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SUMMARY OF RECOMMENDATIONS: 1. Oxytocin for induction or augmentation of labor should not be started when there is a previous scar on the body of the uterus (such as previous classical cesarean section, uterine perforation or myomectomy when uterine cavity is reached) or in any other condition where labor or vaginal delivery are contraindicated. (Moderate quality evidence +++-; Strong recommendation). 2. Oxytocin should not be started before at least 1 h has elapsed since amniotomy, 6 h since the use of dinoprostone (30 min if vaginal insert) and 4 h since the use of misoprostol (Low quality evidence ++- -; Moderate recommendation). 3. Cardiotocography (CTG) should be performed and a normal pattern without tachysystole should be documented for at least 30 min before oxytocin is used. Continuous CTG, with adequate monitoring of both fetal heart rate and uterine contractions, should be maintained for as long as oxytocin is used, and thereafter until delivery (Low ++- - to moderate +++- quality evidence; Strong recommendation). 4. For labor induction, at least 1-h should be allowed after amniotomy before oxytocin infusion is started, to evaluate whether adequate uterine contractility has meanwhile ensued. For augmentation of labor, if the membranes are intact and there are conditions for a safe amniotomy, the latter should be considered before oxytocin is started (Very low quality evidence +- --; Weak recommendation). 5. Oxytocin should be administered intravenously using the following regimen: 5 IU oxytocin diluted in 500 mL of 0.9% normal saline (NaCl) (each mL contains 10 mIU of oxytocin), in an infusion pump at increasing rates, as shown in Table 1, until a frequency of 3-4 contractions per 10 min is reached, a non-reassuring CTG pattern ensues, or maximum rates are reached (Low quality evidence ++ - -; Strong recommendation). If the frequency of contractions exceeds 5 in 10 min, the infusion rate should be reduced, even if a normal CTG pattern is present. With a non-reassuring CTG pattern, urgent clinical assessment by an obstetrician is indicated, and strong consideration should be given to reducing or stopping the oxytocin infusion. The minimal effective dose of oxytocin should always be used. (Low ++- - to Moderate +++- - quality evidence; Strong recommendation). 6. Use of oxytocin for induction and augmentation of labor should be regularly audited (Low quality evidence ++--; Strong recommendation).

OF RECOMMENDATIONS1. Oxytocin for induction or augmentation of labor should not be started when there is a previous scar

1. Episiotomy should be performed by indication only, and not routinely (Moderate quality evidence +++-; Strong recommendation). Accepted indications for episiotomy are to shorten the second stage of labor when there is suspected fetal hypoxia (Low quality evidence ++–; Weak recommendation); to prevent obstetric anal sphincter injury in vaginal operative deliveries, or when obstetric sphincter injury occurred in previous deliveries (Moderate quality evidence +++-; Strong recommendation) 2. Mediolateral or lateral episiotomy technique should be used (Moderate quality evidence +++-; Strong recommendation). Labor ward staff should be offered regular training in correct episiotomy techniques (Moderate quality evidence +++-; Strong recommendation). 3. Pain relief needs to be considered before episiotomy is performed, and epidural analgesia may be insufficient. The perineal skin needs to be tested for pain before an episiotomy is performed, even when an epidural is in place. Local anesthetics or pudendal block need to be considered as isolated or additional pain relief methods (Low quality evidence ++–; Strong recommendation). 4. After childbirth the perineum should be carefully inspected, and the anal sphincter palpated to identify possible injury (Moderate quality evidence +++-; Strong recommendation). Primary suturing immediately after childbirth should be offered and a continuous suturing technique should be used when repairing an uncomplicated episiotomy (High quality evidence ++++; Strong recommendation)

International audience; Background: Induction of labor is among the most common procedures for pregnant women. Only a few randomized clinical trials with relatively small samples have compared misoprostol with dinoprostone. Although their efficacy seems similar, their safety profiles have not been adequately evaluated, and economic data are sparse. Objective: This study aimed to test the noninferiority of vaginal misoprostol (prostaglandin E1) (25 μg) to a slow-release dinoprostone (prostaglandin E2) pessary (10 μg) for induction of labor with an unfavorable cervix at term. Study Design: This was an open-label multicenter randomized noninferiority trial at 4 university hospitals of the Research Group in Obstetrics and Gynecology between 2012 and 2015. We recruited women who underwent induction of labor for medical reasons, those with a Bishop score of ≤5 at ≥36 weeks’ gestation, and those with a cephalic-presenting singleton pregnancy with no previous cesarean delivery. Women were randomly allocated to receive either vaginal misoprostol at 4-hour intervals (25 μg) or a 10-mg slow-release dinoprostone pessary. The primary outcome was the total cesarean delivery rate. Noninferiority was defined as a difference in the cesarean delivery rates between the groups of no more than 5%. Secondary outcomes included neonatal and maternal morbidity, vaginal delivery at

Introduction The objective of this study was to compare neonatal respiratory morbidity and rate of emergency caesarean section between elective caesarean sections at 38 gestational weeks following a course of corticosteroids and planned caesarean sections at 39 gestational weeks. Material and methods This was a multicentre randomised controlled trial. The study was conducted between 2007 and 2013 in level 2 and 3 maternity units in France. A total of 208 women with an indication for elective caesarean section were enrolled and 200 analysed in per-protocol analysis. Women were randomised to either elective caesarean section at 38 gestational weeks after a course of corticosteroids (trial group) or elective caesarean section at 39 weeks (control group). The primary outcome was the rate of admission to the neonatal intensive care unit for respiratory distress. Results Two (2.1%) newborn in the tested group were admitted because of respiratory distress versus four (3.8%) in the control group. The relative risk was 0.54 in favour of the corticosteroid group (95% CI: 0.10; 2.86). There were fewer emergency caesareans in the trial group than in the control group: 12 (12.69%) versus 28 (26.67%), p = 0.01. Conclusions Our study suggests that planning caesarean sections at 38 gestational weeks after a course of corticosteroids would enable a significant reduction in the number of emergency caesareans without increasing the risk of neonatal respiratory distress. Limitations of this study include difficulties in patient recruitment and the small number of subjects.

Background: Several studies have investigated the efficacy of moxibustion with or without acupuncture for fetal version, but the results are discordant. Meta-analyses pointed out the need for robust, methodologically sound, randomized controlled trials. Objective: The objective of this study was to assess the effectiveness of acupuncture with fire needling on acupoint BL67 for version of breech presentation. Study design: This was a randomized, sham-controlled, single-blinded trial, which took place in Strasbourg teaching maternity hospital, France. A total of 259 patients between 32 and 34 weeks of gestation have been randomized and analyzed. Patients were randomized to either acupuncture with fire needling or sham group, and were analyzed in their initial allocation group. Statistical analysis was conducted using Bayesian methods, in univariate analysis and in multivariate analysis after adjustment on parity. Results: The primary outcome was the rate of cephalic presentations at ultrasound examination performed between 35 and 36 weeks of gestation. A total of 49 (37.7%) fetuses were in cephalic presentation in the acupuncture group, versus 37 (28.7%) in the sham group: RR 1.34 [0.93-1.89], Pr RR>1=94.3%. After adjustment on parity, the acupuncture did not increase the rate of fetal cephalic version: OR 1.47 [0.84-2.42], Pr OR>1=90.3%. Conclusions: Our study suggests that acupuncture with fire needling on acupoint BL67 does not promote fetal cephalic version. Further studies might investigate effectiveness of other protocols of acupuncture. Randomization should be stratified for nulliparous and parous patients. Keywords: Acupuncture; Breech presentation; Fire needling; Version.

Objective To determine the diagnostic value of fetal ST-segment analysis (STAN) in predicting neonatal acidosis. Methods The STAN S21® was used to monitor singleton fetuses in labor with abnormal FHR. Physicians later reviewed tracings to identify any ST events dictating intervention. Outcome measures were umbilical artery pH ≤ 7.15 and pH ≤ 7.05 at birth. The sensitivity, specificity, PPV, and NPV of a significant ST event to predict both outcomes were calculated. Results Analysis included 411 women. Sensitivity of a significant ST event for screening pH ≤ 7.15 (21.9%) was 38% (41/108), specificity 83% (252/303), PPV 45% (41/92) and NPV 79% (252/319), and for pH ≤ 7.05, it was (3.4%), 62.5% (10/16), 79% (313/395), 11% (10/92), and 98% (313/319), respectively. Conclusion In a population with abnormal FHR in labor, STAN sensitivity is moderate (almost 40%) for predicting pH ≤ 7.15 and better (almost 60%) for more severe acidosis (pH ≤ 7.05).

Objective To compare the responses of medical staff using the STAN S21 fetal heart monitor versus standard cardiotocography (CTG) to monitor abnormal fetal heart rate in labor. Method Questionnaires were completed by medical staff involved in a randomized controlled trial to compare STAN surveillance with traditional surveillance before the trial had finished. Respondents were questioned about their experience and confidence using the STAN system. Results The response rate was 82% (89/109). Overall, 71% of respondents preferred using STAN surveillance, while 5% preferred standard CTG. Reasons given for preference over CTG alone were the continuous nature of surveillance (47%), the need for fewer scalp pH tests (39%), and its capacity to screen for severe fetal distress (30%). Conclusion Most of the medical staff surveyed preferred using STAN versus standard surveillance techniques to monitor abnormal fetal heart rate during labor.

The purpose of this study was to assess whether knowledge of ST-segment analysis was associated with a reduction in operative deliveries for nonreassuring fetal status (NRFS) or with a need for at least 1 scalp pH during labor.Seven hundred ninety-nine women at term with abnormal cardiotocography or meconium-stained amniotic fluid (7%) were assigned randomly to the intervention group (cardiotocography + STAN) or the control group (cardiotocography) in 2 university hospitals in Strasbourg, France. Scalp pH testing was optional in both groups. Abnormal neonatal outcome was pH7.05 or umbilical cord blood artery base deficit of12 or a 5-min Apgar score of7 or neonatal intensive care unit admission or convulsions or neonatal death. Study power was 80% for the detection of a prespecified reduction from 50%-40% in operative delivery for NRFS.The operative delivery (cesarean or instrumental) rate for NRFS did not differ between the 2 groups: 33.6% (134/399) in the cardiotocography + STAN analysis group vs 37% (148/400) in the cardiotocography group (relative risk, 0.91; 95% CI, 0.75-1.10). The rate of operative delivery for dystocia was also similar in both groups. The percentage of women whose fetus had at least 1 scalp pH measurement during labor was substantially lower in the group with ST-segment analysis: 27% compared with 62% (relative risk, 0.44; 95% CI, 0.36-0.52). Neonatal outcomes did not differ significantly between groups.In a population with abnormal cardiotocography in labor, cardiotocography combined with ST-segment analysis was not associated with a reduction in operative deliveries for NRFS. The proportion of infants without scalp pH sampling during labor increased substantially, however.