Factors and outcomes associated with the induction of labour in Latin America

Risk factors for labour induction and augmentation: a multicentre prospective cohort study in India

Background

Guidelines for labour induction/augmentation involve evaluating maternal and fetal complications, and allowing informed decisions from pregnant women. This study aimed to comprehensively explore clinical and non-clinical factors influencing labour induction and augmentation in an Indian population.

Methods

A prospective cohort study included 9305 pregnant women from 13 hospitals across India. Self-reported maternal socio-demographic and lifestyle factors, and maternal medical and obstetric histories from medical records were obtained at recruitment (≥28 weeks of gestation), and women were followed up within 48 h after childbirth. Maternal and fetal clinical information were classified based on guidelines into four groups of clinical factors: (i) ≥2 indications, (ii) one indication, (iii) no indication and (iv) contraindication. Associations of clinical and non-clinical factors (socio-demographic, healthcare utilisation and lifestyle related) with labour induction and augmentation were investigated using multivariable logistic regression analyses.

Findings

Over two-fifths (n = 3936, 42.3%, 95% confidence interval [CI] 41.3-43.3%) of the study population experienced labour induction and more than a quarter (n = 2537, 27.3%, 95% CI 26.4-28.2%) experienced augmentation. Compared with women with ≥2 indications, those with one (adjusted odds ratio [aOR] 0.50, 95% CI 0.42-0.58) or no indication (aOR 0.24, 95% CI 0.20-0.28) or with contraindications (aOR 0.12, 95% CI 0.07-0.20) were less likely to be induced, adjusting for non-clinical characteristics. These associations were similar for labour augmentation. Notably, 34% of women who were induced or augmented did not have any clinical indication. Several maternal demographic (age at labour, parity and body mass index in early pregnancy), healthcare utilization (number of antenatal check-ups, duration of iron-folic acid supplementation and individuals managing childbirth) and socio-economic factors (religion, living below poverty line, maternal education and partner's occupation) were independently associated with labour induction and augmentation.

Interpretation

Although decisions about induction and augmentation of labour in our study population in India were largely guided by clinical recommendations, we cannot ignore that more than a third of the women did not have an indication. Decisions could also be influenced by non-clinical factors which need further research.

Funding

The MaatHRI platform is funded by a Medical Research Council Career Development Award (Grant Ref: MR/P022030/1) and a Transition Support Award (Grant Ref: MR/W029294/1).

Indications of Induction and Caesarean Sections Performed Using the Robson Classification in a University Hospital in Spain from 2010 to 2021

Background: The Robson Ten Group Classification System (RTGCS) enables the assessment, monitoring, and comparison of caesarean section rates both within healthcare facilities and between them, and the indications of caesarean sections (CS) performed in a maternity ward. The aims of the present study were to conduct an analysis to assess the levels and distribution of birth from a descriptive approach by CS in La Ribera University Hospital (Spain) between 2010-2021 using the Robson classification; to describe the indications for the induction of labour and the causes of caesarean sections performed; and to examine the association between the induction of labour and CS birth. Methods: A retrospective study between 1 January 2010 and 31 December 2021. All eligible women were classified according to the RTGCS to determine the absolute and relative contribution by each group to the overall CS rate. The odds ratio (OR) of the variables of interest was estimated by logistic regression. In an analysis of the subgroups, the level of significance was adjusted using the Bonferroni method. Results: 20,578 women gave birth during the study period, 19% of them by CS. In 33% of births, induction was performed, and the most common cause was the premature rupture of membranes. Group 2 (nulliparous with induced labour/elective CS before labour) accounted for the largest contribution to the overall rate of CS (31.5%) and showed an upward trend from 23.2% to 39.7% in the time series, increasing the CS rate by 6.7%. The leading cause of CS was suspected fetal distress, followed by induction failure. Conclusions: In our study, Robson Group 2 was identified as the main contributor to the hospital's overall CS rate. Determining the causes of induction and CS in a population sample classified using the RTGCS enables the identification of the groups with the greatest deviation from the optimal rate of CS and the establishment of improvement plans to reduce the overall rate of caesarean sections in the maternity unit.

Impact of the Thompson method on breastfeeding exclusivity and duration: Multi-method design

BACKGROUND

How hospital clinicians facilitate breastfeeding in the first 48-72 h is critical to breastfeeding exclusivity and duration. Mothers who discharge hospital directly breastfeeding are more likely to continue exclusively breastfeeding at 3-months.

OBJECTIVE

To assess the impact of facility-wide implementation of a physiological breastfeeding method (the Thompson method) on direct breastfeeding at hospital discharge and exclusive breastfeeding at 3-months of age.

DESIGN

Multi-method design using interrupted time series analysis and surveys.

SETTING(S)

An Australian tertiary maternity hospital.

PARTICIPANTS

13,667 mother-baby pairs (interrupted time series analysis) and 495 postnatal mothers (surveys).

METHODS

The Thompson method includes cradle position and hold, alignment of mouth-to-nipple, baby-led connection and seal, maternal fine-tuning for symmetry, and leisurely duration. We used a large pre-post implementation dataset and conducted interrupted time series analysis using a 24-month baseline period (January 2016 - December 2017); and a 15-month post-implementation period (April 2018 - June 2019). We recruited a sub-sample of women to complete surveys at hospital discharge and 3-months postpartum. Surveys were primarily used to measure impact of Thompson method on exclusive breastfeeding at 3-months, compared with a baseline survey conducted in same setting.

RESULTS

Following implementation of the Thompson method, the declining trend in direct breastfeeding at hospital discharge was significantly averted by 0.39% each month relative to baseline (95% CI: 0.03% to 0.76%; p = 0.037). While the 3-month exclusive breastfeeding rate in the Thompson group was 3 percentage points higher than the baseline group; this result did not reach statistical significance. However, a subgroup analysis of women who discharged hospital exclusively breastfeeding revealed the relative odds of exclusive breastfeeding at 3-months in the Thompson group was 0.25 (95% CI: 0.17 to 0.38; p < 0.001), significantly better than the baseline group (Z = 3.23, p < 0.01) where the relative odds was only 0.07 (95% CI: 0.03 to 0.19; p < 0.001).

CONCLUSIONS

Implementation of the Thompson method for well mother-baby pairs improved direct breastfeeding trends at hospital discharge. For women who discharged hospital exclusively breastfeeding, exposure to the Thompson method reduced the risk of exclusive breastfeeding discontinuation by 3-months. The positive impact of the method was potentially confounded by partial implementation and a parallel rise in birth interventions which undermine breastfeeding. We recommend strategies to strengthen clinician buy-in to the method, and future research using a cluster randomised trial design.

TWEETABLE ABSTRACT

Facility-wide implementation of the Thompson method improves direct breastfeeding at hospital discharge and predicts breastfeeding exclusivity at 3-months.

Effect of Castor Oil on Cervical Ripening and Labor Induction: a systematic review and meta-analysis

Objectives

Post-term pregnancy is a condition associated with increased maternal and fetal complications. Administration of castor oil causes cervical stimulation by increasing the production of prostaglandins. We examined the effects of castor oil on cervical ripening and labor induction through a systematic review and meta-analysis.

Methods

The search process was performed to obtain relevant articles from databases including Pubmed, Cochrane library, Scopus, Science direct, SID, Iran Medex, and Google Scholar using the English keywords of cervical ripening, post-term, castor oil, labor induction, Bishop score, and pregnancy considering all possible combinations without time constraints and their Persian equivalents from national databases.

Results

A total of eight related articles from the 19 primary studies were extracted and systematically reviewed. According to a cumulative chart, the difference in the post-intervention Bishop score was statistically significant (standard mean difference [SMD] 1.64, 95% confidence interval [CI] 1.67-2.11, p = 0.001), indicating an effect of castor oil on increasing the Bishop score. In addition, the difference in labor induction was statistically significant after the intervention (odds ratio 11.67, 95% CI 3.34-40.81, p = 0.001), indicating an effect of castor oil on increasing the odds ratio of labor induction (experience of vaginal delivery).

Conclusion

This meta-analysis showed that oral administration of castor oil is effective for cervical ripening and labor induction. Midwives should closely monitor pregnant women with prolonged labor and collaborate with obstetricians to employ castor oil as a safe intervention to induce cervical ripening and labor to prevent undue caesarean surgery.

Prediction of low Apgar score at five minutes following labor induction intervention in vaginal deliveries: machine learning approach for imbalanced data at a tertiary hospital in North Tanzania

Background

Prediction of low Apgar score for vaginal deliveries following labor induction intervention is critical for improving neonatal health outcomes. We set out to investigate important attributes and train popular machine learning (ML) algorithms to correctly classify neonates with a low Apgar scores from an imbalanced learning perspective.

Methods

We analyzed 7716 induced vaginal deliveries from the electronic birth registry of the Kilimanjaro Christian Medical Centre (KCMC). 733 (9.5%) of which constituted of low (< 7) Apgar score neonates. The ‘extra-tree classifier’ was used to assess features’ importance. We used Area Under Curve (AUC), recall, precision, F-score, Matthews Correlation Coefficient (MCC), balanced accuracy (BA), bookmaker informedness (BM), and markedness (MK) to evaluate the performance of the selected six (6) machine learning classifiers. To address class imbalances, we examined three widely used resampling techniques: the Synthetic Minority Oversampling Technique (SMOTE) and Random Oversampling Examples (ROS) and Random undersampling techniques (RUS). We applied Decision Curve Analysis (DCA) to evaluate the net benefit of the selected classifiers.

Results

Birth weight, maternal age, and gestational age were found to be important predictors for the low Apgar score following induced vaginal delivery. SMOTE, ROS and and RUS techniques were more effective at improving “recalls” among other metrics in all the models under investigation. A slight improvement was observed in the F1 score, BA, and BM. DCA revealed potential benefits of applying Boosting method for predicting low Apgar scores among the tested models.

Conclusion

There is an opportunity for more algorithms to be tested to come up with theoretical guidance on more effective rebalancing techniques suitable for this particular imbalanced ratio. Future research should prioritize a debate on which performance indicators to look up to when dealing with imbalanced or skewed data.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04534-0.

Predictors of adverse perinatal outcome among women who gave birth at Medical Center of Southwest Ethiopia: a retrospective cohort study

OBJECTIVES

The aim of this study was to determine predictors of adverse perinatal outcome among women who gave birth at Medical Center of Southwest Ethiopia.

SETTING

Institutional based retrospective cohort study was conducted among women who gave birth at Medical Center of Southwest Ethiopia.

PARTICIPANTS

Medical record of 777 women was included in the study by using maternity HMIS logbook as entry point. Simple random sampling technique without replacement was employed to select individual medical record using computer generated random numbers.

PRIMARY OUTCOME MEASURED

Predictors of adverse perinatal outcome were examined using modified Poisson regression with a robust SE.

RESULTS

Majority, 74.1% of the participants were in the age group of 21-34 years and the median age was 26 (IQR=7) years. More than one-third, 35.9% of the mothers were primigravida and only 21.2% of them had above four antenatal cares (ANC) visit. The overall incidence of adverse perinatal outcome was 31.5% (95% CI: 28.3 to 34.9). Maternal age less than 20 years (adjusted risk ratio, aRR=1.3; 95% CI: 1.01 to 1.5), rural residence (aRR=1.27; 95% CI: 1.04 to 1.59), presence of antepartum haemorrhage in current pregnancy (aRR=1.7; 95% CI: 1.38 to 2.07), maternal anaemia (aRR=1.25; 95% CI: 1.03 to 1.53), lack of ANC visit (aRR=2.29; 95% CI: 1.35 to 3.90), induced labour (aRR=1.77; 95% CI: 1.43 to 2.19) and being positive for venereal disease research laboratory (VDRL) test in current pregnancy (aRR=2.0; 95% CI: 1.16 to 3.38) were found to be significantly associated with adverse perinatal outcome.

CONCLUSION

The incidence of adverse perinatal outcome in the study area is high and maternal age less than 20, rural residency, maternal anaemia, antepartum haemorrhage in the current pregnancy, inadequate ANC visit, induction of labour and being positive for VDRL test were found to predict occurrence of adverse perinatal outcome. Majority of these problems can be managed by providing quality antenatal, intrapartum and post-natal care.

Proportion and Outcome of Induction of Labor Among Mothers Who Delivered in Teaching Hospital, Southwest Ethiopia

Background: Despite the induction of labor (IOL) having had some undesired consequences, it also has several benefits for maternal and perinatal outcomes. This study aimed to assess the proportion and outcome of IOL among mothers who delivered in Teaching Hospital, southwest Ethiopia.

Methods: A retrospective cross-sectional study was conducted from June 10 to June 20, 2019, among 294 mothers who gave birth between November 30, 2018, and May 30, 2019, by reviewing their cards using a structured checklist to assess the prevalence, outcome, and consequences of induction of labor. A binary logistic regression analysis was computed to look for the association between outcome variables and independent variables.

Results: The prevalence of labor induction was 20.4%. The most commonly reported cause of induction was preeclampsia (41.6%). The factors associated with IOL were mothers aged 25–34 years [AOR = 2.55, 95% CI (1.18–5.50)] and ≥35 years [AOR = 10.6, 95% CI (4.20–26.9)], having no history of antenatal care [AOR = 2.12, 95% CI (1.10–4.07)], and being Primipara AOR = 2.33, 95% CI (1.18–3.24)]. Of the 60 induced mothers, 23.3% had failed induction. The proportion of mothers with dead fetal outcomes and maternal complications was 5 and 41.7%, respectively. The unfavorable Bishop Score before induction [AOR = 1.85, 95% CI (1.32–4.87)] and induction using misoprostol [AOR = 1.48, 95% CI (1.24–5.23)] were the factors associated with failed induction of labor.

Conclusion: The prevalence of induced labor was considerably higher than rates in other Ethiopian studies; however, the prevalence of induction failure was comparable to other studies done in Ethiopia. The study found that Bishop's unfavorable score before induction and induction using misoprostol was the factor associated with unsuccessful induction. Therefore, the health professionals should confirm the favorability of the cervical status before the IOL to increase the success rate of induction of labor.

Induction of labour in low-resource settings

Due to the disparity in resource availability between low- and high-resource settings, practice recommendations relevant to high-income countries are not always relevant and often need to be adapted to low-resource settings. The adaptation applies to induction of labour (IOL) which is an obstetric procedure that deserves special attention because it involves the initiation of a process that requires regular and frequent monitoring of the mother and foetus by experienced healthcare professionals. Lack of problem recognition and/or substandard care during IOL may result in harm with long-term sequelae. In this article, the authors discuss unique challenges such as insufficient resources (including staff, midwives, doctors, equipment, and medications) that result in occasional inadequate patient monitoring and/or delayed interventions during IOL in low-resource settings. We also discuss modifications in indications and methods for IOL, issues related to human immunodeficiency virus (HIV) infections, the feasibility of outpatient induction, clinical protocols and a minimum dataset for quality improvement projects. Overall, the desire to achieve a vaginal birth with IOL should not cloud the necessity to observe the required safety measures and implement necessary interventions; given that childbirth practices are the major determinants of pregnancy outcomes and patient satisfaction.

Fetomaternal Outcome Among the Pregnant Women Subject to the Induction of Labor

Introduction

Induction of labor (IOL) is characterized by stimulating contractions of the uterus just before the instantaneous onset of labor, with or without amniotomy. According to the recommendation of the World Health Organization (WHO), induction must only be carried out when there is a clear medical need for one and when potential benefits outweigh the expected harm that may be caused by it. The present study was to determine the frequency of fetomaternal outcomes among pregnant women subject to the induction of labor.

Methods

The present prospective cross-sectional study was conducted over a period of one year starting from June 17, 2018, to July 25, 2019, in the Department of Obstetrics and Gynecology Unit III, Civil Hospital Karachi. After institutional ethical committee approval, 302 pregnant women who were subject to induction of labor were enrolled using a non-probability consecutive sampling technique. Outcome variables, i.e., postpartum hemorrhage, mode of delivery, hospital stay more than seven days, birth asphyxia, Apgar score < 7 at five minutes, neonatal jaundice, and low birth weight were noted. IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows, version 21.0 (IBM Corp., Armonk, NY) was used for data analysis.

Results

A total of 302 women with an average age range was 18-45 years with a mean age of 28.5 ± 4.47, body mass index (BMI) 29.83 ± 3.83, and mean gestational age was 37 ± 4.3. Almost 205 (67.9%) of the cases were booked. One hundred and eighty (59.6%) were nulliparas, 57(18.8%) had para-1, 43 (14.4%) had para-2, and 22 (7.14%) had par-3. When fetomaternal outcome among the pregnant women subject to induction of labor was observed, postpartum hemorrhage was observed in 55 (18.21%), hospital stay more than seven days was in 51 (17%), birth asphyxia was in 45 (14.9%), neonatal jaundice was in 53 (17.6%), low birth weight was in 15 (4.96%), Apgar score < 7 was in 48 (16%), 39 (13%) women underwent for C-section and 263 (87%) of the women delivered vaginally.

Conclusion

This study concludes that the induction of labor (IOL) is safe and reliable and less risk of adverse feto-maternal outcome is associated with pregnancies between 37 weeks and 42 weeks of gestation. The evidence regarding IOL prior to 37 weeks and beyond 42 weeks of gestation is inadequate to reach any conclusion.

Predicting factors of failed induction of labor in three hospitals of Southwest Ethiopia: a cross-sectional study

Introduction

Failed induction of labor affects maternal and neonatal outcomes as well as the cost of healthcare, especially in low-resource setting regions in which the prevalence of failed induction is higher despite the incidence of labor induction is low. This study aimed to assess the prevalence of failed induction of labor in southwest Ethiopia.

Method

A hospital-based cross-sectional study was conducted among 441 induced women from March 1 to August 30, 2018. A systematic random sampling technique was used to select study participants. Data were collected using a pretested and structured questionnaire. Bivariable and multivariable logistic regression models were done and fitted to identify predictors of failed induction. An adjusted odds ratio with 95% confidence interval (CI) was calculated to determine the level of significance.

Result

Premature rupture of membrane was the most common cause of labor induction and the commonly used method of labor induction were oxytocin infusion. Cesarean section was done for 28.1% of induced women. Failed induction of labor was found to be 21%. Primiparous [AOR = 2.35 (1.35–4.09)], analgesia/anesthesia [AOR = 4.37 (1.31–14.59)], poor Bishop Score [AOR = 2.37 (1.16–4.84)], Birth weight ≥ 4 k grams [AOR = 2.12 (1.05–4.28)] and body mass index [AOR = 5.71 (3.26–10.01)] were found to be significantly associated with failed induction of labor.

Conclusion

The prevalence of failed induction of labour was found to be high. Preparation of the cervix before induction in primi-parity women is suggested to improve the success of induction. To achieve the normal weight of women and newborns, proper nutritional interventions should be given for women of reproductive age. It is better to use analgesia/anesthesia for labor induction when it becomes mandatory and there are no other optional methods of no- pharmacologic pain management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03862-x.

Factors and outcomes associated with the induction of labor in referral hospitals of Amhara regional state, Ethiopia: a multicenter study

BACKGROUND

Induction of labor is an artificial initiation of uterine contractions after fetal viability with the aim of vaginal delivery prior to the onset of spontaneous labor. Prevalence of induction of labor is increasing worldwide with subsequent increase in failure rate. However, there is limited evidence on labor induction in Ethiopia. Therefore, this study was aimed at assessing the prevalence and associated factors of failed induction of labor among women undergoing induction of labor at referral hospitals of Amhara national regional state, Ethiopia, 2016.

METHOD

A multicenter cross-sectional study was conducted at referral hospitals found in Amhara national regional state from February 01 to September 30, 2016. Multistage sampling technique was employed to select a total of 484 women who underwent labor induction. Pre-tested structured questionnaires and checklists were used to collect the data. Data were entered into EPI info version 7 and analyzed using SPSS version 20 software. Stepwise Binary Logistic regression model was fitted to identify factors associated with failed induction of labor. The level of significance was determined based on the adjusted odds ratio with 95% confidence interval at the p-value of ≤0.05.

RESULT

The prevalence of failed induction of labor among women undergoing induction of labor was 31.4% (95% CI: 27.0, 36.0). Failed induction of labor was independently predicted by a Bishop score of ≤5 (AOR = 2.1; 95% CI: 1.3, 3.6), prolonged latent first stage of labor (AOR = 2.0; 95% CI: 1.2, 3.5), induction with oxytocin alone (AOR = 4.2; 95% CI: 2.2, 8.1), nulliparity (ARO = 1.9; 95% CI: 1.2, 2.9), post term pregnancy (AOR = 4.1; 95% CI: 1.8, 9.3) and hypertensive disorder of pregnancy (AOR = 2.4; 95% CI: 1.5, 5.1).

CONCLUSION

Failed induction of labor was high in the study area compared to the reports of previous studies done in Ethiopia. The majority of the determinants of failed induction of labor were connected with unjustifiable and inconsistent indication of induction of labor. Thus, preparing standardized practical guidelines and preventing unjustifiable case selection may help reduce the current high failure rates.

Inpatient versus outpatient induction of labour: a systematic review and meta-analysis

Background

As the number of indications for labour induction continue to increase, the focus has shifted to performing these procedures in an outpatient setting. This study aims to systematically review published data from randomized controlled trials that compare outpatient with inpatient labour induction, to ascertain the role of outpatient labour induction for low-risk pregnancies.

Methods

We conducted a systematic review wherein we searched MEDLINE, EMBASE, Biosis Previews®, and International Pharmaceutical Abstracts from inception to January 2020 to identify randomized controlled trials that reported on maternal, fetal and resource-related outcomes following outpatient versus inpatient labour induction. Pooled incidences and mean differences were calculated using random-effects meta-analysis. Risk-of-bias was assessed using the Cochrane Risk of Bias tool. Subgroup analysis was conducted based on the method of induction.

Results

Of the 588 records identified, 12 publications, representing nine independent randomized controlled trials conducted in Australia, Europe and North America, were included. These reported on 2615 cases of labour induction (1320 outpatients versus 1295 inpatients). Overall, apart from a higher number of suspicious fetal heart rate tracings [RR = 1.43 (1.10, 1.86)] and a shorter mean length of hospital stay [MD = 282.48 min (160.23, 404.73) shorter] in the outpatient group, there were no differences in delivery method, adverse outcomes or resource-use between the two arms. On subgroup analysis, when comparing the use of balloon catheters in both arms, those induced as outpatients had fewer caesarean deliveries [RR = 0.52 (0.30, 0.90)], a shorter admission-to-delivery interval [MD = 370.86 min (19.19, 722.54) shorter], and a shorter induction to delivery interval [MD = 330.42 min (120.13, 540.71) shorter].

Conclusion

Outpatient labour induction in resource-rich settings is at least as effective and safe, in carefully selected patient populations, when compared with inpatient labour induction. Whether outpatient labour induction results in lower rates of caesarean deliveries needs to be explored further.

Trial registration

This systematic review was prospectively registered in Prospero (CRD42019118049).

Induction of labor in continuing pregnancies

This chapter aims to provide an evidence-based approach to cervical-ripening methods and induction of labor in high-, middle-, and low-income countries. We will review the epidemiology of induction and will also review pharmacological and mechanical methods of cervical-ripening as well as oxytocin for induction. Lastly, we will review current guidelines of when to determine an induction to be failed.

Misoprostol administered sublingually at a dose of 12.5 μg versus vaginally at a dose of 25 μg for the induction of full-term labor: a randomized controlled trial

Background

Labor induction is defined as any procedure that stimulates uterine contractions before labor begins spontaneously. The vaginal and oral routes of administration of misoprostol are those most used for the induction of labor in routine practice, with the recommended dose being 25 μg. Nevertheless, the sublingual route may reduce the number of vaginal examinations required, increasing patient comfort and lowering the risk of maternal and fetal infection. Based on a previous systematic review, the objective of this study was to compare the frequency of tachysystole as the main outcome measure when misoprostol is administered sublingually at the dose of 12.5 μg versus vaginally at a dose of 25 μg to induce labor in a full-term pregnancy with a live fetus.

Methods

A randomized, placebo-controlled, triple-blind clinical trial was conducted at two maternity hospitals in northeastern Brazil. Two hundred patients with a full-term pregnancy, a live fetus, Bishop score ≤ 6 and an indication for induction of labor were included. Following randomization, one group received 12.5 μg misoprostol sublingually and a vaginal placebo, while the other group received a sublingual placebo and 25 μg misoprostol vaginally. The primary outcome was the frequency of tachysystole. Student’s t-test, the chi-square test of association and Fisher’s exact test were used, as appropriate. Risk ratios and their 95% confidence intervals were calculated.

Results

The frequency of tachysystole was lower in the group using 12.5 μg misoprostol sublingually compared to the group using 25 μg misoprostol vaginally (RR = 0.15; 95%CI: 0.02–0.97; p = 0.002). Failure to achieve vaginal delivery within 12 and 24 h was similar in both groups. Sublingual administration was preferred to vaginal administration by women in both groups; however, the difference was not statistically significant.

Conclusion

The effectiveness of labor induction with low-dose sublingual misoprostol was similar to that achieved with vaginal administration of the recommended dose; however, the rate of tachysystole was lower in the sublingual group, and this route of administration may prove a safe alternative.

Trial registration

Registration number: NCT01406392, ClinicalTrials.gov. Date of registration: August 1, 2011.

Clinical practice outcomes and differential results in maternal and neonatal morbidity among pregnant women in Spain who are candidates for a normal birth: a cross-sectional study

OBJECTIVE

To determine the percentage of pregnant women who are potential candidates for a normal birth in the region of Cantabria, Spain. Also, to compare the main clinical practice outcome indicators and the rates of maternal and neonatal morbidity among the group of candidate women versus non-candidates.

DESIGN

A cross-sectional study.

SETTING

A tertiary Hospital in Cantabria (Northern region of Spain).

PARTICIPANTS

The study population comprised the total number of hospital births that took place between 1 January 2014 and 31 December 2014 (n=3315).

RESULTS

Secondary registers were accessed to review the main indicators of care and the outcome of births. The χ2 test or the Student's t-test were used to compare both groups for the categorical and continuous variables, respectively. In total, 1863 births (56.20%) were candidates for applying the strategy of care for a normal birth. In 50.86% of these candidate births, an episiotomy was performed, compared with 60.96% in the group of non-candidates (p<0.001). Regarding caesarean sections, these were carried out in 19.32% of the candidate births, compared with 26.79% of non-candidate births (p<0.001). Furthermore, there were statistically significant differences between the groups according to the type of birth, the need for instrumental birthing methods, the existence of perineal tears, Apgar scores and the requirement for the infant to be admitted to the neonatal intensive care unit.

CONCLUSIONS

Our results suggest a differential clinical practice, in line with the recommendations of the Clinical Practice Guidelines for Care of Normal Birth. Nonetheless, improvements are necessary regarding the care provided to women and infants, as the percentages of episiotomies and caesarean sections are still high when compared with current standards and compared with other reports.

Relationship between parity and the problems that appear in the postpartum period

Parity is associated with the incidence of problems in pregnancy, delivery and the puerperium. The influence of parity in the postpartum period has been poorly studied and the results are incongruous. The objective of this study was to identify the association between parity and the existence of distinct discomfort and problems during the postpartum period. Cross-sectional study with puerperal women in Spain. Data was collected on demographic and obstetric variables and maternal manifestations of discomfort and problems during the postpartum period. An ad hoc online questionnaire was used. Crude odds ratios (ORs) and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were estimated by conditional logistic regression. 1503 primiparous and 1487 multiparous participated in the study. 53.4% (803) of the primiparous women affirmed to have feelings of sadness, as opposed to 36.2% (539) of multiparous women (aOR: 1.60; 95% CI: 1.35-1.89). 48.3% (726) of primiparous had lactation problems vs 24.7% (367) of multiparous (aOR: 2.46; 95% CI: 2.05-2.94). 37.2% (559) of primiparous reported anxiety, while the percentage in multiparous was 25.7% (382) (aOR: 1.34; 95% CI: 1.12-1.61). 22.2% (333) of primiparous had depressive symptoms, and 11.6% (172) of multiparous (aOR: 1.65; CI 95%: 1.31-2.06). Faecal incontinence was more present in primiparous than in multiparous, 6.5% (97) and 3.3% (49) respectively (aOR: 1.60; 95% CI: 1.07-2.38). Parity is associated with the presence of certain problems in the postpartum period. Thus, primiparous are more likely to have lactation problems, depressive symptoms, anxiety, sadness, and faecal incontinence.

A comparison of machine learning algorithms and covariate balance measures for propensity score matching and weighting

Propensity score matching (PSM) and propensity score weighting (PSW) are popular tools to estimate causal effects in observational studies. We address two open issues: how to estimate propensity scores and assess covariate balance. Using simulations, we compare the performance of PSM and PSW based on logistic regression and machine learning algorithms (CART; Bagging; Boosting; Random Forest; Neural Networks; naive Bayes). Additionally, we consider several measures of covariate balance (Absolute Standardized Average Mean (ASAM) with and without interactions; measures based on the quantile-quantile plots; ratio between variances of propensity scores; area under the curve (AUC)) and assess their ability in predicting the bias of PSM and PSW estimators. We also investigate the importance of tuning of machine learning parameters in the context of propensity score methods. Two simulation designs are employed. In the first, the generating processes are inspired to birth register data used to assess the effect of labor induction on the occurrence of caesarean section. The second exploits more general generating mechanisms. Overall, among the different techniques, random forests performed the best, especially in PSW. Logistic regression and neural networks also showed an excellent performance similar to that of random forests. As for covariate balance, the simplest and commonly used metric, the ASAM, showed a strong correlation with the bias of causal effects estimators. Our findings suggest that researchers should aim at obtaining an ASAM lower than 10% for as many variables as possible. In the empirical study we found that labor induction had a small and not statistically significant impact on caesarean section.

Effectiveness and safety of herbal medicines for induction of labour: a systematic review and meta-analysis

OBJECTIVE

The use of herbal medicines for induction of labour (IOL) is common globally and yet its effects are not well understood. We assessed the efficacy and safety of herbal medicines for IOL.

DESIGN

Systematic review and meta-analysis of published literature.

DATA SOURCES

We searched in MEDLINE, AMED and CINAHL in April 2017, updated in June 2018.

ELIGIBILITY CRITERIA

We considered experimental and non-experimental studies that compared relevant pregnancy outcomes between users and non-user of herbal medicines for IOL.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by two reviewers using a standardised form. A random-effects model was used to synthesise effects sizes and heterogeneity was explored through I2 statistic. The risk of bias was assessed using 'John Hopkins Nursing School Critical Appraisal Tool' and 'Cochrane Risk of Bias Tool'.

RESULTS

A total of 1421 papers were identified through the searches, but only 10 were retained after eligibility and risk of bias assessments. The users of herbal medicine for IOL were significantly more likely to give birth within 24 hours than non-users (Risk Ratio (RR) 4.48; 95% CI 1.75 to 11.44). No significant difference in the incidence of caesarean section (RR 1.19; 95% CI 0.76 to 1.86), assisted vaginal delivery (RR 0.73; 95% CI 0.47 to 1.14), haemorrhage (RR 0.84; 95% CI 0.44 to 1.60), meconium-stained liquor (RR 1.20; 95% CI 0.65 to 2.23) and admission to nursery (RR 1.08; 95% CI 0.49 to 2.38) was found between users and non-users of herbal medicines for IOL.

CONCLUSIONS

The findings suggest that herbal medicines for IOL are effective, but there is inconclusive evidence of safety due to lack of good quality data. Thus, the use of herbal medicines for IOL should be avoided until safety issues are clarified. More studies are recommended to establish the safety of herbal medicines.

Breastfeeding Outcomes After Oxytocin Use During Childbirth: An Integrative Review

INTRODUCTION

Despite widespread use of exogenous synthetic oxytocin during the birth process, few studies have examined the effect of this drug on breastfeeding. Based on neuroscience research, endogenous oxytocin may be altered or manipulated by exogenous administration or by blocking normal function of the hormone or receptor. Women commonly cite insufficient milk production as their reason for early supplementation, jeopardizing breastfeeding goals. Researchers need to consider the role of birth-related medications and interventions on the production of milk. This article examines the literature on the role of exogenous oxytocin on breastfeeding in humans.

METHODS

Using the method described by Whittemore and Knafl, this integrative review of literature included broad search criteria within the PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, and Scopus databases. Studies published in English associating a breastfeeding outcome in relation to oxytocin use during the birth process were included. Twenty-six studies from 1978 to 2015 met the criteria.

RESULTS

Studies were analyzed according to the purpose of the research, measures and methods used, results, and confounding variables. The 26 studies reported 34 measures of breastfeeding. Outcomes included initiation and duration of breastfeeding, infant behavior, and physiologic markers of lactation. Timing of administration of oxytocin varied. Some studies reported on low-risk birth, while others included higher-risk experiences. Fifty percent of the results (17 of 34 measures) demonstrated an association between exogenous oxytocin and less optimal breastfeeding outcomes, while 8 of 34 measures (23%) reported no association. The remaining 9 measures (26%) had mixed findings. Breastfeeding intentions, parity, birth setting, obstetric risk, and indications for oxytocin use were inconsistently controlled among the studies.

DISCUSSION

Research on breastfeeding and lactation following exogenous oxytocin exposure is limited by few studies and heterogeneous methods. Despite the limitations, researchers and clinicians may benefit from awareness of this body of literature. Continued investigation is recommended given the prevalence of oxytocin use in clinical practice.

Misoprostol administered sublingually at a dose of 12.5 μg versus vaginally at a dose of 25 μg for the induction of full-term labor: a randomized controlled trial protocol

Background

Various methods are currently used for the induction of labor. Nevertheless, the most effective method with the fewest side effects remains to be established. Misoprostol, administered vaginally, has been routinely used for this purpose; however, other forms of administration are being proposed, including the use of sublingual tablets. No studies have yet compared the effectiveness and safety of 12.5-μg misoprostol administered sublingually compared to a 25-μg vaginal dose of the drug for the induction of labor.

Methods

A triple-blind, multicenter, placebo-controlled, randomized clinical trial will be conducted in Brazil at the Instituto de Medicina Integral Prof. Fernando Figueira and at the Assis Chateaubriand Maternity Teaching Hospital of the Federal University of Ceará. A total of 140 patients with full-term pregnancies, a live fetus, a Bishop score ≤ 6 and a recommendation of induction of labor will be randomized to one of two groups. One group will receive 12.5-μg sublingual tablets of misoprostol and placebo vaginal tablets, while the other group will receive placebo sublingual tablets and vaginal tablets containing 25 μg of misoprostol. The principal endpoint is the rate of tachysystole. The secondary endpoints are vaginal delivery within 24 h of induction, uterine hyperstimulation, Cesarean section, severe neonatal morbidity or perinatal death, severe maternal morbidity or maternal death, and maternal preference regarding the route of administration of the drug. Student’s t-test, and the chi-square test of association or Fisher’s exact test, as appropriate, will be used in the data analysis. Risk ratios and their respective 95% confidence intervals will be calculated.

Discussion

Misoprostol has been identified as a safe, inexpensive, easily administered option for the induction of labor, with satisfactory results. An experimental study has shown that misoprostol administered sublingually at a dose of 25 μg appears to be effective and is associated with greater maternal satisfaction when labor is induced in women with an unfavorable cervix. Nevertheless, the rate of tachysystole remains high; therefore, further studies are required to determine the ideal dose and the ideal interval of time between doses.

Trial registration

ClinicalTrial.gov, NCT01406392.

Management of pregnancy at and beyond 41 completed weeks of gestation in low-risk women: a secondary analysis of two WHO multi-country surveys on maternal and newborn health

BACKGROUND

The World Health Organization (WHO) recommends induction of labour (IOL) for women who have reached 41 completed weeks of pregnancy without spontaneous onset of labour. Many women with prolonged pregnancy and/or their clinicians elect not to induce, and chose either elective caesarean section (ECS) or expectant management (EM). This study intended to assess pregnancy outcomes of IOL, ECS and EM at and beyond 41 completed weeks.

METHODS

This study is a secondary analysis of the WHO Global Survey (WHOGS) and the WHO Multi-country Survey (WHOMCS) conducted in Africa, Asia, Latin America and the Middle East. There were 33,003 women with low risk singleton pregnancies at ≥41 completed weeks from 292 facilities in 21 countries. Multilevel logistic regression model was used to assess associations of different management groups with each pregnancy outcome accounted for hierarchical survey design. The results were presented by adjusted odds ratios (aORs) with 95% confidence intervals (CIs) after adjusting for age, education, marital status, parity, previous caesarean section (CS), birth weight, and facility capacity index score.

RESULTS

The prevalence of prolonged pregnancy at facility setting in WHOGS, WHOMCS and combined databases were 7.9%, 7.5% and 7.7% respectively. Regarding to maternal adverse outcomes, EM was significantly associated with decreased risk of CS rate consistently in both databases i.e. (aOR0.76; 95% CI: 0.66-0.87) in WHOGS, (aOR0.67; 95% CI: 0.59-0.76) in WHOMCS and (aOR0.70; 95% CI: 0.64-0.77) in combined database, compared to IOL. Regarding the adverse perinatal outcomes, ECS was significantly associated with increased risks of neonatal intensive care unit admission (aOR1.76; 95% CI: 1.28-2.42) in WHOMCS and (aOR1.51; 95% CI: 1.19-1.92) in combined database compared to IOL but not significant in WHOGS database.

CONCLUSIONS

Compared to IOL, ECS significantly increased risk of NICU admission while EM was significantly associated with decreased risk of CS. ECS should not be recommended for women at 41 completed weeks of pregnancy. However, the choice between IOL and EM should be cautiously considered since the available evidences are still quite limited.

Pharmacological and mechanical interventions for labour induction in outpatient settings

BACKGROUND

Induction of labour is carried out for a variety of indications and using a range of methods. For women at low risk of pregnancy complications, some methods of induction of labour or cervical ripening may be suitable for use in outpatient settings.

OBJECTIVES

To examine pharmacological and mechanical interventions to induce labour or ripen the cervix in outpatient settings in terms of effectiveness, maternal satisfaction, healthcare costs and, where information is available, safety.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials examining outpatient cervical ripening or induction of labour with pharmacological agents or mechanical methods. Cluster trials were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed evidence using the GRADE approach.

MAIN RESULTS

This updated review included 34 studies of 11 different methods for labour induction with 5003 randomised women, where women received treatment at home or were sent home after initial treatment and monitoring in hospital.Studies examined vaginal and intracervical prostaglandin E₂ (PGE₂), vaginal and oral misoprostol, isosorbide mononitrate, mifepristone, oestrogens, amniotomy and acupuncture, compared with placebo, no treatment, or routine care. Trials generally recruited healthy women with a term pregnancy. The risk of bias was mostly low or unclear, however, in 16 trials blinding was unclear or not attempted. In general, limited data were available on the review's main and additional outcomes. Evidence was graded low to moderate quality. 1. Vaginal PGE₂ versus expectant management or placebo (5 studies)Fewer women in the vaginal PGE₂ group needed additional induction agents to induce labour, however, confidence intervals were wide (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.27 to 0.99; 150 women; 2 trials). There were no clear differences between groups in uterine hyperstimulation (with or without fetal heart rate (FHR) changes) (RR 3.76, 95% CI 0.64 to 22.24; 244 women; 4 studies; low-quality evidence), caesarean section (RR 0.80, 95% CI 0.49 to 1.31; 288 women; 4 studies; low-quality evidence), or admission to a neonatal intensive care unit (NICU) (RR 0.32, 95% CI 0.10 to 1.03; 230 infants; 3 studies; low-quality evidence).There was no information on vaginal birth within 24, 48 or 72 hours, length of hospital stay, use of emergency services or maternal or caregiver satisfaction. Serious maternal and neonatal morbidity or deaths were not reported. 2. Intracervical PGE₂ versus expectant management or placebo (7 studies) There was no clear difference between women receiving intracervical PGE₂ and no treatment or placebo in terms of need for additional induction agents (RR 0.98, 95% CI 0.74 to 1.32; 445 women; 3 studies), vaginal birth not achieved within 48 to 72 hours (RR 0.83, 95% CI 0.68 to 1.02; 43 women; 1 study; low-quality evidence), uterine hyperstimulation (with FHR changes) (RR 2.66, 95% CI 0.63 to 11.25; 488 women; 4 studies; low-quality evidence), caesarean section (RR 0.90, 95% CI 0.72 to 1.12; 674 women; 7 studies; moderate-quality evidence), or babies admitted to NICU (RR 1.61, 95% CI 0.43 to 6.05; 215 infants; 3 studies; low-quality evidence). There were no uterine ruptures in either the PGE₂ group or placebo group.There was no information on vaginal birth not achieved within 24 hours, length of hospital stay, use of emergency services, mother or caregiver satisfaction, or serious morbidity or neonatal morbidity or perinatal death. 3. Vaginal misoprostol versus placebo (4 studies)One small study reported on the rate of perinatal death with no clear differences between groups; there were no deaths in the treatment group compared with one stillbirth (reason not reported) in the control group (RR 0.34, 95% CI 0.01 to 8.14; 77 infants; 1 study; low-quality evidence).There was no clear difference between groups in rates of uterine hyperstimulation with FHR changes (RR 1.97, 95% CI 0.43 to 9.00; 265 women; 3 studies; low-quality evidence), caesarean section (RR 0.94, 95% CI 0.61 to 1.46; 325 women; 4 studies; low-quality evidence), and babies admitted to NICU (RR 0.89, 95% CI 0.54 to 1.47; 325 infants; 4 studies; low-quality evidence).There was no information on vaginal birth not achieved within 24, 48 or 72 hours, additional induction agents required, length of hospital stay, use of emergency services, mother or caregiver satisfaction, serious maternal, and other neonatal, morbidity or death.No substantive differences were found for other comparisons. One small study found that women who received oral misoprostol were more likely to give birth within 24 hours (RR 0.65, 95% CI 0.48 to 0.86; 87 women; 1 study) and were less likely to require additional induction agents (RR 0.60, 95% CI 0.37 to 0.97; 127 women; 2 studies). Women who received mifepristone were also less likely to require additional induction agents (average RR 0.59, 95% CI 0.37 to 0.95; 311 women; 4 studies; I² = 74%); however, this result should be interpreted with caution due to high heterogeneity. One trial each of acupuncture and outpatient amniotomy were included, but few review outcomes were reported.

AUTHORS' CONCLUSIONS

Induction of labour in outpatient settings appears feasible and important adverse events seem rare, however, in general there is insufficient evidence to detect differences. There was no strong evidence that agents used to induce labour in outpatient settings had an impact (positive or negative) on maternal or neonatal health. There was some evidence that compared to placebo or no treatment, induction agents administered on an outpatient basis reduced the need for further interventions to induce labour, and shortened the interval from intervention to birth.We do not have sufficient evidence to know which induction methods are preferred by women, the interventions that are most effective and safe to use in outpatient settings, or their cost effectiveness. Further studies where various women-friendly outpatient protocols are compared head-to-head are required. As part of such work, women should be consulted on what sort of management they would prefer.

Does a policy of earlier induction affect labour outcomes in women induced for postmaturity? A retrospective analysis in a tertiary hospital in the North of England

OBJECTIVES

to investigate whether a change in the management of postmature pregnancy to earlier induction affects the length of labour and the induction process. Secondly, to assess the feasibility of the research process to inform a future larger study.

DESIGN

a change in management of postmature pregnancy in an NHS hospital in October 2013, from induction at 42 weeks gestation to induction between 41-42 weeks, provided an opportunity to conduct a retrospective analysis. Pre-existing data from the maternity database and casenotes were collected and primary outcomes analysed using the Mann-Whitney test and the Hodges-Lehman confidence interval for differences in medians.

SETTING

a large city based tertiary referral hospital in the North of England.

PARTICIPANTS

125 women induced before the change in policy were compared with 309 women induced after the change.

MEASUREMENTS

primary outcomes were length of 1st and 2nd stage of labour, overall length of labour, length of induction to established labour and length of induction to birth.

FINDINGS

the median overall length of labour for women induced at 42 weeks was 6.5hours, while for women induced at 41-42 weeks this was 5.2hours. The difference was not statistically significant (p=0.15, 95% CI for median difference -0.27 to 1.93hours) with a small effect size (Pearson's r=-0.08). The median length of induction to birth was 13.6hours for women induced at 42 weeks and 16.5hours for women induced at 41-42 weeks. This difference was also not statistically significant (p=0.14, 95% CI for median difference -7.25 to 1.20hours) with a small effect size (Pearson's r=-0.13).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This study demonstrated no statistically significant differences in length of labour and induction following a change in the management of postmature pregnancy to earlier induction. A large study is needed to establish definitively the effects of earlier induction on labour outcomes.

Use of Robson classification to assess cesarean section rate in Brazil: the role of source of payment for childbirth

Background

Cesarean section (CS) rates are increasing worldwide but there is some concern with this trend because of potential maternal and perinatal risks. The Robson classification is the standard method to monitor and compare CS rates. Our objective was to analyze CS rates in Brazil according to source of payment for childbirth (public or private) using the Robson classification.

Methods

Data are from the 2011–2012 “Birth in Brazil” study, which used a national hospital-based sample of 23,940 women. We categorized all women into Robson groups and reported the relative size of each Robson group, the CS rate in each group and the absolute and relative contributions made by each to the overall CS rate. Differences were analyzed through chi-square and Z-test with a significance level of < 0.05.

Results

The overall CS rate in Brazil was 51.9 % (42.9 % in the public and 87.9 % in the private health sector). The Robson groups with the highest impact on Brazil’s CS rate in both public and private sectors were group 2 (nulliparous, term, cephalic with induced or cesarean delivery before labor), group 5 (multiparous, term, cephalic presentation and previous cesarean section) and group 10 (cephalic preterm pregnancies), which accounted for more than 70 % of CS carried out in the country. High-risk women had significantly greater CS rates compared with low-risk women in almost all Robson groups in the public sector only.

Conclusions

Public policies should be directed at reducing CS in nulliparous women, particularly by reducing the number of elective CS in these women, and encouraging vaginal birth after cesarean to reduce repeat CS in multiparous women.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-016-0228-7) contains supplementary material, which is available to authorized users.

Maternal and perinatal outcomes in women with and without hypertensive syndromes submitted to induction of labor with misoprostol

OBJECTIVES

To determine maternal and perinatal outcomes according to the mode of delivery in normotensive and hypertensive women bearing a live, full-term fetus, who were submitted to labor induction with misoprostol.

METHODS

Retrospective cohort study. The endpoints were tachysystole, uterine hyperstimulation, indications for cesarean section, severe maternal morbidity, side effects, maternal death, 1st/5th minute Apgar, neonatal death, requirement for neonatal intensive care, and birth weight (grams). The chi-square or Fisher's exact test was applied at a significance level of 5%. Risk ratios (RRs) and their 95% confidence intervals (95% CI) were calculated.

RESULTS

No significant differences were found in maternal outcome as a function of mode of delivery. First-minute Apgar score <7 was less common with vaginal deliveries in normotensive women (RR = 0.41; 95% CI: 0.18-0.90), this being the only significant difference in perinatal outcome.

CONCLUSION

Maternal and perinatal outcomes were similar in hypertensive and normotensive women submitted to labor induction with misoprostol.

Reduction in resource use with the misoprostol vaginal insert vs the dinoprostone vaginal insert for labour induction: a model-based analysis from a United Kingdom healthcare perspective

Background

In view of the increasing pressure on the UK’s maternity units, new methods of labour induction are required to alleviate the burden on the National Health Service, while maintaining the quality of care for women during delivery. A model was developed to evaluate the resource use associated with misoprostol vaginal inserts (MVIs) and dinoprostone vaginal inserts (DVIs) for the induction of labour at term.

Methods

The one-year Markov model estimated clinical outcomes in a hypothetical cohort of 1397 pregnant women (parous and nulliparous) induced with either MVI or DVI at Southmead Hospital, Bristol, UK. Efficacy and safety data were based on published and unpublished results from a phase III, double-blind, multicentre, randomised controlled trial. Resource use was modelled using data from labour induction during antenatal admission to patient discharge from Southmead Hospital. The model’s sensitivity to key parameters was explored in deterministic multi-way and scenario-based analyses.

Results

Over one year, the model results indicated MVI use could lead to a reduction of 10,201 h (28.9 %) in the time to vaginal delivery, and an increase of 121 % and 52 % in the proportion of women achieving vaginal delivery at 12 and 24 h, respectively, compared with DVI use. Inducing women with the MVI could lead to a 25.2 % reduction in the number of midwife shifts spent managing labour induction and 451 fewer hospital bed days. These resource utilisation reductions may equate to a potential 27.4 % increase in birthing capacity at Southmead Hospital, when using the MVI instead of the DVI.

Conclusions

Resource use, in addition to clinical considerations, should be considered when making decisions about labour induction methods. Our model analysis suggests the MVI is an effective method for labour induction, and could lead to a considerable reduction in resource use compared with the DVI, thereby alleviating the increasing burden of labour induction in UK hospitals.

Elective induction of labour and maternal request: a national population-based study

OBJECTIVE

To estimate the rate of elective inductions in France and the proportion of them that were maternally requested, and to study the factors associated with elective inductions that were or were not requested by women.

DESIGN

Cross-sectional population-based study.

SETTING

All maternity units in France.

POPULATION

About 14 681 women from the 2010 French National Perinatal Survey of a representative sample of births.

METHODS

Inductions were classified as elective based on their indications and maternal and fetal characteristics, collected from medical records. Elective inductions requested by women were identified from the mother's postpartum interviews. Polytomous logistic regression analysis was used to study the determinants of inductions that were or were not maternally requested. Women with spontaneous labour served as the comparison group.

MAIN OUTCOME MEASURE

Rate of elective inductions.

RESULTS

The induction rate was 22.6, 13.9% elective. Among elective inductions, 47.3% were requested by women. The characteristics of mothers, pregnancies, and maternity units were similar in both groups of elective inductions. The main associated factors were parity 2 or more [adjusted odds ratio (OR) 4.7, 95% confidence interval (CI) 3.1-7.2 for maternally requested inductions and aOR of 1.8 (95% CI1.2-2.7) for unrequested inductions, compared with parity 0] and private hospital status [aOR 4.5 95% (CI 3.3-6.0) for maternally requested inductions and aOR 3.7 (95% CI 2.8-4.9) for inductions not requested by the mother]. We found no association between maternal social characteristics and type of elective induction.

CONCLUSION

Parity and organisational factors appear to influence the decision about elective inductions. It would be interesting to determine how obstetricians and women make this decision and for what reasons.

TWEETABLE ABSTRACT

About 13.9% of inductions of labour were elective in France, 47.3% of these requested by women.

Special considerations--Induction of labor in low-resource settings

Induction of labor in resource-limited settings has the potential to significantly improve health outcomes for both mothers and infants. However, there are relatively little context-specific data to guide practice, and few specific guidelines. Also, there may be considerable issues regarding the facilities and organizational capacities necessary to support safe practices in many aspects of obstetrical practice, and for induction of labor in particular. Herein we describe the various opportunities as well as challenges presented by induction of labor in these settings.

Comparing vaginal misoprostol versus Foley catheter plus vaginal isosorbide mononitrate for labor induction

OBJECTIVE(S)

To compare the effectiveness and safety of intra-cervical Foley catheter combined with intra-vaginal isosorbide mononitrate (IMN) versus intra-vaginal misoprostol for cervical ripening and labor induction in pregnant women with unripe cervices.

METHODS

Open-labeled randomized controlled trial in Cairo university hospital, Cairo, Egypt during 2012-2014. Three hundred and ninety-five pregnant women at term or post-term with an indication for labor induction and unripe cervix were included in the study. The subjects were randomly divided into two groups. Vaginal misoprostol was used in group 1 (n = 197) and intra-cervical Foley catheter plus vaginal IMN in group 2 (n = 198). Our main outcome measure was cesarean section rate.

RESULTS

Among the 395 included patients there were significantly lower duration of induction of labor (p < 0.001) in group 1with lower cesarean section rates [22.8% in group 1versus 33.3% in group 2; RR 0.7 (0.6-0.9), (p = 0.020)]. Whereas the uterine hyperstimulation (p < 0.001) was significantly higher in group 1. There were no significant differences between both groups as regard patients' demographic characteristics.

CONCLUSIONS(S)

Vaginal misoprostol is more effective but less safe than Foley catheter combined with vaginal IMN for induction of labor in term and post-term pregnancy.

Factors associated with vaginal delivery in hypertensive and normotensive pregnant women submitted to labor induction with misoprostol: a cohort study

OBJECTIVE

To determine the factors associated with vaginal delivery in hypertensive and normotensive pregnant women submitted to induction of labor with misoprostol.

METHODS

A cohort study.

RESULTS

The factors associated with vaginal delivery in both normotensive and hypertensive women were, respectively, Bishop score ≥ 4 (OR = 1.87; 95% CI: 1.06-3.29; p = 0.03) and (OR = 2.31; 95% CI: 1.25-4.28; p = 0.008) and parity ≥ 1 (OR = 4.36; 95% CI: 2.16-8.80; p < 0.0001) and (OR = 2.61; 95% CI: 1.36-5.04; p = 0.004).

CONCLUSION

The factors associated with vaginal delivery were Bishop score ≥ 4 and parity ≥ 1 irrespective of whether or not the women were hypertensive.

Pharmacological Labor-Stimulating Agents and Neonatal Outcomes

This study examined the physiological and feeding outcomes of term neonates in relation to if they were delivered with pharmacological labor-stimulating agents or not. A retrospective chart review was conducted at a regional hospital. Infant and mother charts were selected from a 6-week timeframe. Descriptive and inferential statistics were used to analyze the 296 charts that were included. There were no statistically significant differences in physiological and feeding parameters of term neonates in relation to pharmacological labor-stimulating agents. The only significant difference found was that deliveries, which received no labor-stimulating agents, had higher rates of meconium staining.

Relation between induced labour indications and neonatal morbidity

PURPOSE

To assess the main neonatal morbidity results in relation to induced labour indications.

METHODS

Historical groups from a total of 3,817 deliveries over a three year period (2009, 2010 and 2011) in "Mancha-Centro" Hospital (Alcázar de San Juan) formed the study group. All programmed and non-avoidable caesarean sections and pregnancies under 35 weeks were excluded. The main variable result was a neonatal morbidity variable made up of the Apgar score after 5 min, pH of umbilical artery <7.10 and the neonatal need for resuscitation type III-V. Multivariate analysis was used to control confounding variables.

RESULTS

The incidence of induced labour was 22.6 % (862). The highest indication was premature rupture of membranes for more than 12 h 22.8 % (190), poorly controlled diabetes 22.6 % (189) and oligoamnios 16.2 % (135). The rate of pH lower than 7.10 was 2.8 % (22), the rate of the Apgar score lower than 7 after 5 min was 0.2 % (2) and the neonatal need for resuscitation type III-IV was 5.7 % (48) for induced labour. The relation between induced labour and neonatal morbidity indicators were not statistically significant. 10.1 % (4) of induced labour for suspected intrauterine growth restriction and 8.6 % (10) of postterm pregnancies required neonatal resuscitation type III-IV.

DISCUSSION

No relation was found between induced labour and the neonatal morbidity indicators. The highest neonatal risk indicator is when a intrauterine growth restriction, hypertensión/preeclampsia or a postterm pregnancy is suspected.

Patterns and Outcomes of Induction of Labour in Africa and Asia: a secondary analysis of the WHO Global Survey on Maternal and Neonatal Health

Background

Labour induction should be performed where benefit outweighs potential harm, however epidemiology of induction in lower-income countries is not well described. We used the WHO Global Survey dataset to describe the epidemiology and outcomes of labour induction in 192,538 deliveries in 253 facilities across 16 countries in Africa and Asia.

Methods

Data was analyzed separately for Africa and Asia. Prevalence of indications, methods, success and characteristics associated with labour induction were determined. Multilevel logistic regression was used to determine the relationship between induction (with medical indication and elective) and maternal/perinatal outcomes.

Results

Induction accounted for 4.4% (Africa) and 12.1% (Asia) of deliveries. Oxytocin alone was the most common method (45.9% and 37.5%) and success rates were generally over 80%. Medically indicated inductions were associated with increased adjusted odds of Apgar <7 at 5 minutes, low birthweight, NICU admission and fresh stillbirth in both regions. The odds of caesarean section in Africa were reduced (Adj OR 0.61, 95%CI 0.42–0.88). Elective induction was associated with increased adjusted odds of NICU (Africa) and ICU (Asia) admissions.

Discussion

Induction was generally less common than in higher-income countries. Prostaglandin use was uncommon despite evidence supporting use. Induction for medical indications may be associated with poorer outcomes due to maternal baseline risks. Despite one-third of elective inductions occurring at <39 weeks, the risk of maternal, fetal and neonatal mortality was not elevated following elective inductions.

Unmet need for induction of labor in Africa: secondary analysis from the 2004 - 2005 WHO Global Maternal and Perinatal Health Survey (A cross-sectional survey)

Background

Induction of labor is being increasingly used to prevent adverse outcomes in the mother and the newborn.This study assessed the prevalence of induction of labor and determinants of its use in Africa.

Methods

We performed secondary analysis of the WHO Global Survey of Maternal and Newborn Health of 2004 and 2005. The African database was analyzed to determine the use of induction of labor at the country level and indications for induction of labor. The un-met needs for specific obstetric indications and at country level were assessed. Determinants of use of induction of labor were explored with multivariate regression analysis.

Results

A total of 83,437 deliveries were recorded in the 7 participating countries. Average rate of induction was 4.4% with a range of 1.4 – 6.8%. Pre-labor rupture of membranes was the commonest indication for induction of labor. Two groups of women were identified: 2,776 women with indications had induction of labor while 7,996 women although had indications but labor was not induced.

Induction of labor was associated with reduction of stillbirths and perinatal deaths [OR – 0.34; 95% CI (0.27 – 0.43)].

Unmet need for induction of labor ranged between 66.0% and 80.2% across countries. Determinants of having an induction of labor were place of residence, duration of schooling, type of health facility and level of antenatal care.

Conclusion

Utilization of induction of labor in health facilities in Africa is very low. Improvements in social and health infrastructure are required to reverse the high unmet need for induction of labor.

Fatores associados à indução do parto em gestantes com óbito fetal após a 20ª semana

OBJETIVOS: determinar os fatores associados à indução do trabalho de parto em gestantes com óbito fetal. MÉTODOS: estudo seccional, com 258 gestantes após a 20ª semana e diagnóstico ultrassonográfico de óbito fetal, no período de janeiro/2005 a dezembro/2008, na maternidade do Hospital Barão de Lucena, Recife, Brasil. Características sociodemográficas, causas e tipos de óbito fetal, antecedentes obstétricos e características do parto foram variáveis estudadas. Foram utilizados testes qui-quadrado, exato de Fisher e "t" de Student. Razão de prevalência e análise de regressão logística múltipla também foram realizados. O nível de significância foi de 5%. RESULTADOS: a indução do parto ocorreu em 83 (32,2%) gestantes. Após análise multivariada, observou-se que a idade gestacional acima da 40ª semana de gravidez (OR= 126,5; IC95%= 3,83-4.201,5) e óbito fetal tardio (OR= 6,86; IC95%= 2,55-18,47) foram fatores de risco que permaneceram associados à indução do parto. Cesariana (OR= 0,02; IC95%= 0,004-0,09), funiculopatias (OR= 0,12; IC95%= 0,02-0,68), presença de uma ou menos gestações anteriores (OR= 0,34; IC95%= 0,14-0,81) e uma ou mais cesáreas anteriores (OR= 0,16; IC95%= 0,04-0,71) foram negativamente associados à indução. CONCLUSÕES: idade gestacional acima da 40ª semana e óbito fetal tardio são fatores de risco que podem estar associados à indução do parto em gestantes com óbito fetal.