Term Labor Induction Research Articles

Laminiria Tents versus Vaginal Prostaglandin in Cervical Ripening in Term Induction of Labor with Unfavorable Cervix: A Randomized Controlled Trial

Abstract Background Mechanical methods used for induction of labor received a great attention nowadays due to the serious side effects of the pharmacological methods. Hygroscopic dilators are considered important subtype of these mechanical methods. One of them is Laminaria which is a synthetic type of sea algae that induces cervical dilation by absorbing water from the cervix and gradually increasing in thickness. Objective To compare the effectiveness and safety of Laminiria tents to intravaginal prostaglandins for cervical ripening in induction of labor at term gestation in women with unfavorable cervix. Methods A total of 90 pregnant women at term gestation with unfavorable cervix admitted to the labor ward for induction of labor at Ain Shams University Maternity Hospital, in the period from March 2022 to March 2023, were enrolled in the study and underwent assessment using Bishop score with monitoring differences between two groups in mode of delivery, time to enter active phase, time to delivery, changes in bishop score and noted complications. This study was registered on clinicaltrials.gov with number (NCT06151925) Results In the present study we demonstrated that in laminaria group, there was 66.7% had NVD and 33.3% had CS while in prostaglandin group, there was 71.1% had NVD and 28.9% had CS in which there was no statistically significant difference between laminaria and prostaglandin groups regarding routes of delivery. In this study we demonstrated that Time needed to enter active phase (hours) in laminaria group was 16 (10 – 19) while in prostaglandin group was12 (8 – 16) in which there was a statistically significant difference between laminaria and prostaglandin groups regarding Time needed to enter active phase (hours) (p = 0.022). In this study we demonstrated that regarding induction delivery time (hours) in laminaria group was 20 (13 – 25) while in prostaglandin group was 16 (11 – 20) in which there was a statistically significant difference between laminaria and prostaglandin groups regarding induction delivery time (hours) (P = 0.036). Conclusion Vaginal prostaglandin is more effective than laminaria tent for ripening of cervix before induction and can decrease labor duration and time to delivery. However, for better results further studies with a larger sample size are recommended.

Buccal versus Vaginal Misoprostol Combined with a Foley Catheter among Individuals with Obesity Undergoing Induction.

Combining pharmacologic agents with mechanical ripening achieves the shortest labor duration, yet there is no clear evidence on route of drug administration in obese individuals. The use of buccal misoprostol has shown greater patient acceptance but remains understudied. Our objective was to evaluate the difference in time to delivery of buccal compared with vaginal misoprostol in combination with a Foley catheter (FC) for induction of labor (IOL) in the obese population. This was a secondary analysis of a randomized controlled trial comparing identical dosages (25 μg) of buccal and vaginal misoprostol in combination with a FC. The parent trial was an institutional review board-approved, randomized clinical trial conducted from June 2019 through January 2020. Labor management was standardized among participants. Women undergoing IOL at ≥37 weeks with a singleton gestation and cervical dilation ≤2 cm were included. Body mass index (BMI, kg/m2) was stratified. The primary outcome was time to delivery. A total of 215 participants were included. Demographic characteristics were similar between the three groups. Vaginal drug administration achieved a faster median time to delivery than the buccal route among patients with a body mass index greater than or equal to 30 kg/m2 (vaginal misoprostol-FC: 21.3 hours vs. buccal misoprostol-FC: 25.2 hours, p = 0.006). There was no difference in the cesarean delivery rate between the two groups. Furthermore, patients with a BMI greater than or equal to 30 kg/m2 receiving vaginal misoprostol delivered 1.2 times faster than women who received buccal misoprostol after censoring for cesarean delivery and adjusting for parity (hazard ratio: 1.2, 95% confidence interval: 1.1-1.7). There were no significant differences in maternal and neonatal outcomes. We found that vaginal misoprostol was superior to buccal misoprostol when combined with a FC among individuals with a BMI greater than or equal to 30 kg/m2. Vaginal misoprostol should be the preferred route of drug administration for term IOL in this population. · Vaginal misoprostol was superior to buccal route among patients with obesity.. · There was no difference in the cesarean delivery rate between the two groups.. · Vaginal misoprostol should be the preferred route of administration among patients with obesity..

Feasibility Study to Compare Oxytocin Function Between Body Mass Index Groups at Term Labor Induction

ObjectiveTo determine the feasibility of a protocol to examine the association between oxytocin system function and birth outcomes in women with and without obesity before induction of labor. DesignProspective descriptive. SettingAcademic medical center in the U.S. Midwest. ParticipantsPregnant women scheduled for induction of labor at 40 weeks of gestation or greater (n = 15 normal weight; n = 15 obese). MethodsWe collected blood samples and abstracted data by chart review. We used percentages to examine adherence to protocol. We used t tests and chi-square tests to describe differences in sample characteristics, oxytocin system function variables, and birth outcomes between the body mass index groups. ResultsThe recruitment rate was 85.7%, protocol adherence was 97.1%, and questionnaire completion was 80.0%. Mean plasma oxytocin concentration was higher in the obese group (M = 2774.4 pg/ml, SD = 797.4) than in the normal weight group (M = 2193.5 pg/ml, SD = 469.8). Oxytocin receptor DNA percentage methylation (CpG −934) was higher in the obese group than in the normal weight group. ConclusionOur protocol was feasible and can serve as a foundation for estimating sample sizes in forthcoming studies investigating the diversity in oxytocin system measurements and childbirth outcomes among pregnant women in different body mass index categories.

The Relationship between Gestational Weight Gain and Cesarean Delivery among Patients undergoing Induction of Labor.

This study aimed to determine the impact of pregnancy weight gain above National Academy of Medicine (NAM) guidelines on cesarean delivery rates following induction. This is a secondary analysis of a prospective cohort study of patients who underwent induction at a single tertiary care center between July 2017 and July 2019. Included in the primary study were patients undergoing term (≥37 weeks) labor induction with a singleton gestation, intact membranes, and unfavorable cervical examination (Bishop score of ≤6 and cervical dilation ≤ 2 cm). Eligibility for this analysis was limited to patients with a documented prenatal body mass index (BMI) < 20 weeks' gestation. The primary exposure was gestational weight gain greater than NAM guidelines (WGGG) for a patient's initial BMI category. The primary outcome was cesarean delivery for any indication. Of 1,610 patients included in the original cohort, 1,174 (72.9%) met inclusion criteria for this analysis and 517 (44.0%) of these had weight gain above NAM guidelines. Of the entire cohort, 60.0% were Black and 52.7% had private insurance. In total, 160 patients (31%) with WGGG underwent cesarean compared with 127 patients (19.3%) without WGGG (p < 0.001), which equates to a 59% increased odds of cesarean when controlling for initial BMI category, parity, gestational diabetes, and indication for induction (Adjusted Odds Ratio [aOR] 1.58, 95% confidence interval [CI] 1.17-2.12). Among only nulliparous patients, WGGG was associated with an increased odds of cesarean (26.4 vs. 38.2%, aOR 1.50, 95% CI 1.07-2.10). In multiparous patients, however, there was no difference in cesarean between those with and without WGGG (8.8 vs. 14.1%, aOR 1.85, 95% CI 0.96-3.58). This study demonstrates that weight gain above NAM guidelines is associated with more than a 50% increased odds of cesarean. Patients should be informed of this association as gestational weight gain may be a modifiable risk factor for cesarean delivery. · Weight gain above NAM guidelines was associated with a 59% increased odds of cesarean delivery.. · Nulliparous patients with weight gain above NAM guidelines are at higher risk of cesarean delivery.. · No difference in cesarean delivery among multiparous patients regardless of gestational weight gain..

Clinical Effects of Cervical Dilation Balloon and Castor Oil Meal Nursing Interventions in Term Induction of Labor

This study analyzed the clinical effects of cervical dilation balloon and castor oil meal nursing interventions in term induction of labor. The eighty pregnant women who were scheduled for delivery in our hospital between March 2020 and January 2022 were recruited into an observation group and a control group using a random number table. The control group received oxytocin for labor induction while the observation group received cervical dilation balloon and castor oil meal nursing interventions for labor induction. In addition to clinical treatment experiments, cell experiments are performed. BeWo cells were cultured to study the effect of estrogen on cell viability, and the expression of matrix metalloproteinase 2 and 9 (MMP2, MMP9) was detected using Western blotting. The endpoints of this study were to investigate the impact of estrogen changes on term-induced pregnant women and to compare the cervical dilation balloon and castor oil meal nursing interventions with regards to duration of labor, efficacy of cervical ripening, Bishop score of the cervix, postpartum complications, and other relevant indicators. The viability of BeWo cells did not significantly differ after treatment with different concentrations of 17β-E2 (-&gt; 0.05). The expression of MMP9 after different levels of treatment did not significantly differ (P &gt;0.05), whereas the expression of MMP2 protein in the 5×10−7 and 5×10−8 M treatment groups was lower than that in the control group (P &lt;0.05). The first stage and total duration of labor were significantly shorter in the observation group than that in the control group (P &lt;0.05). The efficacy of cervical ripening was significantly higher in the observation group than that in the control group (P &lt;0.05). The Bishop score of the cervix was significantly higher in the observation group after intervention (P &lt;0.05). The incidence of complications in the observation group was significantly lower than that in the control group (P &lt;0.05). Estrogen levels may affect the invasive function of trophoblast cells, causing abnormal placental function. Castor oil has hormonal effects and contains precursors for prostaglandin synthesis and can induce and strengthen contractions, soften the cervix, and dilate the cervix. The combined use of cervical dilation balloon and castor oil meal in term induction of labor has clear clinical effects, including the effective shortening of labor duration, favorable cervical ripening, significant improvement in the Bishop score of the cervix, and reduced incidence of complications. This study suggests its potential for clinical application and wider use.

Pharmacokinetics of oral misoprostol for induction of labor in pregnancies complicated by obesity

Birthing parents with obesity have increased risk of medical and obstetric complications during pregnancy, often leading to a recommendation for induction of labor (IOL). Misoprostol is commonly used for IOL, however there is limited data on whether it’s pharmacokinetics (PK) are altered by body size. The objective of this study is to evaluate PK parameters of oral misoprostol in pregnancies complicated by obesity. Pilot, single-center, observational study of non-fasting, term, singleton pregnancies with body mass index (BMI) > 30.0 kg/m2 at time of IOL with 50 mcg oral misoprostol. Plasma concentrations of active metabolite misoprostol acid (MPA) were measured at four time points using liquid chromatography mass spectrometry. Plasma MPA-time data analyzed using a non-compartmental PK model to derive the area under the curve from the first time point to the last measured concentration (AUC0-t) using the trapezoidal rule. Terminal slope (λz) used to extrapolate plasma concentration to infinity (AUC0-∞). Maximum serum concentration (Cmax) and time to maximum plasma concentration (Tmax) also described. 26 plasma observations from 7 subjects were included (Table 1). Observed plasma concentrations over time (Figure 1) demonstrate median(range) Cmax 26.63 (7.18-56.24) pg/mL, AUC0-t 10.93 (2.43-24.64) pg-h/mL, λz 2.68 (2.00-3.07) h-1, AUC0-∞ 22.67 (12.09-30.60) pg-h/mL. Tmax observed at 0.25 hours. Prior study evaluating 50 mcg oral misoprostol in 12 subjects with normal BMI (mean 28.6 kg/m2) reports mean±SD Cmax 53.97±23.79 pg/mL, AUC0-t 55.02±28.80 pg-h/mL, λz 1.05±0.86 h-1, AUC0-∞ 66.63±33.22 pg-h/mL, Tmax 0.23±0.14 hours. To our knowledge, this study is the first examination of 50 mcg oral misoprostol PK parameters among parturients with obesity undergoing term IOL. Data show decreases in PK parameters in this population, however some results are still within reported margin of error and there is marked variance between subjects. A future, powered, comparative trial is necessary to confirm these findings as well as further investigate clinically relevant outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Successful Peripartum Venoarterial Extracorporeal Membrane Oxygenation for Pheochromocytoma-Induced Cardiogenic Shock

We describe a 37-year-old multiparous woman with cardiogenic shock resulting from pheochromocytoma crisis. She had term labor induction after developing hypertension attributed to preeclampsia. Severe hemodynamic instability followed on postpartum day 2 requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO). Suspicion for pheochromocytoma arose after a computed tomography scan showed a large adrenal mass, and the diagnosis was confirmed with plasma and 24-hour urine metanephrine levels. She initially had cardiomyopathy with left ventricular ejection fraction less then 10%, which rapidly improved, and she was successfully weaned off VA-ECMO. This patient case illustrates the clinical challenges concerning pheochromocytoma during pregnancy.

Validation of three models (Tolcher, Levine, and Burke) for predicting term cesarean section in Chinese population

Background: Some models predicting cesarean section (CS) have been proposed, with Tolcher, Levine, and Burke model well acknowledged. Tolcher model targets nulliparous women with term labor induction; Levine model targets women with term labor induction with intact membranes and an unfavorable cervix. Burke model targets term nulliparous woman with an uncomplicated pregnancy. Our objective was to assess the predictive performance of these three models, and to disclose the variables which may predict the risk of CS in Chinese population. Methods: A retrospective study was conducted on women with singleton, term, cephalic pregnancies at a tertiary academic center (2011–2017). A predicted probability for CS was calculated for women in the dataset by the algorithm of each model. The performance of the model was evaluated for discrimination. Univariate analysis was used to screen out the factors that may increase the risk of CS. Results: The three models predicted CS as following (expressed by an area under the receiver operating characteristic curve [AUC ROC]) (in the population defined/employed by each model): Tolcher model with AUC ROC of 0.659; Levine model with 0.697; and Burke model as 0.623. Different interventional measures or characteristics of labor were also evaluated; the nulliparous and multiparous were analyzed separately. Still, most of the results were unsatisfactory (AUC ROC &lt;0.7). Univariate analyses on the clinical parameters that may affect the incidence of CS were performed. The followings affected the incidence/probability of CS: maternal age, height, body mass index (BMI), weight gain during pregnancy, gestational age, mode of labor induction, meconium-stained amniotic fluid, presence of complications, neonatal weight/gender. Conclusion: These three models may not be suitable for predicting CS for Chinese population. Some maternal and fetal characteristics increased the risk of CS, which should be taken into account in creating some appropriate models for predicting CS in Chinese population.

Association between plasma leptin and cesarean section after induction of labor: a case control study

BackgroundObesity in pregnancy is common, with more than 50% of pregnant women being overweight or obese. Obesity has been identified as an independent predictor of dysfunctional labor and is associated with increased risk of failed induction of labor resulting in cesarean section. Leptin, an adipokine, is secreted from adipose tissue under the control of the obesity gene. Concentrations of leptin increase with increasing percent body fat due to elevated leptin production from the adipose tissue of obese individuals. Interestingly, the placenta is also a major source of leptin production during pregnancy. Leptin has regulatory effects on neuronal tissue, vascular smooth muscle, and nonvascular smooth muscle systems. It has also been demonstrated that leptin has an inhibitory effect on myometrial contractility with both intensity and frequency of contractions decreased. These findings suggest that leptin may play an important role in dysfunctional labor and be associated with the outcome of induction of labor at term. Our aim is to determine whether maternal plasma leptin concentration is indicative of the outcome of induction of labor at term. We hypothesize that elevated maternal plasma leptin levels are associated with a failed term induction of labor resulting in a cesarean delivery.MethodsIn this case-control study, leptin was measured in 3rd trimester plasma samples. To analyze labor outcomes, 174 women were selected based on having undergone an induction of labor (IOL), (115 women with successful IOL and 59 women with a failed IOL). Plasma samples and clinical information were obtained from the UI Maternal Fetal Tissue Bank (IRB# 200910784). Maternal plasma leptin and total protein concentrations were measured using commercially available assays. Bivariate analyses and logistic regression models were constructed using regression identified clinically significant confounding variables. All variables were tested at significance level of 0.05.ResultsWomen with failed IOL had higher maternal plasma leptin values (0.5 vs 0.3 pg, P = 0.01). These women were more likely to have obesity (mean BMI 32 vs 27 kg/m2, P = 0.0002) as well as require multiple induction methods (93% vs 73%, p = 0.008). Logistic regression showed Bishop score (OR 1.5, p < 0.001), BMI (OR 0.92, P < 0.001), preeclampsia (OR 0.12, P = 0.010), use of multiple methods of induction (OR 0.22, P = 0.008) and leptin (OR 0.42, P = 0.017) were significantly associated with IOL outcome. Specifically, after controlling for BMI, Bishop Score, and preeclampsia, leptin was still predictive of a failed IOL with an odds ratio of 0.47 (P = 0.046). Finally, using leptin as a predictor for fetal outcomes, leptin was also associated with of fetal intolerance of labor, with an odds ratio of 2.3 (P = 0.027). This association remained but failed to meet statistical significance when controlling for successful (IOL) (OR 1.5, P = 0.50).ConclusionsMaternal plasma leptin may be a useful tool for determining which women are likely to have a failed induction of labor and for counseling women about undertaking an induction of labor versus proceeding with cesarean delivery.

Term Induction of Labour in Nulliparous Women: When to draw the line?

There exists uncertainty surrounding the most effective and efficient means of inducing labour, particularly in the setting of an unfavourable cervix. This study aims to determine the merit of repeating dinoprostone administration when a single application has failed to render the cervix favourable for amniotomy.

114 Early versus delayed amniotomy following combination foley catheter-misoprostol for term labor induction

We sought to assess whether early amniotomy reduces the duration of labor or increases the proportion of women delivered within 24 hours among patients undergoing combined Foley Catheter-Misoprostol (FC-M) labor induction at term. This was a planned secondary analysis of a randomized controlled trial. Women with a term (≥37 weeks), singleton pregnancy undergoing FC-M cervical ripening were included. Early amniotomy was defined as artificial rupture of membranes prior to or at 4cm cervical dilation. Amniotomy beyond 4cm was categorized as delayed. Our primary outcome was time from induction initiation to delivery. Cox proportional hazard models were used, accounting for maternal age, race, gestational age, and route of misoprostol administration. 215 women were included: 116 (54%) in the early amniotomy group and 99 (46%) in the delayed group. Demographic and clinical characteristics were similar between the two groups. Delayed amniotomy was associated with shorter time to delivery after adjusting for confounders (hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.09-1.89; p=0.01). Women in the delayed group spent a significantly shorter time in labor (20.4 hours vs 23.1 hours, p=0.03). There was no difference in the proportion of women who delivered within 12 or 24 hours. We found no difference in the rate of cesarean delivery between the two groups (19.8% vs 19.2%, p=1.0). There were no significant differences in maternal and neonatal outcomes. Delayed amniotomy was associated with shorter length of labor without increasing maternal or neonatal adverse events. Delaying amniotomy beyond 4cm dilation should be preferred in women undergoing term labor induction with FC-M.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

891 Use of misoprostol for labor induction among women with fetal growth restriction

To determine whether vaginal misoprostol use among women with fetal growth restriction (FGR) for induction of labor (IOL) was associated with cesarean delivery (CD) or neonatal morbidity. This was a secondary analysis of a prospective cohort study of women undergoing IOL at one institution from July 2017-July 2019. Women were included if they were undergoing IOL at ≥37 weeks with intact membranes and an unfavorable cervix (Bishop score of ≤6 and cervical dilation ≤2cm). Women with a prior CD or estimated fetal weight (EFW)<3rd percentile with abnormal umbilical artery dopplers were excluded. FGR was defined as EFW <10th percentile. Our exposed group was those who received any misoprostol during IOL (alone or in combination with cervical Foley); unexposed were those who did not receive misoprostol. Choice of induction agents were at provider discretion. There were 1,610 women in the entire cohort; 419 had known FGR and were included. There was no difference in CD risk among those who received misoprostol versus those who did not (25.3% vs 22.9% p=0.72), even when controlling for confounders including parity, bishop score, and body mass index, (aOR 0.75, 95% CI 0.34-1.67). Among all CDs, the rate of CD for non-reassuring fetal heart tones (NRFHT) was also not significantly different between groups (misoprostol 56% vs no misoprostol 55%, p=0.91). Notably, the rate of neonatal 5 minute Apgar score <7 was lower among those who received misoprostol compared to those who did not (1.3% vs. 6.2%, p=0.02). Neonatal intensive care unit admission >48 hours was also lower among those who received misoprostol, though this did not reach statistical significance (3.2% vs 6.2%, p=0.13). When restricted to those with FGR<5th percentile, results were unchanged. In this large prospective cohort of women with FGR undergoing term IOL, misoprostol exposure did not increase CD risk overall, CD for NRFHT, or neonatal morbidity. These findings provide reassurance that misoprostol can be used safely for cervical ripening in women with FGR.

Metabolic Predictors of High‐ vs. Low‐Oxytocin Requirements During Labor Induction

IntroductionThe purpose of this study was to evaluate differences in the metabolic pathways activated in late‐pregnancy serum samples among African American women who went on to have term (≥37 weeks) labor induction requiring high total oxytocin doses to complete first‐stage labor compared to those in similar women with low‐oxytocin labor inductions.MethodsCase–control study (N = 27 women with labor induction with successful cervical ripening: 13 requiring the highest total doses of synthetic oxytocin to progress from 4‐ to 10‐cm cervical dilation and 14 requiring the lowest total doses) with groups balanced on parity and gestational age. Serum samples obtained between 24 and 30 weeks’ gestation were analyzed using ultra‐high‐resolution metabolomics. Differentially expressed metabolites between high‐oxytocin induction cases and low‐oxytocin induction comparison subjects were evaluated using linear regression with xmsPANDA. Metabolic pathways analysis was conducted using Mummichog Version 2.0, with discriminating metabolites annotated using xMSannotator Version 1.3.ResultsLabor processes were similar by group with the exception that cases received over 6 times more oxytocin between 4‐ and 10‐cm cervical dilation than comparison women. Induction requiring high total doses of synthetic oxytocin was associated with late‐pregnancy serum levels of metabolites from the linoleate and fatty acid activation pathways in term, African American women.DiscussionSerum levels of several lipid metabolites predicted more complicated labor induction involving higher doses of synthetic oxytocin to complete first‐stage labor. Further investigation in larger, more diverse cohorts of women is needed to identify potential targets to prevent failed labor induction.Reprinted with permission. Carlson NS, Frediani JK, Corwin EJ, Dunlop A, Jones D., Metabolic pathways associated with term labor in African‐American women. Biol Res Nurs. 2020;22(2):157‐168.

Term Labor Induction and Cesarean Delivery Risk among Obese Women with and without Comorbidities

Findings of the recent ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial, showing reduced cesarean risk with elective labor induction among low-risk nulliparous women at 39 weeks' gestation, have the potential to change interventional delivery practices but require examination in wider populations. The aim of this study was to identify whether term induction of labor was associated with reduced cesarean delivery risk among women with obesity, evaluating several maternal characteristics associated with obesity, induction, and cesarean risk. We studied administrative records for 66,280 singleton, term births to women with a body mass index ≥30, without a prior cesarean delivery, in New York City from 2008 to 2013. We examined elective inductions in 39 and 40 weeks' gestation and calculated adjusted risk ratios for cesarean delivery risk, stratified by parity and maternal age. We additionally evaluated medically indicated inductions at 37 to 40 weeks among women with obesity and diabetic or hypertensive disorders, comorbidities that are strongly associated with obesity. Elective induction of labor was associated with a 25% (95% confidence interval: 19-30%) lower adjusted risk of cesarean delivery as compared with expectant management at 39 weeks of gestation and no change in risk at 40 weeks. Patterns were similar when stratified by parity and maternal age. Risk reductions in week 39 were largest among women with a prior vaginal delivery. Women with comorbidities had reduced cesarean risk with early term induction and in 39 weeks. Labor induction at 39 weeks was consistently associated with reduced risk of cesarean delivery among women with obesity regardless of parity, age, or comorbidity status. Cesarean delivery findings from induction trials at 39 weeks among low-risk nulliparous women may generalize more broadly across the U.S. obstetric population, with potentially larger benefit among women with a prior vaginal delivery. · We found reduced cesarean risk with induction at 39 weeks.. · Results were consistent for age and comorbidity subgroups.. · Risk reductions were largest among multiparous women..

Factors associated with emergency caesarean section delivery during term induction of labour: A case-control study

Factors associated with emergency caesarean section delivery during term induction of labour: A case-control study

Induction of Labor and Risk of Third- and Fourth-Degree Perineal Tears [18P

INTRODUCTION: The rate of induction of labor (IOL) at term has been increasing over the years. Our objective was to evaluate the risk of third- and fourth-degree perineal tears associated with term induction of labor. METHODS: We conducted a population-based, retrospective cohort study using the United States' Nationwide Inpatient Sample to evaluate the risk of third- and fourth-degree perineal tears in women who underwent IOL at term between 2005 and 2014. We included all term livebirths and excluded, preterm births, previous cesarean deliveries, multifetal gestations, and non-cephalic presentation. Women who underwent an IOL at term were identified using ICD-9 coding. Patient characteristics were compared between those women being induced at term with those who weren't, and logistic regression analysis were carried out to estimate the adjusted effect of IOL at term with risk of 3rd and 4th perineal tears RESULTS: Among 5,982,945 eligible live births, 1,035,003 (17.3%) underwent an IOL at term, increasing from 15.7% to 18.5%. Women with an IOL were more likely to be older, Caucasian, and with comorbid illnesses. Compared with women who did not undergo an IOL, women in the IOL group had lower risk of cesarean deliveries, 0.89 (0.88–0.89), 2nd degree tears, 0.89 (0.89–0.90), 3rd degree tears, OR 0.81 (95% CI 0.79–0.82) and 4th degree tears, OR 0.84 (95% CI 0.82–0.87). CONCLUSION: Induction of labor at term results in significantly lower risk of third- and fourth-degree perineal tears among all deliveries as well as among women with vaginal deliveries.

Maternal and Neonatal Outcomes Associated with Amniotomy among Nulliparous Women Undergoing Labor Induction at Term.

The aim of the study is to evaluate the association between amniotomy at various time points during labor induction and maternal and neonatal outcomes among term, nulliparous women. Secondary analysis of a randomized trial of term labor induction versus expectant management in low-risk, nulliparous women (2014-2017) was conducted. Women met inclusion criteria if they underwent induction ≥38 weeks' gestation using oxytocin with documented time and type of membrane rupture. Women with antepartum stillbirth or fetal anomaly were excluded. The primary outcome was cesarean delivery. Secondary outcomes included maternal and neonatal complications. Maternal and neonatal outcomes were compared among women with amniotomy versus women with intact membranes and no amniotomy at six 2-hour time intervals: before oxytocin initiation, 0 to <2 hours after oxytocin, 2 to <4 hours after, 4 to <6 hours after, 6 to <8 hours after, and 8 to <10 hours after. Multivariable logistic regression adjusted for maternal age, body mass index, race/ethnicity, modified Bishop score on admission, treatment group, and hospital (as a random effect). Of 6,106 women in the parent trial, 2,854 (46.7%) women met inclusion criteria. Of these 2,340 (82.0%) underwent amniotomy, and majority of the women had amniotomy performed between 2 and <6 hours after oxytocin. Cesarean delivery was less frequent among women with amniotomy 6 to <8 hours after oxytocin compared with women without amniotomy (21.9 vs. 29.7%; adjusted odds ratio 0.61, 95% confidence interval 0.42-0.89). Amniotomy at time intervals ≥4 hours after oxytocin was associated with lower odds of labor duration >24 hours. Amniotomy at time intervals ≥2 hours and <8 hours after oxytocin was associated with lower odds of maternal hospitalization >3 days. Amniotomy was not associated with postpartum or neonatal complications. Among a contemporary cohort of nulliparous women undergoing term labor induction, amniotomy was associated with either lower or similar odds of cesarean delivery and other adverse outcomes, compared with no amniotomy.

Association of Term Labor Induction vs Expectant Management With Child Academic Outcomes

Although labor induction at 39 weeks of gestation has been shown to reduce the number of cesarean deliveries, compared with expectant management, without increasing neonatal morbidity in nulliparous, low-risk women, the association between induction at 39 weeks and longer-term childhood cognitive outcomes is not certain. To evaluate educational outcomes of children born by induction at 39 or 40 weeks compared with those whose mothers were expectantly managed beyond those weeks. This statewide cohort study was conducted in Rhode Island. The participants included children of nulliparous women who were born at 39 weeks of gestation or later and then completed third-grade math and reading tests during the 2014 to 2017 academic year. Data analysis was performed from July 2019 to October 2019. Induction of labor compared with expectant management. Third-grade math and reading test scores and proficiency (based on achievement level) among children born after induction in the 39th or 40th week were compared with scores for those who remained in utero beyond that same gestational week. The hypothesis was that induction in the 39th or 40th week would not be associated with differences in math or reading scores or proficiency compared with expectant management past the 39th or 40th week of gestation. Of the 6393 children meeting the inclusion criteria (mean [SD] age, 8.00 [0.22] years; 3208 boys [50.2%]; 376 [5.8%] black; 1280 [22.0%] Hispanic), 455 were delivered by induction in the 39th week and 610 were delivered by induction in the 40th week. There were no differences in mean math or reading test scores or in the frequency of math or reading proficiency between children delivered by induction at 39 or 40 weeks compared with those whose mothers were expectantly managed (overall mean [SD] math score, 744 [33]; overall mean [SD] reading score, 743 [38]; 2945 children [46%] achieved proficiency in math and 2833 [44%] achieved proficiency in reading). After adjusting for plausible confounders (race/ethnicity, maternal education, hypertension, diabetes, and socioeconomic status), induction continued to be associated with similar proficiency in math and reading compared with expectant management. For children born by induction at 39 weeks, the adjusted relative risks were 1.07 (95% CI, 0.97-1.18) for math proficiency and 0.98 (95% CI, 0.88-1.08) for reading proficiency. For children born by induction at 40 weeks, the adjusted relative risks were 0.97 (95% CI, 0.88-1.08) for math proficiency and 0.98 (95% CI, 0.89-1.08) for reading proficiency. These findings suggest that the offspring of nulliparous women for whom labor is induced at 39 or 40 weeks have similar third-grade educational outcomes compared with the offspring of mothers who underwent expectant management past those gestational ages.

Influence of maternal age in mode of delivery after term induction of labor

Objective To determine the impact of maternal age on the rate of cesarean delivery in women undergoing induction at term. Study Design Retrospective cohort study of term singleton gestations in nulliparous women induced for any indication at Lehigh Valley Health Network from July 2010 to July 2013. Exposure of interest was maternal age. Primary outcome was cesarean delivery. For every one woman ≥35 years of age (exposed), 2–3 women <35 years of age were selected as unexposed subjects for comparison. Statistical analysis included bivariate and multivariable techniques. Results 406 patients were included; 101 women ≥35 years of age and 305 women <35 years of age. Women in the ≥35 group were more likely to be induced for maternal medical conditions and less likely to be induced for prolonged pregnancy; few inductions were elective. Few women were induced electively in either group. More than half of women in both groups required cervical ripening. Method of cervical ripening and/or induction and percentage of women with a Bishop score <5 were similar between groups. The primary outcome, cesarean delivery, was similar between groups (45.5% in age ≥35 group vs 40.0% in age <35 group, p = .33). After adjustment for potential confounders, the rate of cesarean delivery was not influenced by maternal age (AOR 1.21 [0.76, 1.91], p = .42) but was higher in women with a Bishop score <5 at the time of induction of labor [AOR 1.64 [1.09, 2.47], p = .02]. Conclusion In the wake of several recent trials underscoring the safety and potential maternal and fetal benefit of labor induction, identifying predictors of induction success (and failure) takes on increasing importance. Our findings suggest that maternal age is not an independent risk factor for cesarean delivery in women undergoing induction.

Factors associated with emergency caesarean section delivery during term induction of labour: A case-control study

Factors associated with emergency caesarean section delivery during term induction of labour: A case-control study