Women In Spontaneous Labor Research Articles

Trends and outcomes of induction of labour among nullipara at term

To determine induction trends and delivery, maternal and neonatal health outcomes by gestational age following induction at term for women having a first baby. Linked birth and hospital data were used to examine the rates of adverse maternal and neonatal health outcomes for the period 2001-2007, among the 212,389 nullipara with singleton cephalic-presenting fetuses delivering between 37(0) and 41(6) weeks of gestation. Rates of caesarean delivery, neonatal transfers and overall severe neonatal and maternal adverse outcomes were determined by gestational age. Between 1990 and 2008, nulliparous term inductions as a proportion of all births increased from 5518 (6.8%) to 11,166 (12.5%). More than 60% of these inductions are performed before 41 weeks. Among induced nullipara, 30.4% delivered by caesarean section. Adverse neonatal outcomes and transfer rates were lowest at 39-40 weeks (overall 2.1 and 0.5%, respectively), regardless of labour onset. Maternal morbidity increased at 40 weeks (from 1.1 to 1.3%) for women in spontaneous labour, was relatively stable in those undergoing induction of labour between 37 and 40 weeks (1.8%) and decreased with gestational age until 40 weeks in those undergoing a prelabour caesarean delivery (from 3.1 to 0.8%). NSW has high rates of both induction and caesarean section following induction. This study highlights the changes to clinical practice that may help reduce the rate of caesarean births in nullipara.

Obstetric outcomes and maternal satisfaction in nulliparous women using patient-controlled epidural analgesia

The purpose of this study was to compare obstetric outcomes and maternal satisfaction in nulliparous women in spontaneous labor who used patient-controlled epidural analgesia (PCEA) vs continuous epidural infusion (CEI). We conducted a double-masked trial of 270 nulliparous women who were assigned randomly to 3 groups (with a concentration 0.1% bupivacaine and 2 μg/mL fentanyl): group I, CEI-only (10 mL/h); group II, CEI + PCEA (CEI 10 mL/h plus PCEA 10 mL, at 20 minutes); group III, PCEA-only (10 mL, at 20 minutes). A PCEA bolus button was given to each subject. The primary outcome was the dosage of local anesthetic that was used. The total milligrams of bupivacaine that were used was less in the PCEA-only group compared with CEI: group I. 74.8 ± 36 mg; group II, 97.3 ± 53 mg; group III, 52.4 ± 42 mg (P < .001). Pain with pushing, however, was worse in the PCEA-only group. Median satisfaction scores were similar (scale, 0 [best] to 100 [worst]: group I, 0; group II, 0; group III, 0 (P = .23). PCEA results in less anesthetic used, and maternal satisfaction remains high without a continuous infusion. Pain with pushing, however, was worse with the PCEA alone.

The Effect of Manipulation of the Programmed Intermittent Bolus Time Interval and Injection Volume on Total Drug Use for Labor Epidural Analgesia

Programmed intermittent bolus administration of epidural anesthetic solution compared with continuous infusion results in decreased anesthetic consumption and increased patient satisfaction. In this randomized and blinded study, we evaluated bupivacaine consumption and other analgesic outcomes when the programmed intermittent bolus time interval and volume were manipulated during the maintenance of epidural labor analgesia. Healthy, term, nulliparous women in spontaneous labor had combined spinal-epidural labor analgesia initiated with intrathecal bupivacaine 1.25 mg and fentanyl 15 μg, followed by an epidural test dose (lidocaine 45 mg with epinephrine 15 μg). Subjects were randomized to 1 of 3 programmed intermittent bolus dose regimens for maintenance of analgesia: 2.5 mL every 15 minutes (2.5/15), 5 mL every 30 minutes (5/30), or 10 mL every 60 minutes (10/60). The maintenance epidural solution consisted of bupivacaine 0.625 mg/mL with fentanyl 1.95 μg/mL. Breakthrough pain was treated initially with patient-administered epidural bolus doses, followed by manual boluses administered by the anesthesiologist if necessary. The primary outcome was total bupivacaine consumption per hour of labor. A linear mixed-effects model was used to model each patient's overall bupivacaine consumption per hour; the fixed effect was basal bupivacaine administration rate and the random effect was the area under the pain score versus time curve. One hundred ninety women were studied. The median (interquartile range) adjusted bupivacaine consumption per hour of labor was 8.8 mg (8.0-9.7 mg) in group 10/60 compared with 10.0 mg (9.3-10.8 mg) in group 5/30 and 10.4 mg (9.6-11.2 mg) in group 2.5/15 (P = 0.005). There were no differences in area under the pain score versus time curve, pain scores at delivery, patient-controlled epidural analgesia requests or administrations, number of manual bolus doses for breakthrough pain, time to first patient-controlled epidural analgesia or manual bolus dose, or patient satisfaction with labor analgesia. Extending the programmed intermittent bolus interval and volume from 15 minutes to 60 minutes, and 2.5 mL to 10 mL, respectively, decreased bupivacaine consumption without decreasing patient comfort or satisfaction.

An Observational Study to Explore the Power and Effect of the Labor Ward Culture on Consent to Intrapartum Procedures

AIM:To explore the concept of informed consent to intrapartum procedures within a hospital labor ward.DESIGN:An ethnographic study using participant observation and follow-up semistructured interviews with women and the attending midwives. Data analysis used principles of grounded theory assisted by the computer-assisted qualitative data analysis software (CAQDAS) package, Non-numerical Unstructured Data Indexing, Searching, and Theorizing (NUD*IST). The study was approved by the Local Research Ethics Committee.PARTICIPANTS AND SETTING:100 healthy English-speaking women in spontaneous labor who were to give birth within the labor ward of a large teaching hospital in England and the attending health professionals.FINDINGS:•The fragmented Western technocratic model of childbirth affected gaining informed consent to intrapartum procedures within the labor ward environment.•Midwives and women adopted certain stereotypical roles relating to how information was given and decisions made about intrapartum procedures.•Not all women wanted to be fully informed about intrapartum care and procedures and trusted the midwife or doctor to make decisions, especially concerning the health of their newborn.•Where a birth plan had been completed, women felt valued and enabled by having contributed to decisions made about their care.CONCLUSIONS:The study revealed that true choices to childbearing women were limited andinformedconsent was rarely obtained. Further exploration is required to establish the optimal timing of information disclosure to gain consent to intrapartum practices prior to the onset of labor, because during labor is not ideal. The 2 typologies may be used by midwives to examine how the culture of the birthing environment can affect women’s choice and the obtaining of informed consent to intrapartum procedures, especially where care is fragmented. Until birth is viewed through a holistic birthing model, health professionals will continue to control the birth experience. However, what is provided in practice should be congruent with the needs and expectations of childbearing women.

The effect of hyoscine butylbromide in shortening the first stage of labor: A double blind, randomized, controlled, clinical trial

Background and objectivesHyoscine butylbromide (HBB) is widely used in labor rooms. There have been many studies on the use of HBB during labor with conflicting results, involving both primiparous and multiparous women. The aim of this trial was to study the efficacy of HBB for shortening the first stage of labor in primiparous women.MethodsThe study was a randomized, double blind, controlled trial. Ninety-seven primigravid term pregnant women in spontaneous labor received either hyoscine butylbromide or a placebo intramuscularly once the women entered the active phase of labor. The primary outcome measured was the duration of the first stage of labor. Secondary outcomes were the duration of the second and third stages of labor, blood loss at delivery, rate of cesarean section, and Apgar scores for the neonates.ResultsA total of 97 women yielded data for analysis. Of these, 45 women received the placebo and 52 received HBB. The mean duration of the first stage in the control group was 215 minutes, compared with 165 minutes in the study group, representing a decrease of 23.3% (P = 0.001). There were no significant changes in the duration of the second (P = 0.063) or third (P = 0.0418) stages of labor, and no significant differences in blood loss or Apgar scores. There was a slightly higher (but statistically insignificant) rate of instrumental delivery in the control group, but no difference in the Cesarean section rate. There was a 60% reduction in opioid analgesic use in the HBB group.ConclusionHBB is effective in significantly reducing the duration of the first stage of labor, and is not associated with any apparent adverse maternal or neonatal outcomes.

316: The maternal demographics and intrapartum characteristics associated with epidural analgesia in spontaneous nulliparous labor

To examine the maternal demographics and labor characteristics associated with epidural use in spontaneous nulliparous term labors in a setting where the management of labor is standardized. This is a prospective observational study of all term nulliparous women in spontaneous labor with a singleton cephalic pregnancy who delivered from January 1st 2008 until December 31st 2008. In our institution the management of women in labor is standardized; all spontaneous nulliparous labors are actively managed. This standardization of care has permitted an effective examination of the influence of epidural analgesia on labor outcomes. The study cohort consisted of 2,442 consecutive deliveries. The overall epidural rate was 64% (n=1559). The onset of labor occurred at a later gestational age (282 vs. 280 days p=0.01) in women who received epidural analgesia and the duration of labor was significantly longer (416 vs.190 mins. p<0.001). These women also had a significantly higher body mass indices (BMI) at first antenatal consultation (24.8 vs. 24.1 kg/m2 p<0.001), though there was no significant difference in maternal age. Women who required oxytocin to augment spontaneous labor were also significantly more likely to require epidural analgesia (69% vs. 18%, p<0.001) The overall caesarean section rate was 7 % (n=177). The overall operative vaginal delivery rate was 24% (n= 585). The incidence of both caesarean (10% vs. 2%, p<0.001) and operative vaginal (31% vs. 11% p<0.001) delivery was significantly higher in those women who received epidural analgesia in labor compared to those that did not. The mean birthweight was also significantly higher in those receiving epidural analgesia (3550 vs. 3336g, p<0.001). The use of epidural analgesia was significantly more common in women with higher BMIs, laboring at later gestational ages. These results, in a contemporary cohort of actively managed spontaneous nulliparous labors, confirm the higher incidence of operative delivery with epidural use.

28: Obstetric outcomes and maternal satisfaction using patient controlled epidural analgesia in nulliparous women

Patient-controlled epidural analgesia (PCEA) has been shown to reduce local anesthetic use during labor. It is unclear if obstetric outcomes and maternal satisfaction are improved with the use of PCEA. Our aim was to compare obstetric outcomes and maternal satisfaction in nulliparous women in spontaneous labor using PCEA vs continuous epidural infusion (CEI).

172: The impact of epidural timing on mode of delivery in nulliparous women at term

To determine if epidural placement in early labor (≤3 cm dilation) compared to late labor (>5 cm dilation) alters the rates of cesarean or operative vaginal delivery in nulliparous women in spontaneous labor at term.

Trends and determinants of caesarean sections births in Queensland, 1997–2006

The determinants of Queensland's rising caesarean section (CS) rate remain poorly understood because of the historical absence of standard classification methods. We applied the Robson Ten Group Classification System (RTGCS) to population-based data to identify the main contributors to Queensland's rising CS rate. The RTGCS was applied retrospectively to the Queensland Perinatal Data Collection. CS rates were described for all ten RTGCS groups using data from 2006. Trends were evaluated using data for the years 1997-2006. Public and private sector patients were evaluated separately. In Queensland, in 2006, CS rates were 26.9 and 48.0% among public and private sector patients, respectively. Multiparous women with a previous caesarean birth (Group 5) made the greatest contribution to the CS rate in both sectors, followed by nulliparous women who had labour induced or were delivered by CS prior to the onset of labour (Group 2) and nulliparous women in spontaneous labour (Group 1). CS rates have risen in all RTGCS groups between 1997 and 2006. The trend was pronounced among multiparous women with a previous caesarean delivery (Group 5), among women with multiple pregnancies (Group 8) and among nulliparous women who had labour induced or were delivered by CS prior to the onset of labour (Group 2). The CS rate in Queensland in 2006 was higher than in any other Australian state. The increase in Queensland's CS rates can be attributed to both the rising number of primary caesarean births and the rising number of repeat caesareans.

A randomised controlled study comparing Drotaverine hydrochloride and Valethamate bromide in the augmentation of labour

Cervical dilatation is a poorly understood process. Various drugs have been used to facilitate this process and reduce the duration of labour and thereby reduce feto-maternal complications. The present study is an attempt to compare and evaluate the efficacy of Drotaverine hydrochloride and Valethamate bromide in the process of cervical dilatation and labour augmentation. A prospective randomised trial of 146 low-risk women in spontaneous labour was conducted. 49 women were given Drotaverine (Group 1), 49 women were given Valethamate (Group 2) and 48 women were given placebo (Group 3). At 4 cm of cervical dilatation, elective amniotomy was done and the injection was given intramuscularly, and repeated every hour for a maximum of three doses. There was a statistically significant difference in the mean injection-delivery times (time from first injection to delivery of the baby), which was 183.2 min (SD 78.8) in the Drotaverine group compared to 206.5 min (SD 69.7) in the Valethamate group, and 245 min (SD 70.9) in the control group. The mean cervical dilatation rate (cm/h) was 3 (SD 1.4), 2.4 (SD 0.9) and 1.9 (SD 0.6) in groups 1, 2 and 3, respectively, and these differences were statistically significant. There were no statistically significant differences in the duration of second and third stage of labour. Transient side effects such as foeto-maternal tachycardia, flushing of the face and dryness of mouth were noted with Valethamate. A few patients complained of headache in the Drotaverine group. Both Drotaverine and Valethamate appear to significantly help cervical dilatation and augment first stage of labour. But, Drotaverine is superior to Valethamate with fewer side effects.

Dressings for superficial and partial thickness burns; Effect of partogram use on outcomes for women in spontaneous labour at term; Exercise for depression; Vitamin C for preventing and treating tetanus

Journal of Advanced NursingVolume 65, Issue 7 p. 1365-1369 Dressings for superficial and partial thickness burns; Effect of partogram use on outcomes for women in spontaneous labour at term; Exercise for depression; Vitamin C for preventing and treating tetanus Prepared byThe Joanna Briggs Institute, Prepared byThe Joanna Briggs InstituteSearch for more papers by this author Prepared byThe Joanna Briggs Institute, Prepared byThe Joanna Briggs InstituteSearch for more papers by this author First published: 01 June 2009 https://doi.org/10.1111/j.1365-2648.2009.05008.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume65, Issue7July 2009Pages 1365-1369 RelatedInformation

Term labor is associated with a core inflammatory response in human fetal membranes, myometrium, and cervix

Identify overlap of the transcriptome of myometrium and cervix in association with human labor. The transcriptional profile of myometrial and cervical biopsies obtained from women in spontaneous labor at term (n = 9) and not in labor (n = 9) were characterized by Affymetrix v2 U133 plus 2 arrays. Common canonical pathways and functional groups were identified by Ingenuity Pathway Analysis. One hundred ten genes (false discovery rate < 1%) were commonly up-regulated by myometrium and cervix in association with labor and 29 genes (false discovery rate < 1%) down-regulated. Fold change in expression of up-regulated genes was strongly correlated; myometrium vs cervix (r = 0.51; P < .001), with no relationship in down-regulated genes (r = 0.26; P = .16). Canonical pathway analysis established up-regulation of inflammatory pathway signaling, with greatest increases in cellular movement and immune response gene ontology groups. Gestational tissues exhibit a core inflammatory response in association with human parturition, with pathways regulating cellular trafficking dominating.

A randomised controlled trial of early versus delayed oxytocin augmentation to treat primary dysfunctional labour in nulliparous women

Oxytocin is widely used to speed up slow labour, especially in nulliparous women, but randomised trials, apart from one reported only in abstract, have been too small to exclude important effects. To test the hypothesis that early use of oxytocin reduces the need for caesarean delivery. A randomised controlled trial. Twelve obstetric units within the Northern and Yorkshire regions in the North East of England. A total of 412 low-risk nulliparous women in spontaneous labour at term, who had been diagnosed with primary dysfunctional labour were recruited from January 1999 to December 2001. Immediate oxytocin administration (active group) or oxytocin withheld for up to 8 hours (conservative group). Caesarean section and operative vaginal delivery rates. The length of labour measured from the time of randomisation to delivery. The rate of maternal Edinburgh Postnatal Depression Scale (EPDS) greater than 12 (major depression) within 48 hours of delivery. The caesarean section rates were 13.5% active versus 13.7% controls (OR 0.98, 95% CI 0.6-1.7). Operative delivery, 24.5% versus 30.9% (OR 0.73, 95% CI 0.5-1.1). The median (interquartile range) randomisation to delivery interval in the active group was 5 hours 52 minutes (3:57-8:28) and in the conservative group 9 hours 8 minutes (5:06-13:16) (P < 0.001). The rate of EPDS >12 was 20% in the active arm versus 15% among controls (OR 1.26, 95% CI 0.7-2.2). There was one perinatal death in each group and no major differences in perinatal outcomes. Among nulliparous women with primary dysfunctional labour, early use of oxytocin does not reduce caesarean section or short-term postnatal depression. However, it shortens labour considerably and may reduce operative vaginal deliveries.

The incidence of maternal fever during labor is less with intermittent than with continuous epidural analgesia: a randomized controlled trial

Background This prospective, randomized study was performed to see if intermittent labor epidural analgesia was protective against maternal intrapartum fever, compared to continuous epidural infusion. Methods Ninety-two healthy, term, nulliparous women in spontaneous labor were assigned to either intermittent (ILEA) or continuous labor epidural analgesia (CLEA), 46 in each group. In both groups, epidural analgesia was established with fentanyl 100 μg, and 8 mL of either 0.125% bupivacaine with fentanyl 0.0002%, or 0.1% ropivacaine with fentanyl 0.0002%. Maintenance in the CLEA group was with the same bupivacaine/fentanyl or ropivacaine/fentanyl solutions at 10-15 mL/h. In the ILEA group, additional boluses of the same solution were given as needed. Maternal tympanic temperature was measured before epidural insertion, 4-hourly during labor and 4 h post partum. Fever was defined as a temperature of ⩾38 °C. Newborn temperature was noted within 60 min of birth. Results The incidence of fever in ILEA was significantly lower at four hours (2/42, vs. 10/44 in CLEA, P = 0.036). No significant differences were detected at other time periods. Mean maternal temperatures did not differ between groups at any time. There were no differences in neonatal temperature or neonatal sepsis evaluation rate (CLEA vs. ILEA 0/46 vs. 2/43, P = 0.45). Conclusions Intermittent epidural injections appear to protect against intrapartum fever in the first 4 hours of labor analgesia, compared to continuous infusion. This may be due to intermittent partial recovery of heat loss mechanisms between injections. Neonatal sepsis evaluation rates were similar in the two groups.

Exodus-1 (CCL20): evidence for the participation of this chemokine in spontaneous labor at term, preterm labor, and intrauterine infection.

CCL20, also known as MIP-3 alpha, is a chemokine that participates in chemotaxis of immature dendritic cells, effector/memory T-cells, and B-lymphocytes. The objectives of this study were to determine whether CCL20 can be detected in amniotic fluid (AF) and if AF concentration of this chemokine changes with advancing gestational age, parturition (term and preterm), and intra-amniotic infection/inflammation (IAI). A cross-sectional study was conducted including the following groups: (1) mid-trimester of pregnancy (n=65); (2) term not in labor (TNL; n=22); (3) term in labor (TIL; n=47); (4) spontaneous preterm labor (PTL) who delivered at term (n=57); (5) spontaneous PTL without IAI who delivered preterm (n=71); and (6) spontaneous PTL with IAI (n=38). AF CCL20 concentrations were determined using ELISA. (1) The median AF CCL20 concentration in TNL was higher than that of mid-trimester patients; (2) Women in spontaneous labor at term had a higher median AF concentration of CCL20 than patients at term not in labor; (3) Patients with spontaneous PTL and IAI had a significantly higher median AF concentration of CCL20 than those without IAI who delivered preterm and those who delivered at term. Moreover, women with spontaneous PTL without IAI who delivered preterm had a significantly higher median AF concentration than those with PTL who subsequently delivered at term. (1) CCL20 is a physiologic constituent of AF and its concentration increases as term approaches; (2) spontaneous labor (term and preterm) in the absence of IAI is associated with increased bioavailability of AF CCL20 suggesting that an increase in CCL20 is part of the common pathway of human parturition; (3) patients with IAI had dramatic elevations in the AF CCL20 concentrations suggesting that this chemokine participates in the host response to infection or other stimuli associated with intra-amniotic infection.

Maternal Body Mass Index in the First Trimester and Risk of Cesarean Delivery in Nulliparous Women in Spontaneous Labor

Maternal Body Mass Index in the First Trimester and Risk of Cesarean Delivery in Nulliparous Women in Spontaneous Labor

Maternal body mass index in the first trimester and risk of cesarean delivery in nulliparous women in spontaneous labor

To evaluate the effect of maternal body mass index (BMI) on the incidence of cesarean delivery. Prospective observational cohort study of 4341 consecutive nulliparous women with a single cephalic presentation, and spontaneous onset of labor between 37 and 42 weeks gestation at High Wycombe General Hospital, London, between January 1, 1995, and December 31, 2000. The incidence of cesarean delivery rose significantly with an increase in BMI. Women in labor with a BMI > 35 had a 3.8 times greater chance of a cesarean delivery than women with a BMI < 25 (after adjustment for variables such as maternal height and age, gestational age, fetal birthweight, and use of oxytocin and epidural analgesia during labor). This was true for cesarean deliveries performed for suspected fetal distress as well as for failure to progress. A high BMI significantly increased the risk of cesarean delivery, but the reasons are not certain.

Impact of Walking Epidural Analgesia on Obstetric Outcome of Nulliparous Women in Spontaneous Labour

Impact of Walking Epidural Analgesia on Obstetric Outcome of Nulliparous Women in Spontaneous Labour

Midwives’ perception of the intrapartum risk of healthy nulliparae in spontaneous labour, in The Flanders, Belgium

Objective to explore midwives’ perception of intrapartum risk for healthy nulliparous women in spontaneous labour at term of a healthy singleton pregnancy, in the Belgian Flanders, and to compare these results with those of a previous study undertaken in England. Design survey of the care midwives would advocate and their perception of intrapartum risk using a standardised scenario. This study replicates part of a survey undertaken with British midwives ( Mead & Kornbrot 2004b). With an added section to capture the particulars of the Belgian situation and explore the likelihood of midwives being fully responsible for the whole intrapartum care of healthy women, including their delivery. The questionnaire was translated into Dutch by MR and distributed by the Flemish Midwives’ Association (Vlaamse Organisatie van Vroedvrouwen—VLOV). Participants all 845 midwives and 143 student midwives who were members of VLOV were sent a questionnaire with their invitation to take part in their annual conference. Two hundred and seventy-five midwives and 107 students attended the conference, and 128 questionnaires were returned at the conference: 99 midwives (36% of the attendees), 26 students (24% of attendees), with three unidentified respondents. This convenience sample represented 12% of all midwives and 18% of all students. Analysis SPSS for Windows was used for the statistical analysis. Descriptive statistics were used and differences between categorical variables were analysed using χ 2 and Fisher's Exact tests, and differences between continuous variables were analysed by analysis of variance. Findings midwives generally described a more medicalised approach to intrapartum care on admission and during the first stage of labour than their British counterparts, but were much more optimistic about the chances of healthy women in spontaneous labour achieving a normal delivery within 12 hours. However, Belgian midwives had only a limited ability to undertake normal deliveries because of the high proportion of obstetricians who fulfil this responsibility. This contravenes the European Union (EU) directive on the activities of the midwife. Key conclusions despite much greater involvement of obstetricians in the care, of women suitable for full midwifery care, and a more medicalised approach to intrapartum care, the Belgian Flanders have a significantly lower caesarean section rate than the UK. The inability of Belgian midwives to fulfil the activities of the midwives as identified by the EU directives raises questions about the migration of midwives trained in Belgium to other EU member states.

Rectal misoprostol versus oxytocin in the prevention of postpartum hemorrhage — A pilot study

Oxytocin has been the oxytocic of choice for Active Management of Third Stage of Labor (AMTSL) [1]. Misoprostol would be a suitable alternative in low resource settings where drug delivery is hampered by storage and problems of parenteral administration. In patients who are vomiting, unable to take medications or under anesthesia, rectal administration may be associated with fewer side effects and ease of administration [2].The use of additional uterotonics is significantly higher with rectal 400 mcg misoprostol than with oxytocin [3]. It is possible that a higher dose of rectal misoprostol may be more effective in reducing blood loss. A prospective, double-blind, randomized pilot study was undertaken in the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India to determine the effectiveness and safety of rectal administration of 600 mcg misoprostol compared to oxytocin as part of the AMTSL in women at low risk for PPH. The study was approved by the ethical committee of the Institute. Two hundred women in spontaneous labor were recruited, and a written informed consent was ob-