Lower Cesarean Section Rate Research Articles

Caesarean delivery in a migration context: the role of prior delivery in the host country

Migrant women in industrialised countries experience high caesarean section (CS) rates but little is known about the effect of a previous delivery in the host country. This study set out to investigate this effect among migrant women in France, using data from the DSAFHIR study on healthcare access of migrant women living in emergency housing hotels, collected in the Paris Metropolitan area in 2017. Respondents reported life-long history of deliveries. We focused on deliveries occurring in France in 2000–2017: 370 deliveries reported by 242 respondents. We conducted chi-square tests and multivariate logistic regressions, adjusting for the clustering of deliveries among respondents by computing standard errors allowing for intragroup correlation. Mode of delivery was associated with duration of residence among multiparous women with no prior CS, with a higher CS rate with shorter duration of residence (16% vs. 7%, p = 0.04). In this group, a previous delivery in France was associated with a lower CS rate (5% vs. 16%, p = 0.008). In multivariate analysis, compared with women with previous birth in France, women giving birth in France for the first time had a higher risk of CS, regardless of duration of residence (aOR = 4.0, 95% CI = 1.3–12.1 for respondents with short duration of residence, aOR = 4.7, 95% CI = 1.2–18.0 for respondents with longer duration of residence). Efforts directed at decreasing the CS rate among migrant women should target women giving birth in the host country for the first time.

Risk of venous thromboembolism in Chinese pregnant women: Hong Kong venous thromboembolism study.

BackgroundPrevious Caucasian studies have described venous thromboembolism in pregnancy; however, little is known about its incidence during pregnancy and early postpartum period in the Chinese population. We investigated the risk of venous thromboembolism in a “real-world” cohort of pregnant Chinese women with no prior history of venous thromboembolism.MethodsIn this observational study, 15,325 pregnancies were identified in 14,162 Chinese women at Queen Mary Hospital, Hong Kong between January 2004 and September 2016. Demographic data, obstetric information, and laboratory and imaging data were retrieved and reviewed.ResultsThe mean age at pregnancy was 32.4±5.3 years, and the median age was 33 years (interquartile range, 29–36 yr). Pre-existing or newly diagnosed diabetes mellitus was present in 627 women (4.1%); 359 (0.7%) women had pre-existing or newly detected hypertension. There was a small number of women with pre-existing heart disease and/or rheumatic conditions. Most deliveries (86.0%) were normal vaginal; the remaining were Cesarean section 2,146 (14.0%). The incidence of venous thromboembolism was 0.4 per 1,000 pregnancies, of which 83.3% were deep vein thrombosis and 16.7% were pulmonary embolism. In contrast to previous studies, 66.7% of venous thrombosis occurred in the first trimester.ConclusionChinese women had a substantially lower risk of venous thromboembolism during pregnancy and the postpartum period compared to that of Caucasians. The occurrence of pregnancy-related venous thromboembolism was largely confined to the early pregnancy period, probably related to the adoption of thromboprophylaxis, a lower rate of Cesarean section, and early mobilization.

Induction of Labor in Primigravid Term Pregnancy with Misoprostol or Dinoprostone: A Comparative Study.

ObjectiveThe objective of this study was to compare the effectiveness of vaginally administered misoprostol to that of vaginally administered dinoprostone at six-hour intervals in a well-homogenized cohort of full-term, nulliparous women with an unfavorable cervix and without any pregnancy complications.Materials and methodsA cohort of 100 nulliparous women at more than 40 weeks of gestation was included in this study. The primary outcomes to be measured were induction to delivery interval and incidence of vaginal births within 12 and 24 hours. Neonatal intensive care unit admissions for poor neonatal outcomes and obstetrical complications were secondary outcomes.ResultsA significant reduction in the induction to delivery interval was observed in the misoprostol group as compared to the dinoprostone group (10.2 ± 0.8 vs. 16.5 ± 0.7, p < 0.001). More women in the misoprostol group delivered within 12 hours as compared to the dinoprostone group (30 [60%] vs. 17 [34%], p < 0.001) and within 24 hours (48 [96%] vs. 39 [78%], p < 0.05). In the misoprostol group, spontaneous rupture of the membranes occurred more frequently (46 [92%] vs. 35 [70%], p < 0.05) with less need for oxytocin augmentation during labor (14% vs. 30%, p < 0.05). A significant reduction in additional dose requirement (7.5% vs. 22%, p < 0.05) and a lower rate of Caesarean section was observed in the misoprostol group (6% vs. 24%, p < 0.04). A statistically insignificant low Apgar score was noted in the dinoprostone group compared to the misoprostol group.ConclusionVaginally administered misoprostol is more effective than vaginally administered dinoprostone at six-hour intervals in nulliparous women beyond 40 weeks of gestation without pregnancy complications.

Foley catheter versus cervical double balloon for labor induction: a prospective randomized study

Objective Cervical ripening by mechanical methods enhances labor induction success. We compared Cervical Ripening Double Balloon catheter (CRDB) to Foley catheter. Study design This prospective blind study randomized 85 nulliparas and 95 multiparas to labor induction by either Foley catheter or CRDB. Primary outcomes were Bishop score increment, time from catheter withdrawal to delivery, and cesarean section rate. Results In multiparas, mean Bishop score increment between pre- and post-catheter was significantly higher in the CRDB catheter than in the Foley group (4.4 ± 1.9 and 3.4 ± 2.0, respectively, p = .02). Mean interval from catheter withdrawal to delivery was shorter in the CRDB catheter (14.6 ± 12.3 and 8.6 ± 5.4) than in the Foley catheter group (22.6 ± 27.2 and 13.9 ± 17.7), in both nulliparas and multiparas (p = .05 and p = .03, respectively). In nulliparas, no statistically significant differences were found in mean Bishop score increment between the two catheters, but cesarean section rate was higher in the Foley group than the CRDB group (46.5% and 20%, respectively, p = .02). Conclusion Bishop score increment by CRDB catheter is more effective than induction by Foley catheter in multiparas. CRDB catheter is associated with decreased time to delivery in both nulliparas and multiparas and a lower cesarean section rate in nulliparas. ClinicalTrials.gov Identifier: NCT00501033

The rising incidence and impact of non-medically indicated pre-labour cesarean section in Latin America

In the poorest populations of the world the difficulties of performing a surgical procedure lead to extremely low cesarean section rates associated with very high perinatal mortality. Meanwhile the proportion of births by cesarean section has been increasing for several decades in many areas of the world, reaching alarmingly high rates especially in Latin America. This review aims to describe this secular trend. The causes of the increase in cesarean deliveries are analyzed with a multidimensional approach, trying to recognize the reasons behind the choice of the route of delivery. We are facing a shift in the guiding paradigm, leaving the classical biomedical one. Advantages and disadvantages of non-medically indicated cesarean section are being sought, comparing it with the results of vaginal delivery, with special emphasis on the short- and long-term morbidity of the newborn. Several variables involved in this controversial topic are considered, with the objective of stimulating critical thoughts about the medical, bioethical and social aspects of the increasing trend in the cesarean section rate.

Factors influencing decision-making for caesarean section in Sweden \u2013 a qualitative study

BackgroundRising rates of caesarean section (CS) are a concern in many countries, yet Sweden has managed to maintain low CS rates. Exploring the multifactorial and complex reasons behind the rising trend in CS has become an important goal for health professionals. The aim of the study was to explore Swedish obstetricians’ and midwives’ perceptions of the factors influencing decision-making for CS in nulliparous women in Sweden.MethodsA qualitative design was chosen to gain in-depth understanding of the factors influencing the decision-making process for CS. Purposive sampling was used to select the participants. Four audio-recorded focus group interviews (FGIs), using an interview guide with open ended questions, were conducted with eleven midwives and five obstetricians from two selected Swedish maternity hospitals after obtaining written consent from each participant. Data were managed using NVivo© and thematically analysed. Ethical approval was granted by Trinity College Dublin.ResultsThe thematic analysis resulted in three main themes; ‘Belief in normal birth – a cultural perspective’; ‘Clarity and consistency – a system perspective’ and ‘Obstetrician makes the final decision, but...’, and each theme contained a number of subthemes. However, ‘Belief in normal birth’ emerged as the core central theme, overarching the other two themes.ConclusionFindings suggest that believing that normal birth offers women and babies the best possible outcome contributes to having and maintaining a low CS rate. Both midwives and obstetricians agreed that having a shared belief (in normal birth), a common goal (of achieving normal birth) and providing mainly midwife-led care within a ‘team approach’ helped them achieve their goal and keep their CS rate low.

Strategies to reduce and maintain low perinatal mortality in resource-poor settings - Findings from a four-decade observational study of birth records from a large public maternity hospital in Papua New Guinea.

In many low- to middle-income countries (LMIC) assisted vaginal birth rates have fallen, while caesarean section (CS) rates have increased, with potentially deleterious consequences for maternal and perinatal mortality. To review birth mode and perinatal mortality in a large LMIC hospital with strict labour management protocols and expertise in vacuum extraction. We conducted a retrospective observational study at Port Moresby General Hospital in Papua New Guinea. Birth registers from 1977 to 2015 (39 years) were reviewed. Overall and modified (fresh stillbirths and early neonatal deaths ≥500 g) perinatal mortality rates (PMRs) were calculated by birthweight/birth mode. There were 365 056 births (5215 in 1977; 14 927 in 2015), of which 14 179 (3.9%) were vacuum extractions, 609 (0.2%) forceps births and 14 747 (4.4%) CS (increase from 2% to 5%). The failure rate of vacuum extraction was 2.5% (range 0.5-5.4%). Symphysiotomy was employed for 184 births. From 1989 to 2015, the modified mean PMR for babies ≥2500 g was 8.1/1000 births (range 5.6-12.1; 6.9 in 2015), 9.1/1000 for babies ≥1500 g (7.3-14.8; 9.1 in 2015) and 7.5/1000 (0-21.7; 9.0 in 2015) for vacuum extractions (98% were ≥2500 g). The overall PMR for these years was 29.7/1000 births. In an LMIC with rapidly increasing birth numbers a comparatively low PMR can be achieved while maintaining low CS rates. This may be in part accomplished through strict use of second-stage protocols, perinatal audit, and supportive training that promotes judicious and proficient use of vacuum extraction and CS.

The International Network of Obstetric Survey Systems study of uterine rupture: a descriptive multi-country population-based study.

International comparison of complete uterine rupture. Descriptive multi-country population-based study. International. International Network of Obstetric Survey Systems (INOSS). We merged individual data, collected prospectively in nine population-based studies, of women with complete uterine rupture, defined as complete disruption of the uterine muscle and the uterine serosa, regardless of symptoms and rupture of fetal membranes. Prevalence of complete uterine rupture, regional variation and correlation with rates of caesarean section (CS) and trial of labour after CS (TOLAC). Severe maternal and perinatal morbidity and mortality. We identified 864 complete uterine ruptures in 2 625 017 deliveries. Overall prevalence was 3.3 (95% CI 3.1-3.5) per 10 000 deliveries, 22 (95% CI 21-24) in women with and 0.6 (95% CI 0.5-0.7) in women without previous CS. Prevalence in women with previous CS was negatively correlated with previous CS rate (ρ = -0.917) and positively correlated with TOLAC rate of the background population (ρ = 0.600). Uterine rupture resulted in peripartum hysterectomy in 87 of 864 women (10%, 95% CI 8-12%) and in a perinatal death in 116 of 874 infants (13.3%, 95% CI 11.2-15.7) whose mother had uterine rupture. Overall rate of neonatal asphyxia was 28% in neonates who survived. Higher prevalence of complete uterine ruptures per TOLAC was observed in countries with low previous CS and high TOLAC rates. Rates of hysterectomy and perinatal death are about 10% following complete uterine rupture, but in women undergoing TOLAC the rates are extremely low (only 2.2 and 3.2 per 10 000 TOLACs, respectively.) TWEETABLE ABSTRACT: Prevalence of complete uterine rupture is higher in countries with low previous CS and high TOLAC rates.

Measuring the effectiveness of maternal delivery services: A cross-sectional and qualitative study of perinatal mortality in six primary referral hospitals, Kenya

Background: The effective performance of hospitals is critical to overall health system goal achievement. Global health system performance frameworks are often used as part of global benchmarking, but not within low and middle-income countries as part of service delivery performance measurement. This study explored the utility of perinatal mortality as a measure of hospital effectiveness. Methods: A cross sectional, mixed methods study of six primary referral hospitals, differentiated by ownership, was conducted from 10th June to 9th October 2015. Monthly summary hospital data of maternal delivery services (MDS) were abstracted to determine the perinatal mortality. Tests of associations were used to correlate bed turnover, skilled staffing, method of delivery and perinatal mortality. Additionally, 40 questionnaire interviews were held with hospital board members and the management team to assess the availability of standard operating procedures (SOP) in MDS. Qualitative data was analysed thematically. Results: All six hospitals reported having SOP in managing MDS. The average perinatal mortality rate for all the hospitals was 24.63 per 1,000 live births. However, a perinatal death was 2.6 times more likely in public hospitals compared to private hospitals (29.8 vs 11.4 per 1,000 births respectively). The average caesarean section rate for all hospitals was 25.9%, but the odds of a caesarean section were 1.67 higher in a private hospital compared to a public hospital (P&lt;0.001 95% CI: 1.58-1.77). Perinatal mortality was associated with bed turnover ratio (R squared 0.260, P=0.001), and skilled staff availability (R squared 0.064,P&lt;0.001). Discussion: The high perinatal mortality reported in public hospitals may be due to high bed turnover and relatively low caesarean section rate. Input measures of performance such as reporting standards of care and staffing levels are not useful performance indicators. Perinatal mortality as a performance indicator may be an ideal measure of the effectiveness of hospitals.

Intrapartum Foetal Heart Rate Monitoring and Rate of Caesarean Section: A National Survey

The rate of Caesarean section has dramatically increased in recent decades. Foetal scalp blood sampling and computer software analysing foetal heart rate detection should help in the decision-making for or against Caesarean section. The main aim of this study was to examine how these 2 factors influence the Caesarean section rate. A national survey of all maternity units in Germany was undertaken using a self-reported questionnaire via crowd sourcing. All variables were collected as categorised data sets. Using these data sets, correlation coefficients were calculated. The correlations were additionally analysed using visual mosaic plots. 97 questionnaires were analysed. There were several strong correlations between variables in the data set. Particularly, hospitals that assessed the foetal heart rate in the normal range (110-160 bpm) according to the current FIGO guidelines had a lower C-section rate. Computer-assisted foetal heart rate assessment that is based on the FIGO guidelines correlated with a lower Caesarean section rate. The use and further development of computer-based cardiotocograph assessment analysis should be continued.

Elective induction of labor at 39 weeks among nulliparous women: The impact on maternal and neonatal risk

ObjectiveOptimal management of pregnancies at 39 weeks gestational age is unknown. Therefore, we sought to perform a comparative effectiveness analysis of elective induction of labor (eIOL) at 39 weeks among nulliparous women with non-anomalous singleton, vertex fetuses as compared to expectant management (EM) which included IOL for medical or obstetric indications or at 41 weeks in undelivered mothers.Materials and methodsA Monte Carlo micro-simulation model was constructed modeling two mutually exclusive health states: eIOL at 39 weeks, or EM with IOL for standard medical or obstetrical indications or at 41 weeks if undelivered. Health state distribution probabilities included maternal and perinatal outcomes and were informed by a review of the literature and data derived from the Consortium of Safe Labor. Analyses investigating preferences for maternal versus infant health were performed using weighted utilities. Primary outcome was determining which management strategy posed less maternal and neonatal risk. Secondary outcomes were rates of cesarean deliveries, maternal morbidity and mortality, stillbirth, neonatal morbidity and mortality, and preferences regarding the importance of maternal and perinatal health.ResultsA management strategy of eIOL at 39 weeks resulted in less maternal and neonatal risk as compared to EM with IOL at 41 weeks among undelivered patients. Cesarean section rates were higher in the EM arm (35.9% versus 13.9%, p<0.01). When analysis was performed only on patients with an unfavorable cervix, 39 week eIOL still resulted in fewer cesarean deliveries as compared to EM (8.0% versus 26.1%, p<0.01). There was no statistical difference in maternal mortality (eIOL 0% versus EM 0.01%, p = 0.32) but there was an increase in maternal morbidity among the EM arm (21.2% versus 16.5, p<0.01). There were more stillbirths (0.13% versus 0%, p<0.0003), neonatal deaths (0.25% versus 0.12%, p< 0.03), and neonatal morbidity (12.1% versus 9.4%, p<0.01) in the EM arm as compared to the eIOL arm. Preference modeling revealed that 39 week eIOL was favored over EM.Conclusions and relevanceMathematical modeling revealed that eIOL at 39 weeks resulted in lower population risks as compared to EM with induction of labor at 41 weeks. Specifically, eIOL at 39 weeks resulted in a lower cesarean section rate, lower rates of maternal morbidity, fewer stillbirths and neonatal deaths, and lower rates of neonatal morbidity.

A standardized antenatal class reduces the rate of cesarean section in southern Italy: A retrospective cohort study.

Italy, along with Poland and Hungary, has the highest cesarean section rate (35.7%) in Europe. Among Italian regions, Campania has the highest rate of cesarean section (58.4%).We developed a standardized antenatal class to evaluate whether women who attend this class during pregnancy have a lower cesarean section rate. This antenatal class was developed according to the indication of the Italian Ministry of Health and the World Health Organization. We selected a cohort of women who participated in this antenatal class and a cohort of women who did not participate. We collected information on the mode of delivery, and other characteristics, of these women from certificate of birth assistance form available in 2 hospitals where the women gave birth.Among women who participated in the antenatal class, there were more Italians, the women were more educated, more women were employed and there were more primiparas compared with those who did not participate. Non-participants of antenatal class showed a higher rate of cesarean section than those who participated (56.2% vs 23.1%; relative risk [RR] = 2.43; 95% confidence interval [CI] 1.95–3.03; P < .0001), as well as after adjustment for other variables. This difference was stronger in 1 hospital (RR = 2.88; 95% CI 2.13–3.89; P < .0001) than in the other hospital (RR = 1.86; 95% CI 1.36–2.55; P < .0001).Our standardized antenatal class, which was performed in an area with a high rate of cesarean section, significantly reduced this rate, and this was still significant after adjustment for potential confounders.

Induction of labor in cases of late preterm isolated oligohydramnios: is it justified?

Objectives: To analyze in a retrospective cohort study the outcomes of pregnancies with isolated oligohydramnios at the late preterm period (34–36.6 weeks of gestation).Study design: This retrospective cohort study included three groups of women: (1) Women with isolated oligohydramnios whose pregnancy was managed conservatively (n = 33 births); (2) women with isolated oligohydramnios who were managed actively (i.e. induction of labor) (n = 111 births); and (3) a control group including women with normal amount of amniotic fluid who had a spontaneous late preterm delivery (n = 10,445 births). Maternal and fetal characteristics and obstetrics outcomes were collected from a computerized database of all deliveries at Soroka University Medical Center during the study period.Results: Our cohort included 10,589 births. The rate of inducing labor was higher in the oligohydramnios groups compared to the controls (p < .001). There was an increase in the rate of cesarean section (CS) in the conservative treatment group (p < .001), compared with the other groups. Conservative management was associated with higher rates of maternal infection (p = .026), chorioamnionitis (p = .01), and transitory tachypnea of the newborn (p = .02). After controlling for confounding factors, mal presentation (OR = 19.9), and a prior CS (OR = 2.4) were independently associated with an increased risk for CS, while induction of labor was associated with a reduced risk for CS (OR = 0.28).Conclusions: Women with late preterm isolated oligohydramnios had a higher rate of induction of labor than women with a normal amount of amniotic fluid. Induction of labor seems to be beneficial to both the neonate and the mother as seen by a lower rate of CS conducted in this group, as well as lower maternal and neonatal morbidity in comparison to the conservative group. Therefore, women with oligohydramnios at late preterm may benefit from induction of labor.

A comparison of misoprostol vaginal insert and misoprostol vaginal tablets for induction of labor in nulliparous women: a retrospective cohort study

BackgroundSince Misoprostol Vaginal Insert (MVI - Misodel ®) was approved for labor induction in Europe in 2013, to date, no study has been published comparing MVI to Misoprostol vaginal tablets (MVT). The aim of this study, performed as part of a quality improvement project, was to compare the efficacy and safety of 200 μg MVI versus 25 μg MVT for labor induction in nulliparous women.MethodsThis retrospective cohort study included 171 nulliparous singleton term deliveries induced with MVI (n = 85) versus MVT (n = 86) at Oslo University Hospital Rikshospitalet, Norway, from November 2014 to December 2015. Primary outcomes were time from drug administration to delivery in hours and minutes and the rate of cesarean section (CS). Results were adjusted for Bishop Score and pre-induction with balloon catheter.ResultsMedian time from drug administration to delivery was shorter in the MVI group compared to the MVT group (15 h 43 min versus 19 h 37 min, p = 0.011). Adjusted for confounding factors, mean difference was 6 h 3 min (p = 0.002). The risk of CS was 67% lower in the MVI group compared to the MVT group (11.8% versus 23.3%, OR = 0.33; adjusted 95% CI 0.13–0.81). Adverse neonatal outcomes did not differ between the groups.ConclusionsIn a setting of routine obstetric care, MVI seems to be a more efficient labor induction agent than MVT, and with a lower CS rate and no increase in adverse infant outcomes.

Foley catheter versus intravaginal prostaglandins E2 for cervical ripening in women at term with an unfavorable cervix: a randomized controlled trial

Objective: The objective of this study is to compare the efficacy of labor induction by Foley catheter balloon (FCB) insertion to intravaginal dinoprostone tablet placement in women with an unfavorable cervix.Materials and methods: A prospective randomized controlled trial was conducted. Women were assigned to insertion of a FCB or placement of a vaginal dinoprostone tablets and their outcome were compared.Results: The study comprised 300 women. The time to active labor was significantly shorter in the FCB compared with the dinoprostone group, but required more oxytocin administration. A lower rate of cesarean section was found only in nulliparous women in the FCB group. The neonatal outcome was favorable and similar in both groups.Conclusion: Both methods had similar results regarding achieving vaginal delivery within 24 h and cesarean section rate. For nulliparous women, the FCB induction method had the advantage of a shorter time to active labor and a lower rate of cesarean section.

Management of Spontaneous Labor in Primigravidae: Labor Scale versus WHO Partograph (SLiP Trial) Randomized Controlled Trial

We aimed to compare maternal and neonatal outcomes of spontaneous term labor among primigravidae who were monitored by the novel labor scale versus the World Health Organization (WHO) partograph. A single center, double-blinded randomized trial had been conducted between July 2015 and June 2016. Nulliparous women in spontaneous labor with singleton term pregnancies were randomized to either labor scale or the WHO partograph for management of labor. Primary outcome was successful vaginal delivery. Secondary outcome included low APGAR scores, birth injuries, postpartum hemorrhage, and infection. One hundred ten patients were randomized (55 in each arm). Women managed with labor scale had significantly lower rate of cesarean deliveries than women managed with the partograph arm (3.6% versus 18.2%, P=0.03). There was a significant reduction in the rate and duration of oxytocin administration for augmentation of labor (21.8% versus 69.1%, P < 0.0001) and a significant increase in average 1-minute APGAR score in the labor scale group. Labor monitoring with the labor scale is associated with lower rate of cesarean section, less and shorter use of oxytocin for augmentation of labor. Monitoring of labor progress starting at 5 cm or more is also associated with lower rate of cesarean delivery.

The effect of family policies and public health initiatives on breastfeeding initiation among 18 high-income countries: a qualitative comparative analysis research design

BackgroundThe objective of this study is to examine the effects of macro-level factors – welfare state policies and public health initiatives – on breastfeeding initiation among eighteen high-income countries.MethodsThis study utilizes fuzzy-set Qualitative Comparative Analysis methods to examine the combinations of conditions leading to both high and low national breastfeeding initiation rates among eighteen high-income countries.ResultsThe most common pathway leading to high breastfeeding initiation is the combination of conditions including a high percentage of women in parliament, a low national cesarean section rate, and either low family spending, high rates of maternity leave, or high rates of women working part-time. The most common pathway leading to low breastfeeding initiation includes the necessary condition of low national adherence to the Baby-Friendly Hospital Initiative.ConclusionThis research suggests that there is a connection between broad level welfare state polices, public health initiatives, and breastfeeding initiation. Compliance with the WHO/UNICEF initiatives depends on welfare regime policies and overall support for women in both productive and reproductive labor.

Clinical Outcome Following Induction of Labour with Misoprostol

Background: Induction of labour in the third trimester of pregnancy may be considered beneficial in many clinical circumstances.Objective: The aim of this study was to find the effectiveness and safety of a novel dosing regimen of oral misoprostol in a Bangladeshi sample.Methods: A cross sectional study was conducted in the Department of Obstetrics and Gynecology, Sir Salimullah Medical College &amp; Mitford Hospital, Dhaka from October 2008 to September 2009 based on the guideline of American College of Obstetricians and Gynecologists. Fifty nine cases were enrolled according to inclusion criteria by clinical pelvimetry and bishop scoring. Contracted pelvis, evidence of cephalopelvic disproportion, placenta previa, unexplained vaginal bleeding, grand multipara, fetal malpresentation, previous uterine scar and fetal distress cases were excluded. Misoprostol was administered per orally. Maternal outcome was assessed by normal vaginal delivery, caesarean section, maternal distress, perineal tear, cervical tear, uterine hyper-stimulation and fetal outcome was assessed in the form of fetal distress, meconium stained amnions, neonatal admission, perinatal death and no complication. Statistical analysis was done using SPSS v 13. Probability value was set at P&lt;0.05 for statistical significance.Results: Mean age was 25.69(5.04) years and mean age of gestation was 38.23(4.3) weeks and 59% were in regular antenatal checkup. Misoprostol was administered orally, 15% single, 37% double, 34% three and l4% were more than three doses. Following induction, 85% had normal vaginal delivery, 10% caesarean section and 5% had forceps delivery. For induction, 56% were due to preeclampsia, eclampsia &amp; other pregnancy induced hypertension, 10% postdated pregnancy, 9% were unfavorable cervix, 7% IUD, l4% elective cases due to medical disorder, 2% had premature rupture of membrane, other causes were 3%. By bishop score assessment 54% had unfavorable and 46% had favorable cervix. In neonate's outcome, 34% had no complications, 19% meconium stained, 19% neonatal admission, 9% fetal distress and 20% had perinatal death including IUD. In maternal outcome, 69% no complications, 10% perineal tear, 10% caesarean section, 3% maternal distress, 3% cervical tear, 2% uterine hyper-stimulation, 2% episiotomy. There were no significant differences.Conclusions: Stepwise oral misoprostol was well tolerated with no increase in maternal side effects. There was also a trend towards more fetal safety in the oral misoprostol. Perhaps the most significant finding of our study is the lower cesarean section rate in the women who received the oral regimen.J Shaheed Suhrawardy Med Coll, 2014; 6(2):49-52

Foley catheter for induction of labour filled with 30 mL or 60 mL: A randomized controlled trial

ObjectivesOne of the methods used to induce labour is the placement of a transcervical Foley catheter (FC). The aim of this randomized controlled study was to assess in term pregnant women with an unfavourable cervix, whether there is a difference in efficacy between the two most commonly used insufflation volumes of FC (30mL and 60mL). Study designRandomized controlled trial. ResultsWomen were randomized to induction of labour with a Foley catheter filled with 30mL or with 60mL. Primary outcome was delivery within eight hours after amniotomy. Secondary outcomes included the time interval between placement of the Foley and amniotomy, the mode of delivery, complications and neonatal outcomes. In total, 174 women (87 in each arm) were randomized. The number of deliveries within eight hours after amniotomy was not significantly different between the two groups (40.7% versus 48.83%, OR=0.71(CI; 0.39–1.3)). Sub-analysis showed that more multiparous women in the 60mL group delivered within eight hours (93.10% versus 65.22%, OR=7.2 (CI; 1.35–38.37)). For the nulliparous, the 30mL Foley catheter was associated with a higher caesarean section rate (31.75% versus 15.52% (OR 2.53; CI; 1.1–6.2)). The 60mL Foley catheter was also associated with a higher chance of spontaneous labour after placement (OR 2.35; CI; 1.1–5.1), a shorter time interval for cervical ripening (OR=4.5; CI: 1.2–16.7) and less blood loss. (p=0.002). The Foley catheter ruptured twelve times in the 60mL group whereas this did not happen once in the 30mL group. One case of umbilical cord prolapse was observed in the 60mL group. No differences in neonatal outcomes and patient satisfaction were seen. ConclusionsFor our primary outcome, no difference was observed between the Foley catheter balloon filled with 60mL and the one filled with 30mL. Yet, a Foley catheter filled with 60mL was associated in multiparous women with a higher rate of deliveries within eight hours after amniotomy and in nulliparous with a significantly lower caesarean section rate. These latest findings should be interpreted with cautious as underpowered.

The Routine Use of Intrapartum Ultrasound in Clinical Decision-Making during the Second Stage of Labor - Does It Have Any Impact on Delivery Outcomes?

Background/Aims: The study aimed to assess whether the use of intrapartum transperineal ultrasound (US) can reduce the rate of failed vacuum extraction (VE). Methods: This is a retrospective cohort study including all women delivering at term with the diagnosis of protracted second stage of labor. The mode of delivery and rate of failed VE were compared between women who underwent a US examination prior to the decision on obstetrical interventions (“+US” group) and those in whom clinical decisions were based upon digital assessment only (“no-US” group). Results: The study included 635 women. Among the “no-US” group (536), there were 13 failed VE attempts (3.6%) vs. none in the “+US” group (99, p = 0.1). There was a significant difference between the groups regarding mode of delivery (p = 0.001), with a lower cesarean section (CS) rate (20.2 vs. 27.8%) among the “+US” group. Maternal age, body mass index, nulliparity, gestational age at delivery, and birth weight, as well as neonatal short-term outcome did not differ significantly between the 2 groups. Conclusions: We demonstrate that among women who had the addition of intrapartum US during the second stage of labor there was a trend toward a lower rate of failed VE (although not reaching statistical significance), with a lower rate of CS but not affecting neonatal outcome.