there was a significant result in pain relief after the first application (p = 0.002). VAS was reduced from 8 to 5.5, but not significant. In the CRYO group there was reduction of pain during the first application (p = 0.008), and in the second there was an increase in pain (p = 0.008). There was a significant difference between the techniques in the evaluation performed before the second application, with a lower value attributed to the CRYO group (p = 0.034). Conclusions: CRYO and TENS were effective in relieving pain during the first phase of the initial phase of labor. However, during the treatment, in the parturient women studied, there was maintenance of pain response by the CRYO group and decrease in the TENS group without reduction significant.

Risk Factors Associated With Cesarean Delivery After Induction of Labor in Women With Class III Obesity.

To assess the risk factors associated with cesarean delivery in women with class III obesity (body mass index [BMI, calculated as weight in kilograms divided by height in meters squared] 40 or higher) who are undergoing induction of labor. This was a retrospective cohort of obese women with a BMI of 40 or higher and singleton pregnancy of 34 weeks of gestation or longer who underwent induction of labor at two large teaching institutions from January 2013 to December 2015. The primary outcome was cesarean delivery. Secondary outcomes included maternal and neonatal composite morbidity. We then assessed the applicability of using a previously developed calculator to predict the risk of cesarean delivery. The area under the receiver operating characteristic (ROC) curve was used as a measure of the ability of the calculator to discriminate between women who underwent cesarean compared with vaginal delivery. There were 485 women with class III obesity who underwent induction during the study period. Of the 428 women who met inclusion criteria, 81.8% had a BMI of 40-50, 14.5% had a BMI of 50-60, and 3.7% had a BMI higher than 60. The overall cesarean delivery rate was 49.1% (46% with BMI 40-50, 63% with BMI 50-60, and 69% with BMI higher than 60, P=.012). Of the 428 women studied, 77.6% were black and 55% were nulliparous. Nulliparity, height, initial cervical dilation, and modified Bishop score were associated with a higher rate of cesarean delivery in multivariable models. Maternal and neonatal composite morbidity was higher in obese women who underwent cesarean delivery, compared with those who delivered vaginally. The performance of a previously developed induction calculator applied to this cohort had an area under the ROC curve of 75% (95% CI 0.70-0.79). In women with class III obesity who underwent labor induction, the cesarean delivery rate approaches 50%. Nulliparity, height, and unfavorable cervical examination were the most significant risk factors for cesarean delivery. This information can be used to augment counseling for the obese patient who is undergoing induction.

Mifepristone and misoprostol compared to osmotic dilators for cervical preparation prior to surgical abortion at 15–18 weeks' gestation: a randomised controlled non-inferiority trial

ObjectiveCervical preparation is recommended prior to second-trimester surgical abortion. Osmotic dilators are an effective means to prepare the cervix, but require an additional procedure and may cause discomfort. We compared...

860: Use of acetaminophen and vaginal prostaglandin E2 is associated with longer duration of labor induction

Acetaminophen is widely used for pain management during pregnancy as an alternative to NSAIDs and selectively suppresses peripheral prostaglandin E2 (PGE2) release. Dinoprostone is a naturally occurring PGE2 used for induction of labor. This study sought to determine if acetaminophen's suppressive activity on peripheral PGE2 effects the efficacy of dinoprostone for induction of labor. We conducted a 4 year retrospective cohort study and reviewed charts on women who received dinoprostone for induction of labor for late term pregnancies. Late term pregnancies were defined as pregnancies between 41-42 weeks gestational age without onset of labor and a bishop score of 6 or less. Patients were included in the study if there received dinoprostone vaginally in doses of 10mg every 12 hours as needed for induction for a late term pregnancy and received between 2000-4000mg of acetaminophen per day over the course of their induction. The study included 478 patients, with 231 receiving at least 2000mg of acetaminophen and 247 who did not. Baseline characteristics were not significantly different between treatment groups. Patients receiving acetaminophen experienced a longer duration of induction of labor 8.2±0.8 (1.6-13.7) hours as compared with those not receiving acetaminophen 5.9±1.2 (0.8-10.3), p = 0.03. In crude analysis, compared to those not receiving acetaminophen, receiving acetaminophen was associated with a 32% increased risk of requiring a second dose of dinoprostone (RR 1.68, 95% CI 1.32-1.64, p = 0.03.) After adjusting for BMI, initial cervical dilation at presentation, bishop score, diabetes mellitus, gestational blood pressure >140/90, group b-Streptococcus status, race, advanced maternal age (>34 y), and parity, this risk remained significant. Acetaminophen use over the course of a patient’s labor induction with vaginal dinoprostone appears to be associated with a longer duration of induction.

A factorial-design randomized controlled trial comparing misoprostol alone to Dilapan with misoprostol and comparing buccal to vaginal misoprostol for same-day cervical preparation prior to dilation & evacuation at 14 weeks 0 days–19 weeks 6 days gestation,

ObjectivesTo compare procedure times following same-day cervical preparation using misoprostol 400 mcg alone or misoprostol 400 mcg plus hygroscopic dilators for dilation and evacuation (D&E) before 20 weeks gestation and to compare side effects of buccal and vaginal misoprostol administration. Study DesignWe randomized women undergoing D&E at 14 weeks 0 days–19 weeks 6 days gestation to receive (1) hygroscopic dilators or not and (2) buccal or vaginal misoprostol using a 2 × 2 factorial design. We assessed two primary outcomes: (1) total procedure time, defined as time to insert hygroscopic dilators plus D&E time, and (2) side effects of misoprostol 4–6 h after initiation of cervical preparation using a 5-point Likert scale assessing nausea, emesis, diarrhea, chills and cramps. ResultsWe randomized 163 women and 161 completed the study. We completed all procedures in one day. Mean total procedure time was 14.0 and 10.8 min. with and without hygroscopic dilators (difference 3.2 minutes, 95% CI 1.7, 4.6). Mean D&E procedure time was 0.7 (95% CI −0.8, 2.1) min longer without hygroscopic dilators. Initial cervical dilation was 15.6 and 11.7 mm with and without hygroscopic dilators (difference 3.9 mm, 95% CI 3.1, 4.8). Participants receiving buccal misoprostol reported less chills (1.9) than women receiving vaginal misoprostol (2.3), p = 0.04. ConclusionsHygroscopic dilators with misoprostol requires more time and increases cervical dilation without shortening D&E time when used for cervical preparation 4–6 h prior to D&E before 20 weeks. Women receiving vaginal misoprostol may have more chills compared to buccal misoprostol. ImplicationsAdding hygroscopic dilators to misoprostol for same day D&E procedures at less than 20 weeks gestation increases total intervention time without reducing D&E time and is less favored by patients. Clinical judgment requires balancing relative effectiveness with patient preference. Further studies should evaluate the side effect profile of vaginal misoprostol.

A lariat-based dilatation device for hysteroscopy: an in vitro study.

Hysteroscopy is regarded as the golden standard for the therapeutic and diagnostic methods of many uterine diseases. Carbon dioxide, normal saline and pharmaceuticals are generally used to dilate the uterus to obtain enough operating space and clear vision during the surgery. However, these methods often cause various syndromes. In this study, we designed a novel mechanical dilator and operating system. The dilator contains a structure with a diameter of 9 mm in its initial status to pass through the narrow cervix after initial cervical dilation by cervical dilator and then its diameter can be expanded up to 60 mm in the working status to achieve a favorable operating space. The operating system is composed of an endoscope and the surgical instrument driving tube. The endoscope was motioned by pre-bent hyperelastic wires and the surgical instrument was driven by a pre-bent driving tube. To obtain the parameters for successful expansion and operation, the relationships between the tension, the diameter of the dilator and the visual and operating space of the operating system were analyzed in detail. On the basis of the obtained parameters, the surgical experiment was performed and the experimental results demonstrated the ability of this dilator to expand and the ability of the operator to operate in small spaces for hysteroscopy. According to the achieved results, the dilator could support the inner wall of the simulated organ to act like a cage, so that the space in the cage was large enough. The operating system can thrust into the intracavity of the simulated uterus through the channel (with a diameter of 6 mm) of the dilator to search for and excise the raised polyp. It can be concluded that the proposed dilator and operating system can be efficiently applied in organ expansion and operation in hysteroscopy.

Initial cervical dilation and the association of the success of atosiban

Initial cervical dilation and the association of the success of atosiban

Analysis of labor progression characteristics of 1 089 nulliparas managed by the new partogram

Objective: To analyze labor progression characteristics among nulliparas and provide reference to labor progress management. Methods: A retrospective study was conducted on 1 089 women who went for vaginal delivery at the First Affiliated Hospital, Sun Yet-San University from January 1st, 2015 to May 31th, 2016. The duration of cervical dilation from 1.0 cm to the next and the process of initial cervical dilation (2.0 cm or 3.0 cm) to full cervical dilation of nulliparas were analyzed. Results: The cervical dilation speed was accelerating with the progress of labor. The rate of cervical dilation changed fastest between 5.0-6.0 cm dilation, which was more than 3.0 cm/hour. With regard to labor curves, at admission of 2.0 cm cervical dilation, it rose dramatically from 5.0 cm dilation. At admission of 3.0 cm dilation, it presented approximately linear rising before 5.5 cm dilation, then became steeper. Conclusions: The cervical dilation speed is fast. Both labor curves of initial cervical dilation (2.0 cm or 3.0 cm) to full cervical dilation show obvious acceleration stage with steep slope.

Assessing Maternal and Fetal Risks Associated with Prolonged Induction of Labor.

To assess whether prolonged induction of labor was associated with increased maternal or neonatal morbidity. We performed a retrospective cohort study of women undergoing induction of labor at a single institution. We included women with singletons ≥ 36 weeks with initial cervical dilation ≤4 cm. Prolonged induction of labor was defined as lasting > 36 hours from the time of initial method to delivery. A 2-to-1 propensity score-matched analysis was performed between women with and those without prolonged induction of labor. Maternal outcomes were cesarean delivery, chorioamnionitis, endometritis, postpartum hemorrhage, severe perineal laceration, and length of postpartum admission. Neonatal outcomes included Apgar scores, umbilical artery pH, and neonatal intensive care admission. Among 2,021 women, 407 (20.1%) had a prolonged induction. In unadjusted analyses, prolonged induction of labor was associated with increased cesarean delivery and chorioamnionitis. After 2-to-1 propensity score matching, there were 267 women with prolonged induction and 424 controls. Women with prolonged induction of labor had higher rates of cesarean delivery (35.6 vs. 16%, p < 0.001), chorioamnionitis (14.2 vs. 4.7%, p < 0.001), endometritis (6.4 vs. 1.9%, p = 0.002), and postpartum hemorrhage (18.8 vs. 11.9%, p = 0.008). There were no significant differences in neonatal outcomes. Overall length of induction impacts maternal outcome.

Balloon Catheter for Cervical Priming before Operative Hysteroscopy in Young Women: A Pilot Study

Aim: To investigate regarding the safety and effectiveness of a balloon catheter (Aqueduct-100 device) to dilate the uterine cervix before operative hysteroscopies. Secondary objectives were to evaluate the duration of the dilatation procedure and to investigate on physicians’ satisfaction with the device. Methods: Fifty women younger than 40 years, wishing pregnancies and diagnosed with apparently benign intrauterine lesions and/or uterine anomalies, were enrolled into this study and submitted to cervical priming with Aqueduct-100 device before operative hysteroscopy. Results: Initial cervical dilatation was ≤4 mm in all but one patient. Adequate (10 mm) cervical dilatation was achieved in only one patient, the remaining forty-nine needed additional cervical dilatation. All women, however, presented with a ≥6 mm cervical width after balloon catheter removal. The mean time to final cervical dilatation was 8.5 minutes. No perioperative complications occurred. Physicians reported, in the majority of cases, satisfaction for the dilatation achieved (66%), the ease of balloon catheter insertion/use (82%), and for the ease of additional dilatation (96%). Conclusions: Aqueduct-100 device before operative hysteroscopy is safe and useful to increase the baseline cervical width and facilitate additional dilatation, with good effects on physician satisfaction and acceptable dilatation times.

Twenty-Four Hour Mifepristone Combined With Vaginal Versus Buccal Misoprostol Prior to D&amp;E [7G

INTRODUCTION: The goal of this study was to evaluate oral mifepristone twenty-four hours prior to vaginal versus buccal misoprostol as cervical preparation prior to second-trimester dilation and evacuation (D&amp;E). METHODS: Women desiring abortion between gestational ages 16 weeks 0 days and 20 weeks 6 days were randomized to 200-mg mifepristone 20-24 hours and 400-mcg vaginal or 400-mcg buccal misoprostol 1-2 hours prior to D&amp;E. Primary outcome was intraoperative procedure time defined as time of initial cervical dilation assessment to speculum out. Secondary outcomes included initial Pratt dilator accepted without resistance and participant and provider perceptions. The study was powered to detect a 4-minute difference in procedure time with 36 participants in each arm. RESULTS: Of 72 women enrolled, 70 were randomized and completed the study. Age, BMI, gestational age (mean 18.7 weeks, SD 1.39), and parity did not significantly differ. Total procedure times were 9.4 and 10.6 minutes in the vaginal and buccal groups, respectively, with difference of 1.2 (95% CI -1.2, 3.8). Initial Pratt dilation was 49.6 and 45.6 Fr in the vaginal and buccal groups, respectively, with difference of 4 Fr (95% CI -9.0, 1.0). Participant and provider perceptions did not differ. All 70 procedures were completed without hemorrhage, cervical laceration, or other observed complications. CONCLUSION: Mifepristone 24 hours prior combined with vaginal or buccal misoprostol 2 hours prior is effective as cervical preparation for D&amp;E at 16 weeks through 20 weeks 6 days.

325: Predicting cesarean delivery following nulliparous induction at term: Validation of a prediction model

The impact of labor induction on the cesarean rate remains controversial. The objective of our study was to validate a previously published model for predicting cesarean delivery following induction of labor among nulliparous women at term. This is a retrospective cohort study utilizing a multi-hospital, single academic center database of deliveries from August 2011 - February 2017 to identify nulliparous, term, singleton, cephalic pregnancies who underwent induction of labor. Only deliveries with all eight variables available for the originally developed nomogram (maternal age, height, body mass index (BMI), weight change, gestational age, hypertension, diabetes, and initial cervical dilation) were included. Pregnancies with spontaneous labor, multiple gestations, intrauterine fetal demise, or major congenital malformations were excluded. Results were stratified by high-risk status, with high-risk defined as maternal age >34, BMI >39.9, any hypertension, or any diabetes. The predictive ability of the model was summarized using the area under the curve (AUC). Of 26,110 deliveries, 954 met inclusion criteria (high-risk n=628, 65.8%; cesarean rate 34.1%). There were no observed differences in any of the eight variables included in the nomogram comparing women who underwent a cesarean versus a vaginal delivery (P>0.05) (Table, bolded). There were no differences comparing additional characteristics we evaluated including ethnicity/race, method of payment, hospital type, and high-risk status (P>0.05). The predicted probability of cesarean among the group who had a cesarean did not differ from the group who had a vaginal delivery (40.5% vs. 39.9%, P=0.699). The AUC for the prediction model was 0.51 (95% CI 0.47-0.55). A previously developed model to predict cesarean following nulliparous, term induction was found to be not predictive when applied to a different patient population. Our findings suggest that wide variations in practice patterns in the U.S. make the use of various risk models of questionable benefit in achieving an ideal national cesarean rate, and may explain the historic negligible impact of all attempts to address this issue on a national level. Consensus and standardization of current practice patterns will likely be requisite to achieving a more reasonable cesarean delivery rate.

376: Cervical ripening balloon with and without oxytocin for cervical ripening in multiparas: A randomized controlled trial

To determine if induction of labor with simultaneous use of oxytocin and a cervical ripening balloon (CRB), compared with sequential use, increases the likelihood of delivery within 24 hours in multiparous women. We performed a randomized controlled trial between November 2014 and June 2017. Eligible participants were multiparous women with a vertex presenting, non-anomalous singleton gestation ≥ 34 weeks undergoing induction of labor. Women were excluded for admission cervical examination > 2cm, ruptured membranes, chorioamnionitis or systemic infection, abruption, low-lying placenta, > 1 prior cesarean delivery, or contraindication to vaginal delivery. Patients were randomly allocated to either the simultaneous (CRB with oxytocin) or sequential (oxytocin after CRB expulsion) group. Per protocol, amniotomy was performed upon CRB expulsion. The primary outcome was delivery within 24 hours of CRB placement. Secondary outcomes included induction to delivery interval, time to CRB expulsion, mode of delivery, and adverse maternal or neonatal outcomes. The study was powered to evaluate a 20% increase in the primary outcome from 55% in the sequential group (β=0.2, α=0.05). 180 patients were randomized (90 simultaneous, 90 sequential). Baseline demographic and obstetric characteristics were similar between study groups, including initial cervical dilation and maternal body mass index. Women in the simultaneous group were significantly more likely to deliver within 24 hours of CRB placement compared to the sequential group (87.8% vs 73.3%, p=0.02). Simultaneous administration of CRB and oxytocin also resulted in a significantly shorter induction to delivery interval and greater cervical dilation at CRB expulsion (Table). There were no differences in mode of delivery, chorioamnionitis, or adverse maternal or neonatal outcomes. In multiparous women, simultaneous use of CRB and oxytocin results in an increased frequency of delivery within 24 hours and a shorter induction to delivery interval.

Maternal Outcomes of Prolonged Induction of Labor [9R

INTRODUCTION: To safely reduce the number of cesarean deliveries (CD), the time allowed for induction of labor (IOL) has increased. There is little data regarding the safety of prolonged labor induction. METHODS: We performed a retrospective study of IOL from July, 2014 – June, 2016. Singletons, greater than 36 weeks, with initial cervical dilation 4 or less were included. Bivariate analysis was performed to compare maternal outcomes by induction length. Multivariable logistic regression identified independent predictors of CD and was subsequently stratified by parity. RESULTS: We included 2,032 inductions. For IOL less than 24 hours, 24 to 36 hours, and greater than 36 hours the CD rate was 14.9%, 24.5%, and 43.4% (p &lt; .001) for nulliparous women and 5.5%, 11.2%, and 18.7% (p &lt; .001) for multiparous women. After risk adjustment, the odds of CD were significantly higher for women age 30 or greater, (aOR=1.83, 95%CI 1.42-2.38), BMI 35 or greater, (aOR 1.58, 95%CI 1.21-2.06), previous CD (aOR 12.06 95%CI 6.72-21.67), duration of labor 24 to 36 hours (aOR 1.74 95%CI 1.25-2.42), and duration of labor greater than 36 hours (aOR 1.74 95%CI 1.25-2.42). When stratified, age, BMI, and duration of labor for nulliparous and prior CD and duration of labor for multiparous women were significant. Chorioamnionitis also increased by duration, 5.5%, 8.9%, and 14.6% for nulliparous women (p &lt; .001), and 1.4%, 2.0%, and 9.2% for multiparous women (p=.001). CONCLUSION: As the length of IOL increases the risk of CD and infection increases. This data can be used to better inform patients of the risks of prolonged IOL.

Cervical dilatation in parturient receiving neuraxial analgesia: Comparison of epidural analgesia alone with combined spinal epidural analgesia

Background: Both epidural analgesia and combined spinal epidural analgesia (CSEA) are employed for pain relief during labor because they provide reliable analgesia compared to other modalities. Studies are equivocal with respect to their effect on the rate of cervical dilatation, duration of labor, and labor outcome. The primary outcome of the present study was to compare the effect of epidural analgesia alone with CSEA with respect to the rate of cervical dilatation. Materials and Methods: One hundred and twenty parturients with an initial cervical dilatation of <4 cm were randomized to receive CSEA or epidural analgesia alone for pain relief during labor. The rate of cervical dilatation, onset of effective analgesia, number of epidural top-ups requested, labor outcome, and the quality of analgesia was assessed in both the study groups. Statistical Analysis: Mann–Whitney and Chi-square tests were performed where applicable to compare the data between the two groups. Results: The results of the study showed that the rate of cervical dilatation was rapid with CSEA compared to epidural analgesia alone [median (interquartile range) 2 (1.2,3) v/s 1.16 (1,2)]. The onset of analgesia was earlier with combined spinal epidural (CSE v/s EA, 3.7 ± 1.3 min v/s 23.8 ± 5.8 min). Labor outcome and quality of analgesia was similar between the two groups. The incidence of pruritus was higher with CSEA than with epidural analgesia alone. Conclusion: CSEA is associated with more rapid cervical dilatation and shorter duration of first stage of labor when compared with epidural analgesia alone.

A randomized controlled trial evaluating same-day mifepristone and misoprostol compared to misoprostol alone for cervical preparation prior to second-trimester surgical abortion

ObjectiveWe evaluated initial cervical dilation with the addition of oral mifepristone to vaginal misoprostol as cervical preparation for same-daysecond-trimester dilation and evacuation (D&E). Study designWomen desiring abortion between gestational ages 14weeks 0days and 19weeks 6days were randomized to 200-mg mifepristone or identical placebo immediately followed by 400-mcg misoprostol vaginally 4–6h prior to D&E. Primary outcome was cervical dilation assessed by largest Hegar dilator passed without resistance. Secondary outcomes included total procedure time and participant and provider perceptions. We had 90% power to detect a 2-mm change in initial cervical dilation with a mean of 10mm (SD=3.0mm), requiring 48 participants in each arm. ResultsOf 100 women enrolled, 96 were randomized and completed the study. Age, race, gestational age (mean 17.4weeks, SD=1.3) and parity did not significantly differ. Mean initial Hegar dilation measurements were 11.7 and 10.9mm in the mifepristone and placebo groups, respectively, with difference of 0.8 [95% CI=−0.4, 2.0mm]. We found total procedure times of 11.8 and 13.0min, respectively (difference of 1.2min [95% CI=−2.4, 4.8min]. Participant and provider perceptions did not differ. All 96 procedures were completed without hemorrhage, cervical laceration or other observed complications. ConclusionThe addition of mifepristone to vaginal misoprostol did not provide a significant increase in cervical dilation compared to misoprostol alone as cervical preparation 4–6h prior to D&E at 14weeks through 19weeks 6days. ImplicationsAdding mifepristone for a short interval (4–6h) did not improve cervical preparation with misoprostol prior to D&E at 14–19weeks. Future studies should evaluate alternative timing intervals of medications for this purpose.