Trends in induction of labour, 1998–2007: A population-based study

Induction of labor and cesarean birth in lower-risk nulliparous women at term: A retrospective cohort study

OBJECTIVE

To evaluate whether induction of labor (IOL) is associated with cesarean birth (CB) and perinatal mortality in uncomplicated first births at term compared with expectant management outside the confines of a randomized controlled trial.

METHODS

Population-based retrospective cohort study of all births in Victoria, Australia, from 2010 to 2018 (n = 640,191). Preliminary analysis compared IOL at 37 weeks with expectant management at that gestational age and beyond for uncomplicated pregnancies. Similar comparisons were made for IOL at 38, 39, 40, and 41 weeks of gestation and expectant management. The primary analysis repeated these comparisons, limiting the population to nulliparous women with uncomplicated pregnancies and excluding those with a medical indication for IOL. We compared perinatal mortality between groups using Chi-square tests and multivariable logistic regression for all other comparisons. Adjusted odds ratios and 99% confidence intervals were reported. p < 0.01 denoted statistical significance.

RESULTS

Among nulliparous, uncomplicated pregnancies at ≥37 weeks of gestation in Victoria, IOL increased from 24.6% in 2010 to 30.0% in 2018 (p < 0.001). In contrast to the preliminary analysis, the primary analysis showed that IOL in lower-risk nulliparous women was associated with increased odds of CB when performed at 38 (aOR 1.23(1.13-1.32)), 39 (aOR 1.31(1.23-1.40)), 40 (aOR 1.42(1.35-1.50)), and 41 weeks of gestation (aOR 1.43(1.35-1.51)). Perinatal mortality was rare in both groups and non-significantly lower in the induced group at most gestations.

DISCUSSION

For lower-risk nulliparous women, the odds of CB increased with IOL from 38 weeks of gestation, along with decreased odds of perinatal mortality at 41 weeks only.

Neonatal outcomes of elective labor induction in low-risk term pregnancies

The rate of labor induction has increased in recent years. The results of previously conducted studies examining associations between elective induction of labor (IOL) and neonatal outcomes have been contradictory. The aim of this study was to examine the intrinsic neonatal risks following IOL. We conducted a population-based cohort study, including all women with recorded low-risk singleton pregnancies at a gestational age between 37 + 0 and 41 + 6 weeks in Sweden from 1999 to 2017. Data were collected from the Swedish Medical Birth register. Two study groups were compared-the elective induction group with the spontaneous labor onset group. The results showed that the rate of elective IOL increased from 7.2% in 1999 to 16.4% in 2017. Elective IOL was associated with a higher OR for chorioamnionitis, bacterial sepsis, intracranial hemorrhage, assisted ventilation, hyperbilirubinemia, APGAR < 7 at 5 min, and neonatal seizures compared to deliveries with spontaneous labor onset. Regarding mortality outcomes, no significant differences were shown between the groups for either early term or full-term deliveries. We conclude that IOL is associated with neonatal complications, although causality could not be established in this observational study. It is important to be aware of the increased risk and perform IOL with caution.

The feto-placental metabolome of spontaneous labour is not reproduced following induction of labour

INTRODUCTION

The mechanism for human labour remains poorly understood, limiting our ability to manage complications including spontaneous preterm birth and induction of labour (IOL). The study of fetal signals poses specific challenges. Metabolomic analysis of maternal blood, the cord artery (CA), and cord vein (CV), allows simultaneous interrogation of multiple metabolic pathways associated with different modes of labour onset and birth.

METHODS

Global mass spectrometry metabolomics analysis was performed on serial samples collected from participants during pregnancy, in latent phase of labour, and following birth (CA, CV, and intervillous (IV) blood), from those who spontaneously laboured and birthed vaginally (SL group), had IOL and birthed vaginally (IOL group), or birthed via elective caesarean section (no labour; ECS group).

RESULTS

There were clear differences in fetal and maternal steroid, arachidonate and sphingosine pathways between the SL and IOL groups, despite similar uterine contractions and vaginal birth. The CA/CV ratio for key steroids of the IOL group were more alike the ECS group than the SL group, including progesterone (CA/CV ratio for: SL group=3.5; IOL group=0.5; and ECS group=0.5), and oestriol (CA/CV ratio for: SL group=4.3; IOL group=0.4; and for ECS group=0.2). There were no such changes in the maternal samples.

DISCUSSION

These findings indicate that IOL does not reproduce the pathways activated in spontaneous labour. The decreased placental progesterone production observed with spontaneous labour may represent a local intrauterine progesterone withdrawal, which, together with other signals, would activate parturition pathways involving arachidonate and sphingosine metabolism.

Labor induction in China: a nationwide survey

BACKGROUND

Overmedicalization in labor management and delivery, including labor induction, is an increasing global concern. But detailed epidemiological data on labor induction in China remains unclear.

METHODS

This was a cross-sectional study of data (2015-2016) from 96 hospitals in 24 (of 34) Chinese administrative divisions. Multivariable logistic regression analysis was used to assess the association between medical conditions and cesarean delivery among women undergoing induction. Linear regression analysis was performed to assess the association between the prelabor cesarean delivery and labor-induction rates in each hospital. The impacts of labor induction and prelabor cesarean delivery on maternal and neonatal outcomes were compared in low-risk women.

RESULTS

Among 73 901 eligible participants, 48.1% were nulliparous. The overall weighted rate of labor induction in China was 14.2% (95% CI, 11.1-17.2%), with 18.4% (95% CI, 14.5-22.3%) in nulliparas and 10.2% (95% CI, 7.7-12.8%) in multiparas. Regardless of the induction method, the overall vaginal delivery rate was 72.9% (95% CI, 68.6-77.3%) in nulliparas and 86.6% (95% CI, 79.7-93.5%) in multiparas. Hospitals with a higher rate of nonmedically indicated cesarean delivery had a lower labor-induction rate in nulliparas (β =  - 0.57%; 95% CI, - 0.92 to - 0.22%; P = 0.002). Compared with prelabor cesarean delivery, labor induction in low-risk women was not associated with adverse maternal and neonatal outcomes.

CONCLUSION

The 2015-2016 labor-induction rate in China was 18.4% in nulliparas and 10.2% in multiparas. The proportion of prelabor cesarean delivery may contribute to regional differences in the labor-induction rate. Compared with prelabor cesarean delivery, labor induction in low-risk women may not increase severe maternal and neonatal morbidity.

Labour induction in twin pregnancies

Medically-indicated deliveries are common in twin pregnancies given the increased risk of various obstetric complications in twin compared to singleton pregnancies, mainly hypertensive disorders of pregnancy and foetal growth restriction. Due to the unique characteristics of twin pregnancies, the success rates and safety of labour induction may be different than in singleton pregnancies. However, while there are abundant data regarding induction of labour in singleton pregnancies, the efficacy and safety of labour induction in twin pregnancies have been far less studied. In the current manuscript we summarize available data on various aspects of labour induction in twin pregnancies including incidence, success rate, prognostic factors, safety and methods for labour induction in twins. This information may assist healthcare providers in counselling patients with twin pregnancies when labour induction is indicated.

How much synthetic oxytocin is infused during labour? A review and analysis of regimens used in 12 countries

Objective

To compare synthetic oxytocin infusion regimens used during labour, calculate the International Units (IU) escalation rate and total amount of IU infused over eight hours.

Design

Observational study

Setting

Twelve countries, eleven European and South Africa.

Sample

National, regional or institutional-level regimens on oxytocin for induction and augmentation labour

Methods

Data on oxytocin IU dose, infusion fluid amount, start dose, escalation rate and maximum dose were collected. Values for each regimen were converted to IU in 1000ml diluent. One IU corresponded to 1.67μg for doses provided in grams/micrograms. IU hourly dose increase rates were based on escalation frequency. Cumulative doses and total IU amount infused were calculated by adding the dose administered for each previous hour. Main Outcome Measures Oxytocin IU dose infused

Results

Data were obtained on 21 regimens used in 12 countries. Details on the start dose, escalation interval, escalation rate and maximum dose infused were available from 16 regimens. Starting rates varied from 0.06 IU/hour to 0.90 IU/hour, and the maximum dose rate varied from 0.90 IU/hour to 3.60 IU/hour. The total amount of IU oxytocin infused, estimated over eight hours, ranged from 2.38 IU to 27.00 IU, a variation of 24.62 IU and an 11-fold difference.

Conclusion

Current variations in oxytocin regimens for induction and augmentation of labour are inexplicable. It is crucial that the appropriate minimum infusion regimen is administered because synthetic oxytocin is a potentially harmful medication with serious consequences for women and babies when inappropriately used. Estimating the total amount of oxytocin IU received by labouring women, alongside the institution’s mode of birth and neonatal outcomes, may deepen our understanding and be the way forward to identifying the optimal infusion regimen.

Oxytocin induced labor causes region and sex-specific transient oligodendrocyte cell death in neonatal mouse brain

AIM

Previous reports showed associations between oxytocin induced labor and mental disorders in offspring. However, those reports are restricted in epidemiological analyses and its mechanism remains unclear. In this study, we hypothesized that induced labor directly causes brain damage in newborns and results in the development of mental disorders. Therefore we aimed to investigate this hypothesis with animal model.

METHODS

The animal model of induced labor was established by subcutaneous oxytocin administration to term-pregnant C57BL/6J mice. We investigated the neonatal brain damage with evaluating immediate early gene expression (c-Fos, c-Jun and JunB) by quantitative polymerase reaction and TdT-mediated dUTP nick end labeling staining. To investigate the injured brain cell types, we performed double-immunostaining with TdT-mediated dUTP nick end labeling staining and each brain component specific protein, such as Oligo2, NeuN, GFAP and Iba1.

RESULTS

Brain damage during induced labor led to cell death in specific brain regions, which are implicated in mental disorders, in only male offspring at P0. Furthermore, oligodendrocyte precursors were selectively vulnerable compared to the other cell types. This oligodendrocyte-specific impairment during the perinatal period led to an increased numbers of Olig2-positive cells at P5. Expression levels of oxytocin and Oxtr in the fetal brain were not affected by the oxytocin administered to mothers during induced labor.

CONCLUSION

Oligodendrocyte cell death in specific brain regions, which was unrelated to the oxytocin itself, was caused by induced labor in only male offspring. This may be an underlying mechanism explaining the human epidemiological data suggesting an association between induced labor and mental disorders.

Safety and efficacy of mifepristone versus dinoprostone gel in induction of labor: A randomized controlled trial

AIM

The aim of this study was to evaluate the efficacy and safety of mifepristone for cervical ripening and induction of labor and compare the results with dinoprostone gel which is an established agent for labor induction.

METHODS

A total of 100 patients were enrolled in a prospective study and assigned to one of two treatment protocols. After the exclusion of 10 patients, there were 46 patients in the mifepristone group and 44 in the dinoprostone group. Outcome was evaluated using the improvement in Bishop score, admission delivery interval, duration between induction and the onset of active phase of labor and the mode of delivery.

RESULTS

The baseline demographics in the two groups were comparable. The improvement in Bishop's score at first post-intervention assessment was significantly better in dinoprostone group. Duration between instillation and active phase assessment was significantly lesser in dinoprostone group while the admission delivery interval was lesser in mifepristone group. There was no difference in mode of delivery between the two groups.

CONCLUSION

The results of the study suggest that oral administration of 200 mg mifepristone in term patients is an effective method of labor induction; and is more convenient and equally safe as compared to intravaginal instillation of dinoprostone.

Metabolite Changes in Maternal and Fetal Plasma Following Spontaneous Labour at Term in Humans Using Untargeted Metabolomics Analysis: A Pilot Study

The mechanism of human labour remains poorly understood, limiting our ability to manage complications of parturition such as preterm labour and induction of labour. In this study we have investigated the effect of labour on plasma metabolites immediately following delivery, comparing cord and maternal plasma taken from women who laboured spontaneously and delivered vaginally with women who were delivered via elective caesarean section and did not labour. Samples were analysed using ultra high-performance liquid chromatography-tandem mass spectrometry. Welch’s two-sample t-test was used to identify any significant differences. Of 826 metabolites measured, 26.9% (222/826) were significantly altered in maternal plasma and 21.1% (174/826) in cord plasma. Labour involves changes in many maternal organs and poses acute metabolic demands in the uterus and in the fetus and these are reflected in our results. While a proportion of these differences are likely to be secondary to the physiological demands of labour itself, these results present a comprehensive picture of the metabolome in the maternal and fetal circulations at the time of delivery and can be used to guide future studies. We discuss potential causal pathways for labour including endocannabinoids, ceramides, sphingolipids and steroids. Further work is necessary to confirm the specific pathways involved in the spontaneous onset of labour.

Obstetric interventions, trends, and drivers of change: A 20-year population-based study from Iceland

BACKGROUND

Population data on obstetric interventions is often limited to cesarean delivery. We aimed to provide a more comprehensive overview of trends in use of several common obstetric interventions over the past 2 decades.

METHODS

The study was based on nationwide data from the Icelandic Medical Birth Register. Incidence of labor induction, epidural analgesia, cesarean, and instrumental delivery was calculated for all births in 1995-2014. Change over time was expressed as relative risk (RR), using Poisson regression with 95% confidence intervals (CI) adjusted for several maternal and pregnancy-related characteristics. Analyses were stratified by women's parity and diagnosis of diabetes or hypertensive disorder.

RESULTS

During the study period, there were 81 389 intended vaginal births and 5544 elective cesarean deliveries. Among both primiparous and multiparous women, we observed a marked increase across time for labor induction (RR 1.78 [CI 1.67-1.91] and RR 1.83 [CI 1.73-1.93], respectively) and epidural analgesia (RR 1.40 [CI 1.36-1.45] and RR 1.74 [CI 1.66-1.83], respectively). A similar trend of smaller magnitude was observed among women with hypertensive disorders but no time trend was observed among women with diabetes. Incidence of cesarean and instrumental delivery remained stable across time.

DISCUSSION

The use of labor induction and epidural analgesia increased considerably over time, while the cesarean delivery rate remained low and stable. Increases in labor induction and epidural analgesia were most pronounced for women without a diagnosis of diabetes or hypertensive disorder and were not explained by maternal characteristics such as advanced age.

Elective induction of labor: A prospective observational study

The aim of the present study was to assess indications for induction and describe the characteristics and delivery outcome in medical compared to non-medical/elective inductions. During a three-month period, 1663 term inductions were registered in 24 delivery units in Norway. Inclusion criteria were singleton pregnancies with cephalic presentation at gestational age 37⁺⁰ and beyond. Indications, pre-induction Bishop scores, mode of delivery and adverse maternal and fetal outcomes were registered, and compared between the medically indicated and elective induction groups. Ten percent of the inductions were elective, and the four most common indications were maternal request (35%), a previous negative delivery experience or difficult obstetric history (19%), maternal fatigue/tiredness (17%) and anxiety (15%). Nearly half of these inductions were performed at 39⁺⁰–40⁺⁶ weeks. There were fewer nulliparous women in the elective compared to the medically indicated induction group, 16% vs. 52% (p<0.05). The cesarean section rate in the elective induction group was 14% and 17% in the medically indicated group (14% vs. 17%, OR = 0.8, 95% CI 0.5–1.3). We found that one in ten inductions in Norway is performed without a strict medical indication and 86% of these inductions resulted in vaginal delivery.

Risk Factors for Brachial Plexus Birth Injury

Over the course of decades, the incidence of brachial plexus birth injury (BPBI) has increased despite advances in healthcare which would seem to assist in decreasing the rate. The aim of this study is to identify previously unknown risk factors for BPBI and the risk factors with potential to guide preventative measures. A case control study of 52 mothers who had delivered a child with a BPBI injury and 132 mothers who had delivered without BPBI injury was conducted. Univariate, multivariable and logistic regressions identified risk factors and their combinations. The odds of BPBI were 2.5 times higher when oxytocin was used and 3.7 times higher when tachysystole occurred. The odds of BPBI injury are increased when tachysystole and oxytocin occur during the mother's labor. Logistic regression identified a higher risk for BPBI when more than three of the following variables (>30 lbs gained during the pregnancy, stage 2 labor >61.5 min, mother's age >26.4 years, tachysystole, or fetal malpresentation) were present in any combination.

Assessing the Accuracy of Reporting of Maternal Red Blood Cell Transfusion at Birth Reported in Routinely Collected Hospital Data

Introduction Hospital administrative data collections have been used to describe transfusion practice, particularly in relation to the maternity population. Knowledge of the accuracy of this data is important in order to interpret the results of such studies. The aim of this study was to compare the accuracy of reporting of red cell transfusion around childbirth within hospital data with data submitted by hospital blood banks. Methods Linked hospital and birth data from New South Wales, Australia, between June 2006 and December 2010 were used to identify blood transfusions occurring at delivery. This reporting was compared with the gold standard of blood pack level information submitted by hospital blood banks, and sensitivity, specificity, and positive and negative predictive values calculated. Reporting related to quantity and timing of transfusion were also considered. Results Data were available for 235,796 births, with blood bank data identifying that 2.0 % of received a blood transfusion. Overall the sensitivity of hospital data for identifying transfusion was 84.8 % (95 % CI 83.7 %, 85.8 %) with specificity 99.9 % (99.9 %, 99.9 %). Sensitivity was better for births involving a postpartum haemorrhage [Sn 90.9 % (89.9 %, 91.9 %)], and poorer for births in regional hospitals [Sn 78.8 % (76.0 %, 81.5 %)]. Almost all (96 %) transfusions of 10 or more units were identified in hospital data, and there was no difference in reporting depending on whether the transfusion was on the baby's date of birth or not. Discussion The reliability of hospital reporting of transfusion in maternity patients is high, however with some underreporting of cases.

Comparison of readmission rates between groups with early versus late discharge after vaginal or cesarean delivery: a retrospective analyzes of 14,460 cases

AIM

The aim of this retrospective analysis was to show the readmission rate of cases with and without early discharge following vaginal or cesarean delivery.

METHODS

After exclusion of cases with pregnancy, delivery and neonatal complications, a total of 14,460 cases who delivered at Zeynep Kamil Women and Children's Health Training and Research Hospital were retrospectively screened from hospital database. Subjects were divided into two groups as Group 1: early discharge (n = 6802) and Group 2: late discharge (n = 7658). Groups were compared in terms of readmission rates and indications for readmission.

RESULTS

There were 6802 cases with early discharge whereas the remaining women were discharged after 24 h for vaginal delivery and 48 h following cesarean delivery on regular bases. Among cases with early discharge, 205 (3%) cases readmitted to emergency service with variable indications, while there were 216 (2.8%) readmitted women who were discharged on regular bases. Most common indication for readmission was wound infection in both groups. Neonatal sex distributions were similar between groups (p > .05), where as there was a higher rate of cesarean deliveries in Group 2 (p < .05). Furthermore, cesarean rate was significantly higher in readmitted women with early discharge (p < .05).

CONCLUSION

Similar readmission rates were observed in groups with early and late discharges following vaginal or cesarean delivery without any mortality or permanent morbidity and cost analyses revealed 68 Turkish liras lower cost with early discharge.

Factors associated with cesarean delivery during labor in primiparous women assisted in the Brazilian Public Health System: data from a National Survey

BACKGROUND

The rate of cesarean delivery (CD) in Brazil has increased over the past 40 years. The CD rate in public services is three times above the World Health Organization recommended values. Among strategies to reduce CD, the most important is reduction of primary cesarean. This study aimed to describe factors associated with CD during labor in primiparous women with a single cephalic pregnancy assisted in the Brazilian Public Health System (SUS).

METHODS

This study is part of the Birth in Brazil survey, a national hospital-based study of 23,894 postpartum women and their newborns. The rate of CD in primiparous women was estimated. Univariate and multivariable logistic regression was performed to analyze factors associated with CD during labor in primiparous women with a single cephalic pregnancy, including estimation of crude and adjusted odds ratios and their respective 95 % confidence intervals.

RESULTS

The analyzed data are related to the 2814 eligible primiparous women who had vaginal birth or CD during labor in SUS hospitals. In adjusted analyses, residing in the Southeast region was associated with lower CD during labor. Occurrence of clinical and obstetric conditions potentially related to obstetric emergencies before delivery, early admission with < 4 cm of dilatation, a decision late in pregnancy for CD, and the use of analgesia were associated with a greater risk for CD. Favorable advice for vaginal birth during antenatal care, induction of labor, and the use of any good practices during labor were protective factors for CD. The type of professional who attended birth was not significant in the final analyses, but bivariate analysis showed a higher use of good practices and a smaller proportion of epidural analgesia in women cared for by at least one nurse midwife.

CONCLUSIONS

The CD rate in primiparous women in SUS in Brazil is extremely high and can compromise the health of these women and their newborns. Information and support for vaginal birth during antenatal care, avoiding early admission, and promoting the use of good practices during labor assistance can reduce unnecessary CD. Considering the experience of other countries, incorporation of nurse midwives in childbirth care may increase the use of good practices during labor.

Induction of labour for postdates in nulliparous women with uncomplicated pregnancy - is the caesarean section rate really lower?

Induction for "post-dates" is a very common procedure and in Queensland, Australia, accounts for 35.5% of all inductions. Systematic reviews all conclude that induction of labour does not increase the risk of caesarean section (CS). However, these reviews have generally included a mixed population and have not stratified for parity. We report in a retrospective cohort study involving only nulliparous women with uncomplicated singleton pregnancy at 40° to 41⁶ weeks that compared to spontaneous labour, incidence of CS was significantly higher in the induction group, 22.2% versus 12.1% (OR 2.06; 95% CI 1.93-2.20) at 40° to 41⁶ weeks versus spontaneous labour at 40° to 41⁶ weeks; and also higher at 21.0% versus 14.9% (OR 1.52; 95% CI 1.34-1.73) at 40° to 40⁶ weeks versus spontaneous labour at 41° to 41⁶ weeks (expectant management).

Variation in induction of labour rates across Irish hospitals; a cross-sectional study

BACKGROUND

In developed countries, rates of induction of labour (IOL) have increased and vary between hospitals. We aimed to identify whether national variations could be explained by sociodemographic, clinical and organisational differences.

METHODS

Two national databases in Ireland that routinely collect clinical and administrative data, the National Perinatal Reporting System and the Hospital Inpatient Enquiry Scheme, were used to analyse data for all women with singleton births weighing ≥500 g in 2009. We used logistic multilevel models to examine variation between hospitals, and to determine how much variation was due to individual level sociodemographic, clinical and organisational variables. Analyses were stratified for nulliparas, multiparas without prior caesarean section (CS) and multiparas with prior CS.

RESULTS

Of 69 304 eligible births, the rate of IOL nationally was 25.0% (range 14.5-33.2%).In nulliparas, the mean rate was 30.9% (range 18.6-45.7%). The rate was 24.8% (13.5-33.3%) and 3.8% (0.0-10.2%) for multiparas without and with prior CS, respectively. In nulliparas and multiparas without prior CS IOL was predicted by maternal birth in Ireland, increasing birthweight, antepartum complications, giving birth on a weekday and the model of obstetric care. Even after adjusting for known sociodemographic and clinical variables, variation between hospitals remained.

CONCLUSION

We found that clinical, sociodemographic and organisational factors all contributed to variation. However, unexplained variation persisted possibly due to organisational factors such as hospital-specific policies on IOL. The results indicate that the prevalence of antenatal complications, changing immigration patterns and policies on IOL after previous CS are factors likely to influence future IOL rates.

A retrospective population-based study of induction of labour trends and associated factors among aboriginal and non-aboriginal mothers in the northern territory between 2001 and 2012

Background

Induction of labour (IOL) has become more common among many populations, but the trends and drivers of IOL in the Northern Territory (NT) of Australia are not known. This study investigated trends in IOL and associated factors among NT Aboriginal and non-Aboriginal mothers between 2001 and 2012.

Methods

A retrospective analysis of all NT resident women who birthed in the NT between 2001 and 2012 at ≥32 weeks gestation. Demographic, medical and obstetric data were obtained from the NT Midwives’ Collection. The prevalence of IOL was calculated by Aboriginal status and parity of the mother and year of birth. The prevalence of each main indication for induction among women was compared for 2001–2003 and 2010–2012. Linear and logistic regression was used to test for association between predictive factors and IOL in bivariate and multivariate analysis, separately for Aboriginal and non-Aboriginal mothers.

Results

A total of 42,765 eligible births between 2001 and 2012 were included. IOL was less common for Aboriginal than non-Aboriginal mothers in 2001 (18.0 % and 25.1 %, respectively), but increased to be similar to non-Aboriginal mothers in 2012 (22.6 % and 24.8 %, respectively). Aboriginal primiparous mothers demonstrated the greatest increase in IOL. The most common indication for IOL for both groups was post-dates, which changed little over time. Medical and obstetric complications were more common for Aboriginal mothers except late-term pregnancy. Prevalence of diabetes in pregnancy increased considerably among both Aboriginal and non-Aboriginal mothers, but was responsible for only a small proportion of IOLs. Increasing prevalence of risk factors did not explain the increased IOL prevalence for Aboriginal mothers.

Conclusions

IOL is now as common for Aboriginal as non-Aboriginal mothers, though their demographic, medical and obstetric profiles are markedly different. Medical indications did not explain the recent increase in IOL among Aboriginal mothers; changes in maternal or clinical decision-making may have been involved.

The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth

BACKGROUND

Intrapartum drugs, including fentanyl administered via epidural and synthetic oxytocin, have been previously studied in relation to neonatal outcomes, especially breastfeeding, with conflicting results. We examined the normal neonatal behavior of suckling within the first hour after a vaginal birth while in skin-to-skin contact with mother in relation to these commonly used drugs. Suckling in the first hour after birth has been shown in other studies to increase desirable breastfeeding outcomes.

METHOD

Prospective comparative design. Sixty-three low-risk mothers self-selected to labor with intrapartum analgesia/anesthesia or not. Video recordings of infants during the first hour after birth while being held skin-to-skin with their mother were coded and analyzed to ascertain whether or not they achieved Stage 8 (suckling) of Widström's 9 Stages of newborn behavior during the first hour after birth.

RESULTS

A strong inverse correlation was found between the amount and duration of exposure to epidural fentanyl and the amount of synthetic oxytocin against the likelihood of achieving suckling during the first hour after a vaginal birth.

CONCLUSIONS

Results suggest that intrapartum exposure to the drugs fentanyl and synthetic oxytocin significantly decreased the likelihood of the baby suckling while skin-to-skin with its mother during the first hour after birth.

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.

Labour and delivery interventions in women with intellectual and developmental disabilities: a population-based cohort study

BACKGROUND

Our objectives were to: (1) examine the occurrence of labour induction, caesarean section, and operative vaginal delivery in women with intellectual and developmental disabilities compared to those without and (2) determine whether pre-pregnancy health conditions and pregnancy complications explain any elevated occurrence of these interventions.

METHODS

We conducted a population-based study using linked Ontario (Canada) administrative data. We identified deliveries to women with (N=3932) and without (N=382,774) intellectual and developmental disabilities (2002-2011). Modified Poisson regression was used to estimate adjusted relative risks (aRR) and 95% CIs for interventions, controlling for sociodemographic characteristics. We used generalised estimating equations to determine whether pre-pregnancy health conditions and pregnancy complications explained any statistically significantly elevated aRRs.

RESULTS

After controlling for socio-demographic characteristics, women with intellectual and developmental disabilities were more likely to have labour inductions (aRR, 1.13; 95% CI 1.06 to 1.20) and caesarean sections (aRR, 1.09; 95% CI 1.03 to 1.16) but not operative vaginal deliveries, compared to the referent group. Pre-pregnancy health conditions explained 12.9% of their elevated aRR for labour induction. Pre-pregnancy health conditions and maternal complications explained 27.8% and 13.3%, respectively, of their elevated aRR for caesarean section.

CONCLUSIONS

Women with intellectual and developmental disabilities are slightly more likely to have labour inductions and caesarean sections than women without intellectual and developmental disabilities. The elevated occurrence of these interventions is not fully explained by their pre-pregnancy health conditions or pregnancy complications. Non-medical issues should be evaluated for their influence on the timing of labour and delivery in this population.

Increased planned delivery contributes to declining rates of pregnancy hypertension in Australia: a population-based record linkage study

OBJECTIVE

Since the 1990s, pregnancy hypertension rates have declined in some countries, but not all. Increasing rates of early planned delivery (before the due date) have been hypothesised as the reason for the decline. The aim of this study was to explore whether early planned delivery can partly explain the declining pregnancy hypertension rates in Australia.

DESIGN

Population-based record linkage study utilising linked birth and hospital records.

SETTING AND PARTICIPANTS

A cohort of 1,076,122 deliveries in New South Wales, Australia, 2001-2012.

OUTCOME MEASURES

Pregnancy hypertension (including gestational hypertension, pre-eclampsia and eclampsia) was the main outcome; pre-eclampsia was a secondary outcome.

RESULTS

From 2001 to 2012, pregnancy hypertension rates declined by 22%, from 9.9% to 7.7%, and pre-eclampsia by 27%, from 3.3% to 2.4% (trend p<0.0001). At the same time, planned deliveries increased: prelabour caesarean section by 43% (12.9-18.4%) and labour inductions by 10% (24.8-27.2%). Many maternal risk factors for pregnancy hypertension significantly increased (p<0.01) over the study period including nulliparity, age ≥35 years, diabetes, overweight and obesity, and use of assisted reproductive technologies; some risk factors decreased including multifetal pregnancies, age <20 years, autoimmune diseases and previous pregnancy hypertension. Given these changes in risk factors, the pregnancy hypertension rate was predicted to increase to 10.5%. Examination of annual gestational age distributions showed that pregnancy hypertension rates actually declined from 38 weeks gestation and were steepest from 41 weeks; at least 36% of the decrease could be attributed to planned deliveries. The risk factors for pregnancy hypertension were also risk factors for planned delivery.

CONCLUSIONS

It appears that an unanticipated consequence of increasing early planned deliveries is a decline in the incidence of pregnancy hypertension. Women with risk factors for hypertension were relatively more likely to be selected for early delivery.

A novel misoprostol delivery system for induction of labor: clinical utility and patient considerations

Induction of labor is one of the most commonly performed obstetric procedures and will likely become more common as the reproductive population in developed nations changes. As the proportion of women undergoing induction grows, there is a constant search for more efficacious ways to induce labor while maintaining fetal and maternal safety as well as patient satisfaction. With almost half of induced labors requiring cervical ripening, methods for achieving active labor and vaginal delivery are constantly being investigated. Prostaglandins have been shown to be effective induction agents, and specifically vaginal misoprostol, used off-label, have been widely utilized to initiate cervical ripening and active labor. The challenge is to administer this medication accurately while maintaining the ability to discontinue the medication when needed. The misoprostol vaginal insert initiates cervical ripening utilizing a delivery system that controls medication release and can be rapidly removed. This paper reviews the design, development, and clinical utility of the misoprostol vaginal insert for induction of labor as well as patient considerations related to the delivery system.

Perinatal oxytocin increases the risk of offspring bipolar disorder and childhood cognitive impairment

BACKGROUND

We tested the hypothesis that perinatal oxytocin, given to pregnant women to induce labor, is related to offspring bipolar disorder (BP) and worse childhood cognitive performance among offspring. We also tested the association between childhood cognition and later BP.

METHODS

A population-based birth cohort derived from the Child Health and Development Study (CHDS) which included nearly all pregnant women receiving obstetric care from the Kaiser Permanente Medical Care Plan, Northern California Region (KPNC) between 1959 and 1966. Prospectively obtained medical and offspring cognitive performance were used. Potential cases with BP from the cohort were identified by database linkages. This protocol identified 94 cases who were matched 1:8 to controls.

RESULTS

Perinatal oxytocin was associated with a 2.4 times increased odds of later BP. Oxytocin was also associated with decreased performance on the Raven Matrices, but not on the Peabody Picture Vocabulary Test (PPVT). Childhood cognition was not associated with later BP.

LIMITATIONS

Loss to follow-up must be considered in all birth cohort studies. In addition, the childhood cognitive battery did not include tests related to multiple domains of cognition which have been associated with later BP. A third limitation is the modest sample size of those exposed to oxytocin.

CONCLUSIONS

This study provides evidence for a potentially important perinatal risk factor for BP and cognitive impairment in childhood. While the association between perinatal oxytocin and offspring BP must be viewed cautiously until further studies can attempt to replicate the result, it lends support to the broader view that neurodevelopmental factors contribute to BP.

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.

Epidemiologic considerations: scope of problem and disparity concerns

Elective labor induction is an increasingly common practice not only in high-income countries but also in many low-income and middle-income countries. Many questions remain unanswered on the safety and cost-effectiveness of elective labor induction, particularly in resource-constrained settings wherein there may be a high unmet need for medically indicated inductions, as well as limited or no access to appropriate medications and equipment for induction and monitoring, comprehensive emergency obstetric care, safe, and timely cesarean section, and appropriate supervision from health professionals. This article considers the global perspective on the epidemiology, practices, safety, and costs associated with elective labor induction.

Timing of delivery in women with diabetes in pregnancy

The incidence of both gestational and pre-gestational diabetes is increasing worldwide. The main cause of this increase is likely the concomitant increase in the incidence of global obesity, but in the case of gestational diabetes, changes in the diagnostic criteria are also a contributing factor. The adverse outcomes associated with pre-gestational diabetes are well known and have led clinicians to implement various strategies that include increased fetal surveillance and induction of labour at various gestational ages. In many cases these same strategies have been applied in clinical practice also to women with gestational diabetes despite there being differences in the type and magnitude of perinatal complications associated with this diagnosis. Despite the widespread application of these clinical practices, there is a paucity of quality data in the medical literature to guide the clinician in choosing a strategy for fetal surveillance and timing of delivery in both gestational diabetes and pre-gestational diabetes pregnancies. In the following review, we will discuss the rationale and consequences of planned delivery in gestational diabetes and pre-gestational diabetes, the evidence supporting different strategies for delivery and finally highlight future targets for research in this area.

Obstetric outcome and significance of labour induction in a health resource poor setting

Objectives. The aim of this study was to evaluate the methods, indications, outcome of induced labor and its significance in obstetric practice in the study area. Methods. This was a retrospective study of cases of induced labor at the Catholic Maternity Hospital in Ogoja, Cross-River State, Nigeria, between January 1, 2002, and December 31, 2011. Data on the sociodemographic characteristics of the parturient, induction methods, indications for induction, outcomes and reasons for failed induction were abstracted from personal case files and the hospital's maternity/delivery register. The data were analyzed with SPSS15.0 window version. Result. The induction rate in this study was 11.5%. Induction was successful in 75.9% of cases but failed in 24.1%. Misoprostol was the commonest induction method (78.2%). The commonest indication for induction was postdate pregnancy (45.8%). Failed induction was due to fetal distress, prolonged labor, cephalopelvic disproportion and cord prolapse. The induction-delivery interval was 12 ± 3.6 hours. Conclusion. Induction of labor is a common obstetric procedure which is safe and beneficial in well-selected and properly monitored high risk pregnancies where the benefits of early delivery outweigh the risk of continuing the pregnancy.

What started your labor? Responses from mothers in the third pregnancy, infection, and nutrition study

Many behaviors and substances have been purported to induce labor. Using data from the Third Pregnancy, Infection, and Nutrition cohort, we focus on 663 women who experienced spontaneous labor. Of the women who reported a specific labor trigger, 32% reported physical activity (usually walking), 24% a clinician-mediated trigger, 19% a natural phenomenon, 14% some other physical trigger (including sexual activity), 12% reported ingesting something, 12% an emotional trigger, and 7% maternal illness. With the exceptions of walking and sexual intercourse, few women reported any one specific trigger, although various foods/substances were listed in the "ingesting something" category. Discussion of potential risks associated with "old wives' tale" ways to induce labor may be warranted as women approach term.

Maternal and neonatal outcomes following additional doses of vaginal prostaglandin E2 for induction of labour: a retrospective cohort study

OBJECTIVE

To assess maternal and neonatal outcomes following the use of additional doses of vaginal prostaglandins (PGE2) above the recommended dose for induction of labour in post-dates pregnancies.

STUDY DESIGN

Retrospective cohort study set in Aberdeen Maternity Hospital, Aberdeen, UK. A total of 3514 nulliparous women with labour induced with vaginal PGE2 (3mg tablet or 2mg gel) for a post-dates singleton pregnancy from January 1994 to December 2009 were included. Women receiving≤2 doses of PGE2 were compared with those receiving>2 doses (maximum 5 doses). Binary logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals (CI). Primary outcomes included mode of delivery, terbutaline use, indication for CS, postpartum haemorrhage, neonatal unit admission, and Apgar score<7. A further analysis was conducted which stratified for number of doses of PGE2 given.

RESULTS

Of the 3514 women who met inclusion criteria, 605 (17%) received PGE2 that exceeded the licensed dose. They were more likely to deliver by caesarean section (53.4% vs. 31.8%, OR 2.2, 95% CI 1.8-2.6), have a caesarean section for 'failed' induction of labour (11.4% vs. 1.9%, OR 4.1, 95% CI 1.3-13.2) or lack of progress in labour (37% vs. 17%, OR 2.8, 95% CI 2.3-3.4), but not for fetal concerns (8.2% vs. 8.8% OR 0.9, 95% CI 0.7-1.3). Terbutaline use and postpartum haemorrhage was no more likely (0.7% vs. 0.9% OR 0.6 95% CI 0.3-1.5 and 19.8% vs. 18.9% OR1.01, 95% CI 0.97-1.06 respectively). Apgar score<7 (1.1% vs. 1.3% OR 0.9 95% CI 0.8-1.1) and neonatal unit admission (13.7% vs. 10.7% OR 1.2 95% CI 0.8-1.6) were similar in both groups.

CONCLUSION

The use of additional doses of vaginal PGE2 above the recommended dose for induction of labour was not associated with increased maternal or neonatal morbidity and almost half of these women achieved a vaginal delivery.

Women's experience of induction of labor: a mixed methods study

OBJECTIVE

To investigate women's experience of induction of labor.

DESIGN

Mixed methods study.

SETTING

English maternity units.

SAMPLE

Women who gave birth in a two-week period in late 2009, excluding women aged less than 16 years and women whose baby had died.

METHODS

This study involved secondary analysis of data from questionnaires relating to care in childbirth. Women's experience of induction of labor was compared with that of women who had spontaneous labor by analysis of responses to structured survey questions. Responses to open questions relating to induction were analysed qualitatively.

MAIN OUTCOME MEASURES

Satisfaction with care, mode of delivery, experience of induction of labor.

RESULTS

The response rate to the survey was 55.1% representing 5333 women, 20% of whom were induced. Nulliparous women, those with long-term health problems, or specific pregnancy-related problems were significantly more likely to be induced. Women who were induced were generally less satisfied with aspects of their care and significantly less likely to have a normal delivery. In the qualitative analysis the main themes that emerged concerned delay, staff shortages, neglect, pain and anxiety in relation to getting the induction started and once it was underway; and in relation to failed induction, the main themes were plans not being followed, wasted effort and pain, and feeling let down and disappointed.

CONCLUSIONS

Women having an induction were generally less satisfied with their care, suggesting the need for a focused service for these women to address their additional needs.

Is induction of labor risky for twins compare to singleton pregnancies?

OBJECTIVE

The aim of this study was to investigate whether induction of labor in twin pregnancies is associated with higher rates of maternal complications as compared to singletons.

METHOD

A retrospective population-based study was conducted to compare maternal complications following induction of labor in twin pregnancies and singletons at Soroka University Medical Center, Be'er-Sheva, Israel, between 1988 and 2010. Stratified analysis using a multiple logistic regression model was performed to control for confounders.

RESULTS

The study population included 25 913 patients following induction of labor, of these 191 (0.73%) were in twin pregnancies. Induction of labor in twin pregnancies was not associated with adverse maternal outcomes such as cervical tears, third degree perineal tears, uterine rupture, peripartum hysterectomy, post-partum hemorrhage or retained placenta. However, labor induction in twins was significantly associated with cesarean deliveries (31.2% versus 17.1%; p < 0.001). Using a multivariable analysis controlling for confounders, induction at twins was an independent risk factor for cesarean delivery (CD; adjusted OR = 2.2, 95% CI 1.7-2.7, p < 0.001).

CONCLUSION

Induction of labor in twin pregnancies does not increase the risk for maternal complications. However, it is an independent risk factor for CD.

Risk of caesarean section after induced labour: do hospitals make a difference?

Background

There is a well-known relationship between induced labour and caesarean rates. However, it remains unknown whether this relationship reflects the impact of more complex obstetric conditions or the variability in obstetric practices. We sought to quantify the independent role of the hospital as a variable that can influence the occurrence of caesarean section after induced labour.

Methods

As part of the Portuguese Generation XXI birth cohort, we evaluated 2041 consecutive women who underwent singleton pregnancies with labour induction, at five public level III obstetric units (April 2005-August 2006). The indications for induction were classified according to the guidelines of the American and the Royal Colleges of Obstetricians and Gynaecologists. Poisson regression models were adjusted to estimate the association between the hospital and surgical delivery after induction. Crude and adjusted prevalence ratios (PR) and a 95% confidence interval (95% CI) were computed.

Results

The proportion of women who were induced without formal clinical indications varied among hospitals from 20.3% to 45.5% (p < 0.001). After adjusting for confounders, the risk of undergoing a caesarean section after induced labour remained significantly different between the hospitals, for the cases in which there was no evident indication for induction [the highest PR reaching 1.86 (95% CI, 1.23–2.82)] and also when at least one such indication was present [1.53 (95% CI, 1.12–2.10)]. This pattern was also observed among the primiparous cephalic term induced women [the highest PR reaching 2.06 (95% CI, 1.23–2.82) when there was no evident indication for induction and 1.61 (95% CI, 1.11–2.34) when at least one such indication was present].

Conclusions

Caesarean section after induced labour varied significantly across hospitals where similar outcomes were expected. The effect was more evident when the induction was not based on the unequivocal presence of commonly accepted indications.

Regional variation in obstetrical intervention for hospital birth in the Republic of Ireland, 2005-2009

Background

Obstetrical interventions during childbirth vary widely across European and North American countries. Regional differences in intrapartum care may reflect an inpatient-based, clinician-oriented, interventional practice style.

Methods

Using nationally representative hospital discharge data, a retrospective cohort study was conducted to explore regional variation in obstetric intervention across four major regions (Dublin Mid Leinster; Dublin Northeast; South; West) within the Republic of Ireland. Specific focus was given to rates of induction of labour, caesarean delivery, epidural anaesthesia, blood transfusion, hysterectomy and episiotomy. Logistic regression analyses were performed to assess the association between geographical region and interventions while adjusting for patient case-mix.

Results

323,588 deliveries were examined. The incidence of interventions varied significantly across regions; the greatest disparities were observed for rates of induction of labour and caesarean delivery. Women in the South had nearly two-fold odds of having prostaglandins (adjusted OR: 1.75, 95% CI 1.68-1.82), whereas women in the West had 1.85 odds (95% CI 1.77-1.93) of artificial rupture of membrane. Women delivering in the Dublin Northeast, South and West regions had more than two-fold increased odds of elective caesarean delivery relative to women delivering in the Dublin Mid Leinster region. The Dublin Northeast region had the highest odds of emergency caesarean delivery (adjusted OR: 1.36; 95% CI: 1.31-1.40).

Conclusions

Substantial regional variation in intrapartum care was observed within this small, relatively homogeneous population. The association of intervention use with region illustrates the need to encourage uptake of scientific based practice guidelines to better inform clinical judgment.

Comparison of demographic and obstetric characteristics of Canadian primiparous women of advanced maternal age and younger age

OBJECTIVE

The rate of pregnancy at advanced maternal age (AMA) has increased during recent decades. The purpose of this study is to compare demographic and obstetric characteristics of Canadian primiparous women of AMA with those aged 20 to 29 years.

METHODS

We conducted a secondary analysis of data collected through the national Maternity Experiences Survey (MES) of the Canadian Perinatal Surveillance System. The sample included 301 primiparous women aged 35 years or over and 1,564 primiparous women aged 20 to 29 years. Estimates of prevalence for each group and their odds ratios were calculated using sample weights of the survey, and variances were calculated using bootstrapping methods adjusting for sampling design and weights.

RESULTS

Women of AMA were significantly more likely to be better educated, to have higher income, to be employed, and to continue to work until the end of pregnancy than younger women. They also reported having significantly more information on pregnancy, labour, and birth, and they were more likely to attend prenatal classes. They were more likely to have had a miscarriage or infertility treatment, to request or be offered a Caesarean section, and to have a higher rate of Caesarean section. There were no significant differences in rates of preterm birth, low birth weight, and small-for-gestational age infants.

CONCLUSION

Pregnant women of AMA differ from younger women in demographic characteristics, knowledge level, and some health behaviours and pregnancy outcomes. The growing number of pregnancies at AMA indicates the need for developing appropriate care plans to address the specific needs of this group.

Risk factors for failed induction in nulliparous women

OBJECTIVE

To identify risk factors for failed induction in nulliparous women.

MATERIAL AND METHODS

A retrospective cohort study of nulliparous women admitted for induction of labour (IOL). Identification of risk factors for failed IOL by comparing clinical characteristics of patients with a failed IOL defined as birth by caesarean section (LSCS) with those achieving vaginal birth.

RESULTS

During a 12 month episode, 400 nulliparous women had an IOL; of these 168 (42%) failed to deliver vaginally. Independent antenatal risk factors for failed IOL were higher maternal age (OR = 1.052 per additional year), being shorter (OR = 1.112 per cm less maternal height) and a lower cervical dilatation score (OR = 1.411 per lower cervical dilatation score). A longer active phase (OR = 1.004 per additional minute) was the only independent intrapartum risk factor for having a LSCS.

CONCLUSIONS

Maternal age, height and cervical dilatation are independent antepartum risk factors, while duration of active phase is the single independent intrapartum risk factor for a failed IOL. Increased maternal BMI was less of a risk factor than anticipated with increased risk for failed IOL, as independent risk factor, more or less restricted to the morbidly obese women.

Decreasing length of maternal hospital stay is not associated with increased readmission rates

OBJECTIVE

To investigate changes in maternal length of postnatal stay by mode of birth and hospital type, and examine concurrent maternal readmission rates and reasons for readmission.

METHODS

Linked birth and hospital separation data were used to investigated mothers' birth admissions (n=597,475) and readmissions (n=19,094) in the six weeks post-birth in New South Wales, 2001-2007. Outcomes were postnatal length of stay (mean days) and rate of readmission per 100 deliveries. Poisson regression was used to investigate annual readmission rates and Wilcoxon-Mann-Whitney test was used to compare length of readmission stays.

RESULTS

The overall mean postnatal length of stay declined from 3.7 days in 2001 to 3.4 days in 2007. Private hospitals had longer stays after Caesarean and vaginal deliveries, but mean length of stay fell for both private and public hospitals, and both modes of birth. The maternal readmission rate fell from 3.4% in 2001 to 3.0% in 2007. Leading primary diagnoses at readmission following vaginal birth were postpartum haemorrhage and breast/ lactation complications and following Caesarean section were wound complications and breast/ lactation complications.

CONCLUSIONS

Despite the decrease in mean length of stay for birth admissions, there was no increase, and in fact a decrease, in the rate of postnatal readmissions.

IMPLICATIONS

Current practices in hospital length of stay and care for women giving birth do not appear to be having serious adverse health effects as measured by readmissions.

Induction of labour for improving birth outcomes for women at or beyond term

BACKGROUND

As a pregnancy continues beyond term the risks of babies dying inside the womb or in the immediate newborn period increase. Whether a policy of labour induction at a predetermined gestational age can reduce this increased risk is the subject of this review.

OBJECTIVES

To evaluate the benefits and harms of a policy of labour induction at term or post-term compared with awaiting spontaneous labour or later induction of labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2012).

SELECTION CRITERIA

Randomised controlled trials conducted in women at or beyond term. The eligible trials were those comparing a policy of labour induction with a policy of awaiting spontaneous onset of labour. Cluster-randomised trials and cross-over trials are not included. Quasi-random allocation schemes such as alternation, case record numbers or open random-number lists were not eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion. Two review authors independently assessed trial quality and extracted data. Data were checked for accuracy. Outcomes are analysed in two main categories: gestational age and cervix status.

MAIN RESULTS

We included 22 trials reporting on 9383 women. The trials were generally at moderate risk of bias.Compared with a policy of expectant management, a policy of labour induction was associated with fewer (all-cause) perinatal deaths: risk ratio (RR) 0.31, 95% confidence interval (CI) 0.12 to 0.88; 17 trials, 7407 women. There was one perinatal death in the labour induction policy group compared with 13 perinatal deaths in the expectant management group. The number needed to treat to benefit (NNTB) with induction of labour in order to prevent one perinatal death was 410 (95% CI 322 to 1492).For the primary outcome of perinatal death and most other outcomes, no differences between timing of induction subgroups were seen; the majority of trials adopted a policy of induction at 41 completed weeks (287 days) or more.Fewer babies in the labour induction group had meconium aspiration syndrome (RR 0.50, 95% CI 0.34 to 0.73; eight trials, 2371 infants) compared with a policy of expectant management. There was no statistically significant difference between the rates of neonatal intensive care unit (NICU) admission for induction compared with expectant management (RR 0.90, 95% CI 0.78 to 1.04; 10 trials, 6161 infants). For women in the policy of induction arms of trials, there were significantly fewer caesarean sections compared with expectant management in 21 trials of 8749 women (RR 0.89, 95% CI 0.81 to 0.97).

AUTHORS' CONCLUSIONS

A policy of labour induction compared with expectant management is associated with fewer perinatal deaths and fewer caesarean sections. Some infant morbidities such as meconium aspiration syndrome were also reduced with a policy of post-term labour induction although no significant differences in the rate of NICU admission were seen.However, the absolute risk of perinatal death is small. Women should be appropriately counselled in order to make an informed choice between scheduled induction for a post-term pregnancy or monitoring without induction (or delayed induction).

Outcomes of elective induction of labour compared with expectant management: population based study

OBJECTIVE

To determine neonatal outcomes (perinatal mortality and special care unit admission) and maternal outcomes (mode of delivery, delivery complications) of elective induction of labour compared with expectant management.

DESIGN

Retrospective cohort study using an unselected population database.

SETTING

Consultant and midwife led obstetric units in Scotland 1981-2007.

PARTICIPANTS

1,271,549 women with singleton pregnancies of 37 weeks or more gestation.

INTERVENTIONS

Outcomes of elective induction of labour (induction of labour with no recognised medical indication) at 37, 38, 39, 40, and 41 weeks' gestation compared with those of expectant management (continuation of pregnancy to either spontaneous labour, induction of labour or caesarean section at a later gestation).

MAIN OUTCOME MEASURES

Extended perinatal mortality, mode of delivery, postpartum haemorrhage, obstetric anal sphincter injury, and admission to a neonatal or special care baby unit. Outcomes were adjusted for age at delivery, parity, year of birth, birth weight, deprivation category, and, where appropriate, mode of delivery.

RESULTS

At each gestation between 37 and 41 completed weeks, elective induction of labour was associated with a decreased odds of perinatal mortality compared with expectant management (at 40 weeks' gestation 0.08% (37/44,764) in the induction of labour group versus 0.18% (627/350,643) in the expectant management group; adjusted odds ratio 0.39, 99% confidence interval 0.24 to 0.63), without a reduction in the odds of spontaneous vertex delivery (at 40 weeks' gestation 79.9% (35,775/44,778) in the induction of labour group versus 73.7% (258,665/350,791) in the expectant management group; adjusted odds ratio 1.26, 1.22 to 1.31). Admission to a neonatal unit was, however, increased in association with elective induction of labour at all gestations before 41 weeks (at 40 weeks' gestation 8.0% (3605/44,778) in the induction of labour group compared with 7.3% (25,572/350,791) in the expectant management group; adjusted odds ratio 1.14, 1.09 to 1.20).

CONCLUSION

Although residual confounding may remain, our findings indicate that elective induction of labour at term gestation can reduce perinatal mortality in developed countries without increasing the risk of operative delivery.

Requests and usage of epidural analgesia in grand-grand multiparous and similar-aged women with lesser parity: prospective observational study

BACKGROUND

Epidural analgesia in older and multiparous women has been associated with risks. The aim of this study was to compare epidural analgesia use for labor/delivery in grand-grand multiparous women (GGMP; ≥10 births) relative to that in similar-aged women with lesser parity.

METHODS

This was a prospective observational study of advanced age gravida. All laboring women in a six-month period admitted to a tertiary Israeli center were included if they were advanced age (≥36 years old) with one to two previous births (Low parity; n=128) or four to five previous births (Medium parity; n=181), and all GGMP (any age; n=187). Primary outcome was comparison of requests for and use of epidural analgesia for labor/delivery.

RESULTS

There were no significant differences across parity groups in percent of gravida requesting or receiving epidural analgesia (46.5-59.4%). Time from admission to epidural administration (range mean times: 168-187 min) and from advent of epidural to delivery (range mean times: 155-160 min) were comparable across parity groups. Use of other analgesia (5.8-8%) was not significantly different.

CONCLUSIONS

Requests for and use of epidural analgesia was comparable in older gravida and was not correlated with parity. Mean times from presentation to epidural administration, mean cervical dilatation at epidural initiation, and mean time from performing of epidural to delivery were comparable across groups.

Trends and outcomes of induction of labour among nullipara at term

AIM

  To determine induction trends and delivery, maternal and neonatal health outcomes by gestational age following induction at term for women having a first baby.

METHODS

  Linked birth and hospital data were used to examine the rates of adverse maternal and neonatal health outcomes for the period 2001-2007, among the 212,389 nullipara with singleton cephalic-presenting fetuses delivering between 37(0) and 41(6) weeks of gestation. Rates of caesarean delivery, neonatal transfers and overall severe neonatal and maternal adverse outcomes were determined by gestational age.

RESULTS

  Between 1990 and 2008, nulliparous term inductions as a proportion of all births increased from 5518 (6.8%) to 11,166 (12.5%). More than 60% of these inductions are performed before 41 weeks. Among induced nullipara, 30.4% delivered by caesarean section. Adverse neonatal outcomes and transfer rates were lowest at 39-40 weeks (overall 2.1 and 0.5%, respectively), regardless of labour onset. Maternal morbidity increased at 40 weeks (from 1.1 to 1.3%) for women in spontaneous labour, was relatively stable in those undergoing induction of labour between 37 and 40 weeks (1.8%) and decreased with gestational age until 40 weeks in those undergoing a prelabour caesarean delivery (from 3.1 to 0.8%).

CONCLUSION

  NSW has high rates of both induction and caesarean section following induction. This study highlights the changes to clinical practice that may help reduce the rate of caesarean births in nullipara.

Perinatal Pitocin as an early ADHD biomarker: neurodevelopmental risk?

OBJECTIVE

To investigate a potential relationship between coincidental increases in perinatal Pitocin usage and subsequent childhood ADHD onset in an attempt to isolate a specific risk factor as an early biomarker of this neurodevelopmental disorder.

METHOD

Maternal labor/delivery and corresponding childbirth records of 172 regionally diverse, heterogeneous children, ages 3 to 25, were examined with respect to 21 potential predictors of later ADHD onset, including 17 selected obstetric complications, familial ADHD incidence, and gender. ADHD diagnosis and history of perinatal Pitocin exposure distinguished groups for comparison.

RESULTS

Results revealed a strong predictive relationship between perinatal Pitocin exposure and subsequent childhood ADHD onset (occurring in 67.1% of perinatal Pitocin cases vs. 35.6% in nonexposure cases, χ(2)=16.99, p<.001). Fetal exposure time, gestation length, and labor length also demonstrated predictive power, albeit significantly lower.

CONCLUSION

The findings warrant further investigation into the potential link between perinatal Pitocin exposure and subsequent ADHD diagnosis.