scholarly journals Risk of Cesarean Delivery for Women with Obesity Using a Standardized Labor Induction Protocol

2021 ◽  
Author(s):  
Rebecca F. Hamm ◽  
Christina P. Teefey ◽  
Cara D. Dolin ◽  
Celeste P. Durnwald ◽  
Sindhu K. Srinivas ◽  
...  
Keyword(s):  
Cesarean Delivery ◽  
Prospective Trial ◽  
Secondary Analysis ◽  
Active Phase ◽  
Labor Induction ◽  
Adjusted Relative Risk ◽  
Labor Management ◽  
Increased Risk ◽  
Unfavorable Cervix ◽  
Failed Induction

Objective We aimed to determine the risk of cesarean among women with obesity undergoing labor induction within a prospective trial that utilized a standardized labor protocol. Study Design This was a secondary analysis of a randomized trial of induction methods. Term (≥37 weeks) women with intact membranes undergoing induction with an unfavorable cervix (Bishop's score ≤6 and dilation ≤2 cm) were included. The trial utilized a labor protocol that standardized induction and active labor management, with recommendations for interventions at particular time points. Only women with a recorded body mass index (BMI) at prenatal care start were included in this analysis. The primary outcome was cesarean delivery compared between obese (≥30 kg/m2) and nonobese (<30 kg/m2) women. Indication for cesarean was also evaluated. Results A total of 465 women were included: 207 (44.5%) obese and 258 (55.5%) nonobese. Women with obesity had a higher risk of cesarean compared with women without obesity (33.3 vs. 23.3%, p = 0.02), even when adjusting for parity, weight change over pregnancy, and indication for induction (adjusted relative risk [aRR] = 1.79, 95% confidence interval [CI]: [1.34–2.39]). Compared with women without obesity, women with obesity had a higher risk of failed induction (47.8 vs. 26.7%, p = 0.01) without a difference in arrest of active phase (p = 0.39), arrest of descent (p = 0.95) or fetal indication (p = 0.32), despite adherence to a standardized labor protocol. Conclusion Compared with women without obesity, women with obesity undergoing an induction are at increased risk of cesarean, in particular a failed induction, even within the context of standardized induction management. As standardized practices limit provider variation in labor management, this study may support physiologic differences in labor processes secondary to obesity. Key Points

scholarly journals Oxytocin Discontinuation During Induced Labor in Pregnancies With Suspected Fetal Growth Restriction

2020 ◽  
Author(s):  
Sayuri Iwai ◽  
Kazuya Mimura ◽  
Masayuki Endo ◽  
Yoko Kawanishi ◽  
Aiko Kakigano ◽  
...  
Keyword(s):  
Cesarean Delivery ◽  
Fetal Growth ◽  
Fetal Growth Restriction ◽  
Active Phase ◽  
Labor Induction ◽  
Growth Restriction ◽  
Labor Management ◽  
Induced Labor ◽  
Increased Risk ◽  
Oxytocin Infusion

Abstract Objective: Although fetal growth restriction (FGR) is associated with an increased risk of cesarean delivery during induced labor, there is little evidence to guide labor management in such cases. This study aimed to investigate whether discontinuation of oxytocin infusion affects the cesarean delivery rate and the risk of maternal and neonatal complications associated with induced labor in pregnancies with suspected FGR.Methods: This was a retrospective cohort study of singleton pregnancies with vertex presentation and indications for labor induction due to FGR after 34.0 weeks of gestation at our institution from January 2010 to December 2017. Two parallel groups were compared: women who received oxytocin continuously until delivery (continuation group) and women whose oxytocin was discontinued at the beginning of the active phase of labor (discontinuation group).Results: There were 74 women in the continuation group and 51 women in the discontinuation group. The incidence of cesarean deliveries was higher (5.4% vs 2.0%) in the continuation group, but this difference was not statistically significant. However, the incidence of uterine tachysystole (23.0% vs 9.8%) was significantly higher in the continuation group than in the discontinuation group. Differences in labor management did not affect the lengths of the active phase and second stage of labor (mean, 136 ± 122 minutes and 34.2 ± 45 minutes, respectively; 122 ± 104 minutes and 48.8±67 minutes in the continuation group and discontinuation group, respectively). The incidence of postpartum hemorrhage and adverse neonatal outcomes were not significantly different between groups.Conclusions: Oxytocin can be safely discontinued after the active phase of labor in women undergoing labor induction for FGR without an increased risk of cesarean delivery or other unfavorable outcomes. Therefore, this strategy may be considered an alternative to continued oxytocin infusion.

Influence of Estimated Fetal Weight on Labor Management

2019 ◽  
Vol 37 (03) ◽  
pp. 252-257
Author(s):  
Elisa T. Bushman ◽  
Norris Thompson ◽  
Meredith Gray ◽  
Robin Steele ◽  
Sheri M. Jenkins ◽  
...  
Keyword(s):  
Cesarean Delivery ◽  
Secondary Analysis ◽  
Physical Exam ◽  
Fetal Weight ◽  
Secondary Outcome ◽  
Labor Management ◽  
Increased Risk ◽  
Tertiary Center ◽  
The Impact ◽  
Estimated Fetal Weight

Abstract Objective Prior studies suggest knowledge of estimated fetal weight (EFW), particularly by ultrasound (US), increases the risk for cesarean delivery. These same studies suggest that concern for macrosomia potentially alters labor management leading to increased rates of cesarean delivery. We aimed to assess if shortened labor management, as a result of suspected macrosomia (≥4,000 g), leads to an increased rate of cesarean delivery. Study Design This is a secondary analysis of a retrospective cohort study at a single tertiary center in 2015 of women with singleton pregnancies ≥36 weeks with documented EFW by US within 3 weeks or physical exam on admission. Women were excluded if an initial cervical exam was ≥6 cm or no attempt was made to labor. In addition, patients were excluded for the diagnosis of hypertension, diabetes, or prior cesarean delivery, as these comorbidities influence the use of US, labor management, and cesarean delivery independent of fetal weight. Patients were classified as EFW of ≥4,000 and <4,000 g. Secondary analysis examined the impact of US within 3 weeks of admission when compared with physical exam at the time of admission. The primary maternal outcomes were duration of labor and cesarean delivery. Duration of labor was evaluated as total time from 4 cm to delivery (with 4-cm dilation being a surrogate marker for active labor), length of time allowed from 4 cm until the first documented cervical change (or delivery), and time in second stage of labor (complete dilation to delivery). Cesarean delivery for arrest of labor was a secondary outcome. Student's t-test, Mann–Whitney U-test, chi-squared test, and Fisher's exact test were used for univariate data analysis as appropriate. Results Of 1,506 patients included, 54 (3.5%) had EFW of ≥4,000 g. Women with EFW of ≥4,000 g had a larger body mass index, higher fetal birth weight, were more likely to be undergoing induction of labor, had a more advanced gestational age, and were more likely to have had an US within 3 weeks of delivery. They were more likely to undergo cesarean delivery (29.6 vs. 9.3%, adjusted odds ratio [AOR]: 2.7, 95% confidence interval [CI]: 1.3–5.5) despite not having shortened labor times. When analyzing this population by method of obtaining EFW, those with EFW based on US rather than external palpation were more likely to undergo cesarean delivery (13.1 vs. 7.9%, AOR: 1.5, 95% CI: 1.01–2.12), again without having shortened labor times. Conclusion EFW of ≥4,000 g and use of US to estimate fetal weight do not appear to shorten labor management despite being associated with an increased risk of cesarean delivery.

scholarly journals Bishop score versus transvaginal ultrasonographic measurement of cervical length in predicting successful labor induction in post-term pregnancy: prospective cohort study

2018 ◽  
Vol 7 (11) ◽  
pp. 4646
Author(s):  
Mansour A. Khalifa ◽  
Ahmed M. Abbas ◽  
Mohammed A. Gaber ◽  
Maher Salah
Keyword(s):  
Cervical Length ◽  
Labor Induction ◽  
Study Group ◽  
Bishop Score ◽  
Successful Induction ◽  
Unfavorable Cervix ◽  
Moderate Negative Correlation ◽  
Group 2 ◽  
Failed Induction ◽  
Group 1

Background: The current study aims to compare the efficacy of Bishop score assessment and transvaginal ultrasonographic measurement of the cervical length in prediction of the outcome of labor induction in post-term pregnancy.Methods: A comparative Prospective observational study conducted in Department of Obstetrics and Gynecology, Kom Ombo central hospital from January 2017 to October 2017. Pregnant women were classified into two groups of Bishop Score Group (1): ladies with (Bishop Score <5) = unfavorable cervix and Group (2): those with (Bishop Score >5) = favorable cervix. Also, they were classified into two groups of cervical lengths: Group (1): women with (cervical length <25mm, shorter cervix) and Group (2): those with (cervical length ≥25 mm, longer cervix). The Primary outcome was Bishop score by digital examination and Cervical length by TVS.Results: The study group was 100 women. Regarding sonographic assessment, 44 patients had cervical length <25 mm and the mean cervical length for the whole study group was 25.19±8.16 mm. Successful induction was achieved in 78 patients (78%), while CS was done in 22 patients due to failed induction.  No difference between both groups regarding the parity (p=0.063). When comparing women with successful VD versus those delivered by CS, we found significantly higher Bishop score in the first group 5.12 ± 1.93  vs 3.89 ± 1.71 in the second group (p=0.002). Additionally, VD group had significantly shorter cervix than CS group (22.31 ±7.14 vs. 35.37± 5.80 mm, p=0.007). The Bishop score showed significant moderate negative correlation with the cervical length (r=-0.589, p=0.001).Conclusions: Success of labor induction in women undergoing induction due to prolonged pregnancy can be highly predicted by cervical length as it is more objective and accurate than Bishop Score. The 25 mm cut-off point for cervical length was the best predictor of vaginal delivery.

scholarly journals 563: Is duration of labor induction associated with increased risk of cesarean delivery for labor dystocia?

2018 ◽  
Vol 218 (1) ◽  
pp. S336-S337
Author(s):  
E. Nicole Teal ◽  
Adam K. Lewkowitz ◽  
Sarah Koser ◽  
Carol Tran ◽  
Molly Siegel ◽  
...  
Keyword(s):  
Cesarean Delivery ◽  
Labor Induction ◽  
Labor Dystocia ◽  
Increased Risk

Adherence to Consensus Guidelines for the Management of Labor Arrest Disorders in a Single Academic Tertiary Care Medical Center

2018 ◽  
Vol 36 (09) ◽  
pp. 911-917 ◽  
Author(s):  
Mesk A. Alrais ◽  
Nana-Ama E. Ankumah ◽  
Farah H. Amro ◽  
Tyisha Barrett ◽  
Kendra Folh ◽  
...  
Keyword(s):  
Cesarean Delivery ◽  
Medical Center ◽  
Tertiary Care ◽  
Night Shift ◽  
Perinatal Outcomes ◽  
Active Phase ◽  
Adherence Rate ◽  
Adjusted Relative Risk ◽  
Tertiary Care Medical Center ◽  
Primary Cesarean Delivery

Objective To evaluate the degree of adherence to the new the American College of Obstetricians and Gynecologists/Society for Maternal–Fetal Medicine guidelines in labor arrest management. Study Design A retrospective study of term, live, singleton deliveries with intrapartum primary cesarean delivery solely for failed induction of labor or labor arrest. Adherence was defined according to the Safe Prevention of the Primary Cesarean Delivery 2014 criteria. We evaluated adherence and compared maternal and perinatal outcomes, delivery time frame, and billing provider. Multivariable Poisson regression models with robust error variance were used to calculate adjusted relative risk (aRR) and 95% confidence interval (CI). Results Two-hundred six deliveries met the inclusion criteria; 73% were deemed not adherent to the guidelines. The majority of cases were under the care of nonacademic private practice OB/GYN physicians. The adherence rate was higher in the active phase of labor (45%) than in second stage (17%) and latent phase (14%). There were no differences in perinatal outcomes between the two groups. The adherence to guidelines was higher among academic OB/GYN physicians (aRR, 2.24, 95% CI, 1.49–3.36) and during the weekday–night shift (aRR, 1.81, 95% CI, 1.10–2.98). Conclusion Despite recent guidelines aimed to reduce the primary cesarean delivery rate, most cesarean deliveries performed for labor arrest disorders were not adherent to the guidelines.

Labor Induction at 39 Weeks Compared with Expectant Management in Low-Risk Parous Women

2020 ◽  
Author(s):  
Stephen M. Wagner ◽  
Grecio Sandoval ◽  
William A. Grobman ◽  
Jennifer L. Bailit ◽  
Ronald J. Wapner ◽  
...  
Keyword(s):  
Cesarean Delivery ◽  
Adverse Outcome ◽  
Secondary Analysis ◽  
Expectant Management ◽  
Labor Induction ◽  
Adverse Outcomes ◽  
Low Risk ◽  
Inclusion Criteria ◽  
Elective Induction ◽  
Observational Cohort

Objective Our objective was to compare outcomes among low-risk parous women who underwent elective labor induction at 39 weeks versus expectant management. Study Design This is a secondary analysis of an observational cohort of 115,502 mother–infant dyads who delivered at 25 hospitals between 2008 and 2011. The inclusion criteria for this analysis were low-risk parous women with nonanomalous singletons with at least one prior vaginal delivery after 20 weeks, who delivered at ≥390/7 weeks. Women who electively induced between 390/7 and 396/7 weeks were compared with women who expectantly managed ≥390/7 weeks. The primary outcome for this analysis was cesarean delivery. Secondary outcomes were composites of maternal adverse outcome and neonatal adverse outcome. Multivariable logistic regression was used to estimate adjusted odds ratios (aOR). Results Of 20,822 women who met inclusion criteria, 2,648 (12.7%) were electively induced at 39 weeks. Cesarean delivery was lower among women who underwent elective induction at 39 weeks than those who did not (2.4 vs. 4.6%, adjusted odds ratio [aOR]: 0.70, 95% confidence interval [CI]: 0.53–0.92). The frequency of the composite maternal adverse outcome was significantly lower for the elective induction cohort as well (1.6 vs. 3.1%, aOR: 0.66, 95% CI: 0.47–0.93). The composite neonatal adverse outcome was not significantly different between the two groups (0.3 vs. 0.6%; aOR: 0.60, 95% CI: 0.29–1.23). Conclusion In low-risk parous women, elective induction of labor at 39 weeks was associated with decreased odds of cesarean delivery and maternal morbidity, without an increase in neonatal adverse outcomes. Key Points

Racial Disparities in the Rates of and Indications for Cesarean Delivery in California: Are They Changing Over Time?

2021 ◽  
Author(s):  
E. Nicole Teal ◽  
Kelechi Anudokem ◽  
Rebecca J. Baer ◽  
Laura Jelliffe-Pawlowski ◽  
Biftu Mengesha
Keyword(s):  
Racial Disparities ◽  
Cesarean Delivery ◽  
Placenta Previa ◽  
Birth Certificate ◽  
Active Phase ◽  
International Classification Of Diseases ◽  
Birth Certificates ◽  
Obstetric Outcomes ◽  
Adjusted Relative Risk ◽  
Black And White

Objective: The aim of this study was to assess whether racial disparities in rates of and indications for cesarean delivery (CD) between non-Hispanic Black and non-Hispanic White birthing people in California changed from 2011 to 2017. Methods: This was a retrospective cohort study using a database of birth certificates linked to discharge records. Singleton term live births in nulliparous Black and White birthing people in California between 2011 and 2017 were included. Those with noncephalic presentation, placenta previa, and placenta accreta were excluded. CD rate and indication were obtained from birth certificate variables and International Classification of Diseases codes. Differences in CD rate and indication were calculated for Black versus White individuals using univariable and multivariable logistic regression and adjusted for potential confounders. Results: A total of 348,144 birthing people were included, 46,361 Black and 301,783 White. Overall, 30.9% of Black birthing people underwent CD compared with 25.3% of White (adjusted relative risk [aRR]: 1.2, 95% confidence interval [CI]: 1.2–1.3). From 2011 to 2017, the CD rate fell 11% (26.4–23.7%, p < 0.0001) for White birthing people and 1% for Black birthing people (30.4–30.1%, p = 0.037). Over the study period, Black birthing people had a persistent 1.2- to 1.3-fold higher risk of CD and were persistently more likely to undergo CD for fetal intolerance (aRR: 1.1, 95% CI: 1.1–1.2) and less likely for active phase arrest or arrest of descent (aRRs: 0.9 and 0.4; 95% CIs: 0.9–0.9 and 0.3–0.5). Conclusion: The CD rate decreased substantially for White birthing people and minimally for Black birthing people in our cohort over the study period. Meanwhile, disparities in CD rate and indications between the two groups persisted, despite controlling for confounders. Although care bundles for reducing CD may be effective among White birthing people, they are not associated with reduction in CD rates among Black birthing people nor improvements in racial disparities between Black and White birthing people. Precis: Despite increasing attention to racial inequities in obstetric outcomes, there were no changes in disparities in CD rates or indications in California from 2011 to 2017. Key Points

scholarly journals Fidelity to individual components of a standardized labor induction protocol and association with improved obstetric outcomes: secondary analysis of a randomized controlled trial

2020 ◽  
Author(s):  
Rebecca Feldman Hamm ◽  
Rinad S Beidas ◽  
Sindhu K. Srin ◽  
Lisa D. Levine
Keyword(s):  
Cesarean Delivery ◽  
Maternal Morbidity ◽  
Secondary Analysis ◽  
Neonatal Morbidity ◽  
Labor Induction ◽  
Obstetric Outcomes ◽  
Dissemination And Implementation ◽  
Evidence Based ◽  
Type I ◽  
Active Labor

Abstract Background Standardized labor induction protocols improve obstetric outcomes. However, these protocols are complex. The Consolidated Framework for Implementation Research describes intervention components as “core” and “adaptable periphery.” We aimed to identify core components by investigating the individual components of an evidence-based protocol most associated with effectiveness. We planned to utilize this information to simplify our protocol prior to multi-site implementation. Methods This is a secondary analysis of an RCT comparing time to delivery among four labor induction methods. All patients enrolled in the trial had their labor managed with a multidisciplinary-developed, evidence-based labor induction protocol. For each patient’s induction, we assessed fidelity to 7 components of the protocol. Primary effectiveness outcomes included cesarean delivery, maternal morbidity, and neonatal morbidity. Bivariate analyses assessed association of each component with each primary effectiveness outcome. Multivariable logistic regression determined independent predictors of each outcome while controlling for demographic and clinical factors known to be related to our outcomes. Results The 491 patients enrolled in the RCT were included in this analysis. While multiple components were associated with each outcome in bivariate analysis, few were found to be independent predictors of effectiveness in multivariable analysis. For cesarean delivery, only one component “for women in active labor, all cervical exams were performed ≤2.5 hours apart” was an independent predictor. For maternal morbidity, only one “if an intracervical Foley catheter was utilized for cervical ripening, it was removed within 12 hours of placement” remained significant. For neonatal morbidity, two components “all cervical exams performed in latent labor were performed ≤4.5 hours apart” and “for women in active labor, all cervical exams were performed ≤2.5 hours apart” remained independent predictors. Of the independent predictors of effectiveness, most reflected the overarching concept of “frequent exams in labor will allow for more frequent intervention when no change is made”.Conclusions This study demonstrates a novel strategy to identify which components of an evidence-based intervention should be “core” and which are “adaptable periphery”; this provides valuable information when designing for dissemination and implementation. With an understanding of the relationship between fidelity to individual protocol components and effectiveness, we can systematically simplify interventions prior to large-scale implementation, a potential strategy to increase implementation success. These data will be used to streamline our protocol to best target cesarean rate and maternal/neonatal morbidity prior to a planned type I hybrid effectiveness-implementation trial.

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