Describing latent phase duration and associated characteristics among 1281 low-risk women in spontaneous labor

Investigating the associations between early labour onset symptoms and self-diagnosed labour onset in a cohort study of primiparas

OBJECTIVE

The early recognition of possible labour onset symptoms may be pivotal to identifying the beginning of early labour and are usually recognised by the birthing women themselves. The present study illustrates the interrelationship among five labour-onset symptoms and explores the association of these labour-onset symptoms with the self-diagnosed labour onset of primiparas.

METHODS

A prospective cohort study on a sample of 69 primigravida in Giessen, Germany, expecting spontaneous onset of labour at term. The participants filled in a diary from ≥37 + 0 weeks gestation until self-diagnosed labour onset. Descriptive, bivariate and inferential analysis explored association of labour onset symptoms with self-diagnosed labour onset while accounting for maternal and newborn characteristics.

RESULTS

Self-diagnosed labour onset was positively associated with all symptoms and clinical characteristics, apart from irregular pain and maternal weight and age. Moreover, regular pain was negatively correlated with irregular pain; having regular pain increased the odds of self-diagnosed labour onset substantially (OR: 10.18, 95 % CI: 2.39-66.27), followed by gastrointestinal symptoms (OR: 2.07, 95 % CI: 0.40-13.10) and emotional symptoms (OR: 2.05, 95% CI: 0.30-13.98).

CONCLUSION

Being the initiator of intrapartum care without any birth experience, primiparas are prone to experiencing dissatisfaction in care and may enter professional care too late or too early. The present study showed that regular pain may signify primiparas to self-diagnose labour onset within 24 h and indicate early labour symptoms that may be relevant for a self-diagnosed labour onset.

New definitions, old complications: The association between duration of transition from latent to active labor and adverse obstetrical outcomes

OBJECTIVE

To explore the relationship between the duration of transition from latent to active labor and various obstetric, maternal, fetal, and neonatal outcomes.

METHODS

A retrospective cohort study was conducted on term, singleton deliveries at Soroka University Medical Center from 2013 to 2018. Data were extracted from electronic medical records. The exposure variable was defined as prolonged transition, which was itself defined as the upper 10th centile of dilation duration from 4 to 6 cm. Clinical and demographic characteristics were compared using χ2 test. Multivariate logistic regression was used to estimate the contribution of a prolonged transition with each adverse outcome adjusting for potential confounders.

RESULTS

In all, 12 104 deliveries met the inclusion criteria. The mean ± standard deviation of duration of dilation from 4 to 6 cm was 03:07:58 ± 03:03:42 (hours:minutes:seconds). Progress curves varied significantly among patients with different obstetrical and demographic characteristics. Prolonged transition was significantly linked to an increased risk of cesarean delivery (adjusted odds raito 2.607, 95% confidence interval 2.171-3.130, area under the curve 0.689) and higher rates of maternal and neonatal morbidity.

CONCLUSIONS

Patients experiencing transition phases exceeding the 90th centile faced an elevated risk of cesarean delivery and postpartum complications. Future studies should focus on interventions during the transition phase to improve pregnancy outcomes and enhance patient safety.

The Role of Passive Descent and Epidural Analgesia in Outcomes Associated With Prolonged Pushing Among Nulliparous Individuals in Midwifery Care

INTRODUCTION

Efforts to reduce primary cesarean birth may include supporting longer second stages of labor. Although midwifery-led care is associated with lower cesarean use, little has been published on associated outcomes of prolonged second stage (≥3 hours of pushing) for nulliparous individuals in US hospital-based midwifery care. Epidural analgesia and the role of passive descent in midwifery-led care are also underexplored in relation to the second stage. In this study, we report the incidence of prolonged second stage stratified by epidural analgesia and/or passive descent. Secondary aims included calculating the odds of cesarean birth, obstetric anal sphincter injury (OASI), postpartum hemorrhage (PPH), and neonatal complications.

METHODS

Data were collected prospectively from a single academic center in the United States from 2012 through 2019. Our cohort analysis of labors attended by midwives for nulliparous, term, singleton, and vertex pregnancies included both descriptive and inferential statistics comparing outcomes between prolonged versus nonprolonged pushing groups. We stratified the sample and quantified second stage outcomes by epidural analgesia and by use of passive descent.

RESULTS

Of the 1465 births, 17% (n = 247) included prolonged pushing. Cesarean ranged from 2.2% without prolonged pushing to 26.7% with prolonged pushing. Fetal malposition, epidural analgesia, and longer passive descent were more common among those with prolonged active pushing. Despite these factors, neither odds for PPH nor poor neonatal outcomes were associated with prolonged pushing. Those with more than one hour of passive descent in the second stage who also had prolonged active pushing had lower odds for cesarean but higher odds for OASI relative to those who had little passive descent before pushing for more than 3 hours.

DISCUSSION

Prolonged pushing occurred in nearly 2 of 10 nulliparous labors. Fetal malposition, epidural analgesia, and prolonged pushing were commonly observed with longer passive descent, cesarean, and OASI. Passive descent in these data likely reflects individualized midwifery care strategies when pushing was complicated by fetal malposition or other complexities.

Examining Cesarean Among Individuals of Advanced Maternal Age in Nurse-Midwifery Care

INTRODUCTION

Cesarean rates are rising, especially for individuals of advanced maternal age (AMA), defined as aged 35 or older. The Robson 10-Group Classification System (TGCS) facilitates assessment and comparison of cesarean rates among individuals in different settings. In midwifery-led care, in which pregnant people are typically healthier and seek a vaginal birth, it is unknown whether individuals of AMA have different antecedents leading to cesarean compared with younger counterparts. This study aimed to examine antecedents contributing to cesarean using Robson TGCS for individuals across age groups in midwifery care.

METHODS

This study was a secondary analysis of 2 cohort data sets from Oregon Health & Science University (OHSU) and University of Michigan Health Systems (UMHS) hospitals. The samples were individuals in midwifery-led care birthing at either OHSU from 2012 to 2019 or UMHS from 2007 to 2019.

RESULTS

A total of 11,951 individuals were studied. Overall cesarean rates were low; however, the rate for individuals of AMA was higher than the rate of their younger counterparts (18.30% vs 15.10%). The Robson groups were similar; however, the primary contributor among AMA individuals was group 5 (multiparous with previous cesarean), followed by group 2 [nulliparous with labor induced or prelabor cesarean], and group 1 [nulliparous with spontaneous labor]. In contrast, the primary contributors for younger individuals were groups 1, 2, and 5, respectively. In addition, prelabor cesarean and induced labor partly mediated the relationship between AMA and cesarean among nulliparous individuals, whereas prelabor cesarean was the key contributor to cesarean among multiparous people.

DISCUSSION

The cesarean rate in midwifery-led care was low. Using Robson TGCS provided additional insight into the antecedents to cesarean, rather than viewing cesarean as a single outcome. Future studies should continue to use Robson TGCS and investigate antecedents to cesarean, including factors influencing successful vaginal birth after cesarean in individuals of AMA.

Effect of epidural analgesia on cervical ripening using dinoprostone vaginal inserts

OBJECTIVE

To clarify whether the duration from cervical ripening induction to labor onset is prolonged when epidural analgesia is administered following application of dinoprostone vaginal inserts vs. cervical ripening balloon.

METHODS

This retrospective study included mothers with singleton deliveries at a single center between 2020-2021. Nulliparous women who underwent labor induction and requested epidural analgesia during labor after 37 weeks of gestation were included. The duration from cervical ripening induction to labor onset was compared between women using a dinoprostone vaginal insert and those using a cervical ripening balloon and between women who received epidural analgesia before and after labor onset.

RESULTS

In the dinoprostone vaginal insert group, the duration was significantly shorter in the subgroup that received epidural analgesia after labor onset (estimated median, 545 [95% confidence interval: 229-861 min]) than the subgroup that received it before labor onset (estimated median, 1,570 [95% confidence interval: 1,226-1,914] min, p = 0.004). However, in the cervical ripening balloon group, the difference between subgroups was not significant. The length of labor among the groups was also not significantly different.

CONCLUSION

Epidural analgesia as labor relaxant adversely affected the progression of uterine cervical ripening when dinoprostone vaginal inserts were used, whereas it did not affect cervical ripening when a mechanical cervical dilatation balloon was used. The present results are significant for choosing the appropriate ripening method.

Evaluation of labor management practices during spontaneous labor

INTRODUCTION

In 2017, the French national authority for health issued national guidelines to support physiologic labor and reduce medical interventions. This study's primary aim was to evaluate the association between the publication of these guidelines and the vaginal delivery rate in a type IIb perinatal center. The secondary objectives were to evaluate the implementation of these guidelines, their association with the duration of labor, and the rates of postpartum hemorrhage and adverse neonatal outcomes.

MATERIAL AND METHODS

A before-and-after, retrospective, single-center study comparing a "before" group (2016) and an "after" group (2018), one year after the recommendations were published. Women were eligible if they had no prior cesarean delivery and gave birth after 37 weeks of gestation to a singleton fetus in cephalic presentation after spontaneous labor. The analysis was stratified by parity.

RESULTS

Oxytocin administration decreased between the two periods (48% vs 35 %, P < 0.0001), as did the frequency of amniotomies (artificial rupture of membranes) (39.5 % vs 27.7 %, P < 0.0001). The duration of labor was significantly prolonged (360 vs 390 min, P < 0.0001), especially in nulliparous women (465 min vs 562 min, P<0.0001). The frequency of vaginal delivery rose between the two periods (94.6 % vs 96 %, P = 0.05), and the postpartum hemorrhage rate fell (6 % vs 4.5 %, P = 0.04). The numbers of neonates with an umbilical artery pH< 7.10 and of neonatal transfers also decreased.

CONCLUSIONS

The reduction of active interventions during labor is associated with a longer duration of labor and a decrease in the rates of cesarean births, postpartum hemorrhages, and neonatal transfers.

Describing the transition from late pregnancy into early labour - A prospective cohort study

OBJECTIVE

The time between self-assessed first symptoms and clinical confirmation of labour onset is marked by uncertainty, particularly for primiparas. Accordingly, primiparas often seek professional care to confirm their perceptions of labour onset. This paper describes the transition into early labour among primiparas considering their level of certainty in labour onset and their perception of labour onset symptoms prior to birth.

METHODS

A prospective exploratory cohort study was conducted in Germany between July 2020 - March 2021 among a convenience sample of 69 primiparas. Respondents recorded in a non-validated questionnaire their perceptions of nine symptoms and degree of certainty about labour onset every day from 37 weeks gestation. Descriptive analysis included certainty in labour onset and dedicated symptoms in relation to days before birth.

RESULTS

The participants (n=69) reported a little certainty of labour onset up to 32 days before birth and most of them became certain up to four days before birth. Associated symptoms were regular and irregular pain, symptoms of vaginal loss and emotional symptoms. Gastrointestinal symptoms and nausea were not indicated by a majority. Uncertainty of labour onset, however, was indicated up until the day of birth.

CONCLUSION

Although interpretation is based on a small sample size, primiparas are able to self-diagnose labour onset and report connected symptoms up to four days before birth. We suggest calling this time between self-diagnosis of labour onset and confirmed labour onset based on clinical parameters the transition into early labour.

New insights on labor progression: a systematic review

The past 20 years witnessed an invigoration of research on labor progression and a change of thinking regarding normal labor. New evidence is emerging, and more advanced statistical methods are applied to labor progression analyses. Given the wide variations in the onset of active labor and the pattern of labor progression, there is an emerging consensus that the definition of abnormal labor may not be related to an idealized or average labor curve. Alternative approaches to guide labor management have been proposed; for example, using an upper limit of a distribution of labor duration to define abnormally slow labor. Nonetheless, the methods of labor assessment are still primitive and subject to error; more objective measures and more advanced instruments are needed to identify the onset of active labor, monitor labor progression, and define when labor duration is associated with maternal/child risk. Cervical dilation alone may be insufficient to define active labor, and incorporating more physical and biochemical measures may improve accuracy of diagnosing active labor onset and progression. Because the association between duration of labor and perinatal outcomes is rather complex and influenced by various underlying and iatrogenic conditions, future research must carefully explore how to integrate statistical cut-points with clinical outcomes to reach a practical definition of labor abnormalities. Finally, research regarding the complex labor process may benefit from new approaches, such as machine learning technologies and artificial intelligence to improve the predictability of successful vaginal delivery with normal perinatal outcomes.

Latent phase duration and associated outcomes: a contemporary, population-based observational study

BACKGROUND

Little is known about the latent phase of labor, including whether its duration influences subsequent labor processes or birth outcomes.

OBJECTIVE

This study aimed to describe the duration of the latent phase of labor from self-report of the onset of painful contractions to a cervical dilation of 5 cm in a large, Swedish population and evaluate the association between the duration of the latent phase of labor and perinatal processes and outcomes that occurred during the active phase of labor, second stage of labor, birth and immediately after delivery, stratified by parity.

STUDY DESIGN

This was a population-based cohort study of 67,267 pregnancies with deliveries between 2008 and 2020 in the Stockholm-Gotland Regions, Sweden. Nulliparous and parous women without a history of cesarean delivery in spontaneous labor with a term (≥37 weeks of gestation), singleton, live, and vertex fetus without major malformations were included. Imputation was used if the notation of the end of the latent phase of labor (ie, cervical dilation of 5 cm) was missing in the partograph. Multivariable logistic regression was used to estimate the association with adjusted odds ratios and 95% confidence intervals, controlling for potential covariates.

RESULTS

Including the time from painful contraction onset to a cervical dilation of 5 cm, the median durations of the latent phase of labor were 16.0 (interquartile range, 10.0-26.6) hours for nulliparous women and 9.4 (interquartile range, 5.9-15.3) hours for multiparous women. The durations of the latent phase of labor beyond the median were associated with increased odds of labor dystocia diagnosis during the first stage active phase or second stage of labor and interventions commonly associated with dystocia (amniotomy, oxytocin augmentation, epidural, and cesarean delivery). The duration of the latent phase of labor of ≥90th percentile vs less than the median in nulliparous women demonstrated an increased risk of adverse neonatal outcomes (Apgar score of <7 at 5 minutes and neonatal intensive care unit admission), chorioamnionitis, and fetal occiput posterior. In multiparous women, longer duration of the latent phase of labor was associated with an increased risk of neonatal intensive care unit admission and chorioamnionitis but was not associated with an Apgar score of <7 at 5 minutes. The duration of the latent phase of labor was not associated with additional markers of maternal risk.

CONCLUSION

The duration of the latent phase of labor in nulliparous women was longer than that of multiparous women at each point of distribution. A longer duration of the latent phase of labor was associated with more frequent dystocia diagnoses and related interventions during the first stage active phase or second stage of labor, including cesarean delivery, nulliparous fetal occiput posterior position, chorioamnionitis, and markers of neonatal morbidity. More research is needed to identify potential mediating paths between the duration of the latent phase of labor and neonatal morbidity.

The latent phase of labor

The latent phase of labor extends from the initiation of labor to the onset of the active phase. Because neither margin is always precisely identifiable, the duration of the latent phase often can only be estimated. During this phase, the cervix undergoes a process of rapid remodeling, which may have begun gradually weeks before. As a consequence of extensive changes in its collagen and ground substance, the cervix softens, becomes thinner and dramatically more compliant, and may dilate modestly. All of these changes prepare the cervix for the more rapid dilatation that will occur during the active phase to follow. For the clinician, it is important to recognize that the latent phase may normally extend for many hours. The normal limit for the duration of the latent phase should be considered to be approximately 20 hours in a nullipara and 14 hours in a multipara. Factors that have been associated with a prolonged latent phase include deficient prelabor or intrapartum cervical remodeling, excessive maternal analgesia or anesthesia, maternal obesity, and chorioamnionitis. Approximately 10% of women with a prolonged latent phase are actually in false labor, and their contractions eventually abate spontaneously. The management of a prolonged latent phase involves either augmenting uterine activity with oxytocin or providing a sedative-induced period of maternal rest. Both are equally effective in advancing the labor to active phase dilatation. A very long latent phase may be a harbinger of other labor dysfunctions.

Induction of labor or expectant management? Birth outcomes for nulliparous individuals choosing midwifery care

BACKGROUND

Induction of labor (IOL) has been studied as a strategy to reduce rates of cesarean birth (CB). Midwifery care models are also associated with lower CB rates, even considering that midwives perform fewer IOLs. In this study, we examined childbirth outcomes among individuals undergoing IOL in certified nurse-midwifery (CNM) care as compared to two categories of expectant management (EM).

METHODS

Data were from two CNM practices in the United States (2007-2018). The sample was limited to term nulliparous, nondiabetic, singleton, vertex pregnancies. Individuals having an IOL in each week of gestation (37th, 38th, etc) were compared with those having EM. Two methods for defining EM were considered as each method when used alone limits interpretation. Inclusive EM included all births starting in the same week as IOL. The exclusive EM group was comprised of all births occurring in the next gestational age week relative to the IOL cases (ie, 39th week IOL versus all births occurring at 40 weeks or later). Adjusted regression models were used to examine differences in CB by IOL versus EM (inclusive or exclusive) at each week of gestation.

RESULTS

Among 4057 CNM-attended pregnancies, the overall rate of IOL was 28.9% (95% CI 27.5%-30.3%) and CB was 19.4% (95% CI 18.1%-20.6%). Most IOLs involved obstetric indications. CB rates did not differ by IOL versus inclusive EM when performed between 37 and 40 weeks, though post hoc power calculations indicate these comparisons were low-powered. In multivarable models, IOL in the 40th week was associated with lower odds for CB versus exclusive EM definition (ie, births occurring at 41 0/7 weeks or later, OR (95% CI) = 0.57 (0.36-0.90)). This finding is explained by the large increase in CB rates after IOL during the 41st week (34.3%, up from 21.9% in the 40th week). Furthermore, the adjusted odds for CB in the 41st week were 55% higher relative to inclusive EM (all labors 41st week and later), OR (95% CI) = 1.55(1.11-2.15). Neonatal outcomes (aside from macrosomia) did not differ by IOL/EM at any gestational age.

DISCUSSION

Outcomes for nulliparous individuals having IOL or EM in the context of a midwifery model of care include low overall use of CB and low frequency of IOL before 41 weeks. In this model, IOL in the 40th week may lower CB odds, especially in comparison to those who do not have spontaneous labor and later undergo an IOL in the 41st week.

Development of and Experiences With an Informational Website on Early Labor: Qualitative User Involvement Study

Background

The period of regular contractions before 4 cm of cervical dilatation is often referred to as the latent phase or early labor. Women find it challenging to prepare for and cope with this phase of labor, and easily accessed web-based information from reliable sources may be useful in this preparation.

Objective

The aim of this study is to describe the development of a Norwegian website, Latens.no, for people seeking information on early labor and to explore users’ experiences with the website to increase its user-friendliness.

Methods

We developed a website using an iterative process involving a multidisciplinary research team, health personnel, users, a graphic designer, and an expert in software development. We explored the website’s user-friendliness using semistructured individual interviews and the think-aloud method. All interviews were audio recorded and transcribed. We then analyzed the participants’ feedback on the website.

Results

Participants included women who had recently given birth to their first baby (n=2), women who were pregnant with their first baby (n=4), and their partners (n=2). Results from participants’ experiences completing tasks included positive feedback related to the content of Latens.no, positive feedback related to the website’s design, and suggestions for improvement. Participants wanted to find information on early labor on the internet. Moreover, they found the information on the website relevant, trustworthy, and easy to read, and the design was attractive and easy to use. Overall, the participants performed the tasks easily, with few clicks and minimal effort.

Conclusions

The think-aloud method, while performing tasks, allowed for detailed feedback. The participants confirmed the user-friendliness of the website but at the same time provided information enabling improvement. We expect that changes made based on this user-centered design study will further increase the usability and acceptability of Latens.no.

Intrapartum Nurses' Beliefs Regarding Birth, Birth Practices, and Labor Support

OBJECTIVES

To examine the relationships among intrapartum (IP) nurses' beliefs regarding birth (physiologic birth/medicalized birth) and their experience, education, and certification; to assess IP nurses' beliefs about birth practices and labor support; to describe the birth practices of the most effective IP nurses; and to elicit recommendations from IP nurses for quality improvement in IP nursing practice.

DESIGN

Cross-sectional, descriptive study.

SETTING

Three urban hospitals from one state in the northeastern United States.

PARTICIPANTS

One hundred twelve IP registered nurses who were primarily staff nurses.

METHODS

We collected quantitative and qualitative data using a Web-based survey that included the Intrapartum Nurses' Beliefs Related to Birth Practice-Modified scale. We used Burgess's conceptual definition of laborsupport as the framework to analyze findings.

RESULTS

Participants favored physiologic birth and not medicalized birth, and their beliefs were associated with experience (p = .01) and certification (p = .04). Participants reported that effective IP nurses demonstrate labor practices supportive of physiologic birth. Recommendations from participants for quality improvement in IP nursing practice included ways to optimize physical support, emotional support, informational support, and advocacy for women during labor. Participants made no recommendations related to partner support.

CONCLUSION

Participants held beliefs that favored physiologic birth and supported many labor practices that can facilitate physiologic birth. However, some labor practices associated with medicalized birth were also supported. Further quality improvement strategies to provide partner support during labor are needed.

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.

The association between longer durations of the latent phase of labor and subsequent perinatal processes and outcomes among midwifery patients

BACKGROUND/OBJECTIVE

To evaluate the association between the duration of the latent phase of labor and subsequent processes and outcomes.

METHODS

Secondary analysis of prospectively collected data among 1,189 women with low-risk pregnancies and spontaneous labor.

RESULTS

Longer latent phase duration was associated with labor dystocia (eg, nulliparous ≥ mean [compared with < mean] aOR 3.95 [2.70-5.79]; multiparous ≥ mean [compared with < mean] aOR 5.45 [3.43-8.65]), interventions to ameliorate dystocia, and epidurals to cope or rest (eg, oxytocin augmentation: nulliparous > 80th% [compared with < 80th%] aOR 6.39 [4.04-10.12]; multiparous ≥ 80th% [compared with < 80th%] aOR 6.35 [3.79-10.64]). Longer latent phase duration was also associated with longer active phase and second stage. There were no associations between latent phase duration and risk for cesarean delivery or postpartum hemorrhage in a practice setting with relatively low rates of primary cesarean. Newborns born to multiparous women with latent phase of labor durations at and beyond the 80th% were more frequently admitted to the NICU (≥80th% [compared with < 80th%] aOR 2.7 [1.22-5.84]); however, two-thirds of these NICU admissions were likely for observation only.

CONCLUSIONS

Longer duration of the spontaneous latent phase of labor among women with low-risk pregnancies may signal longer total labor processes, leading to an increase in diagnosis of dystocia, interventions to manage dystocia, and epidural use. Apart from multiparous neonatal NICU admission, no other maternal or child morbidity outcomes were elevated with longer duration of the latent phase of labor.

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.

Induction of labor compared to expectant management in term nulliparas with a latent phase of labor of more than 8 hours: a randomized trial

Background

Prolonged latent phase of labor is associated with adverse maternal and neonatal outcomes. Preliminary data indicate that labor induction for prolonged latent phase may reduce cesarean delivery. We performed a study powered to Cesarean delivery to evaluate labor induction compared to expectant management in full term nulliparas hospitalized for persistent contractions but non-progressive to established labor after an overnight stay.

Methods

From 2015 and 2017, nulliparas, ≥ 39 weeks’ gestation with prolonged latent phase of labor (persistent contractions after overnight hospitalization > 8 h), cervical dilation ≤3 cm, intact membranes and reassuring cardiotocogram were recruited. Participants were randomized to immediate induction of labor (with vaginal dinoprostone or amniotomy or oxytocin as appropriate) or expectant management (await labor for at least 24 h unless indicated intervention as directed by care provider). Primary outcome measure was Cesarean delivery.

Results

Three hundred eighteen women were randomized (159 to each arm). Data from 308 participants were analyzed. Cesarean delivery rate was 24.2% (36/149) vs. 23.3%, (37/159) RR 1.0 95% CI 0.7–1.6; P = 0.96 in induction of labor vs. expectant arms. Interval from intervention to delivery was 17.1 ± 9.9 vs. 40.1 ± 19.8 h; P < 0.001, intervention to active labor 9.6 ± 10.2 vs. 29.6 ± 18.5 h; P < 0.001, active labor to delivery 7.6 ± 3.6 vs. 10.5 ± 7.2 h; P < 0.001, intervention to hospital discharge 2.4 ± 1.2 vs. 2.9 ± 1.4 days; P < 0.001 and dinoprostone use was 19.5% (29/149) vs. 8.2% (13/159) RR 2.4 95% CI 1.3–4.4; P = 0.01 in IOL compared with expectant arms respectively. Intrapartum oxytocin use, epidural analgesia and uterine hyperstimulation syndrome, postpartum hemorrhage, patient satisfaction on allocated intervention, during labor and delivery and baby outcome were not significantly different across trial arms.

Conclusions

Induction of labor did not reduce Cesarean delivery rates but intervention to delivery and to hospital discharge durations are shorter. Patient satisfaction scores were similar. Induction of labor for prolonged latent phase of labor can be performed without apparent detriment to expedite delivery.

Trial registration

Registered in Malaysia National Medical Research Register (NMRR-15-16-23,886) on 6 January 2015 and the International Standard Randomised Controlled Trials Number registry, registration number ISRCTN14099170 on 5 Nov 2015.