Low-risk Parous Women Research Articles

817 Utility of ultrasound and antenatal testing in women undergoing outpatient cervical ripening

To evaluate indications for exclusion in women who participated in outpatient cervical ripening studies (Outpatient Foley For Starting Induction at Term I and II). These data will assist in evaluating which parts of the scientific protocol are informative and should be retained in clinical application. This is a secondary analysis of women evaluated for enrollment in, but eventually excluded from, two randomized trials evaluating outpatient cervical ripening in low-risk parous (OFFSITE-I) and nulliparous (OFFSITE-II) women. Participants were considered low risk if they had no medical problems (other than well-controlled diabetes or hypertension), singleton pregnancies, and were 39-42 weeks gestation. Women identified as eligible at the time of pre-enrollment screening underwent an enrollment visit that included blood pressure (to rule out hypertensive disorders), ultrasound (to assess presentation, fluid, and growth), antenatal testing (to rule out non-reassuring fetal status), and a cervical exam (to determine need for ripening). In this analysis, we evaluate indications for exclusion based on the findings at the enrollment visit. Baseline maternal and pregnancy characteristics were balanced between groups. Among 354 women who presented for an enrollment visit, 98 were excluded from the trials at the study visit and included in this analysis. Of these, the majority (n=60, 17% of all women evaluated) were excluded for ultrasound findings. In this group, 49 women (14% of all women evaluated) were excluded due to a diagnosis of fetal growth restriction (regardless of antenatal testing), and 11 (3.1% of all women evaluated) were found to have polyhydramnios. (Fig 1). As we consider implementing outpatient cervical ripening into clinical practice, appropriate identification of low-risk patients is crucial. A third trimester ultrasound prior to outpatient cervical ripening identifies findings that may influence plans for outpatient cervical ripening and should be performed as part of clinical protocols.

Labor Induction at 39 Weeks Compared with Expectant Management in Low-Risk Parous Women

Our objective was to compare outcomes among low-risk parous women who underwent elective labor induction at 39 weeks versus expectant management. This is a secondary analysis of an observational cohort of 115,502 mother-infant dyads who delivered at 25 hospitals between 2008 and 2011. The inclusion criteria for this analysis were low-risk parous women with nonanomalous singletons with at least one prior vaginal delivery after 20 weeks, who delivered at ≥390/7 weeks. Women who electively induced between 390/7 and 396/7 weeks were compared with women who expectantly managed ≥390/7 weeks. The primary outcome for this analysis was cesarean delivery. Secondary outcomes were composites of maternal adverse outcome and neonatal adverse outcome. Multivariable logistic regression was used to estimate adjusted odds ratios (aOR). Of 20,822 women who met inclusion criteria, 2,648 (12.7%) were electively induced at 39 weeks. Cesarean delivery was lower among women who underwent elective induction at 39 weeks than those who did not (2.4 vs. 4.6%, adjusted odds ratio [aOR]: 0.70, 95% confidence interval [CI]: 0.53-0.92). The frequency of the composite maternal adverse outcome was significantly lower for the elective induction cohort as well (1.6 vs. 3.1%, aOR: 0.66, 95% CI: 0.47-0.93). The composite neonatal adverse outcome was not significantly different between the two groups (0.3 vs. 0.6%; aOR: 0.60, 95% CI: 0.29-1.23). In low-risk parous women, elective induction of labor at 39 weeks was associated with decreased odds of cesarean delivery and maternal morbidity, without an increase in neonatal adverse outcomes. · 39-week elective induction is associated with decreased cesarean delivery in low-risk parous women.. · Compared with expectant management, maternal adverse outcomes were lower with elective induction.. · Neonatal adverse outcomes are unchanged between elective and expectant management groups..

Patient Satisfaction with Outpatient Cervical Ripening in Parous Women.

This study aimed to assess whether patient satisfaction differs between women beginning cervical ripening in the outpatient versus inpatient setting. We performed a planned secondary analysis evaluating patient satisfaction randomized to outpatient versus inpatient cervical ripening. In the original randomized controlled trial, low-risk parous women ≥39 weeks who required cervical ripening for induction and had reassuring fetal heart rate monitoring were included and randomized to inpatient versus outpatient ripening with a transcervical Foley's catheter. All women were then admitted to the labor ward on the following day. Patient satisfaction was evaluated using three separate surveys. The first two surveys, Six Simple Questions and Lady-X, were previously validated. The third survey used visual analog scales to assess overall pain experienced during Foley's placement, overall pain experienced during labor, how likely they would be to choose the same type of care for their next pregnancy, and how likely they would be to recommend their method of cervical ripening to friends/family. From May 2016 to October 2017, 129 women were randomized (outpatient, 65; inpatient, 64). Based on survey results, there was no difference in satisfaction between outpatient and inpatient cervical ripening with transcervical Foley's catheterization, with high satisfaction in both groups. Patients in both the outpatient and inpatient groups would choose the same type of care for their next pregnancy (on a scale of 1-7, median (25th-75th percentile): 7 [7-7] vs. 7 [6-7], respectively, p = 0.75) and would be very likely to recommend their method of induction to a friend or family member (on a scale of 0-100, 99 [80-100] vs. 99 [65-100], respectively, p = 0.60). Parous women's satisfaction does not differ between inpatient and outpatient cervical ripening with transcervical Foley's catheterization. · Outpatient cervical ripening may allow providers to incorporate the benefits of electively inducing women as well as decrease the time spent in the labor and delivery unit.. · Parous women's satisfaction does not differ between inpatient and outpatient cervical ripening with transcervical Foley.. · Additional prospective evaluation is warranted to further characterize patient preferences in relation to the location of cervical ripening..

Use of admission CTG in low-risk parous women: a clinical audit

Use of admission CTG in low-risk parous women: a clinical audit

570: Labor induction at 39 weeks compared with expectant management in low-risk parous women

570: Labor induction at 39 weeks compared with expectant management in low-risk parous women

Neonatal and Maternal Adverse Outcomes Among Low-Risk Parous Women at 39-41 Weeks of Gestation.

To compare the composite neonatal or maternal adverse outcome among low-risk, parous women at 39-41 weeks of gestation. This was a retrospective cohort study using the U.S. vital statistics data sets (2012-2016). We evaluated low-risk parous women with nonanomalous singleton gestations who delivered at 39, 40, or 41 weeks of gestation (as reported in completed weeks, eg, 39 weeks includes 39 0/7-39 6/7 weeks of gestation). The primary outcome, the composite neonatal adverse outcome, included any of the following: Apgar score less than 5 at 5 minutes, assisted ventilation for longer than 6 hours, neonatal seizure, or neonatal mortality. The secondary outcome, the composite maternal adverse outcome, included any of the following: intensive care unit admission, blood transfusion, uterine rupture, or unplanned hysterectomy. We used multivariable Poisson regression analyses to estimate the association between gestational age and adverse outcome (using adjusted relative risks [aRR] and 95% CI). Of 19.9 million live births during the study period, 5.4 million (27.1%) met inclusion criteria. Among them, 54.4% delivered at 39 weeks of gestation, 35.7% at 40 weeks, and 9.9% at 41 weeks. The overall rate of the composite neonatal adverse outcome was 4.86 per 1,000 live births. The risk of the composite neonatal adverse outcome was higher for those delivered at 40 (aRR 1.18; 95% CI 1.15-1.22) and 41 (aRR 1.59; 95% CI 1.53-1.65) weeks of gestation when compared with 39 weeks. The overall rate of the composite maternal adverse outcome was 2.31 per 1,000 live births. The risk of the composite maternal adverse outcome was also significantly higher with delivery at 40 (aRR 1.15; 95% CI 1.11-1.19) and 41 weeks of gestation (aRR 1.50; 95% CI 1.42-1.58) than at 39 weeks. Though only modestly, the rates of the composite neonatal and maternal adverse outcomes increase, from 39 through 41 weeks of gestation, among low-risk parous women.

Influence of midwifery presence in United States centers on labor care and outcomes of low-risk parous women: A Consortium on Safe Labor study.

Sixty percent of United States births are to multiparous women. Hospital-level policies and culture may influence intrapartum care and birth outcomes for this large population, yet have been poorly explored using a large, diverse sample. We sought to use national United States data to analyze the association between midwifery presence in maternity care teams and the birth processes and outcomes of low-risk parous women. We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk parous women in either interprofessional care (n=12125) or noninterprofessional care centers (n=8996). Unadjusted, adjusted (age, race, health insurance type), propensity-adjusted, and propensity-matched logistic regression models were used to assess processes and outcomes. There was concordance in outcome differences across regression models. With propensity score matching, women at interprofessional centers, compared with women at noninterprofessional centers, were 85% less likely to have labor induced (risk ratio [RR] 0.15; 95% CI 0.14-0.17). The risk for primary cesarean birth among low-risk parous women was 36% lower at interprofessional centers (RR 0.64; 95% CI 00.52-0.79), whereas the likelihood of vaginal birth after cesarean for this population was 31% higher (RR 1.31; 95% CI 1.10-1.56). There were no significant differences in neonatal outcomes. Parous women have significantly higher rates of vaginal birth, including vaginal birth after cesarean, and lower likelihood of labor induction when cared for in centers with midwives. Our findings are consistent with smaller analyses of midwifery practice and support integrated, team-based models of perinatal care to improve maternal outcomes.

Elective Induction of Labor and the Risk of Cesarean Section in Low-risk Parous Women

Objective To estimate the association between elective induction of labor and cesarean section in low-risk parous women, and to assess whether the association is influenced by induction method. Design Cohort study. Setting University hospital in Sweden. Population Parous women without pregnancy complications or previous cesarean section, and with a planned vaginal term (37–41 weeks), singleton birth, in vertex position were included. Methods Information was collected from a local database containing prospectively entered antenatal and delivery data. Odds ratios for cesarean section were calculated using generalized estimating equations logistic regression and adjusted for parity, maternal age, gestational length, birthweight, use of epidural anesthesia and year of birth. Main outcome measures Emergency cesarean section. Results Among 7973 pregnancies that fulfilled the inclusion criteria, 343 (4%) had an elective induction of labor. Intravenous oxytocin was administered in 5% of these inductions, amniotomy was performed in 62%, and a cervical ripening agent was used in 33%. Electively induced labor more than doubled the risk of cesarean section compared with spontaneous labor onset (OR 2.5, 95% CI 1.4–4.2) and this risk was more than tripled when cervical ripening was used (OR 3.6, 95% CI 1.7–7.6). Conclusions In low-risk parous women, electively induced labor has an increased risk of emergency cesarean section compared with spontaneous onset labor. This risk increase is more pronounced if cervical ripening agents are required. Women need to be counseled about these risks before elective induction of delivery is decided.

Women in the limelight: a varied issue

Women in the limelight: a varied issue

Elective induction of labor and the risk of cesarean section in low‐risk parous women: a cohort study

To estimate the association between elective induction of labor and cesarean section in low-risk parous women, and to assess whether the association is influenced by induction method. Cohort study. University hospital in Sweden. Parous women without pregnancy complications or previous cesarean section, and with a planned vaginal term (37-41weeks), singleton birth, in vertex position were included. Information was collected from a local database containing prospectively entered antenatal and delivery data. Odds ratios for cesarean section were calculated using generalized estimating equations logistic regression and adjusted for parity, maternal age, gestational length, birthweight, use of epidural anesthesia and year of birth. Emergency cesarean section. Among 7973 pregnancies that fulfilled the inclusion criteria, 343 (4%) had an elective induction of labor. Intravenous oxytocin was administered in 5% of these inductions, amniotomy was performed in 62%, and a cervical ripening agent was used in 33%. Electively induced labor more than doubled the risk of cesarean section compared with spontaneous labor onset (OR 2.5, 95% CI 1.4-4.2) and this risk was more than tripled when cervical ripening was used (OR 3.6, 95% CI 1.7-7.6). In low-risk parous women, electively induced labor has an increased risk of emergency cesarean section compared with spontaneous onset labor. This risk increase is more pronounced if cervical ripening agents are required. Women need to be counseled about these risks before elective induction of delivery is decided.

P17. Significance of uteroplacental Doppler at midtrimester in low risk parous women

P17. Significance of uteroplacental Doppler at midtrimester in low risk parous women

Third degree tears and subsequent delivery

IntroductionOverall risk of third degree tears (3DT) is about 1% of all vaginal deliveries and a previous 3DT increases the risks of recurrence in future vaginal deliveries.AimTo identify the factors...

The effect of amniotomy on the outcome of spontaneous labour in uncomplicated pregnancy

SummaryThe objective of this study is to determine the effect of amniotomy on the outcome of spontaneous labour in uncomplicated pregnancy. A prospective randomised study of low-risk parous women with spontaneous onset of labour at term with singleton fetus in cephalic presentation and intact amniotic membranes and a cervical dilatation between 4 and 5 cm were randomly assigned to have amniotomy (Case) or no amniotomy (Control) during the course of labour. Maternal demographics, labour-delivery data and newborn outcome were compared. A total of 128 women were studied. The duration of labour was significantly shorter in the amniotomy group than the control group (208 vs 292 min; p < 0.05) with the only difference being in the first stage of labour. There was however no difference on the oxytocin requirement for labour augmentation, caesarean section rate, incidence of suspected fetal distress or instrumental delivery in both groups. Newborn outcome measured by Apgar scores at 1 and 5 min showed no significant difference. In conclusion, amniotomy significantly reduced the duration of the first stage of labour without affecting the oxytocin requirement, the rate of caesarean section and newborn outcome.