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Background: Vaginal examination to monitor labor progress is recommended at least every 4 hours, but it can cause pain and embarrassment to women. Trial data are limited on the best intensity for vaginal examination. Vaginal examination is not needed for oxytocin dose titration after an amniotomy has been performed and oxytocin infusion started. The Foley balloon commonly ripens the cervix without strong contractions. Amniotomy and oxytocin infusion are usually required to drive labor., Objective: This study aimed to evaluate the first vaginal examination at 8 vs 4 hours after amniotomy-oxytocin after Foley ripening in multiparous labor induction., Study Design: A randomized controlled trial was conducted from October 2021 to September 2022 at the University Malaya Medical Center, Kuala Lumpur, Malaysia. Multiparas at term were recruited at admission for labor induction. Participants were randomized to a first routine vaginal examination at 8 or 4 hours after Foley balloon ripening and amniotomy. Titrated oxytocin infusion was routinely commenced after amniotomy to initiate contractions. The 2 primary outcomes were the time from amniotomy to delivery (noninferiority hypothesis) and maternal satisfaction (superiority hypothesis). Data were analyzed using the Student t test, Mann-Whitney U test, and chi-square test (or Fisher exact test), as suitable for the data., Results: A total of 204 women were randomized, 102 to each arm. Amniotomy to birth intervals were 4.97±2.47 hours in the 8-hour arm and 5.79±3.17 hours in the 4-hour arm (mean difference, -0.82; 97.5% confidence interval, -1.72 to 0.08; P=.041; Bonferroni correction), which were noninferior within the prespecified 2-hour upper margin, and the maternal satisfaction scores (11-point 0-10 numerical rating scale) with allocated labor care were 9 (interquartile range, 8-9) in the 8-hour arm and 8 (interquartile range, 7-9) in the 4-hour arm (P=.814). In addition, oxytocin infusion to birth interval difference was noninferior within the 97.5% confidence interval (-1.59 to 0.23) margin of 1.3 hours. Of the maternal outcomes, the amniotomy to first vaginal examination intervals were 3.9±1.8 hours in the 8-hour arm and 3.4±1.3 hours in the 4-hour arm (P=.026), and the numbers of vaginal examinations were 2.00 (interquartile range, 2.00-3.00) in the 8-hour arm and 3.00 (interquratile range, 2.00-3.25) in the 4-hour arm (P<.001). For the 8-hour arm, the first vaginal examination was less likely to be as scheduled and more likely to be indicated by sensation to bear down (P<.001), and the epidural analgesia rates were lower (13/102 participants [12.7%] in the 8-hour arm vs 28/102 participants [27.5%] in the 4-hour arm; relative risk, 0.46; 95% confidence interval, 0.26-0.84; P=.009). Other outcomes of the mode of delivery, indications for cesarean delivery, and delivery blood loss were not different. Neonatal outcomes were not different., Conclusion: Routine first vaginal examination at 8 hours compared with that at 4 hours was noninferior for the time to birth but did not improve maternal satisfaction., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Outpatient term preinduction cervical ripening with mechanical agents has been associated with reduced length of stay, decreased cesarean delivery rates, low maternal and neonatal complications, and increased incidence of vaginal delivery within 24 hours., Objective: This study aimed to demonstrate equivalent efficacy between synthetic hygroscopic dilators and the single-balloon catheter for outpatient cervical ripening., Study Design: This randomized control equivalence trial compared synthetic hygroscopic dilators with the 30-mL silicone single-balloon catheter in primiparous and multiparous patients undergoing labor induction. The primary outcome was time from admission to delivery, with a prespecified 3-hour margin of equivalence. The secondary objectives were patient outcomes and perspectives., Results: Between March 1, 2019, and May 31, 2021, 1605 patients met the screening criteria, and 174 patients completed the study. The mean admission-to-delivery time was equivalent at 18.01 hours for the dilator group vs 17.55 hours for the balloon group (P=.04). The cesarean delivery rate of primiparous patients was similar at 28.1% with dilators vs 29.7% with the balloon. The groups had similar median cervical dilation and pain scores on insertion and admission. Overall patient satisfaction was high, 92.8% with dilators vs 96.2% with the balloon. The balloon group had significantly higher rates of early admission and device expulsion., Conclusion: Although the enrollment goal was not met, our study suggests that synthetic hygroscopic dilators and the single-balloon catheter for outpatient cervical ripening are both efficacious with similar time from admission to delivery, pain scores, and patient satisfaction with the procedure., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Neonatal and maternal risks increase in term pregnancy as gestational age advances and become increasingly evident post-term. Management practices of late- and post-term pregnancies vary, and the optimal time point for intervention by labor induction is yet to be determined., Material and Methods: This randomized controlled trial of 381 nulliparous women with unripe cervices compared labor induction at 41 +0 gestational weeks (early induction) with expectant management and labor induction at 41 +5 to 42 +1 gestational weeks (expectant management). This multicenter study included all five university hospitals and the largest central hospital in Finland. The study period was 2018-2022. Participants were randomized to either early induction (48.8%, n = 186) or expectant management (51.2%, n = 195) with equal randomization ratios of 1:1. This was a superiority trial, and the primary outcomes were rates of cesarean section (CS) and composite of adverse neonatal outcomes. The trial was registered at the ISRCTN registry (ISRCTN83219789, https://doi.org/10.1186/ISRCTN83219789)., Results: The rates of CS (16.7% [n = 31] vs. 24.1% [n = 47], RR 0.7 [95% CI: 0.5-1.0], p = 0.07) and a composite of adverse neonatal outcomes (9.7% [n = 18] vs. 14.4% [n = 28], RR 0.7 [95% CI: 0.4-1.2] p = 0.16) did not significantly differ between the groups, but the operative delivery rate was lower in the early induction group than in the expectant management group (30.6% [n = 57] vs. 45.6% [n = 89], p = 0.003). The rates of hemorrhage ≥1000 mL and neonatal weight ≥4000 g were also lower in the early induction group, as was the vacuum extraction rate in women with vaginal delivery. Of the women with expectant management, 45.6% (n = 89) had spontaneous onset of labor. No perinatal deaths occurred, but one case of eclampsia appeared in the expectant management group., Conclusions: Offering labor induction to nulliparous women at 41 +0 gestational weeks may decrease the probability of operative delivery, postpartum hemorrhage, and neonatal weight ≥4000 g. However, this study was underpowered to affirm the trends of rising rates of CS and adverse neonatal outcomes in the expectant management group. Thus, expectant management could remain an option for some, as one in two women with expectant management had a spontaneous onset of labor., (© 2023 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Background: With the increasing popularity of elective induction after 39 + 0 weeks, the question of whether induction of labor (IOL) is safe in women with isolated polyhydramnios has become more relevant. We aimed to evaluate the pregnancy outcomes associated with IOL among women with and without isolated polyhydramnios. Methods: This was a multicenter retrospective cohort that included women who underwent induction of labor at term. The study compared women who underwent IOL due to isolated polyhydramnios to low-risk women who underwent elective IOL due to gestational age only. The main outcome measure was a composite adverse maternal outcome, while the secondary outcomes included maternal and neonatal adverse pregnancy outcomes. Results: During the study period, 1004 women underwent IOL at term and met inclusion and exclusion criteria; 162 had isolated polyhydramnios, and 842 had a normal amount of amniotic fluid. Women who had isolated polyhydramnios had higher rates of the composite adverse maternal outcome (28.7% vs. 20.4%, p = 0.02), prolonged hospital stay, perineal tear grade 3/4, postpartum hemorrhage, and neonatal hypoglycemia. Multivariate analyses revealed that among women with IOL, polyhydramnios was significantly associated with adverse composite maternal outcome [aOR 1.98 (1.27-3.10), p < 0.01]. Conclusions: IOL in women with isolated polyhydramnios at term was associated with worse perinatal outcomes compared to low-risk women who underwent elective IOL. Our findings suggest that the management of women with polyhydramnios cannot be extrapolated from studies of low-risk populations and that clinical decision-making should take into account the individual patient's risk factors and preferences.

Background: Misoprostol is widely used for cervical ripening and labour induction as it is heat-stable and inexpensive. Oral misoprostol 25 μg given 2-hourly is recommended over vaginal misoprostol 25 μg given 6-hourly, but the need for 2-hourly fetal monitoring makes oral misoprostol impractical for routine use in high-volume obstetric units in resource-constrained settings., Objectives: To compare the efficacy and safety of oral misoprostol initiated at 25 or 50 μg versus 25 μg vaginal misoprostol given at 4- to 6-hourly intervals for labor induction in women at or beyond term (≥ 37 weeks) with a single viable fetus and an unscarred uterus., Search Strategy: We identified eligible randomized, parallel-group, labor-induction trials from recent systematic reviews. We additionally searched PubMed, Cochrane CENTRAL, Epistemonikos, and clinical trials registries from February 1, 2020 to December 31, 2022 without language restrictions. Database-specific keywords for cervical priming, labor induction, and misoprostol were used., Selection Criteria: We excluded labor-induction trials exclusively in women with ruptured membranes, in the third trimester, and those that initiated misoprostol at doses not specified in the review's objectives. The primary outcomes were vaginal birth within 24 h, cesarean section, perinatal mortality, neonatal morbidity, and maternal morbidity. The secondary outcomes were uterine hyperstimulation with fetal heart rate changes, and oxytocin augmentation., Data Collection and Analysis: Two or more authors selected studies independently, assessed risk of bias, and extracted data. We derived pooled weighted risk ratios with 95% confidence intervals (CIs) for each outcome, subgrouping trials by the dose and frequency of misoprostol regimens. We used the I 2 statistic to quantify heterogeneity and the random-effects model for meta-analysis when appropriate. We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach to assess certainty (confidence) in the effect estimates., Main Results: Thirteen trials, from Canada, India, Iran, and the US, randomizing 2941 women at ≥37 weeks of gestation with an unfavorable cervix (Bishop score <6), met the eligibility criteria. Five misoprostol regimens were compared: 25 μg oral versus 25 μg vaginal, 4-hourly (three trials); 50 μg oral versus 25 μg vaginal, 4-hourly (five trials); 50 μg followed by 100 μg oral versus 25 μg vaginal, 4-hourly (two trials); 50 μg oral, 4-hourly versus 25 μg vaginal, 6-hourly (one trial); and 50 μg oral versus 25 μg vaginal, 6-hourly (two trials). The overall certainty in the evidence ranged from moderate to very low, due to high risk of bias in 11/13 trials (affecting all outcomes), unexplained heterogeneity (1/7 outcomes), indirectness (1/7 outcomes), and imprecision (4/7 outcomes). Vaginal misoprostol probably increased vaginal deliveries within 24 h compared with oral misoprostol (risk ratio [RR] 0.82, 95% CI 0.70-0.96; 11 trials, 2721 mothers; moderate-certainty evidence); this was more likely with 4-hourly than with 6-hourly vaginal regimens. The risk of cesarean sections did not appreciably differ (RR 1.00, 95% CI 0.80-1.26; 13 trials, 2941 mothers; very low-certainty evidence), although oral misoprostol 25 μg 4-hourly probably increased this risk compared with 25 μg vaginal misoprostol 4-hourly (RR 1.69, 95% CI 1.21-2.36; three trials, 515 mothers). The risk of perinatal mortality (RR 0.67, 95% CI 0.11-3.90; one trial, 196 participants; very low-certainty evidence), neonatal morbidity (RR 0.84, 95% CI 0.67-1.06; 13 trials, 2941 mothers; low-certainty evidence), and maternal morbidity (RR 0.83, 95% CI 0.48-1.44; 6 trials; 1945 mothers; moderate-certainty evidence) did not differ appreciably. The risk of uterine hyperstimulation with fetal heart rate changes may be lower with oral misoprostol (RR 0.70, 95% CI 0.52-0.95; 10 trials, 2565 mothers; low-certainty evidence). Oxytocin augmentation was probably more frequent with oral compared with vaginal misoprostol (RR 1.29, 95% CI 1.10-1.51; 13 trials, 2941 mothers; moderate-certainty evidence)., Conclusions: Low-dose, 4- to 6-hourly vaginal misoprostol regimens probably result in more vaginal births within 24 h and less frequent oxytocin use compared with low-dose, 4- to 6-hourly, oral misoprostol regimens. Vaginal misoprostol may increase the risk of uterine hyperstimulation with fetal heart changes compared with oral misoprostol, without increasing the risk of perinatal mortality, neonatal morbidity, or maternal morbidity. Indirect evidence indicates that 25 μg vaginal misoprostol 4-hourly may be more effective and as safe as the recommended 6-hourly vaginal regimen. This evidence could inform clinical decisions in high-volume obstetric units in resource-constrained settings., (© 2023 International Federation of Gynecology and Obstetrics.)

Purpose: Prolonged duration of intrapartum oxytocin exposure is included as a risk factor within widely adopted obstetric hemorrhage risk stratification tools. However, the duration of exposure that confers increased risk is poorly understood. This study aimed to assess the association between duration of intrapartum oxytocin exposure and obstetric blood loss, as measured by quantitative blood loss, and hemorrhage-related maternal morbidity., Methods: This was a retrospective cohort study of all deliveries from 2018 to 2019 at a single medical center. We included patients who had received any intrapartum oxytocin, and we categorized them into 1 of 5 groups: > 0-2, ≥ 2-4, ≥ 4-6, ≥ 6-12, and ≥ 12 h of intrapartum oxytocin exposure. The primary outcomes were mean quantitative blood loss, proportion with obstetric hemorrhage (defined as quantitative blood loss ≥ 1000 mL), and proportion with obstetric hemorrhage-related morbidity, a composite of hemorrhage-related morbidity outcomes. Secondary outcomes were hemorrhage-related pharmacologic and procedural interventions. A stratified analysis was also conducted to examine primary and secondary outcomes by delivery mode., Results: Of 5332 deliveries between January 1, 2018 and December 31, 2019 at our institution, 2232 (41.9%) utilized oxytocin for induction or augmentation. 326 (14.6%) had exposure of > 0-2 h, 295 (13.2%) ≥ 2-4 h, 298 (13.4%) ≥ 4-6 h, 562 (25.2%) ≥ 6-12 h, and 751 (33.6%) ≥ 12 h. Across all deliveries, there was higher mean quantitative blood loss (p < 0.01) as well as increased odds of obstetric hemorrhage (adjusted odds ratio [aOR] 1.52, 95% confidence interval [CI] 1.21-1.91) for those with ≥ 12 h of oxytocin compared to all groups between > 0-12 h of exposure. In our stratified analysis, ≥ 12 h of oxytocin exposure was associated with higher mean quantitative blood loss (p = 0.04) and odds of obstetric hemorrhage in vaginal deliveries (aOR 1.47, 95% CI: 1.03-2.11), though not in cesarean deliveries (aOR 1.16, 95% CI 0.82-1.62). There were no differences in proportion with obstetric hemorrhage-related morbidity across all deliveries (p = 0.40) or in the stratified analysis., Conclusion: Intrapartum oxytocin exposure of ≥ 12 h was associated with increased quantitative blood loss and odds of obstetric hemorrhage in vaginal, but not cesarean, deliveries., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: This study aimed to evaluate the bibliographic references available on the contribution of acupuncture as a strategy to avoid labor induction and the methodology used; and explore the characteristics of the population and the results of the intervention in order to direct the design of future studies., Data Source: A systematic search for publications between January 2000 and September 2023 of the CENTRAL, PubMed, CINAHL, SCOPUS, ClinicalTrials.gov, and EUDRACT databases was performed., Study Eligibility Criteria: We included randomized clinical trials of pregnant women who underwent acupuncture before labor induction with a filiform needle or acupressure, including at least 1 of the following outcomes: spontaneous labor rate, time from procedure to delivery, and cesarean delivery rate. Articles published in English or German language were included., Methods: Whenever possible, a meta-analysis using RevMan software was performed using a random effects model with the I2 statistic because important heterogeneity in the different acupuncture treatments was expected. When enough data were available, the effect of the participants' characteristics on the results of the interventions were explored using the following subgroups: 1-Age (≥35 vs <35 years), and 2- body mass index (≥30 vs <30 kg/m 2 ). When a meta-analysis was not possible, a narrative synthesis of the results was performed. The quality of the evidence was assessed using GRADE., Results: Seventeen studies including 3262 women fulfilled our inclusion criteria. The meta-analysis showed no statistically significant differences between groups for outcomes (relative risk, 1.00; 95% confidence interval, 0.91-1.10; I 2 , 11%) comparing acupuncture vs sham acupuncture. However, there was a statistically significant increase in the spontaneous onset of labor rate favoring acupuncture vs no acupuncture (relative risk, 1.12; 95% confidence interval, 1.03-1.23; I 2 , 25%). Regarding the age analysis, no differences between groups were observed in the spontaneous labor rate and cesarean delivery rate for acupuncture vs sham and acupuncture vs no acupuncture comparisons (difference between groups, P>.05)., Conclusion: This study suggests that acupuncture may be beneficial in reducing the rate of induction of labor; however, well-designed randomized controlled trials are necessary. Maternal age ≥35 years and a high body mass index were underrepresented, and the findings may not be representative of the current population in our context., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: Small-for-gestational-age (SGA) pregnancy is a condition often leading to labor induction due to concerns about the possibility of an increased risk for fetal morbidity and mortality. In this retrospective cohort study, we try to evaluate the safety of oral misoprostol for labor induction in near-term and term pregnancies in SGA fetuses compared to dinoprostone as well as to planned primary cesarean section. Materials and methods: Retrospective analysis of labor indution and primary cesarean section in SGA pregnancies 37 weeks and beyond in a tertiary care centre. In total, 284 consecutive patients with SGA fetuses were included. 80 recieved oral misoprostol, 85 dinoprostone as vaginal Gel and 119 were delivered by means of primary cesarean section. Primary endpoints were umbilical aterial pH and APGAR 5′. Secondary endpoints were APGAR 1′ and 10′, rates of relevant acidosis with a pH < 7.11 and depressed children, NICU admissions and vaginal operative deliveries as well as cesarean sections after labor induction. Results: No significant differences were found concerning the umbilical arterial pH. No significant differences were found concerning APGAR 5′ after labor induction; however, APGAR 5′ was significantly lower after primary cesarean section. Similar results were found concerning APGAR 1′, 10-min APGAR values were not significantly different. Rates of relevant acidosis and depressed children did not differ; no significant differences were found concerning NICU admissions between all groups and vaginal operative deliveries and CS rates after labor induciton. Conclusion: Oral misoprosol is a safe method for labor induction in SGA near-term and term pregnancies and, concerning the neonatal outcome, comparable with other methods of labor induction or primary CS. Our study showed no adverse neonatal outcomes related to the use of oral misoprostol. [ABSTRACT FROM AUTHOR]

Objective: To examine the awareness, prevalence of use, and knowledge of risks of pepper injection (PI), an injection of highly concentrated oxytocin used to augment or induce labor, among clinicians. Methods: An anonymous pre‐ and post‐workshop evaluation conducted among 227 clinicians participating in emergency obstetric and newborn care training in Sierra Leone from June to October 2018. Results: Overall, 225 participants completed the surveys. Of these, 198 (88.0%) of clinicians reported awareness of PI, and 123 (54.7%) self‐reported prior use, which was highest among midwives (94/129; 72.9%). Before EmONC training, 82 (36.4%) clinicians reported that they were likely to use PI; this decreased to 39 (17.3%) after training (P<0.05). The mean number of participants correctly identifying risks of PI increased from 149 (66.2%) to 204 (90.7%) after training (P<0.05). Conclusion: There was widespread awareness of PI use among clinicians, and prevalent self‐reported prior use among midwives. Risk awareness improved after EmONC training, and the proportion of clinicians reporting likelihood of future use decreased. Improper use of oxytocin may be a major contributor to maternal and newborn morbidity and mortality in Sierra Leone. Initiatives to educate clinicians and to regulate and stop the practice are needed. Synopsis: Most midwives undergoing an obstetric training program in Sierra Leone reported prior use of pepper injection—namely, highly concentrated oxytocin—for labor augmentation or induction. [ABSTRACT FROM AUTHOR]

Purpose: Evaluation of simplified Bishop score and ultrasound cervicometry in the assessment of labor induction success in nulliparous women. Methods: Prospective cohort study included 146 nulliparous women with singleton pregnancy and indications for labor induction. Prior to labor induction, cervicometry and Bishop score were determined. Upon delivery, patients were classified as those delivered vaginally and by cesarean section (CS) after unsuccessful labor induction. Results: Bishop score >5 was found in 47.95% of vaginally delivered women and 12.33% of patients delivered by CS (p <.01). Cervicometry had appropriate findings in 34.2% of vaginally delivered women and 75.3% of those delivered by CS (p <.01). Bishop score (>5 versus ≤5) had lower sensitivity (52.05%) and specificity (12.33%) than cervicometry (good versus unfavorable findings) (sensitivity 65.75%, specificity 75.34%) for prediction of labor induction success. If Bishop score was ≤5, cervicometry had 50.0% sensitivity and 78.13% specificity, while if Bishop score was >5, 82.86% sensitivity and 55.56% specificity. Obtained model for predicting labor induction outcome in nulliparous women based on their clinical and ultrasonographical characteristics identified the Bishop score as the most important predictor. Conclusions: Study confirmed the usefulness of simplified Bishop score and ultrasound cervicometry in the assessment of labor induction success in nulliparous women. [ABSTRACT FROM AUTHOR]

Objectives: This study aims to investigate the independent influence of maternal age on the risk of emergency cesarean section (CS) due to nonreassuring fetal heart rate or arrest disorder. Methods: This was a cross-sectional study on women with nulliparous pregnancies, who are attempting vaginal delivery at term and have a cephalic presentation without the indication of elective CS at the onset of labor. The primary outcome was the rate of emergency CS. Independent risk factors were elucidated using multivariate logistic regression analysis. Results: Of 3513 women, 541 (15.4%) delivered by emergency CS during a trial of vaginal delivery, with theses being due to nonreassuring fetal heart rate (N = 150) or arrest disorder (N = 391). In univariate analysis, both individual CS rate due to nonreassuring fetal heart rate or arrest disorder and total emergent CS rate increased with maternal age. The risk of emergency CS was also significantly higher when labor induction was performed (odds ratio (OR) 2.489, 95% confidence interval (CI) 2.043–3.033), while fetal weight was heavier (neonatal weight ≥3.5 kg; OR 2.396, 95% CI 1.956–2.934), and maternal BMI was higher (before pregnancy ≥25 kg/m2; OR 2.751, 95% CI 1.980–3.823, at delivery ≥28 kg/m2; OR 2.375 95% CI 1.915–2.946). Multivariate stepwise regression analysis showed a statistically significant increase in the risk of total emergency CS in mothers over 35 years of age, compared to that in women less than 30 years old (35–39 years group; adjusted OR 1.805 95% CI 1.347–2.418, ≥40 years group; adjusted OR 4.659 95% CI 2.709–8.013). CS due to nonreassuring fetal heart rate increased in mothers over 40 years of age (adjusted OR 5.354, 95% CI 2.386–12.017) and CS due to arrest disorder was also increased in mothers over 30 years of age (30–34 years group; adjusted OR 1.343, 95% CI 1.010–1.785, 35–39 years group; adjusted OR 1.906, 95% CI 1.357–2.679, ≥40 years group; adjusted OR 4.663, 95% CI 2.480–8.768). Similar to the result of univariate analysis, labor induction increased the risk of emergency CS (adjusted OR 2.241, 95% CI 1.828–2.747). Conclusions: Advanced maternal age is an independent risk factor of emergency CS due to nonreassuring fetal heart rate or arrest disorder during the trial of vaginal delivery. The risk of emergency CS was also increased when labor induction was performed. Therefore, the risk of emergency CS needs to be considered, especially when the labor induction is planned, in women aged 40 or more. [ABSTRACT FROM AUTHOR]

Background: A history of previous cardiac disease increases the maternal mortality risk by as much as 100%. There is no consensus on the absolute contraindications to vaginal delivery in valvular heart disease, but central regional anesthesia is traditionally considered contraindicated in patients with severe aortic stenosis.Case Presentation: A 29-year-old primigravid woman with severe aortic stenosis was admitted to the obstetrics department for programmed labor induction. With epidural anesthesia and mini-invasive hemodynamic monitoring labor and operative vaginal delivery were well tolerated, and hemodynamic stability was always maintained.Conclusions: Epidural analgesia and oxytocin induction are possible for the labor management of parturients with severe aortic stenosis given that continuous non-invasive followed by invasive hemodynamic monitoring can be provided and given the absence of any obstetric or cardiologic contraindications and the strong will of the patient. [ABSTRACT FROM AUTHOR]

Objective: To compare the Bishop score and cervical length measured by transvaginal ultrasound concerned with prediction over the success of labor induction. Methods: This cross-sectional observational analytical study was conducted from May 2017 to October 2017 at several teaching hospitals of Obstetrics and Gynecology Department, Faculty of Medicine Hasanuddin University of Makassar, India. There were 110 samples of pregnant women undergoing labor induction process including 79 samples of successful induction and 31 samples of induction failure. The data analysis used Pearson Chi-square test and multivariate logistic regression to see the effect of Bishop score and measurement of cervical length with successful induction of labor. Results: Number of samples with successful labor induction with Bishop score ⩾3 was 25 (31.6%) and Bishop score was 54 (68.4%), with rate ratio=3.714 and P=0.000. With measurement of cervical length (cut-off point 2.98 cm), number of samples with successful labor induction with cervical length ⩽2.98 cm was 12 (15.2%) and cervical length >2.98 cm was 67 (84.8%), with rate ratio=3.124 and P=0.000. Multivahate analysis of logistic regression was found to be more influential in the predicted success of labor induction (P=0.014 with Bishop score

Abstract Background Since Misoprostol Vaginal Insert (MVI - Misodel ®) was approved for labor induction in Europe in 2013, to date, no study has been published comparing MVI to Misoprostol vaginal tablets (MVT). The aim of this study, performed as part of a quality improvement project, was to compare the efficacy and safety of 200 μg MVI versus 25 μg MVT for labor induction in nulliparous women. Methods This retrospective cohort study included 171 nulliparous singleton term deliveries induced with MVI (n = 85) versus MVT (n = 86) at Oslo University Hospital Rikshospitalet, Norway, from November 2014 to December 2015. Primary outcomes were time from drug administration to delivery in hours and minutes and the rate of cesarean section (CS). Results were adjusted for Bishop Score and pre-induction with balloon catheter. Results Median time from drug administration to delivery was shorter in the MVI group compared to the MVT group (15 h 43 min versus 19 h 37 min, p = 0.011). Adjusted for confounding factors, mean difference was 6 h 3 min (p = 0.002). The risk of CS was 67% lower in the MVI group compared to the MVT group (11.8% versus 23.3%, OR = 0.33; adjusted 95% CI 0.13–0.81). Adverse neonatal outcomes did not differ between the groups. Conclusions In a setting of routine obstetric care, MVI seems to be a more efficient labor induction agent than MVT, and with a lower CS rate and no increase in adverse infant outcomes.

Objective: To compare the effect of misoprostol combined with a cervical single or double-balloon catheter versus misoprostol alone for labor induction of singleton pregnancies with an unfavorable cervix.Methods: Systematic review and meta-analysis of randomized controlled trials (RCTs) regarding the comparison of two schemes for labor induction of singleton cephalic pregnancies with a Bishop score ≤7 and no contraindication for vaginal delivery. Six research databases were searched for articles published in all languages up to 10 May 2018 comparing misoprostol (oral or vaginal) in combination with a cervical placed single or double balloon catheter versus misoprostol treatment alone. Random effects models and inverse variance were used for meta-analyses. Summary measures were mean differences (MDs) and risk ratios (RRs) with 95% confidence interval (CI). Risk of bias was evaluated with the Cochrane tool and publication bias was assessed with Begg's and Egger's tests.Results: Fifteen RCTs reported predefined outcomes. Pooled analyses showed that the combined treatment (misoprostol + catheter) was associated with a shorter induction to delivery time interval (MD = -1.99 hours; 95% CI: -3.42, -0.56); in addition to fewer uterine hyperstimulations (RR = 0.39; 95% CI: 0.23, 0.67) and Neonatal Intensive Care Unit (NICU) admissions (RR = 0.75; 95% CI: 0.58, 0.97) as compared to misoprostol alone. There were no significant differences in RRs for tachysystole, chorioamnionitis, cesarean delivery rate, birthweight, and Apgar score at 5 minutes.Conclusion: The combined use of misoprostol and a cervical balloon catheter reduces the intervention to delivery time interval and number of NICU admissions in women induced with an unfavorable cervix. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to evaluate if maternal serum hormones along the maternal–fetal hypothalamic–pituitary–adrenal (HPA) axis, when drawn prior to labor induction, differed between women who delivered vaginally and those who underwent cesarean. Study Design  This was a prospective observational study at a single perinatal center performed from August 2017 to May 2018. Nulliparous women with uncomplicated singleton pregnancies ≥39 weeks had maternal serum collected prior to induction. Corticotrophin-releasing hormone (CRH) was measured by ELISA; dehydroepiandrosterone sulfate (DHEA-S), cortisol, estriol (E 3) estradiol (E 2), and progesterone (P 4) were measured by chemiluminescent reaction. Mean analyte concentrations as well as three ratios (E 2 /P 4 , E 3 /P 4, and E 2 /E 3) were compared between women who had a vaginal versus cesarean delivery. Logistic regression was used to model the relationship between CRH and the odds of vaginal birth. We estimated that a sample size of 66 would have 90% power to detect a 25% difference in mean CRH levels assuming a vaginal:cesarean ratio of 2:1 with a baseline CRH concentration of 140 (standard deviation = 36) pg/mL. Results  Of the 88 women who had their serum analyzed, 27 (31%) underwent cesarean. Mean maternal serum CRH levels were similar between the vaginal delivery and cesarean groups (122.6 ± 95.2 vs. 112.3 ± 142.4, p  = 0.73). Similarly, there were no significant differences in any other maternal serum analytes or ratios. Logistic regression showed a nonsignificant odds ratio for successful vaginal birth (p  = 0.69) even when evaluating only the 16 women who had a cesarean for an arrest disorder (p  = 0.08). Conclusion  In low-risk nulliparous women undergoing full-term labor induction, there were no differences noted in a broad array of other maternal-fetal HPA-axis hormones between women who had a vaginal or cesarean delivery. [ABSTRACT FROM AUTHOR]

The aim of this study was to determine the predictive value of cervical length (CL) measurement in the result of labor induction in term nulliparous women who had a strict cervix. A total of 78 pregnancies were evaluated prospectively. Dinoprostone ovule was used for the induction of labor in all cases. Low dose oxytocin was administered for augmentation of the labor. Statistical analyses were performed using SPSS Version 24. A p-value <0.05 was determined as to be statistically significant. Dinoprostone's indication for labor induction was seen in 57.7% of cases at post-term pregnancy and unsafe fetal wellbeing observed in the remaining 42.3% of the patients. 59% of patients delivered their babies vaginally, and we performed a cesarean section in 41% of patients. The most cesarean indication was fetal distress (40.6%). The arrest of labor was considered in 31.2% of the patients and failed labor induction was observed in 28.1% of the patients. A significant correlation was found between CL and successful labor induction. The Area Under the Curve (AUC) for CL was: 0.6975 (95% CI: 0.5816-0.8134). The sensitivity and specificity of CL≤ 20 mm were 94% and 45%, respectively, while the positive and negative predictive values associated with it were 57% and 90%. Sensitivity was 23%, and specificity was 84% at the CL≥ 30 mm cut-off point. There was no significant difference between umbilical cord pH and the route of delivery (p: 0.185). Our study indicates that CL measurement is a highly effective method to predict labor induced, particularly in nulliparous and having unfavorable cervix. [ABSTRACT FROM AUTHOR]

This study aimed to explore the feasibility of transperineal virtual touch tissue quantification (VTQ) for predicting the outcome of labor induction. A total of 80 nulliparous pregnant women were included. Before labor induction, cervical length was measured by B-mode sonography, cervical stiffness was measured by VTQ, and Bishop score was assessed by vaginal examination. Subsequently, labor was induced using standard oxytocin infusion in all patients. Delivery within 24 hours after labor induction was classified as spontaneous delivery; otherwise, cesarean delivery was performed. Out of 80 participants, 48 (60%) delivered vaginally and 32 (40%) underwent cesarean delivery. The cervical length was significantly longer and the shear wave velocity (SWV) was greater in the cesarean delivery group than in the vaginal delivery group (p = 0.004 and p < 0.000, respectively). Logistic regression analysis indicated that only the mean SWV had independent predictive value for the outcome of labor induction (p = 0.011). The best diagnostic cut-off point of the mean SWV was 1.23 m/s, with a sensitivity of 93.8% and a specificity of 89.6%. Transperineal VTQ technique could predict the outcome of labor induction using oxytocin. [ABSTRACT FROM AUTHOR]

Background: The rate of induction of labor in the U.S. has risen from 9.6% in 1990 to 25.7% in 2018, including 31.7% of first-time births. Recent studies that have examined inductions have been small qualitative studies or relied on either medical records or administrative data. This study examines induction from the perspective of those women who experienced it, with a particular focus on the prevalence and predictors of inductions for nonmedical indications, women's experience of pressure to induce labor and the relationship between the attempt to medically initiate labor and cesarean section.Methods: Study data are drawn from the 2119 respondents to the Listening to Mothers in California survey who were planning to have a vaginal birth in 2016. Mothers were asked if there had been an attempt to medically initiate labor, if it actually started labor, if they felt pressured to have the induction, if they had a cesarean and the reason for the induction. Reasons for induction were classified as either medically indicated or elective.Results: Almost half (47%) of our respondents indicated an attempt was made to medically induce their labor, and 71% of those attempts initiated labor. More than a third of the attempts (37%) were elective. Attempted induction overall was most strongly associated with giving birth at 41+ weeks (aOR 3.28; 95% C.I. 2.21-4.87). Elective inductions were more likely among multiparous mothers and in pregnancies at 39 or 40 weeks. The perception of being pressured to have labor induced was related to higher levels of education, maternal preference for less medical intervention in birth, having an obstetrician compared to a midwife and gestational ages of 41+ weeks. Cesarean birth was more likely in the case of overall induction (aOR 1.51; 95% C.I. 1.11-2.07) and especially following a failed attempt at labor induction (aOR 4.50; 95% C.I. 2.93-6.90).Conclusion: Clinicians counselling mothers concerning the need for labor induction should be aware of mothers' perceptions about birth and engage in true shared decision making in order to avoid the maternal perception of being pressured into labor induction. [ABSTRACT FROM AUTHOR]

Purpose: The aim of our study was to assess the outcomes of a prolonged induction carried out with a second sequential cycle of pharmacological stimulation after unsatisfactory response to a first attempt, and to highlight variables correlated with higher response rates.Methods: A retrospective study was carried out on 157 women who underwent a two-step labor induction by vaginal prostaglandins followed by a second cycle of prostaglandins or intravenous oxytocin. Outcomes assessed were mode of delivery and maternal and neonatal morbidity. Main variables of pregnancy and delivery were collected to identify factors predicting the mode of delivery.Results: Among 157 patients, 63 (40.1%) achieved a vaginal delivery, whereas 94 (59.9%) underwent Cesarean section, 9 women (5.7%) had postpartum hemorrhage; in 2 cases (1.3%), an Apgar score < 7 at 5 min from birth was reported. Higher risk of Cesarean section was observed with advanced maternal age (OR 1.13 for additional year, CI 1.04-1.22) and nulliparity (OR 8.84, CI 2.69-29.06), whereas the response rates were better in carriers of group B streptococcus colonization (OR 0.38, CI 0.17-0.84) and in women with favorable cervical status after the first stimulation (OR 0.81 for additional point of Bishop score, CI 0.70-0.94).Conclusion: Labor induction with two cycles of pharmacological stimulation is a procedure with fairly good success rates and a low risk of maternal and neonatal complications. Factors predicting its success encompass younger age, parity, a positive recto-vaginal swab for group B streptococcus and a favorable cervix following the first cycle of stimulation. [ABSTRACT FROM AUTHOR]

Objective: The aim of this work was to identify independent risk factors influencing the achievement of vaginal delivery among women undergoing labor induction for late-onset fetal growth restriction (FGR).Methods: This was a retrospective cohort study of 201 singleton pregnancies with late-onset FGR (diagnosed >32 + 0 weeks) that required labor induction with cervical ripening from 37 + 0 weeks, either with dinoprostone (from 2014 to 2015) or Foley balloon (from 2016 to 2018). Independent factors for successful vaginal delivery were identified. A prediction model of vaginal delivery with the identified factors was made using logistic regression and bootstrapping with 1,000 re-samples performed for bias correction.Results: Perinatal results were more favorable in the vaginal delivery group, with significantly lower neonatal admission rates (4.0 vs. 13.7%) and lower composite neonatal morbidity (4.0 vs. 15.7%). The labor induction method (Foley balloon), higher cerebro-placental ratio, lower pre-gestational BMI, and absence of pre-eclampsia were identified as independent factors associated to vaginal delivery. The area under the curve of the model was of 0.75 (95% CI 0.70-0.79).Conclusions: The use of a Foley balloon is the only modifiable risk factor to improve the chances of vaginal delivery when attempting induction of labor in singleton pregnancies with late-onset FGR. [ABSTRACT FROM AUTHOR]

Introduction: preeclampsia/eclampsia contributed to 30% of maternal mortality in RSUP Dr. Kariadi. Pre-induction bishop score assessment is a standard for cervical maturity estimation. Other predictors currently being developed, including insulin-like growth factor binding protein-1 (IGFBP-1). However, there is no cut-off point for IGFBP-1 examination in full term pregnancy, especially with preeclampsia and its complications. Objective: to find IGFBP-1 levels and Bishop Score differences in preeclampsia women with induction labor. Methods: this prospective observational cohort study was conducted in preeclampsia women with gestational age ≥37 weeks planned labor induction at Obstetrics and Gynecology Ward RSUP Dr. Kariadi Semarang and networking hospital during study period (n=66). History taking, physical examination, proteinuria, cervical mucus IGFBP-1, and bishop score calculation was performed. Statistical analysis was performed with paired-t test, followed by ROC for cut-off value of successful induction prediction, and logistic regression to determine confounding variables effect on IGFBP-1 levels. Results: The average Bishop score of 66 subjects was 2.5±1.81 and 2.6±1.8 for women who deliver ≤24 labor and in labor for ≤12 hours, respectively. Although the bishop score was higher in the successful labor group, there was no significant difference between groups. Mean IGFBP-1 value was 8.29±5.033 mcg/L with median value of 10.8 mcg/L. Successful induction had significant higher IGFBP-1 levels with area-under-curve (AUC) 0.76 and 8.145 cutoff value (p=0.002, RR=5.1). Conclusion: IGFBP-1 level with cutoff point 8.145 can be used as predictor of successful labor induction in term pregnancy with preeclampsia. [ABSTRACT FROM AUTHOR]

Objective: The objective of this literature review is an evaluation of the current scientific evidence for acupuncture as a treatment for labor induction or cervical ripening. Design: Alt HealthWatch, CINAHL, and Medline with Full Text databases were searched to identify relevant studies between 1999 and 2020. Inclusion Criteria: Any study or systematic review of acupuncture to induce labor in human, pregnant at-term individuals. Exclusion Criteria: Animal studies, studies in languages other than English, studies of acupressure/acupuncture for pain with labor. Results: Five relevant studies met the inclusion criteria. Two of these studies were randomized controlled studies and two were systematic literature reviews. The fifth study was a theoretical article to inform physicians. The results of the randomized controlled studies and the systematic reviews are inconclusive as two had favorable outcomes and two had unfavorable outcomes. The sample sizes of all randomized controlled studies including those evaluated in the systematic literature reviews were inadequate to provide definitive results. Conclusion: There is a deficit of research into the field of acupuncture and obstetrics. There is a need for large scale, multi-center, well-designed, randomized controlled trials into acupuncture for induction of labor and cervical ripening. This review is limited by databases used and retrieval only of full text, which can result in excluding meta-analyses or other trials from the search. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to describe the effect of obesity on the duration of labor, specifically latent and active phases of labor, and on mode of delivery, among nulliparous women with epidural analgesia.Study design: We conducted a retrospective cohort study, comparing a sample of nulliparous obese women (body mass index ≥30 kg/m2, n = 121) with a random sample of normal weight nulliparous (18.5 kg/m2 ≤body mass index ≤25 kg/m2, n = 161). Analysis included all obese women delivered at the Department of Obstetrics and Gynecology of Centro Hospitalar, São João, Porto, Portugal between 1 January and 31 December, 2016. Only women submitted to epidural analgesia were included. Information on maternal age, obstetric history, current pregnancy and labor characteristics (gestational age, birthweight, mode of delivery, total duration of labor, latent and active phases duration) was retrieved from electronic obstetrical databases and labor charts.Results: In our department, the prevalence of maternal obesity was 12.0%. Obese women had a significantly higher rate of cesarean delivery (47.1 versus 27.3%), fewer normal vaginal deliveries (28.9 versus 32.9%) and fewer instrumental vaginal deliveries (24.0 versus 39.8%). Labor induction was significantly more frequent among obese women (51.2 versus 29.2%; p = 0.001). The median (interquartile range) for length of latent phase when labor was induced with prostaglandins in the obese group was 23.3 hours (20.9). This was significantly longer than in normal weight women -15.6 hours (13.15) (p = 0.001). However, there was no significant difference in latent phase duration when labor was induced with oxytocin (12.4 versus 9.4 hours; p = 0.150). The medians (interquartile range) for length of latent phase in spontaneous delivery -6.5 hours (6.8) versus 6.6 hours (6.5) did not differ (p = 0.992). The duration of active phase was not significantly different between obese and normal weight (5.1 versus 5.1 hours; p = 0.784). For spontaneous labor, there was no difference between the two groups in the total duration of labor (11.9 versus 11.3 hours; p = 0.573). But for induced labor, the total duration was significantly higher among obese women (31.1 versus 21.4 hours; p = 0.001).Conclusion: Latent phase was longer in obese than normal weight women undergoing labor induction with prostaglandins. Obesity had no effect on duration of active phase. Obese women undergoing labor induction had a longer total duration of labor, compared to normal weight women mainly due to prolonged latent phase. [ABSTRACT FROM AUTHOR]

Background: The cesarean birth rate in the United States is 32%, and there is discussion about the cause of high surgical birth rates. Our purpose was to determine whether mode of birth is influenced by maternal, nurse, and system factors. Methods: Secondary analysis of a data set of 163 women having postdates labor induction with oxytocin. Kaplan‐Meier survival curves were calculated to compare the time for patients to reach an infusion rate of 6 mU/min, consistent with endogenous oxytocin levels in active labor. We used the log‐rank test to evaluate survival curve differences. Multiple logistic regression and Cox proportional hazards models were conducted and included covariates that had statistically significant bivariate relationships with the time variable, or were clinically meaningful. Results: The mean time to reach 6 mU/min was longer for women who birthed by cesarean (172.5 minutes) than for women who had vaginal birth (125.0 minutes, P =.024). The mean time to reach 6 mU/min was also longer for women admitted on night shift (147.0 minutes) than day shift (110.2 minutes, P =.018). No maternal characteristics were significantly related to the time to reach a rate of 6 mU/min. Conclusions: Even during the initial hours of labor induction, it is important that the oxytocin infusion is titrated appropriately to aid women in achieving timely vaginal birth. Intrapartum nurses should receive education about the pharmacokinetics of intravenous oxytocin to understand proper administration of this high‐alert medication. [ABSTRACT FROM AUTHOR]

Objective: The goal of the study was to develop and validate a prediction model for cesarean delivery after labor induction that included factors known before the start of induction, unlike prior studies that focused on characteristics at the time of induction. Materials and Methods: Using 17,370 term labor inductions without documented medical indications occurring at 14 U.S. hospitals, 2007–2012, we created and evaluated a model predicting cesarean delivery. We assessed model calibration and discrimination, and we used bootstrapping for internal validation. We externally validated the model by using 2122 labor inductions from a hospital not included in the development cohort. Results: The model contained eight variables—gestational age, maternal race, parity, maternal age, obesity, fibroids, excessive fetal growth, and history of herpes—and was well calibrated with good risk stratification at the extremes of predicted probability. The model had an area under the curve (AUC) for the receiver operating characteristic curve of 0.82 (95% confidence interval 0.81–0.83), and it performed well on internal validation. The AUC in the external validation cohort was 0.82. Conclusion: This prediction model can help providers estimate a woman’s risk of cesarean delivery when planning a labor induction. [ABSTRACT FROM AUTHOR]

Background: A wide uterocervical angle >95° detected during the second trimester was associated with an increased risk for spontaneous preterm birth.Objective: We aimed to determine whether an ultrasonographic marker, uterocervical angle, correlates with satisfactory response to labor induction.Study design: We conducted a prospective cohort study from May 2016 through December 2017 of singleton term gestations undergoing transvaginal ultrasound for cervical length screening and uterocervical angle measurement. Uterocervical angle was measured between the lower uterine segment and the cervical canal. Latent phase duration >720 min was accepted to be a prolonged latent phase. The primary outcome was a prediction of satisfactory response to labor induction (latent phase duration <720 min).Results: Both anterior uterocervical angle (AUC = 0.802, p < .001) and the cervical length (AUC = 0.679, p < .05) significantly predicted satisfactory response to labor induction. Optimal cutoff value was obtained at the value of 97° (64% sensitivity, 91% specificity) for anterior uterocervical angle and 27 mm (64% sensitivity, 64% specificity) for the cervical length. Kaplan-Meier survival analysis showed that duration from labor induction to delivery was significantly higher in a group with longer cervical length (p = .04), additionally labor induction to delivery time was significantly higher in a group with lower UCA (p = .04).Conclusions: Both the cervical length and anterior uterocervical length were predictors for the satisfactory response to labor induction, and both parameters were found to be significantly associated with time from induction to delivery in survival analysis. [ABSTRACT FROM AUTHOR]

Objective  Our objective was to determine if obese women are more likely to require oxytocin rates > 20 mU/min to achieve vaginal delivery, compared with normal weight women. Study Design  This is a retrospective cohort study of deliveries at the MedStar Washington Hospital Center and MedStar Georgetown University Hospital. Results  There were 4,284 births included in the analysis. Thirty-three per cent of deliveries were among women classified as overweight (body mass index [BMI] 25–29.9 kg/m 2) and 58% were among women classified as obese (BMI >30.0 kg/m 2), 12% were classified as class III obesity (BMI >40 kg/m 2). Overall 110 (2.6%) women required an oxytocin rate of >20 mU/min. Doses of oxytocin >20 mU/min for women in the overweight, class I obesity, and class II obesity groups were 2.6, 1.9, and 1.6%, respectively. Deliveries among women with class III obesity had a significantly longer duration of oxytocin exposure (10.7 hours) compared with the normal weight group (8.2 hours, p  < 0.001), and had a higher maximum rate of oxytocin compared (10 mU/min) to normal weight women (8 mU/min, p  < 0.001). Conclusion  Obese women are more likely to require oxytocin rates more than 20 mU/min, higher doses of oxytocin, and greater duration of oxytocin exposure to achieve a vaginal delivery. [ABSTRACT FROM AUTHOR]

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Introduction: In Denmark, the rate of induced labor from 37 gestational weeks has increased by 108% from 12.4% in 2000 to 25.1% in 2012, and today more than 1 in 4 deliveries are induced. Standard procedure at North Zealand Hospital changed in 2016 from a dosage of 50 µg oral misoprostol 2-3 times daily, to 25 µg up to 8 times daily. Also, since 2016 healthy women with uncomplicated pregnancies (primiparous and multiparous) have been offered induction as an outpatient procedure. This study aimed to compare the current low-dosage procedure (25 µg) with the former high-dosage procedure (50 µg) in terms of induction to delivery time, maternal and fetal outcomes, and risk of uterine hyperstimulation.Material and Methods: Data from June 2015 to October 2016 were included. Comparable baseline, demographic, and obstetric data for women induced according to high-dosage or low-dosage protocols were retrieved from local medical files. Descriptive statistics, Pearson's chi-squared tests, Kaplan-Meier survival estimates, and logistic regression analyses were performed.Results: The study included 816 induced deliveries. The high- and low-dosage groups differed in rates of plurality and place of induction. Induction to delivery times lasting longer than 72 hours were significantly decreased in the low-dosage group (adjusted odds ratio [aOR] 0.48, 95% confidence interval [95% CI] 0.27 to 0.86). Women in the low-dosage group also less often needed additional induction (P = 0.02), and the rate of uterine hyperstimulation was low irrespective of protocol (1% vs 3%, P = 0.16). There were no cases of uterine rupture in either group. The probability of vaginal delivery in the low-dosage group increased (adjusted hazard ratio 1.27, 95% CI 1.08 to 1.49), as did the risk of delivery with vacuum extraction (aOR 2.27, 95% CI 1.24 to 4.15), whereas delivery by cesarean section slightly decreased (aOR 0.89, 95% CI 0.59 to 1.33). The risk of meconium-stained liquor was nonsignificantly decreased (aOR 0.82, 95% CI 0.55 to 1.23).Conclusions: The low-dosage induction protocol was associated with favorable obstetric outcomes in terms of increased probability of vaginal delivery, but with higher risk of vacuum extraction. Protracted inductions and additional nonmedical interventions were reduced. There were no cases of uterine rupture. Statistically nonsignificant, the risk of uterine hyperstimulation was increased whereas the risk of meconium-stained liquor and of cesarean section was slightly decreased. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the effect of maternal body mass index (BMI) on the success of labor induction with a cervical ripening double-balloon catheter and maternal pain perception during the catheter insertion process. Methods: This observational study included 103 women with singleton pregnancies, who underwent labor induction with a double-balloon catheter at =39 weeks of gestation for obstetric indications. The study population was divided into two groups according to the BMI (group 1 <30 kg/m2 and group 2 =30 kg/m2). The two groups were compared in terms of their clinical characteristics, labor outcomes, cesarean delivery rate, delivery rate within 24 hours of insertion, and maternal pain perception during catheter insertion. Results: The two BMI groups showed no significant differences in the cesarean delivery rate (31.5% vs. 42.9%), the delivery rate within 24 hours of labor induction (85.2% vs. 81.6%), and Visual Analog Scale (VAS) score (4.8±2.9 vs. 4.6±2.5) (p>0.05). The cesarean delivery rate was 19.6% in multiparous women and 57.4% in nulliparous women (p<0.001). The median Bishop scores upon admission and at the time of balloon expulsion were higher in women who delivered vaginally than in those who underwent cesarean sections [4 (1-5) vs. 2 (1-5) and 7 (4- 11) vs. 6 (2-8), respectively, p<0.001]. The VAS scores recorded during double-balloon catheter insertion (4.8±2.9 vs. 4.6±2, p=0.772) were also similar in both groups. Conclusion: Maternal BMI did not affect the success of labor induction with a cervical ripening double-balloon catheter. Parity and Bishop scores were the factors influencing labor induction success. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this paper is to identify predictors of cesarean delivery (CD) in patients with an unfavorable cervix undergoing cervical ripening and labor induction with Foley catheter.Materials and methods: A retrospective cohort study of singleton pregnancies induced using Foley catheter was performed to evaluate whether factors in the maternal history and during the process of labor induction are useful in predicting the risk of CD.Results: During the study period there were 2221 births in the Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, Poland. From a cohort of 402 women with Foley catheter induction (FCI), 327 met inclusion criteria. There were 236 vaginal labors (72.2%) and 91 CDs (27.8%). Nulliparity (OR 2.344), Bishop score of 1-2 points (OR 1.473), and meconium-stained amniotic fluid (OR 1.980) are linked to the risk of CD. In nulliparous patients, factors associated with an increased risk of CD included maternal age greater than 30 years (OR 3.200), meconium-stained amniotic fluid (OR 2.505), and birthweight ≥3400 g (OR 1.803). Among multiparous women none of the evaluated factors was significantly connected to CD.Conclusions: Nulliparity, low Bishop score, and meconium-stained amniotic fluid are important risk factors of CD after FCI. [ABSTRACT FROM AUTHOR]

Labor induction is an activity that artifi cially stimulates uterine contractions. The defi nition of labor induction could be simplifi ed as “causing contractions of the uterus before their spontaneous onset that leads to the childbirth.” During pregnancy, certain obstetric conditions require the induction of labor. Thanks to various mechanical means and medications that speed up the cervix’s maturation and stimulate uterine contractions, maternal and perinatal morbidity, and mortality are reduced. Different methods: mechanical or pharmacological are used for labor induction, proposed for maturation and dilatation of the cervix, and stimulation of the uterine contractions. Labor naturally usually starts between 38 and 42 weeks of pregnancy, leading to a child’s birth. In non-laboring women beyond 41 gestational weeks or if a rupture of membranes occurs before labor, one should consider the method for its induction in the mother’s interest and child. [ABSTRACT FROM AUTHOR]

Abstract Purpose To assess cases of labor induction with vaginal 25-μg tablets of misoprostol and maternal outcomes in a tertiary hospital in southeastern Brazil. Methods This was a retrospective cohort study of 412 pregnant women with indication for labor induction. Labor induction was performed with vaginal 25-μg tablets ofmisoprostol in pregnant women with Bishop scores < 6. Stepwise regression analysis was used to identify the factors present at the beginning of induction that could be used as predictors of successful labor induction. Results A total of 69% of the pregnant women who underwent labor induction progressed to vaginal delivery, and 31% of the women progressed to cesarean section. One or two misoprostol tablets were used in 244 patients (59.2%). Of the 412 patients, 197 (47.8%) required oxytocin later on in the labor process, after induction with misoprostol. The stepwise regression analysis showed that only Bishop scores of 4 and 5 and previous vaginal delivery were independent factors with statistical significance in the prediction of successful vaginal labor induction (β = 0.23, p < 0.001, for a Bishop score of 4 and 5, and β = 0.22, p < 0.001, for previous vaginal delivery). Conclusion Higher Bishop scores and previous vaginal delivery were the best predictors of successful labor induction with vaginal 25-μg tablets of misoprostol.

Background: Decreased birth satisfaction has been associated with labor induction. Yet, there is a paucity of data evaluating risk factors for decreased satisfaction associated with labor induction. We aimed to determine what factors impact low birth satisfaction in labor induction and evaluate racial disparities in birth satisfaction.Methods: We performed a prospective cohort study of women with term, singleton gestations undergoing labor induction at our institution from Jan 2018 to Jun 2018. Women completed the validated Birth Satisfaction Scale-Revised postpartum, which is subdivided into 3 domains: (1) quality of care provision, (2) women's personal attributes, and (3) stress experienced during labor. A total satisfaction score above the mean was classified as "satisfied", and below as "unsatisfied." Domain and item scores were compared by race.Results: Three hundred thirty of 414 (79.7%) eligible women were included. There was no significant difference in birth satisfaction by age, body mass index, Bishop score, or labor induction agent. Black women were 75% more likely to be unsatisfied than non-Black women (54.0% vs. 37.2%, OR 1.75 [95% CI 1.11-2.76], p = 0.037), nulliparas were 71% more  likely to be unsatisfied than multiparas (54.2% vs. 40.9%, OR 1.71 [95% CI 1.09-2.67], p = 0.019), and women whose labor resulted in cesarean birth were almost 3 times more likely to be unsatisfied than women with a vaginal birth (67.4% vs. 42.3%, OR 2.82 [95% CI 1.69-4.70], p < 0.001). Additionally, increased labor length quartile was associated with decreased satisfaction >(p = 0.003). By race, domain 3 scores, which reflect preparedness for labor, were lower for Black women. No differences were seen for domain 1 or 2.Conclusions: Black race, cesarean birth, and increasing labor length were identified as risk factors for low birth satisfaction among women who underwent labor induction. Further studies should explore interventions to target women at risk for low birth satisfaction. [ABSTRACT FROM AUTHOR]

Objective: To compare the effectiveness and safety of oxytocin and a cervical ripening balloon in women with unfavorable cervices for inducing labor. Material and Methods: A total of eighty pregnant women between 37-41 gestational weeks having singleton pregnancies and intact membranes with unfavorable cervices were randomized into two groups, cervical ripening balloon (n=40) and oxytocin infusion (n=40). The primary outcomes were the labor time and the route of delivery. Secondary outcomes were the effect of parity on time of labor, and obstetric and perinatal outcomes. Results: The median time to delivery was 9.45 hours in cervical ripening balloon group and 13.2 hours in the oxytocin group in multiparous women. The differences were statistically significant (p<0.001). The median time until delivery was 11.48 hours in cervical ripening balloon group and 13.46 hours in the oxytocin group; the differences were statistically significant (p<0.001). Cesarean delivery ratios were similar in both groups (p=0.431). Conclusion: The results of the present study are promising for balloon use, especially in multiparous women. It is beneficial to support these data with wide ranging population-based studies. [ABSTRACT FROM AUTHOR]

Background: In obstetrics, labor induction is a common procedure. It has been proved that both single balloon catheters (Foley's catheter) and double balloon catheters (Cook cervical ripening balloon) are effective and relatively safe in cervical ripening and labor induction. This research aimed to compare the efficacy of single and double balloon catheter in the induction of labor with scarred uterus.Methods: 120 pregnant women who had prior cesarean delivery participated in this research and were randomized into single-balloon catheter group (n = 60) and double-balloon catheter group (n = 60). The cervical ripening effect, security, and influence to the process of childbirth were analyzed in each group.Results: The validity of cervical ripening in single balloon group was better than double balloon group. Double balloon catheters increased the time between insertion and expulsion of the catheter and decreased spontaneous catheter expulsion rate. All the neonatal outcomes in these two groups were comparable.Conclusion: Based on our data, the two different catheters both have their pros and cons in the labor induction of pregnant women with scarred uterus. The appropriate catheter used based on specific circumstance will improve the quality of labor induction. [ABSTRACT FROM AUTHOR]

Aim: Gestational hypertension is a common disorder of pregnancy. This study aims to evaluate the effect of labor induction with dinoprostone vaginal suppositories (Propess) on pregnancy outcomes in pregnant women with gestational hypertension. Methods: The retrospective study included 375 patients with gestational hypertension. All patients were included into three groups according to the characteristics at admission. Women who had initiated labor spontaneously at admission were enrolled in Spontaneous labor group. According to Bishop score, other patients underwent labor induction with Propess or oxytocin were enrolled in Propess group or Oxytocin group. Demographic information and perinatal outcome data were collected. Results: The vaginal delivery rate of the women with gestational hypertension was respectively 93.5% (Spontaneous labor group), 77.0% (Propess group), and 52.5% (Oxytocin group) in three groups with significant difference (P < 0.001). The duration of labor was 8.29 ± 3.70 h (Spontaneous labor group), 8.45 ± 5.21 h (Propess group) and 12.37 ± 11.47 h (Oxytocin group) in three groups, respectively. No differences were found in the intrapartum fever (P = 0.588), intrapartum hemorrhage (P = 0.953), intrapartum maximum blood pressure (P = 0.301 and P = 0.535) and post‐partum hemorrhage (P = 0.075) among three groups. Neonatal outcomes were similar among three groups (Neonatal hospitalization rate, P = 0.437; 1‐min Apgar score, P = 0.304; 5‐min Apgar score, P = 0.340; Birth weight, P = 0.089). No poor maternal and neonatal outcomes occurred. Conclusion: Pregnant women with gestational hypertension could have favorable pregnancy outcomes. Using Propess as a mode of labor induction in gestational hypertension is safe and effective, without increasing intrapartum blood pressure and inducing poor pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Malgorzata Swiatkowska-Freund, Krzysztof Preis Department of Obstetrics, Medical University of Gdansk, Gdansk, Poland Abstract: Uterine cervix is a part of the uterus responsible for maintaining pregnancy till term. As long as the cervix remains long and firm and its internal orifice (os) is closed, it can withstand enlargement of the uterine contents and resultant growing pressure. Mechanical properties of the cervix change during pregnancy; the cervix ripens prior to delivery, then effaces and dilates with contractions of the uterus. Ripening of the cervix can be assessed using the Bishop score and ultrasonographically determined length of the cervical canal and internal os. Consistency is one of the cervical properties that change during the course of the maturation process. Until recently, cervical consistency has been assessed only manually, but in 2007, the first report on elastographic imaging of the cervix during pregnancy has been published. Elastography presents the ability of a tissue to deform under pressure. The softer the tissue, the easier it changes its shape. Different methods of elastography are used – static, when tissue displacement in response to manual compression or physiological movements of vessels is measured, or dynamic, when the speed of shear wave propagation is determined. Irrespective of the method, elastography provides information on the internal os stiffness; this parameter, impossible for manual assessment, was shown to correlate with pregnancy outcome and is a strong predictor of preterm delivery or successful labor induction. Although elastography seems to be a highly promising diagnostic option, still no consensus has been reached regarding an optimal method for uterine cervix assessment, and virtually all previous studies of various elastographic methods produced highly satisfactory results. Future studies need to identify the most promising and objective elastographic method which may serve as a novel tool for pregnancy management, preventing adverse events, such as preterm delivery and unsuccessful labor induction. Keywords: consistency, elastography, labor induction, preterm delivery, uterine cervix

ABSTRACT Objective: Analyzing if the sonographic evaluation of the cervix (cervical shortening) is a prognostic marker for vaginal delivery. Methods: Women who underwent labor induction by using dinoprostone were enrolled. Before the induction and three hours after it, the cervical length was measured by ultrasonography to obtain the cervical shortening. The cervical shortening was introduced in logistic regression models among independent variables and for calculating receiver operating characteristic (ROC) curves. Results: Each centimeter in the cervical shortening increases the odds of vaginal delivery in 24.4% within 6 hours; in 16.1% within 24 hours; and in 10.5% within 48 hours. The best predictions for vaginal delivery are achieved for births within 6 and 24 hours, while the cervical shortening poorly predicts vaginal delivery within 48 hours. Conclusion: The greater the cervical shortening 3 hours after labor induction, the higher the likelihood of vaginal delivery within 6, 24 and 48 hours.

Abstract (english) The objective of research was to compare the effectiveness of transcervical Foley catheter with vaginal misoprostol for labor induction in term pregnancies. Patients undergoing cervical ripening and induction of labor were selected and randomly assigned to be treated with transcervical Foley catheter (Foley group) or vaginal misoprostol (misoprsotol group) who attended to cervical maturation and labor induction at Hospital Central “Dr. Urquinaona”, Maracaibo, Venezuela. Interval between beginning of induction to delivery, vaginal birth rate, maternal complications perinatal variables and adverse effects were evaluated. Patients of Foley group showed a longer interval between beginning of induction to delivery compared with patients in misoprostol group (p < 0.05). There was no significant difference in vaginal birth rate between groups (p = ns). Newborns in Foley group had significantly higher mean value of Apgar scores at 1 minute and 5 minutes compared with those in misoprostol group (p < 0.05). The most common adverse effect in both groups was nausea, but there were no significant differences between groups in frequency of adverse effects (p = ns). It is concluded that use of transcervical Foley catheter is as effective as vaginal misoprostol for induction of labor in term pregnancy.

Introduction: Several studies have shown that late- and post-term pregnancies are associated with an increased risk of perinatal morbidity and mortality. In this case, induction of labor is the recommended approach. For full-term pregnancies, various methods exist to prepare the cervix and/or commence labor. Prostaglandins serve the dual purpose of cervical ripening and labor induction, blurring the distinction between the two processes. The aim of this research was to evaluate the effect of maternal age and body mass index (BMI) on oral misoprostol induction of labor for late-term pregnancies., Methods: This was a retrospective cross-sectional study (ClinicalTrial ID: NCT06184139), including only late-term pregnancies in healthy nulliparous women carrying a single cephalic fetus with normal birthweight who underwent induction of labor with oral misoprostol. We used the oral misoprostol regimen proposed by the World Health Organization (WHO) for induction of labor in term singleton pregnancies in women who have not had a previous cesarean delivery and a Bishop score &lt;7. The regimen was oral misoprostol in aqueous solution at the low dose of 25 μg every 2 h until a Bishop score ≥7, labor, or for a maximum of 8 doses., Results: One hundred and four pregnant women underwent induction of labor with oral misoprostol for late-term pregnancy on the 290th day of gestation. Study population was divided in two groups based on age (&lt;35 and ≥35 years) and obesity (BMI &lt;30 and ≥30). No statistically significant differences were recorded between younger and older women. Obese women reported a longer time between the last dose of misoprostol and cervical dilation of 6 cm (p = 0.01), a longer time between the last dose of misoprostol and delivery (p = 0.04), and a higher rate of grade II vaginal lacerations (p = 0.02)., Conclusions: Maternal BMI is a factor negatively influencing the efficacy of oral misoprostol for induction of labor in late-term pregnancy., (© 2024 S. Karger AG, Basel.)

Membrane sweeping is considered a simple and effective method for initiating spontaneous onset of labor. Despite the widely accepted membrane sweeping use to prevent post-term birth, the optimal frequency has not been estimated. We aimed to assess the effectiveness and safety of twice-weekly versus once-weekly membrane sweeping in post-term pregnancy prevention. Four different databases were searched for available clinical trials from inception to October 2022. We selected randomized controlled trials (RCTs) that compared twice-weekly membrane sweeping in intervention group versus once-weekly membrane sweeping in control group among pregnant women with singleton pregnancy at ≥ 39 gestational weeks. Our primary outcomes were the rate of spontaneous onset of labor and the requirement for formal methods of labor induction. Our secondary outcomes were sweeping to delivery interval in days, gestational age at delivery in weeks, Bishop score at admission, chorioamnionitis, and premature rupture of membranes. Three RCTs (596 patients) were included. Twice-weekly membrane sweeping was associated with significant increase in the rate of spontaneous onset of labor and significant decline in labor induction rate in comparison with once-weekly group. Duration from sweeping to delivery was significantly shorter among the twice-weekly group (p<0.001). Furthermore, gestational age at delivery was significantly earlier in the twice-weekly group. A significantly higher Bishop score at admission was observed in the twice-weekly group (p=0.02). There were no significant differences across both groups in chorioamnionitis and premature rupture of membranes. In conclusion, twice-weekly membrane sweeping is more effective in preventing post-maturity pregnancy than once-weekly sweeping without added adverse events., (© 2023. The Author(s), under exclusive licence to Society for Reproductive Investigation.)

Objective: To investigate the predictive value of obstetric findings when using dinoprostone (prostaglandin E2 [PGE2]) vaginal inserts for cervical ripening, and to assess the optimal cervical-ripening method between PGE2 vaginal insert and/or cervical dilators., Methods: This prospective observational study enrolled pregnant women who underwent cervical ripening for labor induction in 37-41 week' gestation in 2020. In evaluation 1, optimal obstetric findings predictive of rapid cervical ripening using PGE2 were assessed. In evaluation 2, the duration from PGE2 administration to labor onset and perinatal outcomes were compared between cases in which only PGE2 was used and cases that were treated with PGE2 after mechanical cervical dilators (Dilapan®) for extremely immature cervical ripening (uterine cervical os <2 cm)., Results: In evaluation 1, uterine dilatation before the use of a PGE2 vaginal insert was mostly correlated with the time from PGE2 administration to labor onset (r = -0.428, p < 0.001). When the uterine cervical os dilatation was ≥2 cm, a shorter time-to-labor onset was found. In addition, os dilatation, effacement, and station at the time of PGE2 vaginal insert removal also significantly progressed. In evaluation 2, the median duration from PGE2 administration to labor onset was 1740 min in cases where only PGE2 was used, and 610 min in those where PGE2 was used after mechanical cervical dilators (p = 0.011)., Conclusion: PGE2 vaginal inserts are relatively effective when the uterine cervical os is ≥2 cm in diameter. However, in cases of extremely immature cervical-ripening, it was feasible to use PGE2 vaginal inserts before mechanical cervical dilatation., (© 2023 Japan Society of Obstetrics and Gynecology.)

Objectives: The aim of this study is to compare the evaluation of cervical length measured by the Bishop score and transvaginal ultrasonography in determining the need for prostaglandin application for cervical ripening in term nulliparous pregnancies., Material and Methods: In our study, a total of 120 patients who were admitted to our hospital between February 2015 and August 2015 were divided into two groups as cervical length group and Bishop score group according to hospitalization order by applying the Permuted Block Randomization method, which is one of the Restricted Randomization methods. Each patient included in the study was evaluated with both the Bishop score and transvaginal ultrasonography. Groups were compared according to the APGAR scores in the 1st and 5th minutes, transition within 12 hours, birthing within 24 hours, birthing with only dinoprostone, birthing with only oxytocin, duration of administration of dinoprostone, duration of oxytocin administration, type of birth, rate of cesarean section, and need for neonatal intensive care., Results: While cervical ripening with dinoprostone was applied to 28 (46.7%) of 60 pregnant women in the Bishop group, labor induction with oxytocin was applied to the remaining 32 (53.3%) pregnant women. In the cervical length group, these values were 33 (55.0%) and 27 (45.0%), respectively. There was no statistically significant difference between study groups in terms of the need for dinoprostone for cervical ripening (p = 0.361). Of those with a Bishop score of 4 or below, 78.6% (n = 22) had a cervical length of over 28 mm, and 71.4% (n = 20) needed oxytocin. Of those with a Bishop score above 4, none of them had a cervical length greater than 28 mm. A statistically significant difference was found between those with a Bishop score of 4 or below and those above 4 in terms of cervical length (p < 0.05). Among those with a Bishop score of 4 or below, the percentage of those with a cervical length above 28 mm was significantly higher than that of those with a Bishop score above 4., Conclusions: In our study, the delivery time of those with a cervical length of 28 mm and above was significantly higher than those with a cervical length of less than 28 mm, while the bishop score was significantly lower. In order to develop a more objective method that can replace the Bishop scoring system in determining the need for cervical ripening before labor induction, prospective randomized studies that screen larger numbers of patients are needed.

Objective: During pregnancy, the stiffness of the cervical tissue decreases long before the cervical length decreases. Therefore, several approaches have been proposed in order to ensure a more objective assessment of cervical stiffness than that achieved by digital evaluation. Strain elastography has shown promising results. This technique is based on an ultrasound assessment of the tissue deformation that occurs when the examiner applies pressure on the tissue with the ultrasound probe. However, the results are only semi-quantitative as they depend on the unmeasured force used by the examiner. We, therefore, hypothesized that a force-measuring device applied to the handle of the ultrasound probe may render the technique quantitative. With this approach, the stiffness is the force (measured by the device) divided by the compression (measured by the elastography platform). One perspective is the early identification of women at risk of preterm birth in whom cervical stiffness may decrease long before cervical shortening. Another perspective is cervical evaluation when planning labor induction. In this feasibility study, we aimed to evaluate how quantitative strain elastography performs when a commercially available strain elastography platform (by which the algorithm is unavailable) is combined with a custom-made, force-measuring device. We studied how the assessments were associated with the gestational age in women with uncomplicated pregnancies and how they were associated with cervical dilatation time from 4 to 10 cm in women undergoing labor induction., Methods: In the analysis, we included quantitative strain elastography assessments from 47 women with uncomplicated singleton pregnancies, with gestational age between 12 +0 and 40 +0 , and from 27 singleton term-pregnant women undergoing labor induction. The force-measuring device was mounted on the handle of a transvaginal probe. The strain values (i.e. the compression of the cervical tissue) were obtained by the elastography software of the ultrasound scanner (GE Voluson E10). The region of interest was placed within the central part of the anterior cervical lip. Based on the force data and strain values, we calculated the outcomes cervical elastography index GE ( CEI GE ) and the cervical strength index GE ( CEI GE x cervical length: CSI GE )., Results: The average CEI GE was 0.24 N at week 12 and 0.15 N at week 30-34. For CSI GE these figures were 8.2 and 4.7 N mm, respectively ( p  = 0.002). Among women undergoing labor induction, the CEI GE was associated with a cervical dilatation time (4-10 cm) beyond 7 h. For nulliparous women, this area under the ROC curve was 0.94., Conclusion: Quantitative strain elastography may constitute a tool for the evaluation of a uterine cervix with normal length in women at risk of preterm birth and in women undergoing labor induction. The performance of this tool deserves evaluation in larger clinical trials.