Length of rupture of membranes in the setting of premature rupture of membranes at term and infectious maternal morbidity

Efficacy of controlled-release dinoprostone vaginal insert for elective induction of labor before due date

AIM

The induction of labor before due date has recently been proved to reduce the rate of cesarean sections and is not associated with increased risk of adverse perinatal outcomes as compared to expectant management. Controlled-release dinoprostone (PGE2) vaginal insert has recently been approved for use in Japan. However, evidence regarding its efficacy in cervical ripening and labor induction before due date remains limited. We aimed to compare the efficacy of PGE2 vaginal inserts and mechanical dilation for labor induction before due date.

METHODS

This retrospective cohort study included 206 mothers at 37, 38, and 39 weeks' gestation delivered at our institution between January 2021 and October 2022. Perinatal outcomes, including the success rate of vaginal delivery, were compared between the PGE2 (n = 46) and metreurynter/laminaria tent (non-PGE2) (n = 160) groups. The success rate of vaginal delivery was defined as the proportion of women who delivered vaginally within 48 h of initiating oxytocin augmentation.

RESULTS

The success rate of vaginal delivery was significantly higher in the PGE2 group (37/49, 80.4%) than in the non-PGE2 group (106/177, 66.2%). Emergency cesarean section related to non-reassuring fetal status was performed with none in the PGE2 group and with eight (5.0%) in the non-PGE2 group.

CONCLUSIONS

The rate of vaginal delivery was significantly higher in the PGE2 group for elective labor induction between 37 and 39 weeks. The PGE2 vaginal insert could increase the success rate of vaginal delivery for elective induction of labor at 39 weeks.

Timing of antibiotic prophylaxis in term prelabor rupture of membranes: A retrospective cohort study using propensity-score matching

OBJECTIVE

To assess whether earlier administration of antibiotic prophylaxis after prelabor rupture of membranes (PROM) at term would decrease the incidence of maternal and neonatal infections.

METHODS

This is a retrospective cohort study comparing women with term PROM who were initiated antibiotic prophylaxis within or after 6 h, and within or after 12 h from PROM to delivery during January 2019 to December 2021. Women with term PROM receiving cephalosporin and without contraindications to vaginal delivery or confirmed or suspected infection were included in the study. The primary outcome was puerperal infection, which refers to the reproductive tract infection occurring within 42 days of delivery. The type of pharmacoeconomic evaluation was selected based on the results of compared effectiveness between the early group and the late group. Propensity-score matching (PSM) was used to adjust confounding. Subgroup and sensitivity analyses were used to verify the robustness of results.

RESULTS

We enrolled 5353 women with term PROM, including 4331 initiated with antibiotic within 6 h, 1022 after 6 h, 5077 within 12 h, and 276 after 12 h. After PSM, no significant difference was observed in the baseline characteristics of the groups. There was no statistical difference between antibiotic use within 6 h and after 6 h, or within 12 h and after 12 h, in puerperal infection (4.6% vs. 4.3%, P = 0.826; 2.9% vs. 4.6%, P = 0.471, respectively), total maternal infection, neonatal sepsis, and total neonatal infection. Cost-minimization analysis showed there was no significant difference between antibiotic use within 6 h and after 6 h, or within 12 h and after 12 h, in direct medical costs.

CONCLUSION

This study showed that there was no statistical difference in the efficacy and economy of antibiotic prophylaxis used within 6-12 h after rupture of membranes versus after 6-12 h in women with term PROM.

Pre-labour Rupture of Membranes at Term in Women With Gestational Diabetes and the Risk of Neonatal Hypoglycemia

OBJECTIVES

The management for improving maternal and neonatal outcomes of women with gestational diabetes mellitus (GDM) arriving at the delivery ward with pre-labour rupture of membranes (PROM) has not been elucidated. We tested the hypothesis that prolonged PROM in women with GDM would result in higher rates of neonatal hypoglycemia.

METHODS

We retrospectively enrolled women with diet or insulin-controlled GDM who presented with spontaneous clear PROM. Each woman was allocated into one of two groups based on the PROM-delivery time: <18 hours (group 1) and ≥18 hours (group 2). The primary outcome was the incidence of neonatal hypoglycemia, defined as glucose <40 mg/dL (2.2 mmol/L) within 24 hours of birth.

RESULTS

We ultimately analyzed 631 cases of GDM (6.7%), 371 with PROM-delivery <18 hours, and 260 with PROM-delivery ≥18 hours. The incidence of neonatal hypoglycemia did not differ between the two groups, reaching 7.3%. Women in group 2 were at increased risk of both cesarean delivery (20% vs. 12.4%, P < 0.01) and maternal chorioamnionitis morbidity (6.5% vs. 1.3%, P < 0.001).

CONCLUSIONS

In a sub-group of women with GDM, a PROM-delivery time ≥18 hours is not associated with higher rates of neonatal hypoglycemia, but higher rates of chorioamnionitis and cesarean delivery were noted. Therefore, we suggest consideration for early delivery when managing women with GDM and PROM.

Effect of adjunctive prophylactic macrolides used at the caesarean section on endometritis and surgical site wound infection: A meta-analysis

A meta-analysis investigation was executed to measure the outcome of adjunctive prophylactic macrolides (APM) used at caesarean section (CS) on endometritis and surgical site wound infection (SSWI). A comprehensive literature inspection till February 2023 was applied and 1023 interrelated investigations were reviewed. The 10 chosen investigations enclosed 22 676 females with CS were in the chosen investigations' starting point, 14 034 of them were utilising APM, and 8642 were utilising control. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of APM used at CS on endometritis and SSWI by the dichotomous approaches and a fixed or random model. Adjunctive prophylactic macrolides had significantly lower SSWI (OR, 0.43; 95% CI, 0.34-0.55, P < .001), and endometritis (OR, 0.34; 95% CI, 0.20-0.60, P = .005) compared with those with control in females with CS. Adjunctive prophylactic macrolides had significantly lower SSWI, and endometritis compared with those with control in females with CS. However, care must be exercised when dealing with its values because of the low number of nominated investigations for the meta-analysis.

Effect of maternal age and body mass index on induction of labor with oral misoprostol for premature rupture of membrane at term: A retrospective cross-sectional study

The aim of this study was to evaluate the effect of maternal age and body mass index (BMI) on induction of labor with oral misoprostol for premature rupture of membrane (PROM) at term. We have conducted retrospective cross-sectional study, including only term (37 weeks or more of gestation) PROM in healthy nulliparous women with a negative vaginal-rectal swab for group B streptococcus, a single cephalic fetus with normal birthweight, and uneventful pregnancy that were induced after 24 h from PROM. Ninety-one patients were included. According to the multivariate logistic regression, age and BMI odds ratio (OR) for induction success were 0.795 and 0.857, respectively. The study population was divided into two groups based on age (<35 and ≥35 years) and obesity (BMI <30 and ≥30). Older women reported a higher induction failure rate (p < 0.001); longer time to cervical dilation of 6 cm (p = 0.03) and delivery (p < 0.001). Obese women reported a higher induction failure rate (p = 0.01); number of misoprostol doses (p = 0.03), longer time of induction (p = 0.03) to cervical dilatation of 6 cm (p < 0.001), and delivery (p < 0.001); and higher cesarean section (p = 0.012) and episiotomy rate (p = 0.007). In conclusion, maternal age and BMI are two of the main factors that influence oral misoprostol efficacy and affect the failure of induction rate in term PROM.

Evaluation of mechanical and nonmechanical methods of cervix ripening in women with premature rupture of membranes: a randomized controlled trial

BACKGROUND

Premature rupture of membranes occurs in 8% of pregnancies. In the absence of spontaneous labor, induction of labor is considered an appropriate strategy for term pregnant women with premature rupture of membranes. There are several approaches for preinduction cervical ripening, including mechanical methods, such as Foley catheterization, and nonmechanical methods, such as oral misoprostol.

OBJECTIVE

This study aimed to evaluate and compare the effects of oral misoprostol and Foley catheterization in pregnant women with premature rupture of membranes at ≥34 weeks of gestation who underwent induction of labor.

STUDY DESIGN

A randomized clinical trial was conducted. The inclusion criteria included nulliparous and multiparous pregnant women at ≥34 weeks of gestation with singleton pregnancies, cephalic presentation, and confirmed amniotic fluid leakage for more than 60 minutes. A total of 104 participants were randomly allocated into 2 groups, one receiving sublingual misoprostol and the other receiving transcervical Foley catheter for cervical ripening. The primary outcome was time from intervention to delivery, and the secondary outcomes included delivery method, maternal and neonatal results (chorioamnionitis, Apgar score, neonatal sepsis, and asphyxia), and arterial blood gas analysis of the umbilical cord.

RESULTS

The mean time from induction of labor to delivery (11.6±1.98 hours for Foley catheter vs 10.16±2.35 hours for misoprostol; P=.007) and the median duration of cervical ripening (4.5 hours [interquartile range, 0.0-6.0] for Foley catheter vs 4.0 hours [interquartile range, 1.5-6.0] for misoprostol; P=.04) were longer in the Foley catheter group than in the misoprostol group. There was no statistically significant difference in the cesarean delivery rate between the 2 groups (29.6% for Foley catheter vs 38.5% for misoprostol; P=.2). There was no case of chorioamnionitis or asphyxia in the 2 groups. There was no significant difference between the 2 groups in terms of umbilical cord pH and the 1- and 5-minute Apgar scores (P=.1, P=.4, and P=.1); nevertheless, these values were higher in the Foley catheter group. There was no statistically significant difference among additional secondary outcomes.

CONCLUSION

In premature rupture of membranes cases, cervical ripening with a Foley catheter was associated with a longer duration of ripening and time from induction to delivery than cervical ripening with misoprostol. The cesarean delivery rate and the maternal and neonatal infection rates were not different between these methods.

Neonatal mortality and associated factors among neonates admitted to neonatal intensive care unit of Gandhi memorial hospital in Addis Ababa, Ethiopia, 2019

Background

Ethiopia witnessed an unprecedented decline in under-5 and neonatal mortalities since 2000. But, neonatal mortality still accounts for the largest proportion of under-five child mortality. Quality of service at hospitals may vary and determine the magnitude of neonatal mortality.

Objective

To assess the prevalence and associated factors of neonatal mortality among newborns Admitted to the Neonatal intensive care unit of Gandhi Memorial Hospital Addis Ababa, Ethiopia, 2019.

Methods

Institution-based cross-sectional study was conducted from November 1 to December 31, 2019. A sample of one in every 2 admitted patients was included in the study. our exclusion criterion was neonates who had no mothers or guardians and/or neonatal medical records incomplete for status at discharge. We used the Systematic random sampling technique to select the study participants. A pretested structured interviewer-administered questionnaire and a preliminary tested checklist were used to collect primary and secondary data respectively. Descriptive and summary statistics were performed. A binary logistic regression model was fitted and variables that had a P-value of < 0.05 in the multivariable model were considered statistically significant.

Results

A total of 570 neonates who have mothers were involved in the study giving a response rate of 98.8%. The prevalence of neonatal mortality was 7.7% (95% CI: 5.7, 9.8). Mothers' educational status (No education (AOR 3.37, CI 95%, 1.02–11.20), premature rupture of membrane (prolonged PROM) (AOR 5.59, CI 95%, 1.05–29.76), and birth weight less than 2500gm (AOR 3.23, CI 95%, 1.17–8.90) are the significant factors associated with neonatal mortality.

Conclusion

The prevalence of neonatal mortality at Gandhi memorial hospital was generally high. As our finding revealed, neonates who are underweight and whose mothers have no formal education as well as have prolonged PROM have higher odds of neonatal mortality. Thus, clinicians, policymakers, and program managers should give special attention to neonates of none educated mothers, mothers with prolonged PROM, and neonates with low birth weight.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03339-6.

Use of Vaginal Dinoprostone (PGE2) in Patients with Premature Rupture of Membranes (PROM) Undergoing Induction of Labor: A Comparative Study

Purpose: To evaluate the effect and safety of vaginal dinoprostone in pregnant women with PROM who undergo induction of labor (IoL). Materials and Methods: Prospective observational study conducted at La Mancha Centro hospital from 1 February 2019, to 30 August 2020. Obstetric and neonatal variables of 94 pregnant women with PROM who underwent IoL with vaginal dinoprostone were analyzed, and the results were compared with 330 patients without PROM who also underwent IoL. Bivariate and multivariate analyses were performed using binary and multiple linear regression. Results: A total of 424 women were included in this study. A greater response to cervical ripening (Bishop score > 6) with PGE2 was observed in the PROM group (odds ratio (OR) 2.73, 95% confidence interval (CI) 1.50−4.99, p = 0.001), as well as a shorter total duration of IoL (mean difference (MD) 2823.37 min (min), 95% CI 1257.30−4389.43, p < 0.001). Cesarean sections were performed in 28.7% (n = 27) of patients in the PROM group vs. 34.2% (n = 113) of patients in the non-PROM group, with no significant differences (OR 0.87%, 95% CI 0.47−1.60, p = 0.652). There were no significant differences in changes in the cardiotocographic record (CTG), postpartum hemorrhage (PPH), uterine rupture, or adverse neonatal outcomes between the two groups. Conclusions: The use of vaginal dinoprostone in pregnant women undergoing IoL with PROM is safe for the mother and the fetus, shortens the total delivery time, and does not increase the risk of cesarean section compared with pregnant women undergoing IoL without PROM.

The Association of Cesarean Skin Incision Length and Postoperative Wound Complications

OBJECTIVE

This study was aimed to evaluate the relationship between cesarean skin incision length and wound complications.

STUDY DESIGN

Planned secondary analysis of a multicenter double-blind randomized trial of adjunctive azithromycin versus placebo (in addition to standard cefazolin) in women ≥24 weeks undergoing cesarean delivery during labor or ≥4 hours after membrane rupture. Skin incision length (cm) was measured just prior to skin closure. The primary outcome was a composite of wound complications (wound infection, separation, seroma, hematoma, or dehiscence) up to 6 weeks of postpartum. Individual components of the composite were examined as secondary outcomes. Outcomes were compared between groups defined by the lowest (≤25th), middle (25-75th) and highest (>75th) incision length quartiles. Logistic regression was used to adjust for potential confounding variables.

RESULTS

Of the 2,013 women enrolled in the primary trial, 1,916 had recorded incision lengths and were included in this secondary analysis. The overall rate of composite wound complications was 7.8%. Median incision length was 15.0 cm (interquartile range: 14.0-16.5) with the lowest quartile defined as ≤14, middle as >14 to ≤16.5, and highest as >16.5 cm. Mean BMI, parity, use of staples, and duration of surgery differed significantly between the three incision length groups. In unadjusted analysis, the longest incision lengths were associated with an increased risk of the wound composite and wound infections (odds ratio [OR] = 2.27, 95% confidence interval [CI]: 1.43-3.60 and OR = 2.30, 95% CI: 1.27-4.15, respectively) compared with the shortest incision lengths. However, after multivariable adjustments, these associations were nullified. Additional analyses considering incision length as a continuous variable and using 10th/90th percentile cut-offs still did not suggest any associations with outcomes.

CONCLUSION

Increasing skin incision length is not independently associated with an increased risk of postoperative wound complications.

KEY POINTS

· After multivariable adjustments, skin incision length was not independently associated with an increased risk of postoperative wound complications.. · A reasonable incision length needed to safely perform the procedure should be used..

Factors associated with acute kidney injury during delivery or the postpartum period: A case control study

INTRODUCTION

To investigate the incidence of risk factors associated with acute kidney injury(AKI) occurring during the intrapartum or the immediate postpartum period.

MATERIAL AND METHODS

A retrospective case control study in a tertiary UK hospital of pregnant women identified with AKI in labour or in the postpartum period between July 2019 and June 2020 was carried out. Women identified with pregnancy related AKI (pr-AKI) in labour or postpartum were compared with a matched cohort of women with no evidence of pr-AKI, using multiple regression analysis.

RESULTS

In 4600 births, 71 women with pr-AKI and 142 control women were identified. The antenatal and intrapartum risk factors strongly associated with pr-AKI were pre-eclampsia, prolonged ruptured membranes, delivery by emergency caesarean section and greater blood loss at delivery (all p < 0.001 in multivariable regression).

CONCLUSION

Pr-AKI is relatively common, occurring in 1.5 % of our cohort. Women who are overweight, have prolonged rupture of the membranes, an emergency caesarean section and/or a postpartum haemorrhage are at greatest risk. Clinicians should be check renal function before prescribing non-steroidal medication for postpartum pain relief if there are risk factors for AKI.

Vaginal birth after cesarean in women with pre-labor rupture of membranes at term

INTRODUCTION

Women with a successful vaginal birth after cesarean delivery (VBAC) have less morbidity than women undergoing repeat cesarean delivery. Although several scores and models predict VBAC success, none focus on pregnant women with pre-labor rupture of membranes (PROM). We evaluated different clinical variables that might predict the likelihood of VBAC success in women with PROM.

STUDY DESIGN

A retrospective, 5-year study in a large referral center from December 2013 to December 2018. Inclusion criteria were women with singleton pregnancy, at or beyond 37 weeks' gestation, admitted with spontaneous PROM, with one previous cesarean delivery that consented trial of labor. Exclusion criteria were history of two cesarean deliveries, multiple gestations or obstetrical contraindications for TOLAC, including maternal request for repeat cesarean delivery. Variables associated with successful VBA C were identified using multivariate logistic regression.

RESULTS

Of 302 women in the cohort, 74.8% (226/302) delivered vaginally (successful VBAC) and 25.2% (76/302) by repeat CD (failed TOLAC). Multiple logistic regression showed that duration of PROM-to-delivery time was the only significant factor associated with successful TOLAC (78% delivered vaginally within 24 h and 93.3% within 36 h), while none of the other variables (maternal age, gravidity, BMI, gestational and birthweight at delivery, effacement or station at admission, previous indication for cesarean delivery, time interval between previous and current delivery, presence of meconium-stained liquor, and documented temperature >38 °C) were associated with the prediction of successful VBAC.

CONCLUSION

Women with spontaneous pre-labor PROM and previous cesarean delivery have high success rates of VBAC. The only significant variable associated with successful TOLAC in women with spontaneous PROM at term was the duration of PROM-to-delivery time. Our findings suggest that the success rate of VBAC is likely multifactorial, not-necessarily related to a specific underlying factor, and in the absence of contraindications, a fair trial of labor after cesarean delivery is justified.

Timing of induction for term prelabor rupture of membranes and intravenous antibiotics

BACKGROUND

Induction of labor usually within 24 hours is recommended for term prelabor rupture of membranes. It is still unclear when within the 24 hours induction of labor for term prelabor rupture of membranes should be initiated. Antibiotic prophylaxis for group B Streptococcus is usually recommended for prolonged prelabor rupture of membranes.

OBJECTIVE

The aim of our study was to evaluate whether induction of labor at ≤6 hours from prelabor rupture of membranes with intravenous oxytocin in singleton pregnancies at ≥37 weeks' gestation without regular uterine contractions reduces the administration of intravenous antibiotic agents.

STUDY DESIGN

This was a retrospective cohort study including all women with prelabor rupture of membranes at ≥37 weeks' gestation and without regular uterine contractions in which labor was induced using intravenous oxytocin. Women were divided into 2 groups according to the timing of induction (≤6 hours vs >6 hours after prelabor rupture of membranes).

RESULTS

A total of 166 women with term prelabor rupture of membranes were included, 53 of whom (31.9%) were induced within 6 hours of prelabor rupture of membranes and 113 (68.1%) were induced after 6 hours. There were no differences in demographic characteristics and risk factors for term prelabor rupture of membranes between the 2 groups. Women who underwent induction of labor at ≤6 hours were significantly less exposed to intravenous antibiotic prophylaxis compared with women induced at >6 hours (36% vs 80.5%, respectively; odds ratio, 0.14; 95% confidence interval, 0.07-0.28). Furthermore, for women induced within 6 hours after prelabor rupture of membranes, the chances of delivering at <12 or <24 hours were increased, nonreassuring cardiotocogram significantly less common, and hospital stay significantly shorter. No differences were found in regard to neonatal outcomes.

CONCLUSION

Induction of labor at ≤6 hours with intravenous oxytocin after term prelabor rupture of membranes is significantly associated with lesser use of antibiotic agents, shorter latency to delivery, lower incidence of nonreassuring cardiotocogram, and shorter hospital stay than induction of labor at >6 hours after prelabor rupture of membranes.

A systematic scoping review of clinical indications for induction of labour

BACKGROUND

The proportion of women undergoing induction of labour (IOL) has risen in recent decades, with significant variation within countries and between hospitals. The aim of this study was to review research supporting indications for IOL and determine which indications are supported by evidence and where knowledge gaps exist.

METHODS

A systematic scoping review of quantitative studies of common indications for IOL. For each indication, we included systematic reviews/meta-analyses, randomised controlled trials (RCTs), cohort studies and case control studies that compared maternal and neonatal outcomes for different modes or timing of birth. Studies were identified via the databases PubMed, Maternity and Infant Care, CINAHL, EMBASE, and ClinicalTrials.gov from between April 2008 and November 2019, and also from reference lists of included studies. We identified 2554 abstracts and reviewed 300 full text articles. The quality of included studies was assessed using the RoB 2.0, the ROBINS-I and the ROBIN tool.

RESULTS

68 studies were included which related to post-term pregnancy (15), hypertension/pre-eclampsia (15), diabetes (9), prelabour rupture of membranes (5), twin pregnancy (5), suspected fetal compromise (4), maternal elevated body mass index (BMI) (4), intrahepatic cholestasis of pregnancy (3), suspected macrosomia (3), fetal gastroschisis (2), maternal age (2), and maternal cardiac disease (1). Available evidence supports IOL for women with post-term pregnancy, although the evidence is weak regarding the timing (41 versus 42 weeks), and for women with hypertension/preeclampsia in terms of improved maternal outcomes. For women with preterm premature rupture of membranes (24-37 weeks), high-quality evidence supports expectant management rather than IOL/early birth. Evidence is weakly supportive for IOL in women with term rupture of membranes. For all other indications, there were conflicting findings and/or insufficient power to provide definitive evidence.

CONCLUSIONS

While for some indications, IOL is clearly recommended, a number of common indications for IOL do not have strong supporting evidence. Overall, few RCTs have evaluated the various indications for IOL. For conditions where clinical equipoise regarding timing of birth may still exist, such as suspected macrosomia and elevated BMI, researchers and funding agencies should prioritise studies of sufficient power that can provide quality evidence to guide care in these situations.

Diagnostic value of Chorioquick for detecting chorioamnionitis in women with premature rupture of membranes

OBJECTIVE

To determine the accuracy of a semi-quantitative interleukin-6 (IL-6) vaginal secretion rapid test (Chorioquick) for detecting chorioamnionitis in women with premature rupture of membranes (PROM).

METHODS

A prospective cohort study in five tertiary hospitals in Nigeria involved women with confirmed PROM at term and preterm PROM with or without suspected chorioamnionitis from August 1, 2017, to October 31, 2018. Cervicovaginal fluid samples were tested for chorioamnionitis using the Chorioquick test. Samples were repeated at decision to deliver. The test was considered positive if at least the indicator 'IL-6 low' of the three Chorioquick biomarkers (low, medium, high) was positive, or negative if none of the biomarkers were positive. Chorioamnionitis was histologically confirmed post-delivery using three tissue samples. Primary outcome measures were sensitivity, specificity, and accuracy.

RESULTS

Of 73 women, on histological confirmation, 39 were true positive and 29 were true negative (for chorioamnionitis) to the Chorioquick test at repeat assessment. Overall, the Chorioquick test had a sensitivity of 97.5% (95% confidence interval [CI] 85.3-99.9), specificity 87.9% (70.9-96.0), and accuracy 93.2% (79.5-99.1). Sub-group analysis of women <37 weeks of pregnancy showed a sensitivity of 100.0% (95% CI 83.4-100.0), specificity of 91.3% (70.5-98.5), and accuracy of 95.8% (82.5-99.5). Triple positive samples were 100.0% specific in all gestations.

CONCLUSION

Chorioquick showed favorable utility for detecting chorioamnionitis in PROM and could be a reliable, non-invasive rapid tool in a real-world clinical setting.

Effect of early amniotomy on labor outcome in nulliparous women: a randomized clinical trial

Early amniotomy is one of the main interventions to enhance the labor progress and prevent dystocia in pregnant women. However, the efficacy of amniotomy has not been approved via labor-related indices and outcomes and has remained a subject for debate and future research. The present study was conducted to evaluate the effect of early amniotomy on labor indices and outcomes in nulliparous women. This randomized clinical trial was performed on 151 singleton pregnant women who were referred to Besat Hospital in Sanandaj, Iran, from March 2016 to March 2018. Participants were randomly divided into an early amniotomy (EA) group and a control group. Duration of the first and second phases of labor, corioamionit, dystocia rate, Apgar score at the first and fifth minutes, prolonged labor and post-partum haemorrhage were evaluated and compared between the two groups. Data were recorded in a checklist and analysed using SPSS Version 23. The p value <0.05 was considered significant. Results showed that labor indices such as duration of the first and second phases, Apgar score one and five minutes after delivery and frequency of prolonged labor, foetal distress and postpartum haemorrhage were significantly improved in patients of the early amniotomy group, compared with the control group (p≤0.05). Early amniotomy significantly decreased the total labor duration without significant increase in the rate of maternal and neonatal complications.

Are prophylactic adjunctive macrolides efficacious against caesarean section surgical site infection: A systematic review and meta-analysis

Surgical site infection (SSI) post- caesarean section (CS) remains high, prophylactic adjunctive macrolides may reduce this. This systematic review and meta-analysis evaluated whether adjunctive prophylactic macrolides administered at CS reduce the risk of endometritis and wound infection. MEDLINE, EMBASE, CINHAL and the Cochrane library were searched from inception to July-2018. Observational and randomised studies investigating women undergoing a CS receiving standard prophylactic antibiotics, adjunctive prophylactic macrolides and assessed any SSI outcome was included. Data was double-extracted. Studies were included in a meta-analysis if the same study design and SSI outcome was used. Risk ratios were calculated and heterogeneity was assessed using the I² test. Five studies were included in the systematic review and four in the meta-analysis. Two RCT's (n = 2610) found that macrolides significantly reduce the risk of wound infection RR [0.34; 95 %, 0.22 0.53] P = 0.00001 and endometritis RR [0.66; 95 %, 0.52, 0.85] P = 0.001 with no evidence of heterogeneity (I² = 0 %). Two cohort studies (n = 13,809) found that azithromycin significantly reduces the risk of endometritis RR [0.16; 95 %, 0.04-0.62] P = 0.008, however significant heterogeneity was seen. Macrolides significantly reduce the risk of endometritis and wound infection post-CS. An effectiveness evaluation of post-cord clamping administration is needed to eliminate fetal antibiotic exposure and the long term infant implications this may have.

Trial of labor after cesarean (TOLAC) in women with premature rupture of membranes. J Matern Fetal Neonatal Med 2019;33:2976-2982. [PMID: 30652525 DOI: 10.1080/14767058.2019.1566312]

Introduction: The aim of this study was to assess the success rate of a trial of labor after a previous cesarean section (TOLAC) in the settings of premature rupture of membranes (PROM) and to compare conservative management with spontaneous labor and induction of labor.Methods: This was a retrospective cohort study conducted in a single tertiary care center between January 2011 and March 2017. Women with singleton pregnancy and a previous cesarean section (CS) who presented with PROM and underwent TOLAC were included. Outcomes and rate of successful vaginal delivery after induction of labor were compared to conservative treatment and spontaneous labor.Results: Among 830 women who met the inclusion criteria, 723 (87.1%) had a spontaneous onset of labor following PROM and 107 (12.9%) had an induction of labor. The rate of successful TOLAC was similar between the groups (75.7 vs. 81.6%, respectively, p = .22). However, induction of labor was associated with an increased risk for uterine rupture (1.87 vs. 0.96%, p < .001), operative complications (6.7 vs. 2.3%, p < .001), and composite maternal postpartum complications (21.4 vs. 10.7%, respectively, p = .014) compared to conservative management with spontaneous initiation of labor. There was no difference in neonatal outcome between the groups.Conclusion: Induction of labor following PROM in women with a previous CS is associated with high successful vaginal delivery rate. However, the risk for uterine rupture and operative and maternal complications is significantly increased compared to spontaneous initiation of labor.

Abdominal computed tomography (CT) scan in the evaluation of refractory puerperal fever: impact on management. J Matern Fetal Neonatal Med 2018;33:577-582. [PMID: 29973085 DOI: 10.1080/14767058.2018.1497603]

Introduction: Computed tomography (CT) imaging should be employed judiciously, given its cost, use of intravenous contrast, and ionizing radiation. The aim of this study was to determine the clinical benefit of a CT scan in the evaluation of refractory puerperal fever and to identify the appropriate candidates for its use.Methods: This was a retrospective cohort study conducted in a single tertiary care center between January 2007 to April 2017. Indications for CT scan were refractory postpartum fever of ≥3 days and/or ultrasound findings suggesting complex abdominal fluid collection. Primary outcome was defined as a change in the mode of treatment due to the CT findings. In addition, a multivariate analysis of risk factors for puerperal fever was performed to identify patients who would benefit from the CT scan evaluation.Results: There were 520 women that underwent an abdominal and pelvic CT scan during the study period, 238 (45.7%) met inclusion criteria, 94 (39.5%) had a normal CT scan, and 144 (60.5%) had abnormal findings including 32 (13.4%) cases with pelvic thrombophlebitis and 112 (47%) cases with pelvic fluid collections. Results of the CT changed clinical management in 93 (39.0%) patients, including: switching antibiotics in 24 (10%) patients, adding low molecular weight heparin for 28 (11.8%) patients, and surgical intervention (laparotomy or drainage insertion) in 41 (17.2%) patients. In the regression model, we didn't find any significant risk factors associated with treatment change following the CT scan.Conclusions: Abdominal and pelvic CT scan in women with refractory puerperal fever has a high clinical yield and lead to a change in management in a substantial number of patients.

Effect of Premature Rupture of Membranes on Induction of Labor: A Historical Cohort Study

Objective

The aim of this study was to assess the influence of premature rupture of membranes (PROM) on the induction of labor.

Material and Method

This historical cohort study analyzed 1861 inductions of labor at term using misoprostol which occurred between 2010 and 2015. Exclusion criteria included intrauterine fetal death, previous cesarean section, and fetal structural or chromosomal anomalies. Induction of labor for PROM (PROM group) was compared to induction for other indications (no-PROM group); the primary outcome measure was the cesarean section rate.

Results

The cesarean section rate for the PROM group was significantly lower (21.9% vs. 26.3%, p = 0.029). The induction-to-delivery interval was shorter (mean: 972 [854 – 6734] min vs. 1741 [97 – 10 834] min, p < 0.0001) and the rates of vaginal birth within 24 hours (80.9 vs. 52.0%, p = 0.0001) and 48 hours (98.4 vs. 85.3%, p = 0.0001) were higher in the PROM group. The impact of PROM on the cesarean section rate was not significant in multivariate analysis; however, PROM was found to have the greatest effect on the induction-to-delivery interval (p < 0.0001).

Conclusion

Premature rupture of membranes significantly affects various outcome measures when delivery is induced, particularly the induction-to-delivery interval.

Early versus delayed amniotomy during labor induction with oxytocin in women with Bishop's score of ≥6: a randomized trial

OBJECTIVE

To study the effect of "early amniotomy" {initiating induction of labor (IOL) with amniotomy followed by oxytocin} versus "late amniotomy" (initiating IOL with oxytocin followed by amniotomy 4-8 h later) in induced labor.

METHODS AND MATERIALS

One hundred and fifty women with Bishop's score of ≥6 undergoing IOL were randomized into "early amniotomy" and "delayed amniotomy".

RESULTS

Early amniotomy resulted in a reduced induction-delivery interval (IDI) (7.35 versus 11.66 h with delayed amniotomy, p = .000) but higher the caesarean section (CS) rate was observed (10.7 versus 2.7% with delayed amniotomy, p = .049). With early amniotomy, the proportion of women delivering within 12 h was higher (86.7 versus 60%, p = .000) and the maximum oxytocin concentration used was lower (30.05 versus 39.68 mU/min, p = .001) as compared to delayed amniotomy. The neonatal outcomes were similar in the two groups. Early amniotomy detected meconium prior to initiating uterine contractions with oxytocin in three women who underwent CS for meconium.

CONCLUSION

Initiating IOL with amniotomy in women with a favorable cervix was efficacious in expediting delivery, but it resulted in a higher CS rate. The higher CS rate was partly due to CS for meconium detected as a result of early amniotomy. Clinical Trials Registry (CTRI), India: Registration number CTRI/2015/01/005418.

Risk Factors for Postcesarean Maternal Infection in a Trial of Extended-Spectrum Antibiotic Prophylaxis

OBJECTIVE

To identify maternal clinical risk factors for postcesarean maternal infection in a randomized clinical trial of preincision extended-spectrum antibiotic prophylaxis.

METHODS

We conducted a planned secondary analysis of a randomized clinical trial. Patients were 24 weeks of gestation or greater and delivered by cesarean after a minimum of 4 hours of ruptured membranes or labor. All participants received standard preincision prophylaxis and were randomized to receive azithromycin or placebo. The primary outcome for this analysis is maternal infection: a composite outcome of endometritis, wound infection (superficial or deep), or other infections occurring up to 6 weeks postpartum. Maternal clinical characteristics associated with maternal infection, after controlling for azithromycin assignment, were identified. These maternal factors were included in a multivariable logistic regression model for maternal infection.

RESULTS

Of 2,013 patients, 1,019 were randomized to azithromycin. Overall, 177 (8.8%) had postcesarean maternal infection. In the final adjusted model, compared with the reference groups, women of black race-ethnicity, with a nontransverse uterine incision, with duration of membrane rupture greater than 6 hours, and surgery duration greater than 49 minutes, were associated higher odds of maternal infection (all with adjusted odds ratios [ORs] of approximately 2); azithromycin was associated with lower odds of maternal infection (adjusted OR 0.4, 95% confidence interval 0.3-0.6).

CONCLUSION

Despite preincision azithromycin-based extended-spectrum antibiotic prophylaxis, postcesarean maternal infection remains a significant source of morbidity. Recognition of risk factors may help guide innovative prevention strategies.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov, NCT012235546.

Premature rupture of the membranes at term: time to reevaluate the management

PURPOSE

To compare maternal and neonatal outcomes in induced vs. expectant management of term PROM.

METHODS

This retrospective study included patients with term PROM. A total of 325 were enrolled: 213 managed expectantly and 112 induced at admission and matched according to gestational age. Expectant management group patients were allowed to defer labour induction up to 48 h. Primary outcome measures were maternal or foetal signs of infection (chorioamnionitis, early neonatal sepsis or postpartum endometritis) and prolonged maternal hospitalization. Secondary outcome was caesarean delivery rate.

RESULTS

All group characteristics were comparable except that expectant management included more nulliparous women. Women managed expectantly had a higher rate of prolonged hospitalization [15 (7 %) vs. 2 (1.8 %); P = 0.043] as an indication of maternal complications, compared to induction management. They also had a higher rate of caesarean delivery [34 (16.4 %) vs. 8 (7.1 %), respectively; P = 0.024]. Adjustment for parity did not change the results. Early neonatal outcomes were similar between groups.

CONCLUSIONS

Expectant management increases the likelihood of caesarean delivery and prolonged maternal hospitalization. This should be considered when advising patients with term PROM regarding labour induction.

Management of Foley catheter induction among nulliparous women: a retrospective study

Background

Induction of labour is associated with increased risk for caesarean delivery among nulliparous women. The aims of this study were to evaluate the risk factors for caesarean delivery and to investigate the risk of maternal and neonatal infections in nulliparous women undergoing induction of labour by Foley catheter.

Methods

This clinical retrospective study of 432 nulliparous women with singleton pregnancy and intact amniotic membranes at or beyond 37 gestational weeks scheduled for induction of labour by Foley catheter was conducted over the course of one year, between January 2012 and January 2013, in Helsinki University Hospital. The main outcome measures were caesarean section rate and maternal and neonatal infections. Univariate and multivariate logistic regressions were used to estimate relative risks by odds ratios with 95 % confidence intervals.

Results

The caesarean section rate was 39.1 % (n = 169). In multivariate regression analysis, the factors associated with caesarean section were the need for oxytocin for labour induction [OR 2.9 (95 % CI 1.8-4.5) p < 0.001] and early epidural analgesia [OR 9.9 (95 % CI 2.1-47.5), p = 0.004]. The maternal intrapartum infection rate was 6.3 %, and the clinical neonatal infection rate was 2.8 %. In multivariate analysis, gestational diabetes was associated with maternal intrapartum infection [OR 4.3 (95 % CI 1.7-11.0, p = 0.002] and early epidural analgesia with neonatal clinical sepsis [OR 10.5 (95 % CI 1.4-76), p = 0.02].

Conclusions

Oxytocin induction and early epidural analgesia were associated with caesarean delivery. Gestational diabetes and early epidural analgesia were associated with infectious morbidity. Since the first caesarean delivery has a major impact on subsequent pregnancies, optimising labour induction among nulliparous women is important.

A transcervical amniotic fluid collector: a new medical device for the assessment of amniotic fluid in patients with ruptured membranes

AIM

To describe a new device for the transcervical collection of amniotic fluid (AF) in patients with ruptured membranes, and to compare the concentration of proteins in fluid retrieved by transabdominal amniocentesis and the transcervical AF collector.

STUDY DESIGN

Paired AF samples were collected in patients with preterm prelabor rupture of membranes (PROM) (n=11) by transabdominal amniocentesis and with the transcervical AF collector (Yoon's AF Collector™). Three proteins known to have high concentrations in AF [α-fetoprotein (AFP), β-human chorionic gonadotrophin (β-hCG), and prolactin] were measured.

RESULTS

(1) There was a significant correlation between the concentrations of analytes in AF obtained by transabdominal amniocentesis and by the transcervical AF collector (r=0.94, P<0.001 for AFP; r=0.96, P<0.001 for β-hCG; r=0.72, P<0.05 for prolactin); (2) Bland-Altman plots showed no evidence of heteroscedasticity between transabdominal or transcervical AF concentrations of these markers.

CONCLUSIONS

There was a strong correlation between the concentrations of proteins in AF collected by amniocentesis or with the transcervical device.

Antibiotic prophylaxis for term or near-term premature rupture of membranes: metaanalysis of randomized trials

OBJECTIVE

The objective of the study was to evaluate the efficacy of antibiotic prophylaxis in women with term or near-term premature rupture of membranes.

STUDY DESIGN

Searches were performed in MEDLINE, OVID, Scopus, ClinicalTrials.gov, the PROSPERO International Prospective Register of Systematic Reviews, EMBASE, ScienceDirect.com, MEDSCAPE, and the Cochrane Central Register of Controlled Trials with the use of a combination of key words and text words related to antibiotics, premature rupture of membranes, term, and trials from inception of each database to September 2014. We included all randomized trials of singleton gestations with premature rupture of membranes at 36 weeks or more, who were randomized to antibiotic prophylaxis or control (either placebo or no treatment). The primary outcomes included maternal chorioamnionitis and neonatal sepsis. A subgroup analysis on studies with latency more than 12 hours was planned. Before data extraction, the review was registered with the PROSPERO International Prospective Register of Systematic Reviews (registration number CRD42014013928). The metaanalysis was performed following the Preferred Reporting Item for Systematic Reviews and Meta-analyses statement.

RESULTS

Women who received antibiotics had the same rate of chorioamnionitis (2.7% vs 3.7%; relative risk [RR], 0.73, 95% confidence interval [CI], 0.48-1.12), endometritis (0.4% vs 0.9%; RR, 0.44, 95% CI, 0.18-1.10), maternal infection (3.1% vs 4.6%; RR, 0.48, 95% CI, 0.19-1.21), and neonatal sepsis (1.0% vs 1.4%; RR, 0.69, 95% CI, 0.34-1.39). In the planned subgroup analysis, women with latency longer than 12 hours, who received antibiotics, had a lower rate of chorioamnionitis (2.9% vs 6.1%; RR, 0.49, 95% CI, 0.27-0.91) and endometritis (0% vs 2.2%; RR, 0.12, 95% CI, 0.02-0.62) compared with the control group.

CONCLUSION

Antibiotic prophylaxis for term or near-term premature rupture of membranes is not associated with any benefits in either maternal or neonatal outcomes. In women with latency longer than 12 hours, prophylactic antibiotics are associated with significantly lower rates of chorioamnionitis by 51% and endometritis by 88%.

Antibiotics for prelabour rupture of membranes at or near term

BACKGROUND

Prelabour rupture of the membranes (PROM) at or near term (defined in this review as 36 weeks' gestation or beyond) increases the risk of infection for the woman and her baby. The routine use of antibiotics for women at the time of term PROM may reduce this risk. However, due to increasing problems with bacterial resistance and the risk of maternal anaphylaxis with antibiotic use, it is important to assess the evidence addressing risks and benefits in order to ensure judicious use of antibiotics. This review was undertaken to assess the balance of risks and benefits to the mother and infant of antibiotic prophylaxis for PROM at or near term.

OBJECTIVES

To assess the effects of antibiotics administered prophylactically to women with PROM at 36 weeks' gestation or beyond, on maternal, fetal and neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014).

SELECTION CRITERIA

All randomised trials that compared outcomes for women and infants when antibiotics were administered prophylactically for prelabour rupture of the membranes at or near term, with outcomes for controls (placebo or no antibiotic).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed risk of bias in the included studies. Additional data were received from the investigators of included studies.

MAIN RESULTS

This update includes an additional two studies involving 1801 women, giving a total of four included studies of 2639 women. Whereas the previous version of this review showed a statistically significant reduction in endometritis with the use of antibiotics, no such effect was shown in this update (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.05 to 2.31). No differences were shown on the primary outcome measures of probable early-onset neonatal sepsis (average RR 0.69, 95%; CI 0.21 to 2.33); definite early-onset neonatal sepsis (average RR 0.57, 95% CI 0.08 to 4.26); maternal infectious morbidity (chorioamnionitis and/or endometritis) (average RR 0.48, 95% CI 0.20 to 1.15); stillbirth (RR 3.00, 95% CI 0.61 to 14.82); and perinatal mortality (RR 1.98, 95% CI 0.60 to 6.55), though the number of cases in the control group for these outcomes was low. There were no cases of neonatal mortality or serious maternal outcome in the studies assessed. Caesarean section was increased with the use of antibiotics (RR 1.33, 95% CI 1.09 to 1.61) as was duration of maternal stay in hospital (mean difference (MD) 0.06 days, 95% CI 0.01 to 0.11), largely owing to one study of 1640 women where repeat caesarean section, increased baseline hypertension and pre-eclampsia were evident in the antibiotic group, despite random allocation and allocation concealment.Subgroup analyses by timing of induction (early induction versus late induction) showed no difference in either probable or definite early-onset neonatal sepsis in the early induction group (RR 1.47, 95% CI 0.80 to 2.70 and RR 1.29, 95% CI 0.48 to 3.44, respectively) or the late induction group (RR 0.14, 95% CI 0.02 to 1.13 and RR 0.16, 95% CI 0.02 to 1.34, respectively), although there were trends toward reduced probable and definite early-onset neonatal sepsis in the late induction group. A test for subgroup differences confirmed a differential effect of the intervention on probable early-onset neonatal sepsis between the subgroups (Chi² = 4.50, df = 1 (P = 0.03), I² = 77.8%). No difference in maternal infectious morbidity (chorioamnionitis and/or endometritis) was found in either subgroup, though again there was a trend towards reduced maternal infectious morbidly in the late induction group (average RR 0.34, 95% CI 0.08 to 1.47). No differences were shown in stillbirth or perinatal mortality. The quality of the evidence for the primary outcomes using GRADE was judged to be low to very low.

AUTHORS' CONCLUSIONS

This updated review demonstrates no convincing evidence of benefit for mothers or neonates from the routine use of antibiotics for PROM at or near term. We are unable to adequately assess the risk of short- and long-term harms from the use of antibiotics due to the unavailability of data. Given the unmeasured potential adverse effects of antibiotic use, the potential for the development of resistant organisms, and the low risk of maternal infection in the control group, the routine use of antibiotics for PROM at or near term in the absence of confirmed maternal infection should be avoided.

The Association between Early Artificial Amniotomy and Chorioamnionitis in Nulliparous Induction of Labor

Objectives. To investigate whether early artificial amniotomy (AROM) <4 cm in nulliparous women admitted for induction of labor was associated with an increased rate of chorioamnionitis and cesarean section or a decreased time to vaginal delivery. Study Design. A retrospective cohort study was performed on nulliparous women with a term, singleton gestation and intact membranes who presented for induction of labor (January 2008 to December 2011). Chorioamnionitis was defined using ICD9 codes. Results. 1,567 women were enrolled; 25.4% underwent early AROM. Overall, the prevalence of chorioamnionitis was 12.4%, the rate of cesarean section was 32.2%, and the time from 4 cm cervical dilation to vaginal delivery was 413 min. Compared to women without AROM < 4 cm, early AROM did not affect overall chorioamnionitis rates (10.2 versus 13.2%, P = 0.12) but was associated with an increased cesarean section rate (40.2 versus 29.5%, P < 0.001). However, among those who delivered vaginally, AROM < 4 cm decreased the rate of chorioamnionitis (8.4 versus 14.6%, P = 0.01), which persisted when controlling for potential confounders (OR 0.55, 95% CI 0.33-0.92), and decreased the time from 4 cm dilation to vaginal delivery (329 versus 472 min, P < 0.001). Conclusions. Our findings do not suggest that early AROM is associated with an increased rate of clinical chorioamnionitis.

Significance of cervical ripening in pre-induction treatment for premature rupture of membranes at term

AIM

This study aimed to determine whether mechanical cervical dilatation with a laminaria tent in women with premature rupture of membranes (PROM) at term may influence the maternal/neonatal outcomes.

METHODS

We reviewed the medical records and histopathologic results of the placenta in 782 women with PROM at term. Of the 486 women seen prior to 2010 (group 1), 85 had Bishop scores of 5 or less and underwent insertion of laminaria tents (group A). In the 296 women admitted after 2010 (group 2), 27 had Bishop scores of 5 or less and underwent labor management without insertion of laminaria tents (group B). The patient characteristics, delivery course and neonatal outcomes were compared between the groups.

RESULTS

There were no significant differences in the maternal age, percentage of nulliparas, body mass index, gestational age at delivery or Bishop score between the groups. The Bishop score improved from 2.5 to 6.1 after laminaria tent insertion in group A. However, there were no significant intergroup differences in the frequency of use of labor-inducing agents or the time interval from PROM to delivery. The incidence of clinical/pathological chorioamnionitis was not higher in group A than in group B. No significant differences were found in the Apgar scores, umbilical artery pH or frequency of asphyxia neonatorum between the groups. Mechanical cervical dilatation by laminaria tent insertion neither increased the incidence of infection nor contributed to improvement of the perinatal prognosis.

CONCLUSION

Mechanical cervical dilatation does not provide any benefit for women with PROM at term.

Antibiotic prophylaxis in prelabor spontaneous rupture of fetal membranes at or beyond 36 weeks of pregnancy

OBJECTIVE

To assess the effectiveness of prophylactic antibiotics compared with placebo in preventing neonatal and maternal infection-related morbidity associated with prelabor spontaneous rupture of membranes at or beyond 36 weeks of pregnancy.

METHODS

In the present randomized controlled trial conducted during 2009-2011, 1640 women with prelabor spontaneous rupture of fetal membranes at or beyond 36 weeks of pregnancy were randomly assigned to receive a single dose of prophylactic intravenous antibiotics or placebo on admission to the labor ward of Ain Shams University, Cairo, Egypt. The participants, caregivers, and investigators were blinded to the group assignment. The primary outcome measure was early-onset neonatal sepsis. An intention-to-treat analysis was performed.

RESULTS

Early-onset neonatal sepsis occurred in 34 (4.1%) and 24 (2.9%) neonates in the antibiotics and placebo groups, respectively (risk ratio 1.42; 95% confidence interval 0.85-2.37). Maternal infection outcomes were not significantly different between the 2 trial arms.

CONCLUSION

The routine use of prophylactic antibiotics in women with prelabor spontaneous rupture of fetal membranes at or beyond 36 weeks of pregnancy does not reduce the risk of neonatal and maternal infection-related morbidity.

Early amniotomy after vaginal misoprostol for induction of labor: a randomized clinical trial

OBJECTIVES

To test the effectiveness and safety of early amniotomy after vaginal misoprostol for the induction of labor.

STUDY DESIGN

A randomized clinical trial that included 320 women with medical or obstetric indication for labor induction. They were randomly assigned into two equal groups, amniotomy group and control group. Each participant received vaginal misoprostol 50 μg every 6 h for induction of labor. In amniotomy group, amniotomy was done in the early active phase of labor while in the control group, the membranes were left to rupture spontaneously or as judged by the senior resident in the duty.

RESULTS

More subjects in the amniotomy group achieved vaginal delivery within 24 h than in the control group [117 (73.13 %) vs. 105 (65.63 %)]. Subjects in the amniotomy group reported shorter induction to delivery interval (09.72 ± 4.61 h vs. 13.61 ± 5.61, P = .002), and better neonatal outcome compared to the control group. There were no statistically significant differences between both group with regard to number of doses of misoprostol, need for oxytocin, Cesarean Section indication and maternal side effects.

CONCLUSION

Early amniotomy after vaginal misoprostol for labor induction is associated with higher successful vaginal delivery rate, shorter labor duration and better neonatal outcome.

The efficacy of early amniotomy in nulliparous labor induction: a randomized controlled trial

OBJECTIVE

The purpose of this study was to assess whether early amniotomy reduces the duration of labor or increases the proportion of subjects who are delivered within 24 hours in nulliparous patients who undergo labor induction.

STUDY DESIGN

We performed a randomized controlled trial that compared early amniotomy to standard management in nulliparous labor inductions. Inclusion criteria were nulliparity, singleton, term gestation, and a need for labor induction. Subjects were assigned randomly to early amniotomy (artificial rupture of membranes, ≤4 cm) or to standard treatment. There were 2 primary outcomes: (1) time from induction initiation to delivery and (2) the proportion of women who delivered within 24 hours.

RESULTS

Early amniotomy shortens the time to delivery by >2 hours (19.0 vs 21.3 hours) and increases the proportion of induced nulliparous women who deliver within 24 hours (68% vs 56%). These improvements in labor outcomes did not come at the expense of increased complications.

CONCLUSION

Early amniotomy is a safe and efficacious adjunct in nulliparous labor inductions.

Risk factors for endometritis after low transverse cesarean delivery

OBJECTIVE

To determine independent risk factors for endometritis after low transverse cesarean delivery.

STUDY DESIGN

We performed a retrospective case-control study during the period from July 1999 through June 2001 in a large tertiary care academic hospital. Endometritis was defined as fever beginning more than 24 hours or continuing for at least 24 hours after delivery plus fundal tenderness in the absence of other causes for fever. Independent risk factors for endometritis were determined by means of multivariable logistic regression. A fractional polynomial method was used to examine risk of endometritis associated with the continuous variable, duration of rupture of membranes.

RESULTS

Endometritis was identified in 124 (7.7%) of 1,605 women within 30 days after low transverse cesarean delivery. Independent risk factors for endometritis included age (odds ratio [OR] for each additional year, 0.93 [corrected] [95% confidence interval {CI}, 0.90-0.97]) and anemia or perioperative blood transfusion (OR, 2.18 [CI, 1.30-3.68]). Risk of endometritis was marginally associated with a proxy for low socioeconomic status, lack of private health insurance (OR, 1.72 [CI, 0.99-3.00]); with amniotomy (OR, 1.69 [CI, 0.97-2.95]); and with longer duration of rupture of membranes.

CONCLUSION

Risk of endometritis was independently associated with younger age and anemia and was marginally associated with lack of private health insurance and amniotomy. The odds of endometritis increased approximately 1.7-fold within 1 hour after rupture of membranes, but increased duration of rupture was only marginally associated with increased risk. Knowledge of these risk factors can guide selective use of prophylactic antibiotics during labor and heighten awareness of the risk in subgroups at highest risk of infection.