Uterine Tachysystole Research Articles

Intrapartal cardiotocographic patterns and hypoxia-related perinatal outcomes in pregnancies complicated by gestational diabetes mellitus

AimsIn previous reports, cardiotocographic (CTG) fetal heart rate (FHR) monitoring has shown only limited benefits in decreasing adverse perinatal outcomes in pregnancies complicated by gestational diabetes mellitus (GDM). The aim of the present study was to evaluate whether an association exists between the recently reported ZigZag pattern (FHR baseline amplitude changes of > 25 bpm with a duration of 2–30 min) and asphyxia-related neonatal outcomes in GDM pregnancies.MethodsIntrapartal CTGs were recorded in a one-year cohort of 5150 singleton childbirths. The following CTG changes were evaluated: ZigZag pattern, saltatory pattern, late decelerations, episodes of tachycardia and bradycardia, reduced variability, and uterine tachysystole. The cohort was divided into three groups: women with GDM, women with normal oral glucose tolerance test (OGTT), and women with no OGTT performed. Umbilical artery (UA) blood gases, Apgar scores, neonatal respiratory distress, and neonatal encephalopathy were used as outcome variables.ResultsGDM was diagnosed in 624 (12.1%), OGTT was normal in 4115 (79.9%), and OGTT was not performed in 411 (8.0%) women. Hypoxia-related ZigZag patterns (OR 1.94, 95% CI 1.64–2.34) and late decelerations (OR 1.65, 95% CI 1.27–2.13) of FHR, as well as a greater risk of fetal asphyxia (UA pH < 7.10 and/or UA BE < -12.0 meq/L and/or Apgar scores < 7 at 5-min) (OR 6.64, 95% CI 1.84–12.03) were observed in those with GDM compared with those without GDM.ConclusionsGDM is associated with intrapartal ZigZag pattern and late decelerations, cord blood acidemia and low 5-min Apgar scores at birth indicating increased occurrence of fetal hypoxia in GDM pregnancies.

Maternal and neonatal outcomes of pregnancies complicated by late fetal growth restriction undergoing induction of labor with dinoprostone compared with cervical balloon: A retrospective, international study.

The aim of this study was to compare vaginal dinoprostone and mechanical methods for induction of labor (IOL) in pregnancies complicated by late fetal growth restriction. Multicenter, retrospective, cohort study involving six referral centers in Italy and Spain. Inclusion criteria were pregnancies complicated by late fetal growth restriction as defined by Delphi consensus criteria. The primary outcome was the occurrence of uterine tachysystole; secondary outcomes were either cesarean delivery or operative vaginal delivery for non-reassuring fetal status, a composite score of adverse neonatal outcome and admission to neonatal intensive care unit (NICU). Univariate and multivariate logistic regression analysis was used to analyze the data. A total of 571 pregnancies complicated by late fetal growth restriction undergoing IOL (391 with dinoprostone and 180 with mechanical methods) were included in the analysis. The incidence of uterine tachysystole (19.2% vs. 5.6%; p=0.001) was higher in women undergoing IOL with dinoprostone than in those undergoing IOL with mechanical methods. Similarly, the incidence of cesarean delivery or operative delivery for non-reassuring fetal status (25.6% vs. 17.2%; p=0.027), composite adverse neonatal outcome (26.1% vs. 16.7%; p=0.013) and NICU admission (16.9% vs. 5.6%; p<0.001) was higher in women undergoing IOL with dinoprostone than in those undergoing IOL with mechanical methods. At logistic regression analysis, IOL with mechanical methods was associated with a significantly lower risk of uterine tachysystole (odds ratio 0.26, 95% confidence interval 0.13-0.54; p<0.001). In pregnancies complicated by late fetal growth restriction, IOL with mechanical methods is associated with a lower risk of uterine tachysystole, cesarean delivery or operative delivery for non-reassuring fetal status, and adverse neonatal outcome compared with pharmacological methods.

Cardiotocograph (CTG) changes and maternal and neonatal outcomes in chorioamnionitis and/or funisitis confirmed on histopathology

ObjectiveTo assess the cardiotocographic changes and maternal and neonatal outcomes in cases of chorioamnionitis and or funisitis confirmed on histopathology. Study DesignA retrospective analysis of histopathology reports confirming chorioamnionitis and/or funisitis was carried out from 2014 to 2020 in a single centre. The preterm births (<37 weeks) were excluded. The maternal records were reviewed to determine the maternal and neonatal outcomes such as the mode of delivery, intrapartum and postpartum complications, umbilical cord arterial pH, and admission to the special care baby unit (SCBU). The CTG features were analysed on admission and during the intrapartum period. The study was approved by the Audit and Clinical Effectiveness department within the centre. ResultsOut of the 57 cases of histologically confirmed chorioamnionitis and/or funisitis, 42 women (73.7 %) had intrapartum pyrexia and none of the mothers had an increased temperature at the point of fetal tachycardia (persistent increase in baseline fetal heart rate (FHR) by >10 % compared to the original baseline FHR). 43 (75.4 %) CTGs showed evidence of uterine tachysystole or hyperstimulation. 15 (26.3 %) cases had meconium stained amniotic fluid (MSAF). 54 (94.7 %) women had a caesarean section, and their babies were admitted to special care baby unit after delivery. 54 (94.7 %) babies had an umbilical artery of more than 7.1. 47 (87 %) of the women were readmitted with wound infection.All CTG traces showed a > 10 % increase in the baseline FHR and variable decelerations with overshoot were noted in cases where funisitis was confirmed in 25 cases (92.6 %). Loss of cycling was noted in 54 CTGs (94.7 %) and a sinusoidal pattern was identified in 27 (47.3 %). ConclusionRising (>10 %) baseline during labour along with loss of cycling with or without features of tachysystole or hyperstimulation should be considered in labour as features of ongoing chorioamnionitis. Chorioamnionitis confirmed on histopathology is associated with an increase in caesarean section rate due to fetal heart rate changes, increased risk of wound infection in mothers, and increased admission of the babies to SCBU.

619 Timing of induction of labor has no association with labor or delivery complications

To assess labor, delivery, maternal and neonatal complications associated with timing of induction of labor. This was a secondary analysis of 2 randomized trials involving 6 cervical ripening methods. The inclusion criteria were patients with obstetric or medical indication for IOL, singleton gestation and unfavorable cervix. The 6 cervical ripening methods included: Foley + 4 mg compound PGE (gel) vs Foley + 10 μg misoprostol (oral) vs 100 μg misoprostol (oral) vs 10 mg dinoprostone (pessary) vs Athad + Prepidil 0.5 mg (gel) vs 25 μg then 50 μg misoprostol (intra-vaginal). For this analysis, 905 patients were included and divided into 4 groups according to time period of labor induction: Early Day (ED)- 06:00 to 12:00; Late Day (LD)- 12:00 to 18:00; Early Night (EN)- 18:00 to midnight; Late Night (LN)- midnight to 06:00. The demographic, obstetric, labor and delivery characteristics and neonatal outcomes were compared. Demographic were significant for mean maternal age, BMI categories, mean gestational age and gestational age categories (LN had largest percent < 37 weeks), There were non-significant between the 4 groups for percent of nulliparous, ethnicity, maternal weight, BMI. There were significant differences for indications of induction with more preterm and hypertensive disorders at LN; however the percent of bishop score < 6 was similar. The most common indication for induction is hypertensive disorders follow by oligohydramnios and post-term. The duration of medical induction, 1st and 2nd stage of labor were similar. The mode of delivery and cesarean indications were similar. The rate of meconium, chorioamnionitis and uterine tachysystole were similar. Neonatal outcomes were similar for gender, birth-weight, umbilical cord pH, Apgar < 7 and NICU admission. IOL at LN had younger mom and more at < 37 weeks with hypertensive disorders. There were no difference in duration in medical induction, 1st and 2nd stage of labor, and mode of delivery across the 4 IOL periods. There were differences in labor or neonatal complications associated with timing of IOL.

Efficacy and Safety of Misoprostol Vaginal Insert to Induce Labor beyond 40 + 0 Weeks of Gestation

Objective: Misoprostol vaginal insert (MVI) is proven to induce labor by a continuously release of PGE1. Previous reports showed that MVI reduced induction to delivery time as well as active labor time but it also increased uterine tachysystole. Here we attempted to clarify whether MVI is safe and efficient for women with pregnancies >40 weeks in a single institute. Methods: This study was performed in Lutheran Hospital Bergisch Gladbach, Germany 2014-2019. A total of 304 women between 40 + 0 to 42 + 0 weeks underwent labor induction with MVI. Outcomes were: 1) maternal: time from insertion to delivery, interventions, mode of delivery, and uterine tachysystole, 2) neo-natal: cord blood pH, APGAR scores, and admission to a neonatal clinic. This study ended unexpectedly due to the withdrawal of MVI (MisodelTM) in September 2019. Results: 75.7% (n = 230) of women gave birth within 24 hours after MVI placement. 72.2% (n = 140) nulliparous women and 81.8% (n = 90) parous women delivered within 24 hours. In two cases emergency CS was required. 67.8% (n = 206) of women delivered vaginal. 2.3% (n = 7) of cord pH levels were below 7.10. 3.3% (n = 10) of newborns were transmitted to a neonatal clinic. Conclusion: MVI is an efficient method to induce labor for pregnant women beyond 40 + 0 weeks. However, considering various complications observed (uterine tachysystole and fetal distress leading to a high number of CS), we cannot universally advocate the use of MVI.

Intrapartum fetal heart rate between 150 and 160 bpm at or after 40 weeks and labor outcome.

A baseline fetal heart rate between 110 and 160bpm is considered normal. However, among normal fetuses the average baseline heart rate has been shown to diminish progressively and the 90th centile of the fetal heart rate at 40weeks of gestation has been consistently found at around 150bpm. The aim of our study was to assess the labor and neonatal outcome of fetuses at 40 gestational weeks or beyond, whose intrapartum baseline fetal heart rate was between 150 and 160bpm. Retrospective cohort study including singleton pregnancies with spontaneous onset of labor, gestational age between 40+0 and 42+0 weeks, category I CTG trace according to the FIGO guidelines 2015 with baseline fetal heart rate between 110 and 160bpm during the first 60minutes of active labor. Exclusion criteria were maternal hyperpyrexia at admission, fetal arrhythmias, maternal tachycardia (>110bpm) and uterine tachysystole (>5 contractions/10minutes). The following outcomes were compared between fetuses with a baseline ranging between 110 and 149bpm and those with a baseline ranging between 150 and 160bpm: incidence of meconium-stained amniotic fluid, intrapartum hyperpyrexia, mode of delivery, Apgar at 5 minutes<7, arterial pH<7.1 and Neonatal Intensive Care Unit admission, incidence of a composite adverse neonatal outcome. In all, 1004 CTG traces were included in the analysis, 860 in Group 110-149bpm and 144 in Group 150-160 bpm. Group 150-160bpm had a significantly higher incidence of meconium-stained amniotic fluid (odds ratio [OR] 2.6; 95% CI 1.8-3.8), maternal intrapartum hyperpyrexia (OR 4.7; 95% CI 1.1-14.6), urgent/emergent cesarean section for suspected fetal distress (OR 13.4; 95% CI 3.3-54.3), Apgar<7 at 5th min (OR 9.13; 95% CI 1.5-55.1) and neonatal acidemia (OR 3.5; 95% CI 1.5-55.1). Logistic regression including adjustiing for potential confounders showed that fetal heart rate between 150 and 160bpm is an independent predictor of meconium-stained amniotic fluid (adjusted odds ratio [aOR] 2.2; 95% CI 1.5-3.3), cesarean section during labor for fetal distress (aOR 10.7; 95% CI 2.9-44.6), neonatal acidemia (aOR 2.6; 95% CI 1.1-6.7) and adverse composite neonatal outcome (aOR 2.6; 95% CI 1.2-5.6). In fetuses at 40weeks or beyond, an intrapartum fetal heart rate baseline ranging between 150 and 160bpm seems associated with a higher incidence of labor complications.

Intrapartum zigzag pattern of fetal heart rate is an early sign of fetal hypoxia: A large obstetric retrospective cohort study

IntroductionThe aim of the present study was to identify possible associations of fetal heart rate (FHR) patterns during the last 2 hours of labor with fetal asphyxia expressed by umbilical artery acidemia at birth and with neonatal complications in a large obstetric cohort.Material and methodsCardiotocographic recordings from 4988 singleton term childbirths over 1 year were evaluated retrospectively and blinded to the pregnancy and neonatal outcomes in a university teaching hospital in Helsinki, Finland. Umbilical artery pH, base excess and pO2, low Apgar scores at 5 minutes, need for intubation and resuscitation, early neonatal hypoglycemia, and neonatal encephalopathy were used as outcome variables. According to the severity of the neonatal complications at birth, the cohort was divided into three groups: no complications (Group 1), moderate complications (Group 2) and severe complications (Group 3).ResultsOf the 4988 deliveries, the ZigZag pattern (FHR baseline amplitude changes of >25 bpm with a duration of 2‐30 minutes) occurred in 11.7%, late decelerations in 41.0%, bradycardia episodes in 52.9%, reduced variability in 36.7%, tachycardia episodes in 13.9% and uterine tachysystole in 4.6%. No case of saltatory pattern (baseline amplitude changes of >25 bpm with a duration of >30 minutes) was observed. The presence of the ZigZag pattern or late decelerations, or both, was associated with cord blood acidemia (odds ratio [OR] 3.3, 95% confidence interval [CI] 2.3‐4.7) and severe neonatal complications (Group 3) (OR 3.3, 95% CI 2.4‐4.9). In contrast, no significant associations existed between the other FHR patterns and severe neonatal complications. ZigZag pattern preceded late decelerations in 88.7% of the cases. A normal FHR preceded the ZigZag pattern in 90.4% of the cases, whereas after ZigZag episodes, a normal FHR pattern was observed in only 0.9%.ConclusionsZigZag pattern and late decelerations during the last 2 hours of labor are significantly associated with cord blood acidemia at birth and neonatal complications. The ZigZag pattern precedes late decelerations, and the fact that normal FHR pattern precedes the ZigZag pattern in the majority of the cases suggests that the ZigZag pattern is an early sign of fetal hypoxia, which emphasizes its clinical importance.

Intracervical Foley Catheter Plus Intravaginal Misoprostol vs Intravaginal Misoprostol Alone for Cervical Ripening: A Meta-Analysis.

Currently, there is no meta-analysis comparing intravaginal misoprostol plus intracervical Foley catheter versus intravaginal misoprostol alone for term pregnancy without identifying risk factors. Therefore, the purpose of this study is to conduct a systematic review and meta-analysis of randomized control trials (RCTs) comparing concurrent intravaginal misoprostol and intracervical Foley catheter versus intravaginal misoprostol alone for cervical ripening. We systematically searched Embase, Pubmed, and Cochrane Collaboration databases for randomized controlled trials (RCTs) comparing intracervical Foley catheter plus intravaginal misoprostol and intravaginal misoprostol alone using the search terms “Foley”, “misoprostol”, “cervical ripening”, and “induction” up to 29 January 2019. Data were extracted and analyzed by two independent reviewers including study characteristics, induction time, cesarean section (C/S), clinical suspicion of chorioamnionitis, uterine tachysystole, meconium stain, and neonatal intensive care unit (NICU) admissions. Data was pooled using random effects modeling and calculated with risk ratio (RR) and 95% confidence interval (CI). Pooled analysis from eight studies, including 1110 women, showed that labor induction using a combination of intracervical Foley catheter and intravaginal misoprostol decreased induction time by 2.71 h (95% CI −4.33 to −1.08, p = 0.001), as well as the risk of uterine tachysystole and meconium staining (RR 0.54, 95% CI 0.30–0.99 and RR 0.48, 95% CI 0.32–0.73, respectively) significantly compared to those using intravaginal misoprostol alone. However, there was no difference in C/S rate (RR 0.93, 95% CI 0.78–1.11) or clinical suspicion of chorioamnionitis rate (RR 1.22, CI 0.58–2.57) between the two groups. Labor induction with a combination of intracervical Foley catheter and intravaginal misoprostol may be a better choice based on advantages in shortening induction time and reducing the risk of uterine tachysystole and meconium staining compared to intravaginal misoprostol alone.

TO COMPARE THE EFFECTIVENESS OF EXTRA-AMNIOTIC SALINE INSTILLATION THROUGH FOLEY CATHETER PRIOR TO ORAL MISOPROSTOL WITH ORAL MISOPROSTOL ALONE IN INDUCING LABOUR IN PREGNANCIES &gt;28 WEEKS WITH INTRAUTERINE FOETAL DEATH- A RANDOMIZED CONTROLLED TRIAL AT TE

Background: The present study aims to compare the results of EASI followed by oral misoprostol and oral misoprostol alone for induction of labour in pregnancies of more than 28 weeks with intrauterine foetal death.&#x0D; Methods: The present observational and prospective study is an attempt to compare the efficacy of extra-amniotic saline instillation with Foley catheter prior to oral misoprostol and oral misoprostol alone in induction of labour of pregnancies more than 28 weeks with intrauterine fetal death.&#x0D; Results: Most of the cases delivered vaginally in both study groups. The mean induction delivery time in group I was higher than group II and the results were statistically significant on comparing both groups. In group I, 78% cases were delivered within 24 hours whereas in group II 96% cases delivered within 24 hours of induction. There was no significant difference in the mean number of required misoprostol in both groups (p&gt;0.05). Need of supplementation with oxytocin was more in group I as compared to group II and the p value is significant (p&lt;0.01). Mean birth weight in group I was 2.25±0.75 kg and in group II was 2.27±0.77 kg. Maximum number of babies had birth weight between 1.52-2.50 kg with 44% in group I and 40% in group II (p&gt;0.05). Only 4 cases had uterine tachysystole and only 1case had postpartum pyrexia. Very few complications were recorded in both the study groups (p&gt;0.05).&#x0D; Conclusion: We concluded that oral misoprostol tablet alone is more effective at inducing and setting up the active labour in pregnancies of &gt;28 weeks with intrauterine foetal death than EASI followed by oral misoprostol. It is inexpensive, has a long shelf life, can be easily stored at room temperature and patient remains ambulatory after induction with oral misoprostol. Oral misoprostol alone seems to have an edge over extra-amniotic saline instillation followed by oral misoprostol in all aspects.&#x0D; Keywords: Misoprostol, Extra-amniotic saline, Induction of labour.

The effect of combined spinal epidural versus epidural analgesia on fetal heart rate in laboring patients at risk for uteroplacental insufficiency

Background The effects of neuraxial analgesia on fetal heart tracings have been studied in “healthy” pregnancies. Our objective was to compare the impact of intrapartum epidural analgesia (EA) versus combined spinal epidural analgesia (CSE) on fetal heart rate changes in pregnancies at risk for uteroplacental insufficiency (UPI). Methods Singleton pregnancies diagnosed with chronic hypertension, gestational hypertension and/or preeclampsia, and/or fetal growth restriction (FGR) and receiving neuraxial analgesia intrapartum from 2012 to 2015 were studied retrospectively. The primary outcome was change in fetal heart rate (FHR) category following neuraxial analgesia. Manual review of all FHR tracings was performed and classified by the National Institute of Child Health and Human Development (NICHD) categories. Data collection included maternal demographics, blood pressure, uterine tachysystole, uterine hypertonus, mode of delivery, interventions for FHR abnormalities and neonatal outcomes. Results Of laboring patients at risk for UPI, 110 patients received EA and 127 patients received CSE. The rate and change in FHR categories and abnormalities following neuraxial analgesia were the same in both groups. Both EA and CSE resulted in a significant increase in NICHD FHR category II, from 27.3 to 65.5% for EA and 20.9 to 64.3% for CSE. The occurrence of maternal hypotension, uterine tachysystole, interventions for FHR abnormalities, and uterine hypertonus following neuraxial analgesia was not found to be significantly different between the two groups. When compared to the EA group, CSE had a higher rate of NICU admission (29.5 versus 16.4%, p = .021). Conclusions FHR category increased following both CSE and EA. The side effects of maternal hypotension and need for fetal interventions was not different between CSE and EA.

Induction of Labor: An Overview of Guidelines.

Induction of labor (IOL) is a common obstetric intervention that stimulates the onset of labor using artificial methods. The aim of this study was to summarize and compare recommendations from 4 national or international medical societies on the IOL. A descriptive review was conducted of major published guidelines on IOL: the American College of Obstetricians and Gynecologists' "Induction of Labor" and "Management of Late-Term and Postterm Pregnancies," the guidelines of the Society of Obstetricians and Gynaecologists of Canada (SOGC) on "Induction of Labour," those of the National Institute for Health and Care Excellence (NICE) on "Inducing Labour," and the World Health Organization's (WHO's) "Recommendations for Induction of Labour" and "WHO Recommendations: Induction of Labour at or Beyond Term." These guidelines were compared in terms of their recommendations on clinical indications and methods. Many similar indications and contraindications to IOL are identified between American College of Obstetricians and Gynecologists and SOGC, whereas NICE and WHO do not mention any contraindications. The timing of IOL in postterm pregnancies also differs among the guidelines. Regarding the methods of induction, all the medical societies recommend the use of membrane sweeping, mechanical methods, prostaglandins, and oxytocin, whereas NICE argues against the use of misoprostol for IOL. The American College of Obstetricians and Gynecologists and SOGC consider amniotomy a method of IOL, whereas NICE and WHO do not recommend it. All the guidelines also make similar recommendations regarding the management of uterine tachysystole in cases of IOL. The World Health Organization seems to be the most evidence-based guideline with recommendations based mainly on Cochrane reviews. The variation in the clinical indications and methods of IOL highlights the need to adopt an international consensus, which may help to optimize the quality of obstetric care and further promote evidence-based medicine.

Saltatory Pattern of Fetal Heart Rate during Labor Is a Sign of Fetal Hypoxia

Background: While late decelerations and major bradycardia episodes in intrapartum cardiotocography (CTG) recordings are known to correlate with fetal distress,little is known of the importance of the saltatory pattern. Objective: The aim of the study was to examine whether the fetal heart rate (FHR) saltatory pattern in intrapartum CTG registration is associated with fetal hypoxia during the last 2 h of labor. Design: The study group consisted of CTG recordings from 194 births with a 1-min Apgar score of <8 (birth weight 3,614 ± 512 g; gestational age 40.6 ± 0.7 weeks). The comparison group included 51 infants with a 1-min Apgar score of ≥9 (birth weight 3,624 ± 400 g; gestational age 40.5 ± 0.4 weeks). FHR patterns were evaluated blindly by 2 experienced perinatologists. The pH, base excess (BE), pO₂ and erythropoietin (EPO) were measured from umbilical cord blood at birth as outcome variables. Results: Saltatory pattern occurred in 31/194 (16.0%) of the study group and in 1/51 (2.0%) of the comparison group. Umbilical artery pH, BE, and pO₂ were lower and umbilical vein (UV) EPO higher in the study group than in the comparison group. In the study group, UV EPO level was significantly higher in cases where the saltatory pattern was present (median 241 mU/mL, 95% CI 39.4–16,484), than in those without the saltatory pattern (median 39.4 mU/mL, 95% CI 11–282) (p < 0.0001, for difference). In the study group, no differences in EPO levels were found in cases where episodes of bradycardia, tachycardia, reduced variability, or uterine tachysystole were present or absent. In the study group, saltatory pattern preceded late decelerations in 82.8%. Conclusion: Saltatory pattern in an intrapartum FHR recording is an early sign of fetal hypoxia.

A randomized controlled trial comparing isosorbide dinitrate-oxytocin versus misoprostol-oxytocin at management of foetal intrauterine death.

BackgroundThe metabolic activity of endogenous nitric oxide (NO) and the medical use of nitrovasodilatory drugs like isosorbide dinitrate have been shown to be potential inducers inducers of cervical ripening prior to surgical evacuation of the uterus.ObjectiveTo assess the therapeutic efficacy and safety of combined isosorbide dinitrate-oxytocin in the management of intrauterine foetal death (IUFD).MethodsSixty women with IUFD after 20 weeks of gestation requesting uterine evacuation were randomly selected to receive isosorbide dinitrate gel solution (80 mg/1.5 mL; n = 30) or misoprostol gel solution (100 mcg/1.5 mL; n = 30) every 3 h with a maximum of four doses or until a Bishop score >7 was reached. Subsequently, patients received a high dose of intravenous oxytocin until complete uterus evacuation was achieved. Therapeutic efficacy was evaluated by mean the relative risk of the foetal expulsion based on comparison of event rates, and the proportion of women induced to labor at 7, 10 and 15 h after the administration of isosorbide dinitrate or misoprostol. Safety was assessed on the basis of woman´s vital signs and evaluation of adverse effects, including headache, abdominal pain, pelvic pain, lower back pain, nausea, dizziness and vomiting.ResultsThe foetal expulsion rate using the isosorbide dinitrate-oxytocin combination was approximately 4.4 times, and at least 2.1 times, the foetal expulsion rate with the misoprostol-oxytocin regimen at any given point in time. The proportion of women achieved vaginal delivery at 15 hours was 100% for the isosorbide dinitrate-oxytocin group and 86.7% for the misoprostol-oxytocin group. The average delivery induction interval was significantly lower when isosorbide dinitrate-oxytocin was used (8.7 ± 3.1 h) than when misoprostol-oxytocin (11.9 ± 3.1 h) was used. A total of 20% of patients in the isosorbide dinitrate-oxytocin group recorded headache, and no cases of uterine tachysystole, haemorrhage or coagulopathy were recorded.ConclusionThis study indicates that intravaginal isosorbide dinitrate followed by intravenous oxytocin was more effective than the conventional method used to induce labour in the medical management of foetal death in pregnancies after 20 weeks of gestation.Trial registrationClinicaltrials.gov NCT02488642.

A comparison between induction of labor with 3 methods of titrated oral misoprostol, constant dose of oral misoprostol and Foley catheter with extra amniotic saline infusion (EASI), in women with unfavorable cervix.

Background: Different methods of cervical ripening and induction of labor have been used in the cases of unfavorable cervix with different levels of success, but no method has been found to be the best option. The purpose of the present study was to find the effects and side effects of three different methods of cervical ripening and induction of labor. These three methods were oral titrated misoprostol, constant dose of oral misoprostol and Foley catheter with extra-amniotic saline infusion. Methods: This clinical trial was performed on women with unfavorable cervix who had been admitted in Akbarabadi Teaching Hospital for induction of labor and had bishop score of less than six; between March 2014- March 2015. The eligible women were assigned into three groups. In titrated oral misoprostol group (n=33), titrated solution of misoprostol, and in oral misoprostol group (n=33), 50µg oral misoprostol every four hours and in Foley catheter group (n=50), Foley catheter with extra-amniotic saline infusion were administered. The main outcome was the number of vaginal deliveries during the first 24 hours. In addition, number of cesarean deliveries and adverse effects were compared between the three groups. The obtained data were analyzed using SPSS 18 software. Data analysis was performed according to the intention to treat principle. Chi-square test, Fisher Exact test, Student ttest, and Mann-Whitney U test, were used for comparing data. P-value≤0.05 was considered statistically significant. Results: The three groups did not have any significant difference according to maternal age, gestational age at the time of admission, gravidity, parity, and primary Bishop Score. There was no significant difference between the three groups for the main outcome, which was vaginal delivery during the first 24 hours (p=0.887). There was no significant difference between the three groups according to hypertonicity, uterine hyperstimulation, meconium passage, non-reassuring fetal heart rate, neonatal Apgar score in minutes one and 5, and mean duration of beginning the intervention up to delivery. However, uterine tachysystole and NICU admission were more in the group to whom the titrated solution of misoprostol was administered (p=0.002 and p=0.037 respectively). The number of cesarean deliveries due to failure to progress was higher in the EASI group. However, EASI group showed the least number of none-reassuring fetal heart rate between the three groups. Meconium passage was more in the titrated misoprostol group, but the difference was not significant. Conclusion: All three methods are appropriate methods for induction of labor in the cases of unfavorable cervix; and choosing each method depends on the expertise of labor staff, accessibility to the medications, cost, and taking care for monitoring the patients and adverse effects.

Oxytocin levels in low-risk primiparas following breast stimulation for spontaneous onset of labor: a quasi-experimental study

BackgroundBreast stimulation is performed to self-induce labor. However, there are apparently no reports on hormonal evaluation during stimulation for consecutive days in relation to induction effect. We evaluated the salivary oxytocin level following 3 consecutive days of own breast stimulation for 1 h each day compared with no breast stimulation.MethodsWe used a quasi-experimental design. The participants were low-risk primiparas between 38 and 39 gestational weeks. Eight saliva samples per participant were collected at preintervention and 30, 60, and 75 min postintervention on the first and third days. The primary outcome was change in the salivary oxytocin level on the third day after 3 consecutive days of breast stimulation for 1 h each day compared with no breast stimulation. The secondary outcomes were the rate of spontaneous labor onset and negative events including uterine hyperstimulation and abnormal fetal heart rate.ResultsBetween February and September 2016, 42 women were enrolled into the intervention group (n = 22) or control group (n = 20). As there were differences in the basal oxytocin levels between the 2 groups, to estimate the change in the oxytocin level from baseline, we used a linear mixed model with a first-order autoregressive (AR1) covariance structure. The dependent variable was change in the oxytocin level from baseline. The independent variables were gestational weeks on the first day of intervention, age, education, rs53576 and rs2254298, group, time point, and interaction of group and time. After Bonferroni correction, the estimated change in the mean oxytocin level at 30 min on the third day was significantly higher in the intervention group (M = 20.2 pg/mL, SE = 26.2) than in the control group (M = − 44.4 pg/mL, SE = 27.3; p = 0.018). There was no significant difference in the rate of spontaneous labor onset. Although there were no adverse events during delivery, uterine tachysystole occurred in 1 case during the intervention.ConclusionsThe estimated change in the mean oxytocin level was significantly higher 30 min after breast stimulation on the third day. Thus, consecutive breast stimulation increased the salivary oxytocin level. Repeated stimulations likely increase the oxytocin level.Trial registrationUMIN000020797 (University Hospital Medical Information Network; Prospective trial registered: January 29, 2016).

CONDISOX- continued versus discontinued oxytocin stimulation of induced labour in a double-blind randomised controlled trial

BackgroundOxytocin is an effective drug for induction of labour, but is associated with serious adverse effects of which uterine tachysystole, fetal distress and the need of immediate delivery are the most common. Discontinuation of oxytocin once the active phase of labour is established could reduce the adverse effects.The objective is to investigate how the caesarean section rate is affected when oxytocin stimulation is discontinued in the active phase of labour compared to labours where oxytocin is continued.MethodsCONDISOX is a double-blind multicentre randomised controlled trial conducted at Danish and Dutch Departments of Obstetrics and Gynaecology. The first participant was recruited on April 8 2016.Based on a clinically relevant relative reduction in caesarean section rate of 7%, an alpha of 0.05, a beta of 80%, we aim for 1200 participating women (600 in each arm).The CONDISOX trial includes women at a gestational age of 37–42 complete weeks of pregnancy, who have uterine activity stimulated with oxytocin infusion for the induction of labour. Women are randomised when the active phase of labour becomes established, to study medication containing either oxytocin (continuous group) or placebo (discontinued group) infusion. Women are stratified by birth site, indication for oxytocin stimulation (induction of labour, prelabour rupture of membranes) and parity (nulliparous, parous +/− previous caesarean section).We will compare the primary outcome, caesarean section rate, in the two groups using a chi-square test with a p-value of 0.05. If superiority is not demonstrated, we have a pre-defined post hoc non-inferiority boundary (margin, delta) at 1.09.Secondary outcomes include duration of the active phase of labour, incidence of uterine tachysystole, postpartum haemorrhage, admission to the neonatal intensive care unit, Apgar score, umbilical arterial blood pH, and birth experience.DiscussionThe high frequency of oxytocin use and the potential risks of both maternal and fetal adverse effects of oxytocin emphasise the need to determine the optimal oxytocin regime for induction of labour.Trial registrationNCT02553226 (registered September 17, 2015). Eudra-CT number: 2015–002942-30.

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 and safety of intravaginal misoprostol for the induction of labor in patients with obstetrical or medical indication for labor induction

Background: Labor induction is becoming one of the most frequent procedures in maternity hospitals. However, the optimal agent for labor induction has not yet been established. Misoprostol, a prostaglandin E1 analogue, is receiving much attention due to its labor induction properties. Objective: The aim of this study was to evaluate the efficacy and safety of 25 and 50 mcg of intravaginal misoprostol, every four hours, for the induction of labor. Materials and Methods: This was a randomized controlled study to compare two different regimens of vaginal misoprostol, in women with obstetrical or medical indication for induction of labor. Participants received either a 25- or 50-mcg dose of misoprostol inserted into the posterior vaginal fornix repeated every four hours (maximum six doses), until adequate labor was established. Close monitoring of uterine activity and fetal heart rate was performed in all patients. Data were collected prospectively on epidemiological, obstetric, and care aspects. Results: Both regimens of misoprostol were effective in the induction of labor and most of the women had normal vaginal deliveries (81.08%). Although the mean time intervals from induction to the onset of active labor, and from induction to vaginal delivery for the 50-mcg regimen were lower, there was no significant difference between the two regimens. There were very few complications, with one case of uterine tachysystole in each treatment regimen. Conclusion: The results of the present study show that both regimens of misoprostol appear to be effective for the induction of labor in patients with indication, with few fetal complications.

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.

Buccal versus Vaginal Misoprostol for Term Induction of Labor: A Retrospective Cohort Study

To compare the efficacy of similar buccal and vaginal misoprostol doses for induction of labor. Retrospective chart review of 207 consecutive women undergoing term induction of labor with misoprostol. Misoprostol route and dosing were collected. Time to delivery and other labor outcomes (e.g., vaginal delivery less than 24 hours) were compared between women receiving buccal and vaginal misoprostol. There was no significant difference in time to delivery for women receiving buccal (median 18.2 hour, 95% confidence interval [CI] = [14.9, 21.5]) versus vaginal (median 18.3 hour, 95% CI = [15.0, 20.4]) misoprostol (p = 0.428); even after adjusting for covariates (p = 0.381). Women who presented with premature rupture of membranes were more likely to receive buccal misoprostol (92.7% received buccal vs. 7.3% received vaginal, p < 0.001). A similar number of women delivered vaginally in the buccal group (88.2%) and vaginal misoprostol group (86.8%, p = 0.835). The proportion of women who experienced uterine tachysystole or chorioamnionitis did not significantly differ by route of administration. We found no significant differences in time to delivery or other labor outcomes between buccal or vaginal dosing of misoprostol in women undergoing labor induction at term.