The present study was a prospective observational study done to evaluate elective induction of labour (e-IOL)* in overdate pregnancies (40 1/7 to 40 6/7 weeks) versus expectant management (EM)* up to ...41 weeks. The primary objective was to compare rates of Caesarean section among the two groups. Study design: Women at 40 weeks of gestation satisfying the inclusion and exclusion criteria were recruited for the study. Total sample size was 112. The e-IOL group 1, included 56 participants who were induced at 40 1/7 to 40 6/7 weeks of gestation and EM group 2 had 56 participants, who were given expectant management till 41 weeks of gestation. Group 2 was further divided as group 2a who went into spontaneous labour while on expectant management and group 2b as those who were induced while on expectant management for maternal / fetal reasons or ≥ 41 0/7 weeks of gestation.
Expectant management till 41 weeks of gestation beyond the due date increased the likelihood of spontaneous labour without adversely affecting the perinatal outcome. 73.2% of participants went into spontaneous labour in the EM group and 78% of them delivered vaginally. Caesarean section rates were lesser with EM (37.5%) as compared to e-IOL (58.9%) in our study (p=0.002).
Caesarean section rates were lesser among women with post date pregnancies when expectant management was followed as compared to elective induction of labour. No difference in perinatal outcomes was noted amongst the two groups. Participants who went into spontaneous labour when on expectant management were more likely to deliver vaginally.
Misoprostol is a synthetic PGE1 used for cervical ripening and induction of labour. However, the optimal dose of misoprostol to be used is a controversial issue.
of the study was to determine the ...efficacy and safety of 25 mcg versus 50 mcg vaginal misoprostol for induction of labour at term based on maternal and fetal outcomes.
This prospective cross-sectional study was carried out in the Department of Obstetrics and gynecology, Prathima Institue of Medical Sciences, Naganoor, Karimnagar. The patients were randomly allotted to either receive misoprostol 25 μg (Group I) or misoprostol 50 μg (Group II) respectively. The patient's group was recorded in the case file. After the confirmation of Bishop's score to be less than 6 the choosen dose of misoprostol was kept in the posterior fornix under aseptic conditions. The doses were repeated after 6 hours with a maximum of 4 doses till the patients get adequate uterine contractions which are defined as three contractions per 10 minutes or cervical dilatation of > 3cms.
Group I received 25μg of misoprostol intravaginally and Group II received 50μg of intravaginal misoprostol. The majority of women in this study n = 85 out of n=120 were primigravida. The distribution of primigravida in group I was n=48 and group II was n=37. The maternal complications were recorded in n=2(3.33%) of group II and n=1(1.67%) of group I patients. It appears that the higher doses of misoprostol used in group II is one of the cause although the values were statistically insignificant.
In conclusion, we found that the efficacy of 25µg of intravaginal misoprostol is comparable to 50 µg of intravaginal misoprostol for induction of labour. The advantages of 50µg of intravaginal misoprostol were it expedited vaginal deliveries. However, it also resulted in greater frequencies of complications to mother and fetus. Therefore we recommend the use of 25µg routinely and 50µg intravaginal misoprostol may be reserved for those with lower Bishop's scores.
Induction of labour in low-resource settings Ngene, Nnabuike Chibuoke; Moodley, Jagidesa
Best practice & research. Clinical obstetrics & gynaecology,
November 2021, 2021-11-00, 20211101, Letnik:
77
Journal Article
Recenzirano
Odprti dostop
Due to the disparity in resource availability between low- and high-resource settings, practice recommendations relevant to high-income countries are not always relevant and often need to be adapted ...to low-resource settings. The adaptation applies to induction of labour (IOL) which is an obstetric procedure that deserves special attention because it involves the initiation of a process that requires regular and frequent monitoring of the mother and foetus by experienced healthcare professionals. Lack of problem recognition and/or substandard care during IOL may result in harm with long-term sequelae. In this article, the authors discuss unique challenges such as insufficient resources (including staff, midwives, doctors, equipment, and medications) that result in occasional inadequate patient monitoring and/or delayed interventions during IOL in low-resource settings. We also discuss modifications in indications and methods for IOL, issues related to human immunodeficiency virus (HIV) infections, the feasibility of outpatient induction, clinical protocols and a minimum dataset for quality improvement projects. Overall, the desire to achieve a vaginal birth with IOL should not cloud the necessity to observe the required safety measures and implement necessary interventions; given that childbirth practices are the major determinants of pregnancy outcomes and patient satisfaction.
•Induction of labour (IOL) in low-resource settings (LRS) is associated with adverse pregnancy outcomes.•Socio-economic challenges in LRS may cause inadequate monitoring and delayed interventions.•Modifications in indications and methods of IOL are required in LRS.•Foley balloon catheter and or misoprostol is effective and commonest agents used for cervical priming in LRS.•Clinical practice protocols and minimum dataset for quality improvement on IOL are provided in this review.
In modern obstetrics, one of the common challenges is induction of labour (IOL). WHO Global Survey reported that IOL accounted for 9.6% of all deliveries.
Prostaglandins have evolved and frequently ...used pharmacologic agents for IOL, owing to their dual action of cervical ripening and uterine contraction inducing effect.
: 1. To compare the efficacy and induction to delivery interval (IDI) of PGE2 vaginal insert and Sublingual PGE1 in induction of labor in term pregnant women; 2. To study the maternal and fetal outcome in both groups.
: This a randomized, prospective, comparative study of 100 term pregnant women for induction of labour. Group 1-(50 women) PGE2-10mg vaginal insert and group 2-(50 women) PE1 Sublingual tablets – maximum 200 mcg in 24 hrs, at Dr LH Hiranandani Hospital, Mumbai, India.
: In my study the mean induction to delivery interval in Dinoprostone group was 17.47 hours and 23.44 hours in Misoprostol group. So the mean IDI was shorter in Dinoprostone insert group than Misoprostol group by about 6 hours. There was no significant difference noted in terms of overall incidence of caesarean deliveries among the groups.
Our study concluded that Dinoprostone 10mg vaginal insert was more efficacious than sublingual Misoprostol in reducing induction to delivery interval without maternal and fetal complications.
Our study suggests that the Dinoprostone vaginal insert can be used as both inducing as well as augmentating agent in labour. Dinoprostone vaginal insert maybe more effective in reducing the incidence of caesarean sections.
: Induction of labor is defined as artificially stimulating the uterus to start labor. Mifepristone is a synthetic steroid hormone analog that has both anti-progesterone and anti-glucocorticoid ...activities. This study aimed to study the efficacy of mifepristone in the induction of labor and cervical ripening.
: This study was conducted in Gandhi Hospital from August 2022 to November 2022. A total of 100 antenatal cases were admitted for safe confinement after 37 completed weeks and given oral mifepristone 200 mg and assessed for cervical ripening and need for further augmentation and the outcome was studied based on improvement in bishops score assessed after 24 hours of intake of oral mifepristone.
It was observed that there was a significant improvement in the bishop’s score 24 hours after giving mifepristone. Out of 100 women who were given mifepristone, 79% delivered vaginally and 21% delivered through emergency cesarean section. The major indication for emergency cesarean section was fetal distress. The majority of patients had good neonatal outcomes and there were no serious maternal complications.
Mifepristone is an effective and safe method of induction of labor with significant improvement in Bishop's score within 24 hours of administration.
Background
Beyond term, the risks of stillbirth or neonatal death increase. It is unclear whether a policy of labour induction can reduce these risks. This Cochrane review is an update of a review ...that was originally published in 2006 and subsequently updated in 2012
Objectives
To assess the effects of a policy of labour induction at or beyond term compared with a policy of awaiting spontaneous labour or until an indication for birth induction of labour is identified) on pregnancy outcomes for infant and mother.
Search methods
We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (9 October 2017), and reference lists of retrieved studies.
Selection criteria
Randomised controlled trials (RCTs) conducted in pregnant women at or beyond term, comparing a policy of labour induction with a policy of awaiting spontaneous onset of labour (expectant management). We also included trials published in form only. Cluster‐RCTs, quasi‐RCTs and trials using a cross‐over design are not eligible for inclusion in this review.
We included pregnant women at or beyond term. Since a risk factor at this stage of pregnancy would normally require an intervention, only trials including women at low risk for complications were eligible. We accepted the trialists' definition of 'low risk'. The trials of induction of labour in women with prelabour rupture of membranes at or beyond term were not considered in this review but are considered in a separate Cochrane review.
Data collection and analysis
Two reviewers independently assessed trials for inclusion, assessed risk of bias and extracted data. Data were checked for accuracy. We assessed the quality of evidence using the GRADE approach.
Main results
In this updated review, we included 30 RCTs (reporting on 12,479 women). The trials took place in Norway, China, Thailand, the USA, Austria, Turkey, Canada, UK, India, Tunisia, Finland, Spain, Sweden and the Netherlands. They were generally at a moderate risk of bias.
Compared with a policy of expectant management, a policy of labour induction was associated with fewer (all‐cause) perinatal deaths (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.14 to 0.78; 20 trials, 9960 infants; moderate‐quality evidence). There were two perinatal deaths in the labour induction policy group compared with 16 perinatal deaths in the expectant management group. The number needed to treat to for an additional beneficial outcome (NNTB) with induction of labour in order to prevent one perinatal death was 426 (95% CI 338 to 1337). There were fewer stillbirths in the induction group (RR 0.33, 95% CI 0.11 to 0.96; 20 trials, 9960 infants; moderate‐quality evidence); there was one stillbirth in the induction policy arm and 10 in the expectant management group.
For women in the policy of induction arms of trials, there were fewer caesarean sections compared with expectant management (RR 0.92, 95% CI 0.85 to 0.99; 27 trials, 11,738 women; moderate‐quality evidence); and a corresponding marginal increase in operative vaginal births with induction (RR 1.07, 95% CI 0.99 to 1.16; 18 trials, 9281 women; moderate‐quality evidence). There was no evidence of a difference between groups for perineal trauma (RR 1.09, 95% CI 0.65 to 1.83; 4 trials; 3028 women; low‐quality evidence), postpartum haemorrhage (RR 1.09 95% CI 0.92 to 1.30, 5 trials; 3315 women; low‐quality evidence), or length of maternal hospital stay (average mean difference (MD) ‐0.34 days, 95% CI ‐1.00 to 0.33; 5 trials; 1146 women; Tau² = 0.49; I² 95%; very low‐quality evidence).
Rates of neonatal intensive care unit (NICU) admission were lower (RR 0.88, 95% CI 0.77 to 1.01; 13 trials, 8531 infants; moderate‐quality evidence) and fewer babies had Apgar scores less than seven at five minutes in the induction groups compared with expectant management (RR 0.70, 95% CI 0.50 to 0.98; 16 trials, 9047 infants; moderate‐quality evidence).
There was no evidence of a difference for neonatal trauma (RR 1.18, 95% CI 0.68 to 2.05; 3 trials, 4255 infants; low‐quality evidence), for induction compared with expectant management.
Neonatal encephalopathy, neurodevelopment at childhood follow‐up, breastfeeding at discharge and postnatal depression were not reported by any trials.
In subgroup analyses, no clear differences between timing of induction (< 41 weeks versus ≥ 41 weeks' gestation) or by state of cervix were seen for perinatal death, stillbirth, NICU admission, caesarean section, or perineal trauma. However, operative vaginal birth was more common in the inductions at < 41 weeks' gestation subgroup compared with inductions at later gestational ages. The majority of trials (about 75% of participants) adopted a policy of induction at ≥ 41 weeks (> 287 days) gestation for the intervention arm.
Authors' conclusions
A policy of labour induction at or beyond term compared with expectant management is associated with fewer perinatal deaths and fewer caesarean sections; but more operative vaginal births. NICU admissions were lower and fewer babies had low Apgar scores with induction. No important differences were seen for most of the other maternal and infant outcomes.
Most of the important outcomes assessed using GRADE had a rating of moderate or low‐quality evidence ‐ with downgrading decisions generally due to study limitations such as lack of blinding (a condition inherent in comparisons between a policy of acting and of waiting), or imprecise effect estimates. One outcome (length of maternal stay) was downgraded further to very low‐quality evidence due to inconsistency.
Although the absolute risk of perinatal death is small, it may be helpful to offer women appropriate counselling to help choose between scheduled induction for a post‐term pregnancy or monitoring without (or later) induction).
The optimal timing of offering induction of labour to women at or beyond term warrants further investigation, as does further exploration of risk profiles of women and their values and preferences. Individual participant meta‐analysis is likely to help elucidate the role of factors, such as parity, in influencing outcomes of induction compared with expectant management.
Objective: To compare cervical ripening time with the use of vaginal Misoprostol plus Hyoscine-N-Butylbromide, with vaginal Misoprostol alone.Design: A double-blind randomized controlled trial with ...Pan-African Clinical Trials Registry (PACTR) approval number PACTR202112821475292Setting: Federal Medical Centre, Asaba, Nigeria.Participants: A total of 126 eligible antenatal patients for cervical ripening were enrolled.Interventions: Participants in Group A had 25μg of vaginal misoprostol with 1ml of intramuscular placebo, and those in Group B had 25μg of vaginal misoprostol with 20mg of Intramuscular Hyoscine (1 ml). Oxytocin infusion was used when indicated, and the labour was supervised as per departmental protocol.Main outcome measure: Cervical ripening timeResults: The mean cervical ripening time was statistically significantly shorter in the hyoscine group (8.48±4.36 hours) than in the placebo group (11.40±7.33 hours); p-value 0.02, 95% CI 0.80-5.05. There was no statistically significant difference in the mean induction-delivery interval in Group A (7.38±5.28 hours) compared to Group B (7.75±5.04 hours), with a value of 0.54. The mode of delivery was comparable. However, women in Group B (53, 84.1%) achieved more vaginal deliveries than women in Group A (50, 79.4%); p-value 0.49. Thirteen women in Group A (20.6%) had a caesarean section, while ten women (15.9%) in Group B had a caesarean section (p-value 0.49, RR 0.94, CI 0.80-1.11). Adverse maternal and neonatal outcomes were not statistically significant between the two groups.Conclusion: Intramuscular hyoscine was effective in reducing cervical ripening time when used as an adjunct to vaginal Misoprostol, with no significant adverse maternal or neonatal outcome.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
As the number of indications for labour induction continue to increase, the focus has shifted to performing these procedures in an outpatient setting. This study aims to systematically review ...published data from randomized controlled trials that compare outpatient with inpatient labour induction, to ascertain the role of outpatient labour induction for low-risk pregnancies.
We conducted a systematic review wherein we searched MEDLINE, EMBASE, Biosis Previews®, and International Pharmaceutical Abstracts from inception to January 2020 to identify randomized controlled trials that reported on maternal, fetal and resource-related outcomes following outpatient versus inpatient labour induction. Pooled incidences and mean differences were calculated using random-effects meta-analysis. Risk-of-bias was assessed using the Cochrane Risk of Bias tool. Subgroup analysis was conducted based on the method of induction.
Of the 588 records identified, 12 publications, representing nine independent randomized controlled trials conducted in Australia, Europe and North America, were included. These reported on 2615 cases of labour induction (1320 outpatients versus 1295 inpatients). Overall, apart from a higher number of suspicious fetal heart rate tracings RR = 1.43 (1.10, 1.86) and a shorter mean length of hospital stay MD = 282.48 min (160.23, 404.73) shorter in the outpatient group, there were no differences in delivery method, adverse outcomes or resource-use between the two arms. On subgroup analysis, when comparing the use of balloon catheters in both arms, those induced as outpatients had fewer caesarean deliveries RR = 0.52 (0.30, 0.90), a shorter admission-to-delivery interval MD = 370.86 min (19.19, 722.54) shorter, and a shorter induction to delivery interval MD = 330.42 min (120.13, 540.71) shorter.
Outpatient labour induction in resource-rich settings is at least as effective and safe, in carefully selected patient populations, when compared with inpatient labour induction. Whether outpatient labour induction results in lower rates of caesarean deliveries needs to be explored further.
This systematic review was prospectively registered in Prospero ( CRD42019118049 ).
To compare the effectiveness and safety of Dinoprostone Gel (DG), Misoprostol Vaginal Insert (MVI) and Dinoprostone Vaginal Insert (DVI) for induction of labour (IOL) in twin pregnancies.
...Retrospective cohort study of twin pregnancies > 34 + 0 weeks gestation that underwent induction of labour (IOL) with DG, MVI or DVI between December 2016 and November 2019 in a Tertiary NHS hospital, North West England, UK. Delivery characteristics, maternal complications and neonatal outcomes were compared between the three groups.
A total of 87 twin pregnancies were included for analysis. 27 women received DG, 34 received MVI and 26 DVI. The MVI cohort had a higher proportion of nulliparous women (55.9%) compared to the DG and DVI cohorts, 29.6% and 38.5% respectively. No other differences amongst demographic characteristics were considered clinically significant.
DG demonstrated a significantly quicker time to delivery (minutes) compared to DVI (1021 ± 556 versus 1649 ± 852; P = 0.0026). Significantly fewer women required terbutaline for hyperstimulation/tachysystole in the DG group compared to MVI (0% vs 32%; RR 0.05; 95% CI 0.003–0.88). Both DG and MVI groups required significantly less oxytocin following artificial rupture of membranes compared to DVI (33% vs 65%; RR 0.51; 95% CI 0.28–0.93) and (29% vs 65%; RR 0.45; 95% CI 0.25–0.81). There were no significant differences in mode of delivery, maternal complications and neonatal outcomes.
Our data suggests that for women with a twin pregnancy considering a planned labour that induction with DG, MVI and DVI appear to be equally safe and effective IOL methods. These results should be interpreted with caution due to the study being underpowered to detect significant adverse outcomes. In order to determine the optimal method of IOL in twins, direct randomised comparison is needed.
PDF
