Uterine Hyperstimulation Research Articles

Adverse pregnancy outcomes associated with maternal prenatal ingestion of traditional medicine

Pregnancy is associated with complications ranging from minor ailments to major morbidity and mortality. To prevent such complications, some women, including some in South Africa, resort to the use of traditional medicines. These are meant to either supplement or replace conventional medicines that are offered by their healthcare facilities. Some of these medicines, however, have the potential to cause harm, can increase pregnancy-related complications and may adversely interact with other medicines prescribed during the pregnancy. We present a case of an 18-year-old primigravida who commenced prenatal ingestion of traditional medicine ( moruto wamfene , otherwise called baboon urine) at 28 weeks’ gestation, in an attempt to improve her pregnancy outcomes. However, she instead developed uterine hyperstimulation, fetal bradycardia and thick meconium-stained liquor during labour. This report is intended to raise awareness about prenatal ingestion of traditional medicine (particularly moruto wamfene ), highlights the safety concerns and suggests preventive measures.

Maternal outcomes and factors associated with different methods of induction of labour at the University Teaching Hospital - Lusaka, Zambia

bjectives: To determine maternal outcomes and factors associated with different methods of induction of labour, prevalence of and induction to delivery time at the Women and Newborn Hospital of the University Teaching Hospitals in Lusaka, Zambia.
 Methods: A cross sectional study design was used with 147 women who met inclusion criteria recruited in the study. Convenience sampling was used to recruite study participants using an investigator admnistered data collection tool. Data analysis was stratified by method of induction of labour. Logistic regression was used to determine association between method of induction and maternal outcome. Association between sociodemographic variables and maternal outcomes were analysed using crude odds ratios to determine statistical significance. Simple logistic regression was then used to further analyse associations with p – values of less than< 0.05
 Results: Results showed that in the majority of patients, labour was induced using misoprostol 122 (77.7%) in which most of whom 90 (83%) the vaginal route was used (73.8%) followed by the intracervical balloon catheter. Three (2%) patients suffered uterine hyper stimulation, eight (5.4%) had precipitate labour, one (0.7%) had uterine rupture while three (2%) of the patients had APH and PPH after induction of labour with misoprostol. Regression analysis showed no statistically significant association between uterine hyperstimulation ( p-value 0.503, CI 0.038 – 4.991), Precipitate labour (p value 0.702, CI 0.178 – 12.951), antepartum haemorrhage ( p value 0.999) and post partum haemorrhage ( p value 0.999). There was no association between induction of labour using misoprostol and uterine rupture. There was no statistically significant association between Induction of labour using intracervical ballon catheter and uteine hyperstimulation ( p - value 0.635 CI 0.158 – 20.624), precipitate labour ( pvalue 0.827 CI 0.230 – 6.287), antepartum or post partum haemorrhage. There was no association between induction of labour using intracervical ballon catheter and uterine rupture ( p – value 1.00). Mean induction to delivery time using prostaglandins (misoprostol) was 15.2 hours with a range of 2.9 to 52.4 hours, 21.3 hours with intracervical balloon catheter with a range of 4.0 to 52.4 hours and 20.3 hours for membrane stripping with a range of 19.5 to 20.6 hours.
 Conclusion: Induction of labour using either misoprostol or intracervical balloon catheter were not significantly associated with adverse maternal outcomes. There was no association between uterine rupture and induction of labour using either misoprostol or intracervical ballon catheter. The most common method of induction of labour used at the Women and Newborn Hospital involved use of misoprostol followed by the intracervical balloon catheter.

Maternal Outcomes and Factors Associated with Different Methods of Induction of Labour at the University Teaching Hospital - Lusaka, Zambia

Objectives: To determine maternal outcomes and factors associated with different methods of induction of labour, prevalence of and induction to delivery time at the Women and Newborn Hospital of the University Teaching Hospitals in Lusaka, Zambia.
 Methods: A cross sectional study design was used with 147 women who met inclusion criteria recruited in the study. Convenience sampling was used to recruite study participants using an investigator admnistered data collection tool. Data analysis was stratified by method of induction of labour. Logistic regression was used to determine association between method of induction and maternal outcome. Association betweensociodemographic variables and maternal outcomes were analysed using crude odds ratios to determinestatistical significance. Simple logistic regression was then used to further analyse associations with p– values of less than< 0.05
 Results: Results showed that in the majority of patients, labour was induced using misoprostol 122 (77.7%) in which most of whom 90 (83%) the vaginal route was used (73.8%) followed by the intracervical balloon catheter. Three (2%) patients suffered uterine hyper stimulation, eight (5.4%) had precipitate labour, one (0.7%) had uterine rupture while three (2%) of the patients had APH and PPH after induction of labour with misoprostol.Regression analysis showed no statistically significant association between uterine hyperstimulation ( p-value 0.503, CI 0.038 – 4.991), Precipitate labour (p value 0.702, CI 0.178 –12.951), antepartum haemorrhage ( p value 0.999) and post partum haemorrhage ( p value 0.999).There was no association between induction of labour using misoprostol and uterine rupture. There was no statistically significant association between Induction of labour using intracervical ballon catheter and uteine hyperstimulation ( p - value 0.635 CI 0.158 – 20.624), precipitate labour ( pvalue 0.827 CI 0.230 – 6.287), antepartum or post partum haemorrhage. There was no association between induction of labour using intracervical ballon catheter and uterine rupture ( p – value 1.00). Mean induction to delivery time using prostaglandins (misoprostol) was 15.2 hours with a range of 2.9 to 52.4 hours, 21.3 hours with intracervical balloon catheter with a range of 4.0 to 52.4 hours and 20.3 hours for membrane stripping with a range of 19.5 to 20.6 hours.
 Conclusion: Induction of labour using either misoprostol or intracervical balloon catheter were not significantly associated with adverse maternal outcomes. There was no association between uterine rupture and induction of labour using either misoprostol or intracervical ballon catheter. The most common method of induction of labour used at the Women and Newborn Hospital involved use of misoprostol followed by the intracervical balloon catheter.

Comparison of effectiveness and safety of cervical ripening methods for induction of labour: A population-based study using coarsened exact matching.

There is no consensus about the ideal cervical ripening method to use for induction of labour. To compare in current practice the effectiveness and safety of four cervical ripening methods. We performed a matched comparative study using data from the MEDIP prospective population-based cohort conducted during one month in 2015 in all maternity units of seven French perinatal networks (3042 consecutive women with a live fetus and induction of labour). We analysed 1671 women with singleton cephalic fetus, unscarred uterus, and bishop score <7. Dinoprostone vaginal pessary (reference) was compared to dinoprostone vaginal gel, misoprostol vaginal tablet, and balloon catheter. Effectiveness outcomes were the need for more than one induction agent, oxytocin use, failure to achieve vaginal delivery within 24hours (VD<24hours), and caesarean delivery. Safety outcomes were meconium-stained amniotic fluid, uterine hyperstimulation, NICU admission, and post-partum haemorrhage. Coarsened exact matching was used to balance confounders among the groups. Outcomes were compared using multivariable logistic regression models. Compared to the dinoprostone pessary (N=1142, 68.3%), dinoprostone gel (N=335, 20.1%) was associated with less failure to achieve VD<24hours (adjusted OR 0.66, 95% CI 0.47, 0.91). Misoprostol (N=103, 6.2%) was associated with less need of more than one induction agent (aOR 0.56, 95% CI 0.34, 0.92) and less oxytocin use (aOR 0.60, 95% CI 0.37, 0.99). The balloon catheter (N=91, 5.4%) was associated with more failure to achieve VD<24hours (aOR 2.62, 95% CI 1.37, 5.01), more caesarean delivery (aOR 1.84, 95% CI 1.09, 3.08), and less meconium-stained amniotic fluid (aOR 0.12, 95% CI 0.02, 0.70). Uterine hyperstimulation rates seemed lower with the balloon catheter (1.2% vs 4.2% for the pessary). In current practice, no cervical ripening method appears clearly superior to the others considering all effectiveness and safety outcomes.

The association between induction of labour at 38 to 39weeks pregnancy and indication for caesarean delivery: An observational study.

Induction of labour is associated with a reduction in caesarean delivery, but the mechanism of action and which groups of women might benefit remain unknown. To assess the association between induction of labour at 38-39weeks pregnancy, and caesarean delivery: (i) overall; (ii) for slow progress in labour; and (iii) for suspected fetal compromise. Retrospective observational study in two Sydney hospitals from 2009 to 2016, among nulliparous women with induction of labour at 38 or 39 completed weeks pregnancy and a singleton, cephalic presenting fetus. The comparator was all planned vaginal births beyond 39(+1/7) weeks, whether or not labour was induced. Binary and multinomial multiple logistic regressions adjusting for multiple confounders were performed. There were 2388 and 15259 womenin the study and comparison groupsrespectively. Induction of labour was associated with caesarean delivery overall only for women <25years of age (adjusted odds ratio 1.63; 95% CI 1.17-2.27) and was not associated with caesarean delivery for slow progress. Induction of labour was positively associated with increased caesarean delivery for suspected fetal compromise among young women (<30years), with the association weakening as maternal age increased. The association between induction of labour and caesarean delivery was different for slow progress compared with suspected compromise (P=0.005). Induction of labour has different effects on the likelihood of caesarean delivery for slow progress and for suspected fetal compromise. Women <30years of age are at higher risk of caesarean delivery for suspected fetal compromise, potentially due to uterine hyperstimulation.

Obstetric Synthetic Oxytocin Use and Subsequent Hyperactivity/Inattention Problems in Danish Children

(Acta Obstet Gynecol Scand. 2018;97:880–889) Synthetic oxytocin is commonly used to induce or augment labor. One report found that oxytocin augmentation of spontaneous labor occurred in almost 50% of deliveries in the United States. However, the widespread use of synthetic oxytocin for labor augmentation may be associated with adverse outcomes. For instance, uterine hyperstimulation and low Apgar scores have previously been reported. Oxytocin does cross the placenta and in a study of pregnant rats it was found to have a detrimental effect on central nervous system development of the offspring. Previous studies examining any potential effects of oxytocin use on attention deficit/hyperactivity disorder have had varying results. The objective of this population-based study was to examine the association between synthetic oxytocin use during labor and hyperactivity/inattention problems in the children.

Woman-Centred Induction of Labour (the WOCIL project)

Induction of labour (IOL) is a common obstetric intervention. 32% of women are induced per year in our obstetric unit. We were experiencing delays in starting IOLs due to unit...

The efficacy of misoprostol vaginal insert compared with oral misoprostol in the induction of labor of nulliparous women: A randomized national multicenter trial

Our objective was to compare the efficacy of a 200-μg misoprostol vaginal insert vs oral misoprostol regarding the cesarean section rate and the time interval to vaginal delivery in nulliparous women with unfavorable cervix. In this prospective multicenter trial, 283 nulliparous women at term with Bishop score <6 were randomized to induction of labor with either a misoprostol vaginal insert (n=140) or oral misoprostol (n=143). In the oral misoprostol group, a 50-μg dose of oral misoprostol was administered every 4 hours up to three times during the first day; during the second day, the dose was increased to 100-μg every 4 hours up to three times during the first day, if necessary. Primary outcome was the cesarean section rate. Secondary outcomes were the time from induction of labor to vaginal delivery, the rate of other induction methods needed, labor augmentation with oxytocin and/or amniotomy, use of tocolytics and adverse neonatal and maternal events. In the misoprostol vaginal insert group, median time to vaginal delivery was shorter (24.5hours vs 44.2hours, P<0.001), whereas no difference was found in the cesarean section rate (33.8% vs 29.6%, odds ratio [OR] 1.21, 95% confidence interval [CI] 0.66-1.91, P=0.67). Other induction methods and labor augmentation with oxytocin and/or amniotomy were less frequent in the misoprostol vaginal insert group (OR 0.32, 95% CI 0.18-0.59 and OR 0.56, 95% CI 0.32-0.99, respectively). Need for tocolysis and meconium-stained amniotic fluid were more common in the misoprostol vaginal insert group (OR 3.63, 95% CI 1.12-11.79 and OR 2.38, 95% CI 1.32-4.29, respectively). Maternal and neonatal adverse events did not differ between groups. Misoprostol vaginal insert proved to shorten the time to vaginal delivery and to reduce the use of other methods of labor induction and augmentation, but it did not reduce the cesarean section rate compared with oral misoprostol. The benefit of more rapid delivery associated with misoprostol vaginal insert should be weighed against the greater risks for uterine hyperstimulation and meconium-stained amniotic fluid.

Outcome of induction of labor with prostaglandin E1 25 mg vaginal tablet – A retrospective study

Context: Labor induction with prostaglandin E1 (PGE1) vaginal tablet results in shorter induction delivery interval and decreased rate of failed induction of labor and reduced caesarean section rate. However, higher doses may be associated with uterine hyper stimulation. It is therefore necessary to determine the safe dose of PGE1 for labor induction. Aims: To assess the maternal and neonatal outcome with use of 25 mg vaginal misoprostol for induction of labor. Settings and Design: A retrospective analysis conducted in an obstetric department of a tertiary care teaching institute. Materials and Methods: The sample consists of women with singleton term pregnancy, with Bishop's score Statistical Analysis Used: Statistical significance was assessed at 5% level of significance. Chi-square test, with correction for continuity where applicable, was carried out to compare proportions across subgroups or between induction and spontaneous onset groups. Results: The rate of vaginal delivery was higher among spontaneous onset group compared with induction group (χ2 (1) = 30.3, P Conclusion: Our study showed a higher rate of vaginal delivery with induction delivery interval less than 24 h in a majority of women with better neonatal and maternal outcomes.

Low Doses of Vaginal Misoprostol versus Dinoprostone for Induction of Labor in Uncomplicated Term Pregnancy

Background: Prospective cohort observational study to compare the efficacy low doses (25 micrograms misoprostol) tablet with dinoprostone gel (1 mg) introduced vaginally in term pregnancy for induction of labor as regard maternal and fetal outcome. Methods: Three hundred pregnant women in full term (40-41 weeks) pregnancy were assigned for induction of labor either intravaginal misoprostol tablet or dinoprostone gel. They were divided into 2 groups (A, B). Group A (150 ladies) obtained tablet misoprostol 25 micrograms vaginally 4 hourly and Group B (150 ladies) received dinoprostone gel 1 mg vaginally every 6 hourly, both medications were not to be repeated more than 3 doses. Outcomes were: expression of time interval of induction of labor, augmentation requirement, operative and instrumental rate, expenditure efficiency and neonatal outcome. Results: The demographic criteria as regard the age, body mass index, gestational age, initial Bishop’s score and final Bishop’s score were analogous in both group (the misoprostol and dinoprostone groups), respectively with no significant differences but about parity there was significant difference between them with p value 0.4. No significant differences between both group as regard occurrence of non-reassuring FHR, uterine hyper stimulation and meconium stained amniotic fluid but there was significant differences in spontaneous rupture of the membranes and uterine tachysystole with p value 0.02 and 0.01, respectively. Time of labor induction was shorter in the misoprostol group with p<0.001. The need of more doses was fewer in G1 than G2 with p value 0.03. Also the need to oxytocin for augmentation was lesser in G1 than G2 with p value 0.02. In misoprostol group more deliveries within 24 hour, p<0.04. The vaginal deliveries were more in misoprostol group with lesser percentage of CS but with no significant difference. The fetal outcome in both group was similar according to birth weight, Apgar score and at 5, the requirement for neonatal resuscitation and neonatal intensive care unit admission. Conclusions: The time interval for induction of labor by misoprostol tablet vaginally was shorter than dinoprostone gel, associated with fewer requirements to augmentation of labor with oxytocin and more deliveries in the first 24 hours of induction.

The outcome of induced labor after oxytocin infusion discontinuation in the active phase

Objective The objective was to determine whether discontinuation of oxytocin infusion after established active phase of induced labor gives good obstetric outcome without any adverse maternal and neonatal effect. Background Oxytocin is one of the most widely drugs used in induction of labor. Continuous infusion of oxytocin after establishment of the active phase of labor may lead to uterine atony and postpartum hemorrhage. Therefore, we should stop oxytocin infusion once the active phase has started. Patients and methods A total of 90 pregnant women who required labor induction and fulfilled the criteria of the study population were enlisted in this prospective controlled randomized clinical trial and then were assigned to either group A or B. In group A cases, infusion of oxytocin was started in incremental doses until 5 cm of cervical dilatation and to be maintained at that level throughout the labor, whereas in group B cases, infusion of oxytocin was started incrementally but discontinued when cervical dilatation reached 5 cm. Results This study showed that there was a statistically significant difference between group A and group B regarding the first stage of labor, uterine hyperstimulation, maximal and total doses of oxytocin, neonatal outcome, and incidence of postpartum hemorrhage. There was statistically insignificant difference between group A and group B regarding age, BMI, mean gestational age, parity, indications for induction of labor, detection of meconium upon rupture of membranes, and mode of delivery. Conclusion There is no need to continue oxytocin infusion after the establishment of active phase of labor.

386: A network meta-analysis of cervical ripening interventions

Prior studies and reviews of cervical ripening interventions to initiate labor induction focused on pair-wise comparisons of interventions with regard to select outcomes, making it difficult to establish an overall hierarchy of ideal approaches. We synthesized evidence from a systematic review into a network of 12 cervical ripening interventions and 7 outcomes. We searched the Cochrane Library and MEDLINE for randomized controlled trials of cervical ripening interventions. Citations were screened in duplicate with discrepancies adjudicated independently. Eligible interventions included vaginal (gel and tablet), oral, and intracervical prostaglandins; amniotomy; vaginal, oral, and buccal/sublingual misoprostol; balloon catheter; and membrane sweeping. Eligible outcomes included vaginal delivery after 24 hours, instrumental delivery, cesarean delivery, uterine hyperstimulation, Apgar score, postpartum hemorrhage, and neonatal intensive care unit admission. A network meta-analysis was conducted in a Bayesian setting, with models for each outcome specified as generalized linear mixed models to account for patient clustering within studies. 312 articles were eligible. Across the 7 outcomes, the number of interventions with data ranged from 8 to 12, and the number of studies and participants, respectively, ranged from 38 and 7,492 (vaginal delivery > 24 hours) to 257 and 47,287 (cesarean delivery). Using cesarean delivery as an example (network shown in Figure), buccal/sublingual misoprostol and oral misoprostol were among the least likely to result in cesarean delivery while amniotomy and placebo were among the most likely. The favored interventions differed somewhat across outcomes. For example, buccal/sublingual misoprostol was among the most effective interventions for all outcomes except hyperstimulation and balloon catheter was favored for all outcomes except achieving vaginal delivery within 24 hours. Conversely, placebo had high probability of being among the least effective interventions for all outcomes except hyperstimulation. The ranking of optimal cervical ripening interventions based on findings of published trials differs by outcome, but buccal/sublingual misoprostol and balloon catheter were shown to be among the most likely interventions to have favorable outcomes.

Clinical experience with misoprostol vaginal insert for induction of labor: a prospective clinical observational study

PurposeTo provide real-world evidence using misoprostol vaginal insert (MVI) for induction of labor in nulliparous and parous women at two German Level I Centers in a prospective observational study.MethodsBetween 1 August 2014 and 1 October 2015, eligible pregnant women (≥ 36 + 0 weeks of gestation) requiring labor induction were treated with MVI. Endpoints included time to and mode of delivery rates of tocolysis use, tachysystole, uterine hypertonus or uterine hyperstimulation syndrome and newborn outcomes.ResultsOf the 354 women enrolled, 68.9% (244/354) achieved vaginal delivery (nulliparous, 139/232 [59.9%]; parous 105/122 [86.1%]; p < 0.001). Median time from MVI administration to vaginal delivery was 14.0 h (nulliparous, 14.5 h; parous, 11.9 h; p < 0.001). A total of 205/244 (84.0%) and 228/244 (93.4%) women achieved a vaginal delivery within 24 h and 30 h, respectively. The most common indications for cesarean delivery were pathologic cardiotocography (nulliparous, 41/232 [17.4%]; parous, 13/122 [10.7%]; p = 0.081) and arrested labor (dilation or descent; nulliparous, 45/232 [19.4%], parous, 3/122 [2.5%]; p ≤ 0.001). A total of 24.3% of women experienced uterine tachysystole and 9.6% experienced uterine tachysystole with fetal heart rate involvement, neither of which were significantly different for nulliparous and parous women. In total, 42/345 (12.2%) of the neonates had an arterial pH < 7.15 and 12/345 3.5% had a 5-min Apgar score ≤ 7.ConclusionWhen clinically indicated, MVI was efficient and safe for induction of labor in women with an unfavorable cervix. Women, however, should be counseled regarding the risk of uterine tachysystole prior to labor induction with MVI.

Rules of induction of labor, complication and benefits

Background: induction of labor is a usual obstetric method and it is applied when the benefits to either mother or fetus outweigh those of continuing the pregnancy. Objective: in this review we discussed the advantages and disadvantages and specifically mention about indications. Methodology: we searched MEDLINE and the Cochrane Library up to June 2018. Through our search we used multiple terms and combinations including labor, induced/or induction of labor. Result: for uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 µg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed 'best'. Conclusion: elective IOL needs to only be done in rare or extraordinary circumstances, only when the mom has actually completed 39 weeks of pregnancy, and only when it would be beneficial to the mom and not cause damage to the newborn. Ladies with uncomplicated maternities must be given every opportunity to go into spontaneous labor. Women with uncomplicated pregnancies should typically be offered induction of labor in between 41 +0 and 42 +0 weeks to avoid the threats of prolonged pregnancy.

Dinoprostone Vaginal Insert: A Review in Cervical Ripening.

Dinoprostone vaginal insert (Cervidil®; Propess®), a retrievable vaginal pessary containing 10mg of dinoprostone [prostaglandinE2 (PGE2)] in a controlled-release drug delivery device, is approved in many countries worldwide for the initiation (or continuation) of cervical ripening in patients at term prior to labour induction. The device is designed to provide a constant and sustained release of dinoprostone to the cervix to promote the complex processes involved in cervical ripening. The vaginal insert is attached to a retrieval system that facilitates easy removal of the device at the onset of labour or in the event of complications. The effectiveness of dinoprostone vaginal insert has been demonstrated in a vast range of randomized clinical trials in women at term. The agent is well tolerated, with a generally favourable safety profile, both maternal and foetal/neonatal. As with all prostaglandin agents used in cervical ripening, dinoprostone vaginal insert is associated with a risk of uterine hyperstimulation. However, this is generally rapidly reversible upon removal of the insert. The demonstrated effectiveness and safety of the device, combined with the benefits of controlled drug release from a simple, single application, and efficient dose control, suggest that dinoprostone vaginal insert is a valuable option for promoting cervical ripening in patients with an unfavourable cervix at term.

Rules of induction of labor, complication and benefits

Background: induction of labor is a usual obstetric method and it is applied when the benefits to either mother or fetus outweigh those of continuing the pregnancy. Objective: in this review we discussed the advantages and disadvantages and specifically mention about indications. Methodology: we searched MEDLINE and the Cochrane Library up to June 2018. Through our search we used multiple terms and combinations including labor, induced/or induction of labor. Result: for uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 µg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed 'best'. Conclusion: elective IOL needs to only be done in rare or extraordinary circumstances, only when the mom has actually completed 39 weeks of pregnancy, and only when it would be beneficial to the mom and not cause damage to the newborn. Ladies with uncomplicated maternities must be given every opportunity to go into spontaneous labor. Women with uncomplicated pregnancies should typically be offered induction of labor in between 41 +0 and 42 +0 weeks to avoid the threats of prolonged pregnancy.

428. Trials in low-resource settings: the INFORM study (oral misoprostol versus balloon induction in women with PIH or pre-eclampsia)

Between 62,000 and 77,000 women die annually from pre-eclampsia/eclampsia. Prompt delivery, preferably by the vaginal route, is vital for good maternal and neonatal outcomes. Two low cost interventions -low dose oral misoprostol tablets and transcervical Foley catheterisation- are already used in low resource settings. In this open label, parallel randomised study, our objective was to compare their relative risks and benefits. 602 women with a live fetus requiring delivery for pre-eclampsia or hypertension were randomly assigned to labour induction with oral misoprostol 25 micrograms every 2 h (maximum of 12 doses) or a transcervical Foley catheter (size 18 F with 30 ml balloon) which remained until active labour started, the Foley catheter fell out, or 12 h elapsed. Randomisation was computer-generated with allocation concealment by opaque sequentially numbered sealed envelopes. Induction continued with artificial membrane rupture and oxytocin, administered through a micro-drip gravity infusion set. Fetal monitoring was by intermittent auscultation. The primary outcome was vaginal birth within 24 h, and trial registration as with ClinicalTrials.gov (NCT01801410). 302 women were allocated to misoprostol and 300 women to Foley catheter; all were analysed. More women in the misoprostol arm had a vaginal birth within 24 h (57.0% vs. 47.0%; absolute risk difference (RD) 10.0%, with 95%CI 2.0% to 17.9%). Rates of uterine hyperstimulation were very low in both groups (0.7% vs 0.3%; RD 0.3%; −0.8% to 1.5%) and no differences were seen in neonatal morbidity. More women in the misoprostol group would use the same method in the future should they require another induction (82.8% vs. 72.0%; RD 10.8%; 4.2% to 17.4%). Oral misoprostol 25 micrograms was more effective and more acceptable to women than a transcervical Foley catheter for induction of labour in women requiring delivery because of pre-eclampsia or hypertension. MRC/DFID/Wellcome Trust Joint Global Health Trials Scheme (Ref. G1100686/1).

Continuous oxytocin versus intermittent oxytocin for induction of labor: a randomized study

Objective: To assess whether intermittent usage of oxytocin infusion increases the duration of the active phase of labor and reduces maternal and neonatal complications or not.Materials and Methods: A prospective randomized controlled study was conducted of 200 consenting women with singleton pregnancy in the vertex position undergoing labor induction or augmentation at the Zeynep Kamil Maternity and Children’s Training and Research Hospital. Participants with cervical dilation of 3 cm were randomized to either continued or intermittent oxytocin infusion when cervical dilation reached 5 cm. The primary outcome measures were the duration of the active phase of labor, defined as the period of labor from 5 cm of cervical dilation to vaginal delivery. Secondary outcomes were the duration of oxytocin infusion, mode of delivery, hyperstimulation, abnormalities in fetal heart rate, perineal tears, and neonatal outcomes.Results: The median duration of the active phase for the women with a vaginal delivery was longer in the intermittent oxytocin group than the continued oxytocin group, but it was not statistically significant (median, 6.91 vs. 7.58 h, p = .37). There was a significant difference in the duration of oxytocin infusion (median, 12.38 h in the intermittent group vs. 15.79 h in the continued group, p = .005). The incidence of uterine hyperstimulation was significantly greater in the continued group (21.1%) than the intermittent oxytocin group (3.8%) (p=.001).Conclusions: Intermittent usage of oxytocin infusion seems to make labor less complicated without lengthening duration of labor.

Effect of vaginal washing before intravaginal dinoprostone insertion for labor induction: A randomized clinical trial.

Prostaglandins have a dual action of cervical ripening and induction of uterine contraction. This study was designed to compare the effectiveness of vaginal washing just before insertion of intravaginal dinoprostone. A randomized controlled trial was conducted at the Zeynep Kamil Women and Children's Health Training and Research Hospital. One hundred and ninety-one women with singleton, term pregnancy who underwent labor induction were randomly assigned to two groups: Group 1 consisted of 95 pregnant women with vaginal washing before intravaginal dinoprostone (Propess system for slow release system of 10 mg of dinoprostone) insertion (study group), and 96 pregnant women constituted the control group who did not undergo vaginal washing before intravaginal dinoprostone insertion. A parallel randomized controlled trial was conducted with an allocation ratio of 1:1 to compare the effectiveness of vaginal washing before intravaginal dinoprostone insertion. The groups had similar mean age, body mass index, gestational age, gravidity, parity and Bishop score before agent insertion (P > 0.05). Duration of dinoprostone kept intravaginally, duration from the beginning of dinoprostone insert vaginally to the active phase of labor and duration from the time of intravaginal dinoprostone insertion to delivery were significantly longer in the control group (P < 0.05). Uterine hyperstimulation rate was significantly higher in study group compared to control group (P < 0.05). Meconium passage, fetal infection and neonatal intensive care unit admission were significantly higher in the control group (P < 0.05). Vaginal washing before intravaginal dinoprostone insertion may increase Prostaglandin E2 bioavailability as we found shorter duration and better outcome of labor induction in the present study.

Oxytocin discontinuation after the active phase of induced labor: A systematic review

BackgroundOxytocin is the most widely used drug in the induction of labor, but it could have potential adverse effects that derive from uterine hyperstimulation. AimTo determine the benefits and drawbacks of oxytocin continuation versus oxytocin discontinuation after the active phase of induced labor. MethodsWe systematically searched Pubmed, EMBASE, Scopus, ClinicalTrials.gov and Cochrane Library Plus until October 2017, for randomized controlled trials comparing oxytocin continuation with oxytocin discontinuation when the active phase of labor is reached were included. Data was collected by three reviewers and quality of the included studies assessed using the methodology recommended in the Cochrane Handbook. StatsDirect software was used to calculate risk ratios for binary variables and weighted mean differences for continuous variables. A fixed-effects or random-effects model was used as appropriate. ResultsNine studies were selected including 1538 women, 774 in the oxytocin continuation group and 764 in the oxytocin discontinuation group. The incidence of cesarean sections (14.3% vs. 8.6%; relative risk, 1.67; 95% confidence interval: 1.25–2.23), uterine hyperstimulation (12.4% vs. 4.7%; relative risk, 2.59; 95% confidence interval: 1.70–3.93) and nonreassuring fetal heart rate (19.2% vs.12.5%; relative risk, 1.55; 95% confidence interval: 1.18–2.02) were significantly higher in the oxytocin continuation group. An increase in the duration of the second stage of labor in the oxytocin discontinuation group was observed (pooled mean difference, −7.03; 95% confidence interval: −9.80 to −4.26). ConclusionsAfter the active phase of induced labor, oxytocin continuation increases the risk of cesarean section, uterine hyperstimulation and alterations to the fetal heart rate.