Induced labour with prostaglandin E2 in different parity groups after premature rupture of membranes

The study compared the outcome of induction of labour with prostagl and in E2 vaginal tablets in patients with premature rupture of membranes [PROM] at term in different parity groups. A retrospective review was made of the hospital records of 169 women attending the maternity unit of King Faisal Military Hospital, Saudi Arabia. There were no statistically significant differences between the 3 groups [parity 0, parity 1-4 and parity 5+] in rates of labour augmentation, caesarean sections, neonatal intensive care admissions or low Apgar scores. There were no serious complications of induction of labour such as infection or uterine hyperstimulation or rupture. Prostagl and in E2 may be used with care for labour induction in women with PROM at term, even gr and ultiparas, unless there is history of previous caesarean delivery

Cervical ripening after cesarean section: a prospective dual center study comparing a mechanical osmotic dilator vs. prostaglandin E2

Obejctives Worldwide, the overall cesarean section is rising. Trial of labor after cesarean (TOLAC) is an overall safe option with an immediate impact on neonatal and maternal short- and long-term health. Since the use of prostaglandins in cervical ripening is associated with an increased risk of uterine rupture, mechanical methods as balloon catheters or osmotic dilators have been suggested for cervical ripening prior to induction of labour. Here we are analyzing and comparing the VBAC rate, as well as maternal and fetal outcome in cervical ripening prior to TOLAC. Methods This prospective dual center study analyses maternal and neonatal outcomes of TOLAC in women with an unfavorable cervix requiring cervical ripening agent. The prospective application of an osmotic dilator (Dilapan-S, n=104) was analysed in comparison to the retrospective application of off-label dinoprostone (n=102). Results The overall fetal and neonatal outcome revealed no significant differences in both groups. Patients receiving cervical ripening with the osmotic dilator delivered vaginally/by ventouse in 52% of cases, compared to 53% when using dinoprostone (p=0.603). The interval between application to onset of labor was significantly higher in the osmotic dilator group (37.9 vs.20.7 h, p=<0.001). However, time from onset of labor to delivery was similar in both groups (7.93 vs. 7.44 h, p=0.758). There was one case of uterine rupture in the dinoprostone group. Conclusions Our data shows that the application of the osmotic dilator leads to similar outcomes in VBAC rate and time from onset of labor to delivery as well as safety in both groups compared to off-label use dinoprostone. Cervical ripening using the mechanical dilator is a viable and effective option, without the risk of uterine hyperstimulation.

The Successful Use of Nitroglycerin for Uterine Hyperstimulation with Fetal Heart Rate Abnormality Caused by a Controlled-Release Dinoprostone Vaginal Delivery System (PROPESS): A Case Report

The PROPESS, a controlled-release dinoprostone vaginal delivery system, is a pharmacological cervical ripening intervention and promotes cervical change causing uterine contraction. During insertion of the PROPESS, uterine hyperstimulation could occur and result in fetal heart rate (FHR) abnormality. We report a case of uterine hyperstimulation accompanied with FHR abnormality caused by the PROPESS in a pregnant woman. Postural change, oxygenation, fluid infusion, and the immediate PROPESS removal were ineffective to address the adverse event, so we administered nitroglycerin for acute uterine relaxation. The nitroglycerin resulted in uterine relaxation, and the FHR abnormality was resolved immediately, thereby preventing an emergency cesarean section. Therefore, nitroglycerin could be considered an effective option for uterine hyperstimulation accompanied with FHR abnormality caused by the PROPESS.

Partographic analysis of labour by modified WHO partograph in tertiary care centre

Background: The partograph is a simple, inexpensive tool to provide a continuous pictorial overview of labor. The goal of this study is to use partograph to monitor labor, initiate uterine activity that is sufficient to produce cervical changes, fetal descent while avoiding uterine hyperstimulation, hypostimulation and fetal distress and provide timely surgical intervention where required. Methods: A hospital-based observational study involving prospective review of partographs for births that occurred in 2020 was conducted in 2 hospitals including SVP Hospital and V.S hospital Ahmedabad. A partographic analysis of labour was done in randomly selected 200 patients using modified WHO partogram. The study population was divided into Primigravida (96) and Multigravida (104) term patients. partograph recording were commenced at 4 cm dilatation. close maternal and fetal monitoring was done throughout the labour and partogram was plotted to detect any deviation from normal course.Results: Patients were grouped into primigravida and multigravida and based on partogram finding divided into mode of delivery. 22 of total 96 primigravida underwent caesarean section and 74 delivered vaginally. 8 of total 104 multigravida underwent caesarean section and 96 delivered vaginally. Out of 200 newborn only 11 had Apgar score <7 at 5 minutes.Conclusion: The WHO modified partograph is highly effective in reducing both maternal and neonatal morbidity. It aids in assessing the progress of labour and to identify when intervention is necessary. It is effective in preventing prolonged labour, obstructed labour, reducing operative intervention and improving neonatal outcome.

Outpatient Induction of Labor – Are Balloon Catheters an Appropriate Method?

As the number of labor inductions in high-income countries has steadily risen, hospital costs and the additional burden on obstetric staff have also increased. Outpatient induction of labor is therefore becoming increasingly important. It has been estimated that 20 – 50% of all pregnant women requiring induction would be eligible for outpatient induction. The use of balloon catheters in patients with an unripe cervix has been shown to be an effective and safe method of cervical priming. Balloon catheters are as effective as the vaginal administration of prostaglandin E2 or oral misoprostol. The advantage of using a balloon catheter is that it avoids uterine hyperstimulation and monitoring is less expensive. This makes balloon catheters a suitable option for outpatient cervical ripening. Admittedly, intravenous administration of oxytocin to induce or augment labor is required in approximately 75% of cases. Balloon catheters are not associated with a higher risk of maternal and neonatal infection compared to vaginal PGE2. Low-risk pregnancies (e.g., post-term pregnancies, gestational diabetes) are suitable for outpatient cervical ripening with a balloon catheter. The data for high-risk pregnancies are still insufficient. The following conditions are recommended when considering an outpatient approach: strict selection of appropriate patients (singleton pregnancy, cephalic presentation, intact membranes), CTG monitoring for 20 – 40 minutes after balloon placement, the patient must be given detailed instructions about the indications for immediate readmission to hospital, and 24-hour phone access to the hospital must be ensured. According to reviewed studies, the balloon catheter remained in place between 12 hours (“overnight”) and 24 hours. The most common reason for readmission to hospital was expulsion of the balloon catheter. The advantages of outpatient versus inpatient induction of cervical ripening with a balloon catheter were the significantly shorter hospital stay, the lower costs, and higher patient satisfaction, with both procedures having been shown to be equally effective. Complication rates (e.g., vaginal bleeding, severe pain, uterine hyperstimulation syndrome) during the cervical ripening phase are low (0.3 – 1.5%); severe adverse outcomes (e.g., placental abruption) have not been reported. Compared to inpatient induction of labor using vaginal PGE2, outpatient cervical ripening using a balloon catheter had a lower rate of deliveries/24 hours and a significantly higher need for oxytocin; however, hospital stay was significantly shorter, frequency of pain during the cervical ripening phase was significantly lower, and patientsʼ duration of sleep was longer. A randomized controlled study comparing outpatient cervical priming with a balloon catheter with outpatient or inpatient induction of labor with oral misoprostol would be of clinical interest.

A comparative study of single versus repeat instillation of intravaginal prostaglandin E2 gel for induction of labour

Background: The aim of induction was to achieve successful vaginal delivery where continuation of pregnancy is not desirable. Unfavourable cervix is one of the main causes of failed induction. Introduction of intravaginal prostaglandins E2 has revolutionised the method of cervical ripening. More than one dose of prostaglandin E2 (PGE2) gel may be necessary to facilitate cervical ripening and increase the chances of vaginal delivery.Methods: This retrospective study was done to find the efficacy of repeat instillation of intravaginal PGE2 gel and to compare the maternal and fetal outcome between the single instillation group and repeat instillation group. The women who went into labour or achieved cervical ripening with a single instillation of PGE2 gel forms Group A. Those who required repeat instillation of PGE2 gel forms Group B. Both groups were compared for specific parameters.Results: Primigravidas required repeat instillation. Postdated pregnancy was the most common indication for induction of labour. 45.2% of primis required only single dose and 54.8% required repeat dose. About two third (77.8%) of multipara required only one dose and a third of multipara needed repeat dose. In Group A 90.7% had vaginal delivery, 9.3% had Caesarean section. Group B 95.7% had vaginal delivery and 4.3% had Caesarean section.Conclusions: Prostaglandins PGE2 (0.5 mg) gel is recommended to be used intravaginally. We applied 2 doses of intravaginal PGE2, 24 hours apart and no complications like uterine hyperstimulation was seen. There is no increased fetal risk with repeat instillation of intravaginal PGE2 gel.

COMPARATIVE STUDY BETWEEN OXYTOCIN AND PROSTAGLANDIN IN INDUCTION OF DELIVERY IN POST TERM PREGNANCY

Induction of delivery using medication can be performed by stimulating uterine contractility for establishing delivery prior to the start of spontaneous labor. Two most common ecbolic are Oxytocin and prostaglandins analogues (PGs) e.g. misoprostol. The study aims to compare between the effects of oxytocin & misoprostol in ripening of the cervix and induction of delivery in postdate pregnancy. Results show that the induction delivery period mean was significantly higher when using misoprostol than when using oxytocin. No significantly different results between the both groups regarding uterine hyperstimulation. No significantly different results between the both groups regarding postpartum hemorrhage. No significantly different results between the both groups regarding the mode of delivery. No significantly different results between the both groups regarding Cesarean section indication. No significantly different results between the both groups regarding the mean of Apgar score at 1 and 5 minutes. No significantly different results between the both groups regarding meconium aspiration. No significantly different results between the both groups regarding emergency Cesarean section rate due to fetal distress (pathological fetal heart rates) between the two groups. There was no significant difference between the two groups as regards the neonatal admission to the intensive care unit (N.I.C.U). It is concluded that Usage of both IV oxytocin 5 mIU/minute & vaginal misoprostol 25 µg is safe to induce delivery. It is preferable to use IV oxytocin 5 mIU/minute if the time factor is considered. Keywords: oxytocin, prostaglandin, induction of delivery, postdate pregnancy

Efficacy and safety of prostaglandins vs double balloon catheter in inducing labor: a meta-analysis

Background: To compare the efficacy and safety of double‐balloon catheter with prostaglandin E2 (PGE2) in induction of labor.Methods: We searched electronic sources from Medline, Scopus, PubMed, Science Direct and Cochrane Library Database of Systematic Reviews. Only randomized controlled trials and observational studies comparing the PGE2 agents with double-balloon catheter for cervical ripening and labour induction in women with unfavorable cervix were included in the analysis. The main outcomes included vaginal delivery rate within 24 hours and cesarean delivery rates. We calculated relative risks and mean differences using fixed effects and random‐effects models.Results: Prostaglandin was more favourable for vaginal delivery within 24 hours compared to double balloon catheter, but was not statistically significant (RR 1.17: 95% CI 0.96-1.42 p =0.12). The induction to delivery time yielded a non-significant result that again favors prostaglandin (SMD 0.02 CI:0.18,0.22, p = 0.86). There was no significant difference in the cesarean delivery rates between the two groups (RR 1.02: 95% CI 0.92-1.14, p = 0.68). Uterine hyperstimulation and Neonatal Intensive Care Unit (NICU) admissions were significantly higher with prostaglandin. (RR 0.09: CI 0.04, 0.22 p<0.00001 and RR 0.75 CI: 0.62,0.90 p=003).Conclusions: There is no significant difference in the success of induction of labour between use of PGE2 and double balloon catheter. Uterine hyperstimulation and NICU admissions were significantly higher in Prostaglandin group.

High dose vs. low dose oxytocin for labor augmentation: a systematic review and meta-analysis of randomized controlled trials

ObjectivesTo compare the safety and efficacy between high dose and low dose oxytocin administration for labor augmentation.MethodsWe searched for the available studies during March 2020 in PubMed, Cochrane Library, Scopus, and ISI Web of science. All randomized clinical trials (RCTs) that assessed safety and efficacy of high dose vs. low dose oxytocin for labor augmentation were considered. The extracted data were entered into RevMan software. Dichotomous and continuous data were pooled as odds ratio (OR) and mean difference (MD) respectively, with the corresponding 95% confidence intervals (CI). Our main outcomes were cesarean delivery rate, spontaneous vaginal delivery rate, uterine hyperstimulation and tachysystole, and labor duration from oxytocin infusion.ResultsEight RCTs with 3,154 patients were included. High dose oxytocin did not reduce cesarean delivery rate compared to low dose oxytocin (OR=0.76, 95% CI [0.52, 1.10], p=0.15). After solving the reported heterogeneity, high dose oxytocin did not increase the rate of spontaneous vaginal deliveries vs. low dose oxytocin (OR=1.06, 95% CI [0.84, 1.32], p=0.64). Low dose oxytocin was linked to a significant decline in uterine hyperstimulation and tachysystole (p>0.001). A reduction in labor duration was found in high dose oxytocin group over low oxytocin regimen (MD=−1.02 h, 95% CI [−1.77, −0.27], p=0.008).ConclusionsWe found no advantages for high dose oxytocin over low dose oxytocin in labor augmentation except in reducing labor duration. Low dose oxytocin is safer as it decreases the incidence of uterine hyperstimulation and tachysystole. More trials are needed to confirm our findings.