Uterine Tachysystole Research Articles

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.

Update on uterine tachysystole.

Uterine tachysystole (TS) is a potentially significant intrapartum complication seen most commonly in induced or augmented labors but may also occur in women with spontaneous labor. When it occurs, maternal and perinatal complications can arise if not identified and managed promptly by obstetric care providers. Over recent years, new definitions of the condition have facilitated further research into the field, which has been synthesized to inform clinical management guidelines and protocols. We propose a set of recommendations pertaining to TS in line with contemporary evidence and obstetric practice.

High-dose versus low-dose of oxytocin for labour augmentation: a randomised controlled trial

ProblemDelayed labour progress is common in nulliparous women, often leading to caesarean section despite augmentation of labour with synthetic oxytocin. BackgroundHigh- or low-dose oxytocin can be used for augmentation of delayed labour, but evidence for promoting high-dose is weak.Aim To ascertain the effect on caesarean section rate of high-dose versus low-dose oxytocin for augmentation of delayed labour in nulliparous women.Methods Multicentre parallel double-blind randomised controlled trial (ClinicalTrials.gov: NCT01587625) in six labour wards in Sweden. Healthy nulliparous women at term with singleton cephalic fetal presentation, spontaneous labour onset, confirmed delay in labour and ruptured membranes (n=1351) were randomised to labour augmentation with either high-dose (6.6 mU/minute) or low-dose (3.3 mU/minute) oxytocin infusion. Findings1295 women were included in intention-to-treat analysis (high-dose n=647; low-dose n=648). Caesarean section rates did not differ between groups (12.4% and 12.3%, 95% Confidence Interval −3.7 to 3.8). Women with high-dose oxytocin had: shorter labours (−23.4min); more uterine tachysystole (43.2% versus 33.5%); similar rates of instrumental vaginal births, with more due to fetal distress (43.8% versus 22.7%) and fewer due to failure to progress (39.6% versus 58.8%). There were no differences in neonatal outcomes. DiscussionOur study could not confirm results of two systematic reviews indicating, with weak evidence, that use of high-dose oxytocin was associated with lower frequency of caesarean section. ConclusionWe found no advantages for routine use of high-dose oxytocin in the management of delay in labour. Low-dose oxytocin regimen is recommended to avoid unnecessary events of tachysystole and fetal distress.

Labor Induction in Late-Onset Fetal Growth Restriction: Foley Balloon versus Vaginal Dinoprostone

Objective: To compare vaginal delivery rate and perinatal outcomes of fetuses with late-onset fetal growth restriction (FGR) undergoing labor induction, depending on the method for cervical ripening (dinoprostone vs. Foley balloon). Material and Methods: We conducted a retrospective cohort study of 148 consecutive singleton gestations diagnosed with stage I late-onset FGR and Bishop score < 7, in which labor induction was indicated at ≥37 + 0 weeks. Before January 2016, cervical ripening was achieved with 10 mg of vaginal dinoprostone (n = 77) and afterwards with Fo­ley balloon (n = 71). Logistic regression analysis was used to estimate the association between mode of delivery and induction method. Results: Foley balloon had lower percentages of uterine tachysystole with fetal repercussion (4.2 vs. 16.9%, p = 0.01) and cesarean sections for suspected fetal distress (7.0 vs. 26.0%, p < 0.01) when compared to dino­prostone. Lower percentages of cesarean sections were found in the Foley balloon group (15.5 vs. 37.7%, p < 0.01). The odds ratio and adjusted odds ratio of cesarean section with dinoprostone were of 3.3 and 4.4, respectively. Perinatal mortality and severe morbidity were null in both groups. Conclusion: The use of Foley balloon resulted in a higher percentage of vaginal delivery compared to dinoprostone, with a favorable safety profile in both groups.

Discontinuation of intravenous oxytocin in the active phase of induced labour.

Discontinuation of intravenous oxytocin in the active phase of induced labour.

Synthetic osmotic dilators in the induction of labour—An international multicentre observational study

To evaluate the effects of synthetic osmotic dilators (Dilapan-S/ Dilasoft) in women who required induction of labour in a large prospective multicentre international observational study. Primary outcomes were duration of Dilapan-S/Dilasoft insertion (hours), total induction - delivery interval (hours) and the rate of vaginal deliveries within 24 h (%). Secondary outcomes were the number of dilators inserted, Bishop score increase after extraction of Dilapan-S/Dilasoft, complications during induction (uterine contractions, uterine tachysystole and hyperstimulation, effect on the fetus) and post induction (infections and neonatal outcomes), agents / procedures used for subsequent induction of labour, immediate rate of spontaneous labours following cervical ripening period, rate of spontaneous vaginal deliveries, rate of instrumental vaginal deliveries and caesarean sections. Total of 543 women were recruited across 11 study sites, of which, 444 women were eligible for analysis. With Dilapan-S/Dilasoft use of <12 h (n = 188) the overall vaginal delivery rate was 76.6% with 45.7% of these births occurring within 24 h, 66% within 36 h and 75.5% within 48 h from insertion of Dilapan-S/Dilasoft. The mean insertion-delivery interval for this group was 24.3(±10.4) hours. With Dilapan-S/Dilasoft use of >12 h (n = 256), the overall vaginal delivery rate was 64.8%, with 16% of these births occurring within 24 h, 48.4% within 36 h and 54.7% within 48 h from insertion of Dilapan-S/Dilasoft. The mean insertion-delivery interval for this group was 39.1(±29.2) hours. The mean gain in the Bishops score was +3.6(±2.3). The mean number of Dilapan-S/Dilasoft dilators used was 3.8 (±1.1). The overall rate of caesarean section was 30.1%. The overall complication rate was low including infection risk. No adverse neonatal outcome was attributable to the use of Dilapan-S/Dilasoft. Dilapan-S/Dilasoft are safe and effective methods for cervical ripening. Their use is associated with low maternal and neonatal complication rates. Future research should aim at level I clinical trials comparing Dilapan-S to other mechanical or pharmacological cervical ripening agents. https://clinicaltrials.gov/ct2/show/NCT02318173.

Acute tocolysis for uterine tachysystole or suspected fetal distress

Acute tocolysis for uterine tachysystole or suspected fetal distress

Review of use of Mysodelle as a method of induction of labour

Background: Mysodelle is a 200 mcg misoprostol, vaginal delivery system. It is a PGE1 analogue and accepted as a method of IOL by Scottish medicine consortium in 2014 (Medicines Health and Regulatory Authority; Wing et al., 2013).Aims: The main objective of this project was to determine efficacy of Mysodelle with regards to time interval between insertions to delivery. We also studied the safety profile of Mysodelle with regards to operative delivery rates, foetal concerns and incidence of hyperstimulation.Methodology: A protocol which outlined the criteria for suitability for the use of Mysodelle was developed. This method was used for IOL for primiparous women more than 38 weeks of gestations with unfavourable cervix and intact membranes with no foetal concerns on scan, i.e. suboptimal growth or reduced liquor. Mysodelle was left in situ for maximum duration of 24 hours and CTG was monitored every 4 hours. The data was collected prospectively over 1 year from January 2016.Results: We reviewed 50 women for the study period of one year. All women were primiparous with singleton term gestations between 38 + 5 weeks to term +11 days. The indications for IOL included postdates, reduced foetal movement, big baby and advanced maternal age. Following the use of Mysodelle, 55% of the women progressed to active labour and did not require oxytocin on labour ward. In 20% of the women, Mysodelle was removed for suspicious CTG or tachysystole. Four women failed IOL with Mysodelle. 14% women had hyperstimulation response to Mysodelle and needed terbutaline. 46% women had spontaneous vaginal delivery and 24% needed instrumental delivery. Remaining 30% patients delivered by caesarean section. The median time from Mysodelle administration to vaginal delivery was 21 hours (95% confidence interval 18.8–26.8 hours). There were no neonatal adverse outcomes.Conclusions: Results at AMH overall are in keeping with those from EXPEDITE study (Wing et al. 2013). It was found to be more efficacious in terms of insertion to delivery time, however, was associated with more tachysystole and hyperstimulation requiring terbutaline as previously highlighted in Cochrane review (Alfirevic and Weeks 2006; Hofmeyr et al. 2010). There was no increased risk of operative delivery or adverse neonatal outcome with the use of Mysodelle. A reduction in time to vaginal delivery and time to active labour associated with misoprostol vaginal delivery system may be an advantage for patients and the service (ISD Scotland 2013), but it needs to be seen if this benefit is offset due to increased requirements for foetal monitoring due to uterine tachysystole and hyperstimulation. MHRA have advised that Mysodelle can cause uterine tachysystole, that might not respond to tocolytic treatment. (MHRA medicine update 2018).

Mechanical induction of labor and ecbolic-less vaginal birth after cesarean section: A cohort study

ObjectiveDuring delivery counseling, some women with previous uncomplicated cesarean section (CS) wish mechanical induction of labor (IOL) but they are not accepting the added risk of using ecbolics to induce and/or augment labor. The objective of the study was to assess the safety and efficacy of the isolated use of transcervical Foley's catheter balloon as a mean of mechanical cervical ripening (CR)/IOL and successful ecbolic-less vaginal birth after cesarean section (VBAC). Materials and methodsA cohort study was conducted in two tertiary care maternity hospitals between October 2013 and July 2016 and recruited women with singleton pregnancy and cephalic presentation who had previous one uncomplicated CS and were scheduled for mechanical CR/IOL at term for routine obstetric indications. No ecbolics were used for induction or augmentation of labor as per patients' request. The primary outcome variable was the rate of successful VBAC. Results108 Women had a completed trial of mechanical CR/IOL without ecbolics till delivery. Active labor started in 94 women (87%), however only 43 women (39.8%) had successful VBAC. No woman in the study cohort had uterine rupture, scar dehiscence, uterine tachysystole, postpartum hemorrhage and/or puerperal sepsis. No cases were admitted to intensive care units and there were no maternal mortalities. Prior successful VBAC and post-expulsion BS were the only independent predictors for successful VBAC and shorter duration of labor after balloon expulsion. ConclusionMechanical IOL with the mere use of transcervical Foley's catheter is a safe and effective method of VBAC in women refusing use of ecbolics.

Misoprostol vaginal insert versus misoprostol vaginal tablets for the induction of labour: a cohort study

BackgroundMisoprostol vaginal insert for induction of labor has been recently reported to be superior to dinoprostone vaginal insert in a phase III trial, but has never been compared to vaginal misoprostol in another galenic form. The aim of this study was to compare misoprostol vaginal insert (MVI) with misoprostol vaginal tablets (MVT) for induction of labor in term pregnancies.MethodsIn this retrospective cohort study we compared 200 consecutive women induced with 200-μg misoprostol 24-h vaginal insert (Misodel®) with a historical control of 200 women induced with Misoprostol 25-μg vaginal tablets (Cytotec®) every 4-6 h. Main outcomes variables included induction-to-delivery interval, vaginal delivery within 24-h, incidence of tachysystole, mode of delivery, and neonatal outcome. A subanalysis in the MVI group was performed in order to identify predictive factors for tachysistole and vaginal delivery within 24 h.ResultsThe time from induction to vaginal delivery was 1048 ± 814 min in the MVI group and 1510 ± 1043 min in the MVT group (p < 0.001). Vaginal delivery within 24-h occurred in 127 (63.5%) patients of the MVI group and in 110 (55%) patients of the MVT group (p < 0.001). Tachysystole was more common in the MVI group (36% vs. 18%; p < 0.001). However, no significant predictors of uterine tachysystole in MVI group have been identified in crude and fully adjusted logistic regression models. Bishop score was the only predictor for vaginal delivery within 24 h (p < 0.001) in MVI group. Caesarean delivery rate (27% vs. 20%) and vaginal-operative deliveries (15.5% vs. 15.5%) did not differ significantly between the two groups. Neonatal outcomes were similar in both groups.ConclusionsMVI achieves a more vaginal delivery rate within 24 h and Tachysystole events compared to MVT. However, no differences in caesarean section, operative vaginal delivery, and neonatal outcomes are reported. No predictors of tachysistole after MVI administration have been identified. Bishop score and parity are the only predictors of vaginal delivery within 24 h after MVI administration.

Fetal Heart Changes Following Neuraxial Analgesia in Uteroplacental Insufficiency Pregnancies [30I

INTRODUCTION: Epidural analgesia (EA) and combined spinal epidural (CSE) can cause fetal heart rate changes due to maternal hypotension and uterine tachysystole. Previous studies have focused on CSE or EA in “healthy” pregnancies, excluding uteroplacental insufficiency (UPI) conditions. No studies have discussed the impact of EA and CSE on fetal heart rate in laboring UPI pregnancies. Our objective was to compare the impact of EA versus CSE during labor on fetal heart rate in pregnancies complicated with UPI. METHODS: We conducted a retrospective study of singleton pregnancies complicated with UPI that received EA (n=110) or CSE (n=127) for intrapartum pain relief in a single center from 2012-2015. UPI was defined as pregnancies with chronic hypertension, preeclampsia, and/or fetal growth restriction (IUGR) as per ACOG criteria definitions. Primary outcome was fetal heart rate abnormalities classified as normal, suspicious or pathologic as well as the NICHD criteria. Data collected included maternal demographics, blood pressure, uterine tachysystole, mode of delivery, interventions for FHR abnormalities and neonatal outcomes. Data was analyzed using Student’s t-test, Mann-Whitney U test and Chi-squared or Fisher’s exact test. RESULTS: There was no significant difference among groups in baseline characteristics, rate of maternal hypotension, uterine tachysystole, pregnancy outcome and fetal heart rate categories/abnormalities. When compared to the EA group, CSE had a higher rate of NICU admission (28.3% vs. 16.4%, p-value = 0.031). CONCLUSION: Pregnancies complicated with UPI are neither at higher risk of abnormal fetal heart pattern nor increased rate of fetal intervention.

Oral Misoprostol 2 Hourly for Labor Induction

The objective of this study was to assess the efficacy and safety of the 2 hourly oral misoprostol for labor induction. Between May and November 2013, the hospital records of 83 women who were induced for labor and met the eligibility criteria were retrospectively reviewed. Eligibility criteria were singleton pregnancy of at least 34 weeks’ gestation and a baseline Bishop score 6. Women with a previous cesarean section or other uterine surgery, severe pregnancy-induced hypertension, and parity of 4 or more were excluded. Oral misoprostol was administered as 20 μg 2 hourly unless active labor. A maximum of 12 doses was allowed. The age of the women was 27.9 ± 5.3 years (mean ± SD). Vaginal delivery within 24 hours occurred in 38 (45.8%) women. Cesarean delivery occurred in 17 (20.5%) women. Although more parous women achieved vaginal delivery within 24 hours (52.6%) compared with nulliparous women (40.0%), the difference was not significant (P = .35). Uterine tachysystole occurred in 12 (14.5%) women. No perinatal deaths or neonatal intensive care unit admission occurred in the study group. Evidence supporting an optimal regimen is lacking, and additional research is warranted to optimize the use of oral misoprostol for the induction of labor.

Current Resources for Evidence-Based Practice, January 2018

Current Resources for Evidence-Based Practice, January 2018

The role of prostaglandins E1 and E2, dinoprostone, and misoprostol in cervical ripening and the induction of labor: a mechanistic approach.

Prostaglandins play a critical role in cervical ripening by increasing inflammatory mediators in the cervix and inducing cervical remodeling. Prostaglandin E1 (PGE1) and prostaglandin E2 (PGE2) exert different effects on these processes and on myometrial contractility. These mechanistic differences may affect outcomes in women treated with dinoprostone, a formulation identical to endogenous PGE2, compared with misoprostol, a PGE1 analog. The objective of this review is to evaluate existing evidence regarding mechanistic differences between PGE1 and PGE2, and consider the clinical implications of these differences in patients requiring cervical ripening for labor induction. We conducted a critical narrative review of peer-reviewed articles identified using PubMed and other online databases. While both dinoprostone and misoprostol are effective in cervical ripening and labor induction, they differ in their clinical and pharmacological profiles. PGE2 has been shown to stimulate interleukin-8, an inflammatory cytokine that promotes the influx of neutrophils and induces remodeling of the cervical extracellular matrix, and to induce functional progesterone withdrawal. Misoprostol has been shown to elicit a dose-dependent effect on myometrial contractility, which may affect rates of uterine tachysystole in clinical practice. Differences in the mechanism of action between misoprostol and PGE2 may contribute to their variable effects in the cervix and myometrium, and should be considered to optimize outcomes.

Is Use of Misoprostol Associated With Failed Induction in Pregnancies With Suspected Placental Insufficiency? [12O

INTRODUCTION: Although misoprostol (MP) has demonstrated efficacy for cervical ripening, a concern with use of MP is uterine tachysystole, leading to fetal intolerance of labor and cesarean delivery (CD). We sought to determine whether indicators of placental insufficiency were associated with higher rates of failed induction and CD in pregnancies when MP was used for cervical ripening. METHODS: Population based retrospective cohort study of patients who underwent MP induction between May 2008-2013. Maternal and labor characteristics were compared between patients with FGR (&lt;10th% estimated fetal weight on ultrasound), oligohydramnios, preeclampsia, and infants born SGA (birth weight less than 10th%). Primary outcome was rate of CD. Secondary outcomes included CD for nonreassuring fetal status (NRFS). Multivariable logistic regression estimated association between indicators of placental insufficiency on the outcome of CD. RESULTS: Of 1,617 inductions during the 6 year period, 580 patients were induced using MP. FGR was suspected in 106 (18.2%). FGR was not associated with higher CD rate in MP inductions [22% versus 29%, p=0.11 (aOR 0.89, 95% CI 0.68-1.16)]. Similarly neither SGA nor oligohydramnios were associated with an increased CD rate, however preeclampsia did demonstrate a trend toward increased CD, aOR 1.21 (95% CI 0.97-1.51). The rate of CD for NRFS was similar between those with FGR and those without FGR (16% vs 15%, p=0.7). CONCLUSION: Despite a biologically plausible concern that MP induction in the setting of FGR and other indicators of placental insufficiency may increase risk for CD and CD for NRFS, our data does not support this.

Synthetic Osmotic Dilator Prior to Induction of Labor: Outcomes From International Observational E-Registry [13C

INTRODUCTION: To determine rate of cesarean delivery (CD) and maternal/neonatal adverse outcomes associated with use of synthetic osmotic dilator prior to labor induction. METHODS: This is a multicenter international post-marketing observational study of a synthetic osmotic dilator (Dilapan-S) for cervical ripening prior to labor induction in term pregnancies. Our primary outcome was rate of CD. Data were obtained in a standardized fashion and entered into a centralized electronic data capture system for analysis. RESULTS: Between May 2015 and July 2016, 343 term pregnant women undergoing cervical ripening prior to labor induction were included. Median maternal age was 30 (IQR18-45) years, and average BMI was 27. 68% of participants were nulliparous, 23% had a previous vaginal delivery and 9% had previous cesarean section. The majority (64%) of women received 4-5 dilators and the CD rate was 32%. Bishop score gain was 3.7 (95% CI [3.4-3.9]) with the use of the dilator. There were no cases of uterine tachysystole or FHR abnormalities. Maternal discomfort was reported by 9% of women and the rate of chorioamnionitis was 1.5%. Meconium stained amniotic fluid was present in 11% of patients. All newborns had an Apgar score at 5 minutes ≥ 7. Arterial pH &lt; 7.1 and neonatal intensive care admissions were &lt; 1%. CONCLUSION: Compared to other cervical ripening methods, the use of synthetic osmotic dilators appears to be safe and efficient method of cervical ripening for induction of labor in term pregnant women. Randomized clinical trials are needed to compare its efficacy to other methods of cervical ripening.

Efficacy and Safety of Foley Catheter Balloon for Cervix Priming in Term Pregnancy.

Foley catheter promotes cervix priming by a direct mechanical effect of distension. A prospective observational study was conducted at a tertiary hospital, including all cases of induction of laborwith Foley catheter between September 1, 2013 and November 30, 2015. Women were eligible if they had a singleton pregnancy witha Bishop score < 6 and a gestational age ≥ 41 weeks or a medical indication for induction of labor. The primary outcome was the Bishopscore variation (difference between Bishop score before and after insertion of Foley catheter). Mode of delivery, induction-to-deliverytime, uterine tachysystole with fetal decelerations, peripartum fever ≥ 38º C, maternal pain and mortality were also analyzed. Within 201 inductions with Foley catheter, average increase in Bishop score after catheter placement was three (1 - 7), withonly 5% (11/201) of unmodified cervix after catheter removal/extrusion. Vaginal delivery rate was 71% (142/201) and in women with aprevious cesarean section (n = 40) was 37% (15/40). Average induction-to-delivery time was 38 hours (4 - 120). Uterine infection ratewas 3% (6/201). There was only one case of significant vaginal bleeding which required immediate catheter removal. There has beenno significative maternal or neonatal morbidity. Foley catheter is a safe and effective method of cervical priming for women with an unfavorable cervix, evenin the case of a previous cesarean delivery.

Pre-labour Rapture of Membrane at Term in Patients with an Unfavorable Cervix: Active verses Conservative Management

Objective: The present quasi-experimental (comparative clinical trial) study was conducted to compare the outcome of active versus conservative management in patients with prelabour rupture of membrane (PROM) at term with an unfavourable cervix.&#x0D; Materials &amp; Methods: The study was carried out at Gynae &amp; Obstetrics Department, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka over a period of 12 months from July 2009 to June 2010. Women admitted in the Obstetrics &amp; Gynaecology Ward of BSMMU with pre-mature rupture of membrane (PROM) at term with unfavourable cervix was the study population. A total of 86 women with rupture of membranes at &gt; 37 weeks of gestation with a single foetus in a cephalic presentation, Bishop's score below 6, absence of active labour, no history of previous uterine surgery, no contraindication to vaginal delivery, a normal cardiotocogram and an adequate pelvis on clinical pelvimetry were included in the study and divided into two groups – study group (who received 25 μg of misoprostol every 6 hours in the posterior fornix of the vagina to a maximum of 4 doses) and control (who received conservative treatment for 24 hours).&#x0D; Result: The result shows that the study and control groups were almost identical in terms of age (p = 0.058), parity (p = 0.812), H/O past abortion (p = 0.366). Majority (94.3%) of the patients in case group and 64.4% in control group took 24 or &lt; 24 hours to deliver their babies. The mean interval between PROM and uterine contraction and that between ROM and delivery were significantly less in the study group than those in the control group (p &lt; 0.001 and p &lt; 0.001 respectively). About 63% of study group experienced significant uterine contractions after 1st dose, 23.3% after 2nd dose, 9.3% after 3rd dose and 4.7% after 4th dose of misoprostol, while none of the patients in control group experienced significant contraction during the same period (p &lt; 0.001). Twenty two (50.6%) of controls needed oxytocin for induction as opposed to none in the study group. The need for oxytocin during labour in study group were significantly less (37.2%) than that in control (80.5%) (p= 0.024). The incidence of failed induction was even less in study group (11.6%) than that in control (44.2 %) (p = 0.001). Two (4.7%) patients in the study group developed uterine hyperstimulation, 2.3% uterine tachysystole and another 2.3% nausea/vomiting while none of patients in control group developed the same complications. One (2.3%) of the patients in study group experienced chorioamnionitis and 9.3% exhibited group-B streptococci in high vaginal swab culture. In contrast, 18.6% of the controls developed chorioamnionitis and 14% showed the presence of group-B streptococci in high vaginal swab. In terms of mode of delivery, normal vaginal delivery (NVD) occurred in 88.4% study group as compared to 53.5% of control group (p&lt;0.001). There was no significant difference between the groups in terms of foetal distress (p= 0.747) and neonatal sepsis (p = 0.121). Over half of the patients in the both groups had a history of less than 4 vaginal examinations during labour. There was no significant differences between the groups with respect to Apgar score at 1 minute of birth, neonatal sepsis and foetal distress (p=0.063, p=0.121 and p=0.747 respectively).&#x0D; Conclusion: The study concluded that management of premature rupture of membrane with unfavourable cervix using vaginal misoprostol increases the rate of normal delivery thereby reducing the risk of caesarean section, while conservative management of premature rupture of membrane usually fails to augment normal delivery. So it is safer to give induction to women presenting with premature rupture of membrane with unfavourable cervix using vaginal misoprostol.&#x0D; Ibrahim Card Med J 2015; 5 (1&amp;2): 35-39

Uterine Tachysystole with Prolonged Deceleration Following Nipple Stimulation for Labor Augmentation

Breast stimulation for inducing uterine contractions has been reported in the medical literature since the 18th century. The American college of Obstetricians and Gynecologists (ACOG) has described nipple stimulation as a natural and inexpensive nonmedical method for inducing labor. We report on a 37 year old P2 with a singleton pregnancy at 40 weeks gestation who developed tachysystole with a prolonged deceleration after nipple stimulation for augmentation of labor. Initial resuscitative measures, including oxygen by mask, a bolus of intravenous fluids and left lateral positioning, did not restore the fetal heart rate to normal. After the administration of Terbutaline 250 mcg subcutaneously, the tachysystole resolved and the fetal heart rate recovered after five minutes of bradycardia. Most trials of nipple stimulation for induction or augmentation of labor have had small study populations, and no conclusions could be drawn about the safety of nipple stimulation, though its use is widespread. While there have been a few reports of similar complications during nipple stimulation for contraction stress testing, there are no previous reports of tachysystole with sustained bradycardia following nipple stimulation for labor augmentation. In this report, we draw attention to the dangers of nipple stimulation so that providers will be aware of this potential complication.

Dural Puncture Epidural Technique Improves Labor Analgesia Quality With Fewer Side Effects Compared With Epidural and Combined Spinal Epidural Techniques: A Randomized Clinical Trial

The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal medication administration is withheld. The DPE technique has been shown to improve caudal spread of analgesia compared with epidural (EPL) technique without the side effects observed with the CSE technique. We hypothesized that the onset of labor analgesia would follow this order: CSE > DPE > EPL techniques. A total of 120 parturients in early labor were randomly assigned to EPL, DPE, or CSE groups. Initial dosing for EPL and DPE consisted of epidural 20 mL of 0.125% bupivacaine plus fentanyl 2 μg/mL over 5 minutes, and for CSE, intrathecal 0.25% bupivacaine 1.7 mg and fentanyl 17 μg. Upon block completion, a blinded coinvestigator assessed the outcomes. Two blinded obstetricians retrospectively interpreted uterine contractions and fetal heart rate tracings 1 hour before and after the neuraxial technique. The primary outcome was time to numeric pain rating scale (NPRS) ≤ 1 analyzed by using Kaplan-Meier curves and Cox proportional hazard model. Secondary outcomes included block quality, maternal adverse effects, uterine contraction patterns, and fetal outcomes analyzed by using the χ test with Yates continuity correction. There was no significant difference in the time to NPRS ≤ 1 between DPE and EPL (hazard ratio 1.4; 95% confidence interval [CI] 0.83-2.4, P = .21). DPE achieved NPRS ≤ 1 significantly slower than CSE (hazard ratio 0.36; 95% CI 0.22-0.59, P = .0001). The median times (interquartile range) to NPRS ≤ 1 were 2 (0.5-6) minutes for CSE, 11 (4-120) minutes for DPE, and 18 (10-120) minutes for EPL. Compared with EPL, DPE had significantly greater incidence of bilateral S2 blockade at 10 minutes (risk ratio [RR] 2.13; 95% CI 1.39-3.28; P < .001), 20 minutes (RR 1.60; 95% CI 1.26-2.03; P < .001), and 30 minutes (RR 1.18; 95% CI 1.01-1.30; P < .034), a lower incidence of asymmetric block after 30 minutes (RR 0.19; 95% CI 0.07-0.51; P < .001) and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; P = .011). Compared with CSE, DPE had a significantly lower incidence of pruritus (RR 0.15; 95% CI 0.06-0.38; P < .001), hypotension (RR 0.38; 95% CI 0.15-0.98; P = .032), combined uterine tachysystole and hypertonus (RR 0.22; 95% CI 0.08-0.60; P < .001), and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; p = .011). Analgesia onset was most rapid with CSE with no difference between DPE and EPL techniques. The DPE technique has improved block quality over the EPL technique with fewer maternal and fetal side effects than the CSE technique for parturients requesting early labor analgesia.