Morning versus evening induction of labour for improving outcomes

Neuraxial analgesia interfered with the circadian rhythm of labor: a propensity score matched cohort study

Objectives

To investigate whether neuraxial analgesia and other medical interventions have effects on the circadian rhythm of labor.

Methods

It was a retrospective propensity score matched cohort study. Parturients were recruited, who delivered term singletons in cephalic position, from seven hospitals in Harvard University Partners Healthcare Systems, 2016–2018. The parturients were divided into two groups, neuraxial analgesia delivery and spontaneous vaginal delivery, the stratification was performed according to labor induction, oxytocin, operative delivery. The parturients in each group were divided into 12 periods in every 2 h based on the birth time of babies. Cosine function fitting was used to verify whether the birth time had the characteristic of circadian rhythm.

Results

In spontaneous vaginal deliveries, the peak of birth time was at 2:00–4:00, and the nadir was at 14:00–16:00, this showed a circadian rhythm presented by a cosine curve fitting with the formula (y = 0.0847 + 0.01711 × cos(− 0.2138 × x + 0.4471). The labor rhythm of NAD (Neuraxial Analgesia Delivery) group changed completely, inconsistent with the cosine curve fitting of the circadian rhythm. The intervention of induction and oxytocin blurred the circadian rhythm of SVD (Spontaneous Vaginal Delivery) group and increased the amplitude of the fluctuation in NAD (Neuraxial Analgesia Delivery) group. The intervention of operative delivery had changed the distribution curve completely both in the SVD (Spontaneous Vaginal Delivery) group and the NAD (Neuraxial Analgesia Delivery) group.

Conclusions

Neuraxial analgesia did affect on circadian rhythm of labor, changed the cosine rhythm of labor with spontaneous vaginal delivery, and this trend was aggravated by the use of induction, oxytocin and operative delivery.

Use of artificial intelligence to predict mean time to delivery following cervical ripening with dinoprostone vaginal insert

OBJECTIVE

To validate a mathematical model to predict the mean time to delivery (TTD) following cervical ripening with dinoprostone vaginal insert (DVI), and assess its impact on the risk of nocturnal deliveries.

METHODS

We performed a case-control retro-prospective study at Angers University Hospital. In the control group, we retrospectively included 405 patients who underwent cervical ripening with DVI between 01/2015 and 09/2016. Based on the delivery outcomes, we developed a mathematical model that integrates all the factors influencing TTD following cervical ripening with DVI. In the study group, we prospectively included 223 patients who underwent cervical ripening with DVI between 11/2017 and 11/2018. The timing of insertion was calculated using the mathematical model developed in the control group, in order to prevent the occurrence of nocturnal deliveries.

RESULTS

The calculated mean TTD was significantly shorter than the real mean TTD (21h46 min ± 3h28 min versus 25h38 min ± 12h10 min, p < 0.001), and for 44% of patients, there was at least 10 h difference between the two. The real TTD (25h38 min ± 12H10 min versus 20h39 min ± 10h49, p < 0.001), and the rate of nocturnal deliveries (30.5% versus 21.2%, p = 0.01) were significantly higher in the study group compared to the control group.

CONCLUSION

The mathematical model did not help predicting TTD following cervical ripening with DVI, and or reducing the number of nocturnal deliveries.

Feasibility study protocol of a pragmatic, randomised controlled pilot trial: membrane sweeping to prevent post-term pregnancy-the MILO Study

BACKGROUND

Post-term pregnancy is associated with an increased risk of maternal complications, respiratory distress and trauma to the neonate. Amniotic membrane sweeping has been recommended as a simple procedure to promote the spontaneous onset of labour. However, despite its widespread use, there is an absence of evidence on (a) its effectiveness and (b) its optimal timing and frequency. The primary aim of the MILO Study is to inform the optimal design of a future definitive randomised trial to evaluate the effectiveness (including optimal timing and frequency) of membrane sweeping to prevent post-term pregnancy. We will also assess the acceptability and feasibility of the proposed trial interventions to clinicians and women (through focus group interviews).

METHODS/DESIGN

Multicentre, pragmatic, parallel-group, pilot randomised controlled trial with an embedded factorial design. Pregnant women with a live, singleton foetus ≥ 38 weeks gestation; cephalic presentation; longitudinal lie; intact membranes; English speaking and ≥ 18 years of age will be randomised in a 2:1 ratio to membrane sweep versus no membrane sweep. Women allocated randomly to a sweep will then be randomised further (factorial component) to early (from 39 weeks) versus late (from 40 weeks) sweep commencement and a single versus weekly sweep. The proposed feasibility study consists of four work packages, i.e. (1) a multicentre, pilot randomised trial; (2) a health economic analysis; (3) a qualitative study; and (4) a study within the host trial (a SWAT). Outcomes to be collected include recruitment and retention rates, compliance with protocol, randomisation and allocation processes, attrition rates and cost-effectiveness. Focus groups will be held with women and clinicians to explore the acceptability and feasibility of the proposed intervention, study procedures and perceived barriers and enablers to recruitment.

DISCUSSION

The primary aim of the MILO Study is to inform the optimal design of a future definitive randomised trial to evaluate the effectiveness (including optimal timing and frequency) of membrane sweeping to prevent post-term pregnancy. Results will inform whether and how the design of the definitive trial as originally envisaged should be delivered or adapted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04307199 . Registered on 12 March 2020.

Involving service users in the Birth Timing project, a data linkage study analysing the timing of births and their outcomes

INTRODUCTION

We report on service user participation in a population-based data linkage study designed to analyse the daily, weekly and yearly cycles of births in England and Wales, the outcomes for women and babies, and their implications for the NHS. Public Involvement and Engagement (PI&E) has a long history in maternity services, though PI&E in maternity data linkage studies is new in the United Kingdom. We have used the GRIPP2 short form, a tool designed for reporting public involvement in research.

OBJECTIVES

We aimed to involve and engage a wide range of maternity service users and their representatives to ensure that our use of patient-identifiable routinely collected maternity and birth records was acceptable and that our research analyses using linked data were relevant to their expressed safety and quality of care needs.

METHODS

A three-tiered approach to PI&E was used. Having both PI&E co-investigators and PI&E members of the Study Advisory Group ensured service user involvement was part of the strategic development of the project. A larger constituency of maternity service users from England and Wales was engaged through four regional workshops.

RESULTS

Two co-investigators with experience of PI&E in maternity research were involved as service user researchers from design stage to dissemination. Four PI&E study advisors contributed service user perspectives. Engagement workshops attracted around 100 attendees, recruited largely from Maternity Services Liaison Committees in England and Wales, and a community engagement group. They supported the use of patient-identifiable data, believing the study had potential to improve safety and quality of maternity services. They contributed their experiences and concerns which will assist with interpretation of the analyses.

CONCLUSION

Use of PI&E 'knowledge intermediaries' successfully bridged the gap between data intensive research and lived experience, but more inclusivity in involvement and engagement is required. Respecting the concerns and questions of service users provides social legitimacy and a relevance framework for researchers carrying out analyses.

A mathematical model to predict mean time to delivery following cervical ripening with dinoprostone vaginal insert

The main objective of our study was to analyze the mean time to delivery following cervical ripening with a 10 mg dinoprostone vaginal insert. We performed a retrospective observational study at the level III maternity ward of Angers university hospital. We included all women who had cervical ripening with dinoprostone between January 1st, 2015 and September 30th, 2016. Overall, 405 patients were included, and 59.3% (240/405) were nulliparous. The mean time to delivery was 20h39 min ± 10h49 min. 21% of deliveries (86/405) occurred between midnight and 6 h a.m., and the cesarean section rate was 33% (132/405). Multiple regression analysis showed that nulliparity, overweight (BMI ≥ 25), a closed cervix on initial examination and the absence of premature rupture of membranes (PRM) all significantly increased the mean time to delivery. We developed a mathematical model integrating the aforementioned factors and their impact to help predict the mean time to delivery following cervical ripening with dinoprostone vaginal insert: Y = 961.188-80.346 × parity + 21.437 × BMI-165.263 × cervical dilation-241.759 × PRM. This equation allows obstetricians to calculate a personalized time to delivery for each patient, allowing a precise scheduling of dinoprostone insert placement, and thus improving the organization in busy maternity wards.

Births and their outcomes by time, day and year: a retrospective birth cohort data linkage study

Background

Studies of daily variations in the numbers of births in England and Wales since the 1970s have found a pronounced weekly cycle, with numbers of daily births being highest from Tuesdays to Fridays and lowest at weekends and on public holidays. Mortality appeared to be higher at weekends. As time of birth was not included in national data systems until 2005, there have been no previous analyses by time of day.

Objectives

To link data from birth registration and birth notification to data about care during birth and any subsequent hospital admissions and to quality assure the linkage. To use the linked data to analyse births and their outcomes by time of day, day of the week and year of birth.

Design

A retrospective birth cohort analysis of linked routine data.

Setting

England and Wales.

Outcome measures

Mortality of babies and mothers, and morbidity recorded at birth and any subsequent hospital admission.

Population and data sources

Birth registration and notification records of 7,013,804 births in 2005–14, already linked to subsequent death registration records for babies, children and women who died within 1 year of giving birth, were provided by the Office for National Statistics. Stillbirths and neonatal deaths data from confidential enquiries for 2005–9 were linked to the registration records. Data for England were linked to Hospital Episode Statistics (HES) and data for Wales were linked to the Patient Episode Database for Wales and the National Community Child Health Database.

Results

Cross-sectional analysis of all births in England and Wales showed a regular weekly cycle. Numbers of births each day increased from Mondays to Fridays. Numbers were lowest at weekends and on public holidays. Overall, numbers of births peaked between 09.00 and 12.00, followed by a much smaller peak in the early afternoon and a decrease after 17.00. Numbers then increased from 20.00, peaking at around 03.00–05.00, before falling again after 06.00. Singleton births after spontaneous onset and birth, including births in freestanding midwifery units and at home, were most likely to occur between midnight and 06.00, peaking at 04.00–06.00. Elective caesarean births were concentrated in weekday mornings. Births after induced labours were more likely to occur at hours around midnight on Tuesdays to Saturdays, irrespective of the mode of birth.

Limitations

The project was delayed by data access and information technology infrastructure problems. Data from confidential enquiries were available only for 2005–9 and some HES variables were incomplete. There was insufficient time to analyse the mortality and morbidity outcomes.

Conclusions

The timing of birth varies by place of birth, onset of labour and mode of birth. These patterns have implications for midwifery and medical staffing.

Future work

An application has now been submitted for funding to analyse the mortality outcomes and further funding will be sought to undertake the other outstanding analyses.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 7, No. 18. See the NIHR Journals Library website for further project information.

Timing of sequential use of double-balloon catheter and oral misoprostol for induction of labor

AIM

The best time to commence cervical ripening with a balloon catheter is unknown. The aim of this study was to evaluate whether application of a balloon catheter in the morning or in the evening is better when sequential prostaglandin application is planned.

METHODS

This multicenter historical cohort study included 415 women with an unfavorable cervix undergoing labor induction at term. Labor was induced with a double-balloon catheter and the sequential use of oral misoprostol if necessary. The balloon catheter was placed in the morning group between 02:00-15:00 and in the evening group between 15:00-02:00. The primary outcome measure was the cesarean section rate. Secondary outcome measures included failed labor induction (no vaginal delivery within 72 h).

RESULTS

The cesarean section rate did not differ between the groups (morning 26.9%, evening 24.3%; P = 0.5553); however, more women in the morning group did not deliver within 72 h (8.8% vs 3.1%; P = 0.0138). In nulliparous women, labor induction failed more often in the morning group (12% vs. 4%, P = 0.043). In parous women, the induction-to-delivery interval was longer in the morning group (1756 vs. 1349 min; P = 0.046), and there were fewer deliveries within 24 h (35% vs. 56%, P = 0.016).

CONCLUSIONS

When sequential use of a double-balloon catheter and oral misoprostol for labor induction is planned, the preferable time for catheter placement is in the evening. This resulted in fewer failed inductions in nulliparous women and a shorter induction-to-delivery interval and more deliveries within 24 h in parous women.

Timing of induction of labor and association with nighttime delivery: a retrospective cohort

OBJECTIVE

To assess the risk of nighttime delivery associated with timing and method of labor induction.

STUDY DESIGN

We reviewed records of 692 patients undergoing full, late or post-term labor induction at two large hospitals. Primary independent variables were start time (morning or evening) and method (prostaglandin or oxytocin). Relative risk was assessed for the primary outcome of nighttime delivery.

RESULT

Two hundred and ninety-seven (42.9%) patients experienced nighttime delivery. The relative risk of nighttime delivery adjusted for age in multiparous women using oxytocin in the morning compared with oxytocin inductions in the evening was 0.31 (95% confidence interval (CI): 0.22 to 0.45). Among nulliparous women in the same group, the adjusted relative risk was 0.65 (95% CI: 0.36 to 1.19). For prostaglandin inductions, there was no difference in the risk of nighttime delivery based on timing of the induction in the evening (relative risk: 0.89; 95% CI: 0.71 to 1.10).

CONCLUSION

The method used and the time at which induction is started affect risk of nighttime delivery. For multiparous patients receiving oxytocin, morning induction carries lower risk of nighttime delivery. For prostaglandins, timing of initiation did not affect risk of nighttime delivery.

Optimising daytime deliveries when inducing labour using prostaglandin vaginal inserts

OBJECTIVE

To determine induction start time(s) that would maximise daytime deliveries when using prostaglandin vaginal inserts.

METHODS

Women enrolled into the Phase III trial, EXPEDITE (clinical trial registration: NCT01127581), had labour induced with either a misoprostol or dinoprostone vaginal insert (MVI or DVI). A secondary analysis was conducted to determine the optimal start times for induction by identifying the 12-h period with the highest proportion of deliveries by parity and treatment.

RESULTS

Optimal start times for achieving daytime deliveries when using MVI appear to be 19:00 in nulliparae and 23:00 in multiparae. Applying these start times, the median time of onset of active labour would be approximately 08:30 for both parities and the median time of delivery would be the following day at approximately 16:30 for nulliparae and 12:00 (midday) for multiparae. Optimal start times when using DVI appear to be 07:00 for nulliparae and 23:00 for multiparae. Using these start times, the median time of onset of active labour would be the following day at approximately 04:00 and 11:50, and the median time of delivery would be approximately 13:40 and 16:10, respectively.

CONCLUSIONS

When optimising daytime deliveries, different times to initiate induction of labour may be appropriate depending on parity and the type of retrievable prostaglandin vaginal insert used.

Sleep disorders in pregnancy

Sleep disturbances are common in pregnancy and may be influenced by a multitude of factors. Pregnancy physiology may predispose to sleep disruption but may also result in worsening of some underlying sleep disorders, and the de novo development of others. Apart from sleep disordered breathing, the impact of sleep disorders on pregnancy, fetal, and neonatal outcomes is poorly understood. In this article, we review the literature and discuss available data pertaining to the most common sleep disorders in perinatal women. These include restless legs syndrome, insomnia, circadian pattern disturbances, narcolepsy, and sleep-disordered breathing.

Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term

BACKGROUND

Prostaglandins have been used for induction of labour since the 1960s. This is one of a series of reviews evaluating methods of induction of labour. This review focuses on prostaglandins given per vaginam, evaluating these in comparison with placebo (or expectant management) and with each other; prostaglandins (PGE2 and PGF2a); different formulations (gels, tablets, pessaries) and doses.

OBJECTIVES

To determine the effects of vaginal prostaglandins E2 and F2a for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment or other vaginal prostaglandins (except misoprostol).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2014) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment, with each other, or other methods listed above it on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

We assessed studies and extracted data independently.

MAIN RESULTS

Seventy randomised controlled trials (RCTs) (11,487 women) are included. In this update seven new RCTs (778 women) have been added. Two of these new trials compare PGE2 with no treatment, four compare different PGE2 formulations (gels versus tablets, or sustained release pessaries) and one trial compares PGF2a with placebo. The majority of trials were at unclear risk of bias for most domains.Overall, vaginal prostaglandin E2 compared with placebo or no treatment probably reduces the likelihood of vaginal delivery not being achieved within 24 hours. The risk of uterine hyperstimulation with fetal heart rate changes is increased (4.8% versus 1.0%, risk ratio (RR) 3.16, 95% confidence interval (CI) 1.67 to 5.98, 15 trials, 1359 women). The caesarean section rate is probably reduced by about 10% (13.5% versus 14.8%, RR 0.91, 95% CI 0.81 to 1.02, 36 trials, 6599 women). The overall effect on improving maternal and fetal outcomes (across a variety of measures) is uncertain.PGE2 tablets, gels and pessaries (including sustained release preparations) appear to be as effective as each other, small differences are detected between some outcomes, but these maybe due to chance.

AUTHORS' CONCLUSIONS

Prostaglandins PGE2 probably increase the chance of vaginal delivery in 24 hours, they increase uterine hyperstimulation with fetal heart changes but do not effect or may reduce caesarean section rates. They increase the likelihood of cervical change, with no increase in operative delivery rates. PGE2 tablets, gels and pessaries appear to be as effective as each other, any differences between formulations are marginal but may be important.

Shift work and circadian dysregulation of reproduction

Health impairments, including reproductive issues, are associated with working nights or rotating shifts. For example, shift work has been associated with an increased risk of irregular menstrual cycles, endometriosis, infertility, miscarriage, low birth weight or pre-term delivery, and reduced incidence of breastfeeding. Based on what is known about circadian regulation of endocrine rhythms in rodents (and much less in humans), the circadian clock is an integral regulatory part of the reproductive system. When this 24-h program is disordered by environmental perturbation (such as shift work) or genetic alterations, the endocrine system can be impaired. The purpose of this review is to explore the hypothesis that misalignment of reproductive hormones with the environmental light-dark cycle and/or sleep-wake rhythms can disrupt menstrual cycles, pregnancy, and parturition. We highlight the role of the circadian clock in regulating human reproductive physiology and shift work-induced pathology within each step of the reproductive axis while exploring potential mechanisms from the animal model literature. In addition to documenting the reproductive hazards of shift work, we also point out important gaps in our knowledge as critical areas for future investigation. For example, future studies should examine whether forced desynchronization disrupts gonadotropin secretion rhythms and whether there are sleep/wake schedules that are better or worse for the adaptation of the reproductive system to shift work. These studies are necessary in order to define not only whether or not shift work-induced circadian misalignment impairs reproductive capacity, but also to identify strategies for the future that can minimize this desynchronization.