Women's evaluations of induction of labor versus expectant management for prelabor rupture of the membranes at term. TermPROM Study Group

Labor induction information leaflets—Do women receive evidence-based information about the benefits and harms of labor induction?

Objectives

To determine the extent to which a sample of NHS labor induction leaflets reflects evidence on labor induction.

Setting

Audit of labor induction patient information leaflets—local from WILL trial (When to Induce Labor to Limit risk in pregnancy hypertension) internal pilot sites or national-level available online.

Methods

Descriptive analysis [n = 21 leaflets, 19 (one shared) in 20 WILL internal pilot sites and 2 NHS online] according to NHS “Protocol on the Production of Patient Information” criteria: general information (including indications), why and how induction is offered (including success and alternatives), and potential benefits and harms.

Results

All leaflets described an induction indication. Most leaflets (n = 18) mentioned induction location and 16 the potential for delays due to delivery suite workloads and competing clinical priorities. While 19 leaflets discussed membrane sweeping (17 as an induction alternative), only 4 leaflets mentioned balloon catheter as another mechanical method. Induction success (onset of active labor) was presented by a minority of leaflets (n = 7, 33%), as “frequent” or in the “majority”, with “rare” or “occasional” failures. Benefits, harms and outcomes following induction were not compared with expectant care, but rather with spontaneous labor, such as for pain (n = 14, with nine stating more pain with induction). Potential benefits of induction were seldom described [n = 7; including avoiding stillbirth (n = 4)], but deemed to be likely. No leaflet stated vaginal birth was more likely following induction, but most stated Cesarean was not increased (n = 12); one leaflet stated that Cesarean risks were increased following induction. Women's satisfaction was rarely presented (n = 2).

Conclusion

Information provided to pregnant women regarding labor induction could be improved to better reflect women's choice between induction and expectant care, and the evidence upon which treatment recommendations are based. A multiple stakeholder-involved and evidence-informed process to update guidance is required.

Offering women a choice in induction of labour: a prospective cohort study

PURPOSE

To evaluate women's choice in the method of labour induction between oral misoprostol, PGE2 pessary and the Foley catheter. To compare women's satisfaction according to their choice and to identify factors associated with patient satisfaction.

METHODS

We conducted a comparative, prospective cohort study of 520 women who chose their preferred method for labour induction, in a French tertiary hospital, from July 2019 to October 2020. Before and after the delivery, they were asked to argue their choice and to evaluate their satisfaction through the use of questionnaires. The primary outcome was global level of satisfaction.

RESULTS

Of the 520 women included, 67.5% of women chose oral misoprostol compared to 21% PGE2 pessary and 11.5% Foley catheter. Regarding global satisfaction, we found no significant difference between the three groups: 78.4%, 68.8% and 71.2% (p = 0.107) for, respectively, oral misoprostol, PGE2 pessary and Foley catheter. Factors that seem to improve women's satisfaction were nulliparity (aOR = 2.03, 95% CI [1.19-3.53]), delivery within 24 h after the start of induction (aOR = 3.46, 95% CI [2.02-6.14]) and adequate information (aOR = 4.21, 95% CI [1.869.64]). Factors associated with lower satisfaction rates were postpartum haemorrhage (aOR = 0.51, 95% CI [0.30-0.88]) and caesarean section (aOR = 0.31, 95% CI [0.17-0.54]).

CONCLUSION

Women satisfaction rates were not different between the three methods, when chosen by the patients themselves. These finding should encourage caregivers to promote shared decision making when possible.

TRIAL REGISTRATION

The protocol was approved by the French ethics committee for research in obstetrics and gynaecology (CEROG, reference number 2019-OBS-0602) on 1st June 2019.

In labor or in limbo? The experiences of women undergoing induction of labor in hospital: Findings of a qualitative study

BACKGROUND

Induction of labor currently accounts for around 25% of all births in high-resource countries, yet despite much research into medical aspects, little is known about how women experience this process. This study aimed to explore in depth the induction experience of primiparous women.

METHODS

A qualitative study was undertaken, using a sample of 21 first-time mothers from a maternity unit in the south of England. Semi-structured interviews were conducted in women's homes between 3 and 6 weeks postnatally. Data were recorded, transcribed, and analyzed thematically.

RESULTS

Women awaiting induction on the prenatal ward appeared to occupy a liminal state between pregnancy and labor. Differences were noted between women's and midwives' notions of what constituted "being in labor" and the ward lacked the flexibility to provide individualized care for women in early labor. Unexpected delays in the induction process were common and were a source of anxiety, as was separation from partners at night. Women were not always clear about their plan of care, which added to their anxiety.

CONCLUSIONS

Conceptualizing induction as a liminal state may enhance understanding of women's feelings and promote a more woman-centered approach to care. Thorough preparation for induction, including an explanation of possible delays is fundamental to enabling women to form realistic expectations. Care providers need to consider whether women undergoing induction are receiving adequate support, analgesia, and comfort aids conducive to the promotion of physiological labor and the reduction of anxiety.

Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

More than 150,000 pregnant women in England and Wales have their labour induced each year. Multiple pharmacological, mechanical and complementary methods are available to induce labour.

OBJECTIVE

To assess the relative effectiveness, safety and cost-effectiveness of labour induction methods and, data permitting, effects in different clinical subgroups.

METHODS

We carried out a systematic review using Cochrane methods. The Cochrane Pregnancy and Childbirth Group's Trials Register was searched (March 2014). This contains over 22,000 reports of controlled trials (published from 1923 onwards) retrieved from weekly searches of OVID MEDLINE (1966 to current); Cochrane Central Register of Controlled Trials (The Cochrane Library); EMBASE (1982 to current); Cumulative Index to Nursing and Allied Health Literature (1984 to current); ClinicalTrials.gov; the World Health Organization International Clinical Trials Registry Portal; and hand-searching of relevant conference proceedings and journals. We included randomised controlled trials examining interventions to induce labour compared with placebo, no treatment or other interventions in women eligible for third-trimester induction. We included outcomes relating to efficacy, safety and acceptability to women. In addition, for the economic analysis we searched the Database of Abstracts of Reviews of Effects, and Economic Evaluations Databases, NHS Economic Evaluation Database and the Health Technology Assessment database. We carried out a network meta-analysis (NMA) using all of the available evidence, both direct and indirect, to produce estimates of the relative effects of each treatment compared with others in a network. We developed a de novo decision tree model to estimate the cost-effectiveness of various methods. The costs included were the intervention and other hospital costs incurred (price year 2012-13). We reviewed the literature to identify preference-based utilities for the health-related outcomes in the model. We calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit. We represent uncertainty in the optimal intervention using cost-effectiveness acceptability curves.

RESULTS

We identified 1190 studies; 611 were eligible for inclusion. The interventions most likely to achieve vaginal delivery (VD) within 24 hours were intravenous oxytocin with amniotomy [posterior rank 2; 95% credible intervals (CrIs) 1 to 9] and higher-dose (≥ 50 µg) vaginal misoprostol (rank 3; 95% CrI 1 to 6). Compared with placebo, several treatments reduced the odds of caesarean section, but we observed considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 µg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed 'best'. Few studies collected information on women's views. Owing to incomplete reporting of the VD within 24 hours outcome, the cost-effectiveness analysis could compare only 20 interventions. The analysis suggested that most interventions have similar utility and differ mainly in cost. With a caveat of considerable uncertainty, titrated (low-dose) misoprostol solution and buccal/sublingual misoprostol had the highest likelihood of being cost-effective.

LIMITATIONS

There was considerable uncertainty in findings and there were insufficient data for some planned subgroup analyses.

CONCLUSIONS

Overall, misoprostol and oxytocin with amniotomy (for women with favourable cervix) is more successful than other agents in achieving VD within 24 hours. The ranking according to safety of different methods was less clear. The cost-effectiveness analysis suggested that titrated (low-dose) oral misoprostol solution resulted in the highest utility, whereas buccal/sublingual misoprostol had the lowest cost. There was a high degree of uncertainty as to the most cost-effective intervention.

FUTURE WORK

Future trials should be powered to detect a method that is more cost-effective than misoprostol solution and report outcomes included in this NMA.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013005116.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more)

BACKGROUND

Prelabour rupture of membranes (PROM) at term is managed expectantly or by planned early birth. It is not clear if waiting for birth to occur spontaneously is better than intervening, e.g. by inducing labour.

OBJECTIVES

The objective of this review is to assess the effects of planned early birth (immediate intervention or intervention within 24 hours) when compared with expectant management (no planned intervention within 24 hours) for women with term PROM on maternal, fetal and neonatal outcomes.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (9 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of planned early birth compared with expectant management (either in hospital or at home) in women with PROM at 37 weeks' gestation or later.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, extracted the data, and assessed risk of bias of the included studies. Data were checked for accuracy.

MAIN RESULTS

Twenty-three trials involving 8615 women and their babies were included in the update of this review. Ten trials assessed intravenous oxytocin; 12 trials assessed prostaglandins (six trials in the form of vaginal prostaglandin E2 and six as oral, sublingual or vaginal misoprostol); and one trial each assessed Caulophyllum and acupuncture. Overall, three trials were judged to be at low risk of bias, while the other 20 were at unclear or high risk of bias.Primary outcomes: women who had planned early birth were at a reduced risk of maternal infectious morbidity (chorioamnionitis and/or endometritis) than women who had expectant management following term prelabour rupture of membranes (average risk ratio (RR) 0.49; 95% confidence interval (CI) 0.33 to 0.72; eight trials, 6864 women; Tau² = 0.19; I² = 72%; low-quality evidence), and their neonates were less likely to have definite or probable early-onset neonatal sepsis (RR 0.73; 95% CI 0.58 to 0.92; 16 trials, 7314 infants;low-quality evidence). No clear differences between the planned early birth and expectant management groups were seen for the risk of caesarean section (average RR 0.84; 95% CI 0.69 to 1.04; 23 trials, 8576 women; Tau² = 0.10; I² = 55%; low-quality evidence); serious maternal morbidity or mortality (no events; three trials; 425 women; very low-quality evidence); definite early-onset neonatal sepsis (RR 0.57; 95% CI 0.24 to 1.33; six trials, 1303 infants; very low-quality evidence); or perinatal mortality (RR 0.47; 95% CI 0.13 to 1.66; eight trials, 6392 infants; moderate-quality evidence).

SECONDARY OUTCOMES

women who had a planned early birth were at a reduced risk of chorioamnionitis (average RR 0.55; 95% CI 0.37 to 0.82; eight trials, 6874 women; Tau² = 0.19; I² = 73%), and postpartum septicaemia (RR 0.26; 95% CI 0.07 to 0.96; three trials, 263 women), and their neonates were less likely to receive antibiotics (average RR 0.61; 95% CI 0.44 to 0.84; 10 trials, 6427 infants; Tau² = 0.06; I² = 32%). Women in the planned early birth group were more likely to have their labour induced (average RR 3.41; 95% CI 2.87 to 4.06; 12 trials, 6945 women; Tau² = 0.05; I² = 71%), had a shorter time from rupture of membranes to birth (mean difference (MD) -10.10 hours; 95% CI -12.15 to -8.06; nine trials, 1484 women; Tau² = 5.81; I² = 60%), and their neonates had lower birthweights (MD -79.25 g; 95% CI -124.96 to -33.55; five trials, 1043 infants). Women who had a planned early birth had a shorter length of hospitalisation (MD -0.79 days; 95% CI -1.20 to -0.38; two trials, 748 women; Tau² = 0.05; I² = 59%), and their neonates were less likely to be admitted to the neonatal special or intensive care unit (RR 0.75; 95% CI 0.66 to 0.85; eight trials, 6179 infants), and had a shorter duration of hospital (-11.00 hours; 95% CI -21.96 to -0.04; one trial, 182 infants) or special or intensive care unit stay (RR 0.72; 95% CI 0.61 to 0.85; four trials, 5691 infants). Women in the planned early birth group had more positive experiences compared with women in the expectant management group.No clear differences between groups were observed for endometritis; postpartum pyrexia; postpartum antibiotic usage; caesarean for fetal distress; operative vaginal birth; uterine rupture; epidural analgesia; postpartum haemorrhage; adverse effects; cord prolapse; stillbirth; neonatal mortality; pneumonia; Apgar score less than seven at five minutes; use of mechanical ventilation; or abnormality on cerebral ultrasound (no events).None of the trials reported on breastfeeding; postnatal depression; gestational age at birth; meningitis; respiratory distress syndrome; necrotising enterocolitis; neonatal encephalopathy; or disability at childhood follow-up.In subgroup analyses, there were no clear patterns of differential effects for method of induction, parity, use of maternal antibiotic prophylaxis, or digital vaginal examination. Results of the sensitivity analyses based on trial quality were consistent with those of the main analysis, except for definite or probable early-onset neonatal sepsis where no clear difference was observed.

AUTHORS' CONCLUSIONS

There is low quality evidence to suggest that planned early birth (with induction methods such as oxytocin or prostaglandins) reduces the risk of maternal infectious morbidity compared with expectant management for PROM at 37 weeks' gestation or later, without an apparent increased risk of caesarean section. Evidence was mainly downgraded due to the majority of studies contributing data having some serious design limitations, and for most outcomes estimates were imprecise.Although the 23 included trials in this review involved a large number of women and babies, the quality of the trials and evidence was not high overall, and there was limited reporting for a number of important outcomes. Thus further evidence assessing the benefits or harms of planned early birth compared with expectant management, considering maternal, fetal, neonatal and longer-term childhood outcomes, and the use of health services, would be valuable. Any future trials should be adequately designed and powered to evaluate the effects on short- and long-term outcomes. Standardisation of outcomes and their definitions, including for the assessment of maternal and neonatal infection, would be beneficial.

Intravenous oxytocin alone for cervical ripening and induction of labour

BACKGROUND

Oxytocin is the commonest induction agent used worldwide. It has been used alone, in combination with amniotomy or following cervical ripening with other pharmacological or non-pharmacological methods.

OBJECTIVES

To determine the effects of oxytocin alone for third trimester cervical ripening and induction of labour in comparison with other methods of induction of labour or placebo/no treatment.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2009) and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing intravenous oxytocin with placebo or no treatment, or with prostaglandins (vaginal or intracervical) for third trimester cervical ripening or labour induction.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and carried out data extraction.

MAIN RESULTS

Sixty-one trials (12,819 women) are included.When oxytocin inductions were compared with expectant management, fewer women failed to deliver vaginally within 24 hours (8.4% versus 53.8%, risk ratio (RR) 0.16, 95% confidence interval (CI) 0.10 to 0.25). There was a significant increase in the number of women requiring epidural analgesia (RR 1.10, 95% CI 1.04 to 1.17). Fewer women were dissatisfied with oxytocin induction in the one trial reporting this outcome (5.9% versus 13.7%, RR 0.43, 95% CI 0.33 to 0.56).Compared with vaginal prostaglandins, oxytocin increased unsuccessful vaginal delivery within 24 hours in the two trials reporting this outcome (70% versus 21%, RR 3.33, 95% CI 1.61 to 6.89). There was a small increase in epidurals when oxytocin alone was used (RR 1.09, 95% CI 1.01 to 1.17).Most of the studies included women with ruptured membranes, and there was some evidence that vaginal prostaglandin increased infection in mothers (chorioamnionitis RR 0.66, 95% CI 0.47 to 0.92) and babies (use of antibiotics RR 0.68, 95% CI 0.53 to 0.87). These data should be interpreted cautiously as infection was not pre-specified in the original review protocol.When oxytocin was compared with intracervical prostaglandins, there was an increase in unsuccessful vaginal delivery within 24 hours (50.4% versus 34.6%, RR 1.47, 95% CI 1.10 to 1.96) and an increase in caesarean sections (19.1% versus 13.7%, RR 1.37, 95% CI 1.08 to 1.74) in the oxytocin group.

AUTHORS' CONCLUSIONS

Comparison of oxytocin with either intravaginal or intracervical PGE2 reveals that the prostaglandin agents probably increase the chances of achieving vaginal birth within 24 hours. Oxytocin induction may increase the rate of interventions in labour.A suggestion that for women with prelabour rupture of membranes induction with vaginal prostaglandin may increase risk of infection for mother and baby warrants further study.

The Control of Hypertension In Pregnancy Study pilot trial

OBJECTIVE

To determine whether 'less tight' (versus 'tight') control of nonsevere hypertension results in a difference in diastolic blood pressure (dBP) between groups.

DESIGN

Randomised controlled trial (ISRCTN#57277508).

SETTING

Seventeen obstetric centres in Canada, Australia, New Zealand, and UK.

POPULATION

Inclusion: pregnant women, dBP 90-109 mmHg, pre-existing/gestational hypertension; live fetus(es); and 20-33(+6) weeks. Exclusion: systolic blood pressure > or = 170 mmHg and proteinuria, contraindication, or major fetal anomaly.

METHODS

Randomisation to less tight (target dBP, 100 mmHg) or tight (target dBP, 85 mmHg) blood pressure control.

MAIN OUTCOME MEASURES

Primary: mean dBP at 28, 32 and 36 weeks. Secondary: clinician compliance and women's satisfaction. Other: serious perinatal and maternal complications.

RESULTS

A total of 132 women were randomised to less tight (n = 66; seven had no study visit) or tight control (n= 66; one was lost to follow up; seven had no study visit). Mean dBP was significantly lower with tight control: -3.5 mmHg, 95% credible interval (-6.4, -0.6). Clinician compliance was 79% in both groups. Women were satisfied with their care. With less tight (versus tight) control, the rates of other treatments and outcomes were the following: post-randomisation antenatal antihypertensive medication use: 46 (69.7%) versus 58 (89.2%), severe hypertension: 38 (57.6%) versus 26 (40.0%), proteinuria: 16 (24.2%) versus 20 (30.8%), serious maternal complications: 3 (4.6%) versus 2 (3.1%), preterm birth: 24 (36.4%) versus 26 (40.0%), birthweight: 2675 +/- 858 versus 2501 +/- 855 g, neonatal intensive care unit (NICU) admission: 15 (22.7%) versus 22 (34.4%), and serious perinatal complications: 9 (13.6%) versus 14 (21.5%).

CONCLUSION

The CHIPS pilot trial confirms the feasibility and importance of a large definitive trial to determine the effects of less tight control on serious perinatal and maternal complications.

Maternal anxiety and feelings of control during labour: a study of Chinese first-time pregnant women

OBJECTIVE

to explore and examine the relationship between maternal anxiety levels and feelings of control during labour among Hong Kong Chinese first-time pregnant women.

DESIGN

an exploratory descriptive correlation design. Data were collected on three occasions: during latent phase of labour, during active phase of labour and within 24-48 hrs after delivery.

SETTING

an obstetric unit of a public teaching hospital in Hong Kong.

PARTICIPANTS

a convenience sample of 90 Hong Kong Chinese first-time mothers.

MEASUREMENTS AND FINDINGS

the Labour Agentry Scale (LAS) is a self-report scale designed to measure feelings of control during childbirth. A Visual Analogue Scale for anxiety (VAS-A) was used to measure women's self-reported level of anxiety during labour. Pearson Product Moment Correlation coefficient test indicated a significant negative relationship between the feelings of control and maternal anxiety during labour. No statistical relationships were detected between women's attendance at antenatal classes and feelings of control during labour.

KEY CONCLUSIONS

the study showed a significant negative relationship between maternal anxiety and feelings of control during labour.

IMPLICATIONS FOR PRACTICE

midwives should work with women to enhance their personal control during labour and satisfaction with their birth. The insignificant relationship between attendance at antenatal classes and feelings of control suggests the need to evaluate the content of childbirth education in order to empower women's control during labour.

PTSD, risk factors, and expectations among women having a baby: a two-wave longitudinal study

INTRODUCTION

The aim of the study was to evaluate the incidence of chronic post-traumatic stress disorder (PTSD) after childbirth in relation to pre-partum variables (personality characteristics, anamnestic risk factors) and intra-partum obstetrical and neonatal variables. Since expectations before an event could modify the perceptions, reactions, and satisfaction afterward, the representations of the idealized delivery were carefully analyzed. Moreover, the real and desired help perception from physicians and family members were separately considered during pregnancy and after delivery in relation to PTSD.

METHOD

The study was carried out submitting a questionnaire to pregnant women twice: firstly when women were in their 38 << 42 gestational week (Time 1) and secondly after 3-6 months from childbirth (Time 2). 93 women were recruited at a University City Hospital in Milan, Italy. PTSD subscales, depression, and anxiety levels were also assessed.

RESULTS

2.4% of women had a complete PTSD, while 32.1% of them resulted in having one or two positive subscales of symptoms: 15.5% (N = 13) had a positive intrusion subscale, 25.0% (N = 21) had a positive arousal subscale, while only 3.6% (N = 3) had a positive avoidance subscale. Pre-delivery depression influences PTSD, but only for the intrusion subscale. Pre-delivery physical risk factors are linked to PTSD on the avoidance subscale. At Time 2 depression and PTSD are often present simultaneously. Given the high percentage of healthy newborns, intra-partum obstetrical variables do not seem to influence PTSD. High trait anxiety distinctively coexists with a specific expected delivery and a 'deception' in desired and real support from professionals.

CONCLUSIONS

Childbirth is a risk condition for PTSD, depression during pregnancy influences the intrusion subscale, while having physical problems influences the arousal subscale. Expectations and support are modulated by the anxiety levels and they are not directly related to chronic PTSD.

Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more)

BACKGROUND

Prelabour rupture of membranes at term is managed expectantly or by elective birth, but it is not clear if waiting for birth to occur spontaneously is better than intervening.

OBJECTIVES

To assess the effects of planned early birth versus expectant management for women with term prelabour rupture of membranes on fetal, infant and maternal wellbeing.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (November 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2004), MEDLINE (1966 to November 2004) and EMBASE (1974 to November 2004).

SELECTION CRITERIA

Randomised or quasi-randomised trials of planned early birth compared with expectant management in women with prelabour rupture of membranes at 37 weeks' gestation or more.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied eligibility criteria, assessed trial quality and extracted data. A random-effects model was used.

MAIN RESULTS

Twelve trials (total of 6814 women) were included. Planned management was generally induction with oxytocin or prostaglandin, with one trial using homoeopathic caulophyllum. Overall, no differences were detected for mode of birth between planned and expectant groups: relative risk (RR) of caesarean section 0.94, 95% confidence interval (CI) 0.82 to 1.08 (12 trials, 6814 women); RR of operative vaginal birth 0.98, 95% 0.84 to 1.16 (7 trials, 5511 women). Significantly fewer women in the planned compared with expectant management groups had chorioamnionitis (RR 0.74, 95% CI 0.56 to 0.97; 9 trials, 6611 women) or endometritis (RR 0.30, 95% CI 0.12 to 0.74; 4 trials, 445 women). No difference was seen for neonatal infection (RR 0.83, 95% CI 0.61 to 1.12; 9 trials, 6406 infants). However, fewer infants under planned management went to neonatal intensive or special care compared with expectant management (RR 0.72, 95% CI 0.57 to 0.92, number needed to treat 20; 5 trials, 5679 infants). In a single trial, significantly more women with planned management viewed their care more positively than those expectantly managed (RR of "nothing liked" 0.45, 95% CI 0.37 to 0.54; 5031 women).

AUTHORS' CONCLUSIONS

Planned management (with methods such as oxytocin or prostaglandin) reduces the risk of some maternal infectious morbidity without increasing caesarean sections and operative vaginal births. Fewer infants went to neonatal intensive care under planned management although no differences were seen in neonatal infection rates. Since planned and expectant management may not be very different, women need to have appropriate information to make informed choices.

Mothers’ Views of Their Childbirth Experiences 2 Years Mter Planned Caesarean Versus Planned Vaginal Birth for Breech Presentation at Term, in the International Randomized Term Breech Trial

OBJECTIVE

To compare mothers' views at 2 years postpartum after participation in a randomized trial of planned Caesarean and planned vaginal birth for a singleton fetus in breech presentation at term.

STUDY DESIGN

In selected centres in the Term Breech Trial, mothers completed a structured questionnaire at approximately 2 years postpartum to assess their likes and dislikes about their childbirth experiences and their views about their intrapartum care and care providers.

RESULTS

Of 1159 mothers from 85 centres, 917 (79.1%) completed a follow-up questionnaire at 2 years postpartum. Baseline information was similar for both the planned Caesarean and planned vaginal birth groups. Planned Caesarean was associated with less worry about the baby's health (P < 0.001). While other differences were noted in likes and dislikes about their childbirth experiences, women's evaluations of the quality of intrapartum care, the helpfulness of staff, and their involvement in decision-making did not differ in the planned Caesarean delivery and planned vaginal birth groups.

CONCLUSION

Planned mode of delivery influences aspects of women's evaluations of their childbirth experiences but does not affect evaluations of the quality of intrapartum care, support from care providers, or amount of involvement in decision-making.

Trends and Issues in Labor Induction in the United States: Implications for Clinical Practice

The labor induction rate is at an all-time high in the United States. Although induction of labor is recommended as a therapeutic option only when the benefits of expeditious birth outweigh the risks of continuing the pregnancy, a "psychosocial indication" has become a common rationale for elective induction in the United States. It is unlikely that all women are provided with a complete discussion of the cascade of interventions that frequently accompany labor induction and the risks of cesarean birth. Although at first glance elective labor induction may seem more convenient, an appreciation of the inconvenience of the greater rates of interventions, the longer labor and overall hospital stay, the higher costs, the additional attention required by the primary health care provider when complications occur, and the risk of an adverse outcome for a mother or baby after an elective procedure with subsequent litigation should cause everyone to exercise caution and reevaluate current practice. Professional organizations should take proactive steps to advocate for pregnant women so they are fully aware of the risks and benefits. A public campaign to discourage elective labor induction for nulliparous women is worth serious consideration.

Maternal satisfaction with active management of labor: a randomized controlled trial

BACKGROUND

Active management of labor reduces the length of labor and rate of prolonged labor, but its effect on satisfaction with care, within a randomized controlled trial, has not previously been reported. The study objectives were to establish if a policy of active management of labor affected any aspect of maternal satisfaction, and to determine the independent explanatory variables for satisfaction with labor care in a low-risk nulliparous obstetric population.

METHODS

Nulliparous women at National Women's Hospital in Auckland, New Zealand, in spontaneous labor at term with singleton pregnancy, cephalic presentation, and without fetal distress were randomized after the onset of labor to active management (n = 320) or routine care (n = 331). Active management included early amniotomy, two-hourly vaginal assessments, and early use of high dose oxytocin for slow progress in labor. Routine care was not prespecified. Maternal satisfaction with labor care was assessed by postal questionnaire at 6 weeks postpartum. Sensitivity analyses were performed, and logistic regression models were developed to determine independent explanatory variables for satisfaction.

RESULTS

Of the 651 women randomized in the trial, 482 (74%) returned the questionnaires. Satisfaction with labor care was high (77%) and did not significantly differ by treatment group. This finding was stable when sensitivity analysis was performed. The first logistic regression model found independent associations between satisfaction and adequate pain relief, one-to-one midwifery care, adequate information and explanations by staff, accurate expectation of length of labor, not having a postpartum hemorrhage, and fewer than three vaginal examinations during labor. The second model found fewer than three vaginal examinations and one-to-one midwifery care as significant explanatory variables for satisfaction with labor care.

CONCLUSIONS

Active management did not adversely affect women's satisfaction with labor and delivery care in this trial. Future studies should concentrate on measurement of potential predictors before and during labor.

Temporal changes in rates and reasons for medical induction of term labor, 1980-1996

OBJECTIVE

This study was undertaken to assess temporal changes in rates and reasons for medical induction of term labor.

STUDY DESIGN

A retrospective medical record review was conducted on a population-based cohort of 1293 women with term deliveries.

RESULTS

The rate of medical labor induction increased from 12.9% in 1980 to 25.8% in 1995. Stated indications also changed, with a 2-fold increase in induction for postdate gestation, a 23-fold increase in induction for macrosomia, a 15-fold increase in elective induction, and a 22-fold decline in induction for premature rupture of membranes. The average gestational age at delivery of postdate pregnancies declined from 41.9 weeks in 1980 to 41.0 weeks in 1995. By 1995, the average maternal length of stay and the percentage of cesarean deliveries were higher among women with induced labor at term than among those with spontaneous labor at term.

CONCLUSION

Induction of term labor has almost doubled in prevalence during the past 15 years. The most common indications are elective induction and postdate pregnancy, often applied to gestations of 40 to 41 weeks' duration.

Intravenous oxytocin alone for cervical ripening and induction of labour

BACKGROUND

Oxytocin is the commonest induction agent used worldwide. It has been used alone, in combination with amniotomy or following cervical ripening with other pharmacological or non-pharmacological methods. Prior to the introduction of prostaglandin agents oxytocin was used as a cervical ripening agent as well. In developed countries oxytocin alone is more commonly used in the presence of ruptured membranes whether spontaneous or artificial. In developing countries where the incidence of HIV is high, delaying amniotomy in labour reduces vertical transmission rates and hence the use of oxytocin with intact membranes warrants further investigation. This review will address the use of oxytocin alone for induction of labour. Amniotomy alone or oxytocin with amniotomy for induction of labour has been reviewed elsewhere in the Cochrane Library. Trials which consider concomitant administration of oxytocin and amniotomy will not be considered. This is one of a series of reviews of methods of cervical ripening and labour induction using a standardised methodology.

OBJECTIVES

To determine the effects of oxytocin alone for third trimester cervical ripening or induction of labour in comparison with other methods of induction of labour or placebo/no treatment.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched: May 2001.

SELECTION CRITERIA

The criteria for inclusion included the following: (1) clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The data is to be extracted from the primary reviews into a series of secondary reviews, arranged by category of woman.

MAIN RESULTS

In total, 110 trials were considered; 52 have been excluded and 58 included examining a total of 11,129 women. Comparing oxytocin alone with expectant management: Oxytocin alone reduced the rate of unsuccessful vaginal delivery within 24 hours when compared with expectant management (8.3% versus 54%, relative risk (RR) 0.16, 95% confidence interval (CI) 0.10,0.25) but the caesarean section rate was increased (10.4% versus 8.9%, RR 1.17, 95% CI 1.01,1.36). This increase in caesarean section rate was not apparent in the subgroup analyses. Women were less likely to be unsatisfied with induction rather than expectant management, in the one trial reporting this outcome (5.5% versus 13.7%, RR 0.43, 95% CI 0.33, 0.56). Comparing oxytocin alone with vaginal prostaglandins: Oxytocin alone was associated with an increase in unsuccessful vaginal delivery within 24 hours (52% versus 28%, RR 1.85, 95% CI 1.41, 2.43), irrespective of membrane status, but there was no difference in caesarean section rates (11.4% versus 10%, RR 1.12, 95% CI 0.95, 1.33). Comparing oxytocin alone with intracervical prostaglandins: Oxytocin alone was associated with an increase in unsuccessful vaginal delivery within 24 hours when compared with intracervical PGE2 (51% versus 35%, RR 1.49, 95% CI 1.12,1.99). For all women with an unfavourable cervix regardless of membrane status, the caesarean section rates were increased (19.0% versus 13.1%, RR 1.42, 95% CI 1.11, 1.82).

REVIEWER'S CONCLUSIONS

Overall, comparison of oxytocin alone with either intravaginal or intracervical PGE2 reveals that the prostaglandin agents probably overall have more benefits than oxytocin alone. The amount of information relating to specific clinical subgroups is limited, especially with respect to women with intact membranes. Comparison of oxytocin alone to vaginal PGE2 in women with ruptured membranes reveals that both interventions are probably equally efficacious with each having some advantages and disadvantages over the others. With respect to current practice in women with ruptured membranes induction can be recommended by either method and in women with intact membranes there is insufficient information to make firm recommendations.

Cochrane pregnancy and childbirth database: resource for evidence-based practice

The Cochrane Pregnancy and Childbirth database is an ongoing meta-analysis of evidence documenting effective health care practices for childbearing women and their neonates. It is proving invaluable to nurse educators, researchers, clinicians, and administrators working in a variety of health care delivery settings. Evidence-based nursing practice that is safe and effective can enhance rather than overpower pivotal and celebratory life events such as childbirth.

Partogram action line study: a randomised trial

OBJECTIVE

To assess the effect of three different partograms on caesarean section and maternal satisfaction.

DESIGN

Prospective randomised clinical trial.

SETTING

Regional teaching hospital in North West of England.

PARTICIPANTS

Nine hundred and twenty-eight primigravid women with uncomplicated pregnancies who presented in spontaneous labour at term.

INTERVENTIONS

The women were randomised to have their progress of labour recorded on a partogram with an action line 2, 3 or 4 hours to the right of the alert line. If the progress reached the action line, a diagnosis of prolonged labour was made. Prolonged labour was managed according to the standard ward protocol.

MAIN OUTCOME MEASURES

Primary: Caesarean section rate and maternal satisfaction; secondary: need for augmentation, duration of labour, analgesia, cord blood gas analysis, postpartum haemorrhage, number of vaginal examinations, Apgar score and admission to special care baby unit.

RESULTS

Caesarean section rate was lowest when labour was managed using a partogram with a 4-hour action line. The difference between the 3- and 4-hour partograms was statistically significant (OR 1 8, 95% CI 1.1-3.2), but the difference between 2 and 4 hours was not (OR 1.4, 95% CI 0.8-2.4). The women in the 2-hour arm were more satisfied with their labour when compared to the women in the 3-hour (P < 00001) and 4-hour (P <00001) arm.

CONCLUSION

Our data suggest that women prefer active management of labour. It is possible that partograms which favour earlier intervention are associated with higher caesarean section rate. As the evidence on which to base the choice of partograms remains inconclusive further research is required.

Changing childbirth: lessons from an Australian survey of 1336 women

OBJECTIVE

To investigate the views and experiences of care in labour and birth of a representative sample of women who gave birth in Victoria, Australia in 1993.

DESIGN

Cross-sectional survey mailed to women 6-7 months after giving birth.

POPULATION

All women who gave birth in a two week period in Victoria, Australia in September 1993, except those who had a stillbirth or neonatal death.

RESULTS

After adjusting for parity, the risk status of the pregnancy, and social and obstetric factors, specific aspects of care with the greatest negative impact on the overall rating of intrapartum care were: caregivers perceived as unhelpful (midwives: adjusted OR 12.03 [95% CI 7.8-18.6], doctors: adjusted OR 6.76 [95% CI 4.4-10.3]); and having an active say in decisions only sometimes, rarely or not at all (adjusted OR 8.90 [95% CI 4.9-16.1]). In a separate regression analysis including parity, risk status, obstetric and social factors, but not specific aspects of care, factors associated with dissatisfaction with intrapartum care included: participation in shared antenatal care programme (adjusted OR 1.89 [95% CI 1.2-3.0]) and being of nonEnglish speaking background (adjusted OR 1.70 [95% CI 1.1-2.6]). The following factors lowered the odds of dissatisfaction: attending a birth centre (adjusted OR 0.34 [95% CI 0.1-1.0]) and knowing the midwives before going into labour (adjusted OR 0.68 [95% CI 0.5-0.9]).

CONCLUSION

The survey demonstrates the potential for 'new' models of care to have either positive or negative effects on women's experiences of care. Evaluation of innovations in perinatal care taking into account women's views is a prerequisite for improvements in maternity care.