Prolonged pregnancy: the management debate.

A prospective trial was conducted to compare the effects of conservative management of prolonged pregnancy (conservative group) with routine induction of labour at 42 weeks'' gestation (active group) in otherwise uncomplicated pregnancies. Of the 402 pregnancies studied, 207 (51%) were allocated to conservative management and 195 (49%) were allocated to have labour induced. The groups were well matched for age, parity, and smoking habits. One hundred and sixty six (80%) of the patients in the conservative group went into spontaneous labour. Of the remainder, two underwent elective caesarean section, 19 had labour induced because of clinical concern, and the remaining 20 had labour induced at the patient''s own request. One hundred and twenty five (64%) of the patients in the planned active group underwent induction of labour. Of the remaining 70, 49 went into spontaneous labour and 21 (11%) asked that they should not have labour induced. Comparison of the two groups showed no difference in the length of the first stage of labour but a trend towards an increased need for intervention for fetal distress (p less than 0.06) in the active group. There were no differences in the length of the second stage, the need for intervention, or the mode of delivery. In terms of Apgar scores the neonatal outcome was not significantly different between the two groups, but a greater proportion of the babies (15% v 8%) in the active group required intubation. Umbilical cord venous pH estimated in the last 183 consecutive deliveries in the study showed a significantly lower mean value in the active group (p less than 0.05). There was no difference in birth weight between the two groups. Two deaths occurred in the study. There was a stillbirth in the conservative group at 292 days after massive abruption, and one neonatal death in the active group owing to multiple congenital abnormalities. The outcome for mother and baby in patients from both groups who went into spontaneous labour was generally good. The outcome for patients for whom conservative management was planned but induction became necessary was no different from that of patients who underwent planned induction at term. Thus from our results we can find no evidence to support the view that women with normal prolonged pregnancy should undergo routine induction of labour at 42 weeks'' gestation.     

COOK双球囊导管在足月妊娠引产中的临床研究

目的:探讨宫颈双球囊导管在足月妊娠促宫颈成熟及引产中的有效性和安全性。方法:回顾性选择符合有引产指征、单胎头位、宫颈评分6分的100例足月妊娠孕妇进行分析,其中51例采用COOK双球囊导管引产者为COOK组,49例采用小剂量缩宫素引产者为对照组,比较分析两组宫颈成熟度、引产效果、分娩方式、分娩结局、产后出血、新生儿窒息等情况。结果:100例孕妇引产指征主要是延期(过期)妊娠、羊水过少、妊娠期高血压、妊娠期糖尿病、妊娠合并甲减等。COOK组51例促宫颈成熟有效49例(96.08%),对照组有效16例(32.65%),COOK组促宫颈成熟有效率显著高于对照组,差异有统计学意义(P0.05)。COOK组诱发临产时间明显少于对照组,两组差异有统计学意义(P0.05)。COOK组阴道分娩41例(80.39%),剖宫产10例(19.61%);对照组阴道分娩20例(40.82%),剖宫产29例(59.18%),COOK组阴道分娩率明显高于对照组,剖宫产率明显低于对照组,两组差异均有统计学意义(P0.05)。两组之间的总产程、羊水污染率、新生儿窒息率、产后出血率等围产结局无显著差异(P0.05);COOK组引产过程中出现不良反应6例(11.76%),对照组5例(10.20%),两组无显著差异(P0.05)。结论:COOK双球囊导管促宫颈成熟及引产效果明显优于缩宫素,且不增加不良反应的发生,由于操作简单,有效性和安全性高,值得国内临床推广。     

Induction of abortion by intra- and extra-amniotic prostaglandin F2 administration

PGF2 alpha was administered intrauterine in 115 patients during the 11th to 20th week of pregnancy for abortion induction. An intra-amniotic method was used in 61 cases, an extra-amniotic one in 54 cases. Average total dose administered was 35.1 (range 5 to 65 mg) in the amniotic group and 6358 mcg (range 1500 to 14000 mcg) in the extra-amniotic group. The intra-amniotic group had an abortion rate of 92% and a 74% rate of side effects, mainly gastrointestinal irritation. Corresponding figures for the extra-amniotic group were 72% and 54% respectively. In the extra-amniotic group, doses of 4750 mcg or more increased the abortion rate up to 80% and side effects up to 64%. There were no serious complications. The intra-amniotic approach of prostaglandin induction is suitable for second trimester therapeutic abortions. The extra-amniotic approach is useful in cases of fetus mortuus and hydatiform mole.     

Outcome of planned home births in an inner city practice.

OBJECTIVE--To assess the outcome of pregnancy for women booking for home births in an inner London practice between 1977 and 1989. DESIGN--Retrospective review of practice obstetric records. SETTING--A general practice in London. SUBJECTS--285 women registered with the practice or referred by neighbouring general practitioners or local community midwives. MAIN OUTCOME MEASURES--Place of birth and number of cases transferred to specialist care before, during, and after labour. RESULTS--Of 285 women who booked for home births, eight left the practice area before the onset of labour, giving a study population of 277 women. Six had spontaneous abortions, 26 were transferred to specialist care during pregnancy, another 26 were transferred during labour, and four were transferred in the postpartum period. 215 women (77.6%, 95% confidence interval 72.7 to 82.5) had normal births at home without needing specialist help. Transfer to specialist care during pregnancy was not significantly related to parity, but nulliparous women were significantly more likely to require transfer during labour (p = 0.00002). Postnatal complications requiring specialist attention were uncommon among mothers delivered at home (four cases) and rare among their babies (three cases). CONCLUSIONS--Birth at home is practical and safe for a self selected population of multiparous women, but nulliparous women are more likely to require transfer to hospital during labour because of delay in labour. Close cooperation between the general practitioner and both community midwives and hospital obstetricians is important in minimising the risks of trial of labour at home.     

Elective Delivery at Term after a Previous Unexplained Intra-Uterine Fetal Death: Audit of Delivery Outcome at Tygerberg Hospital,South Africa

Objectives

To assess the delivery outcome in a pregnancy with a previous unexplained intra-uterine death by elective induction of labour at term.

Methods

An audit of the pregnancy outcome of all women within the catchment area with a current singleton pregnancy; and a previous unexplained or unexplored singleton fetal demise ≥24 weeks (or 500 grams birth weight if gestation unknown) after planned routine induction of labour at full term (39-40 weeks).

Results

During the audit period, 306 patients with a previous intra-uterine fetal death were referred for further management. Of these, 161 had a clear indication for earlier intervention and were excluded from the protocol. Of the remaining 145 patients, 9 met further exclusion criteria and there were 2 patients who defaulted. Forty-two of the remaining study patients (with no known previous medical problems) developed complications during their antenatal course that necessitated a change in clinical management and earlier (<39 weeks) delivery. Of the remaining 92 patients in the audit, 47 (51%) went into spontaneous labour before their induction date; all 92 women delivered without major complications. There were no intra-uterine deaths prior to induction.

Conclusions

Careful follow up at a high risk clinic identifies new or concealed maternal or fetal complications in 29% of patients with a previous intra-uterine death and no obvious maternal or fetal disease in the index pregnancy. When all risks are excluded and the pregnancy allowed to progress to full term (39-40 weeks) before an induction is offered, 50% will go into spontaneous labour.     

Mothers' experiences of induction

Mothers of a random sample of 2182 legitimate live births were interviewed about their experiences of pregnancy, labour, and delivery. Of these, 24% reported that their labours were induced, and data about this from a subsample of mothers tallied with information obtained through the doctors in charge in 88% of cases. All but 3% of the mothers who were induced perceived some medical reason for the induction. The proportion of inductions in the 24 study areas ranged from 6% to 39%. A relatively small proportion of labours in “teaching” hospitals, small hospitals with less than 100 beds, and GP maternity hospitals were induced, but a comparatively high proportion of private patients had an induction. There was no clear association between induction and the mother''s age or parity. Despite being given more pain relief, those who were induced reported similar intensities of pain during the first and second stages of labour to those whose labour started spontaneously; they also reported that they had “bad pains” for a similar period. The period they had contractions was shorter for the induced than for those starting spontaneously, and the intensity of pain at delivery was rated somewhat less by those who were induced.There was no difference between induced babies and others in the proportion who were held by their mothers immediately after their birth. Two-fifths of the mothers who were induced would have liked more information about induction; and a similar proportion said they had not discussed induction with a doctor, midwife, or nurse during their pregnancy. Only 17% of the mothers who had an induction said they would prefer to be induced if they had another baby. This contrasts with 63% of those who had epidural analgesia who would opt for the same procedure next time, while 83% of those who had had a baby in hospital, and 91% of those having had a home birth, would want their next baby in the same type of place.     

Influence of simultaneous low amniotomy and oxytocin infusion and other maternal factors on neonatal jaundice: a prospective study.

In a prospective study of 196 consecutive single births a significant increase in serum bilirubin concentrations was found in infants born after low amniotomy induction and oxytocin infusion compared with those born spontaneously. This relationship was not dose-dependent and may have been associated with artificial interruption of pregnancy rather than the oxytocin itself. Infants delivered after spontaneous labour accelerated by oxytocin showed no such increase. The hormonal surge at the spontaneous onset of labour may affect fetal enzyme induction, but other factors, such as methods of infant feeding and oral contraceptive use, were found not to be significant.     

Cervical ripening with intravaginal prostaglandin E2 gel.

We describe a technique of administering prostaglandin E2 (PGE2) in a viscous cellulose gel into the vagina to ripen the unfavourable cervix in patients requiring induction of labour. A total of 168 primigravidae were studied, of whom 102 received 2 mg PGE2 in 2% gel and 66 received 5 mg PGE2 in 4% gel. In the latter group, the state of the cervix was significantly improved in 58 patients (87.9%), while 32 (48.5%) had started labour before planned induction. There were no maternal or fetal side effects or complications.     

Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. Zurich Study Team.

OBJECTIVE: To assess procedures and outcomes in deliveries planned at home versus those planned in hospital among women choosing the place of delivery. DESIGN: Follow up study of matched pairs. SETTING: Antenatal clinics and reference hospitals in Zurich between 1989 and 1992. SUBJECTS: 489 women opting for home delivery and 385 opting for hospital delivery; the women comprised all those attending members of the study team for antenatal care and those attending the reference hospital for antenatal care who could be matched with the women planning home confinement. MAIN OUTCOME MEASURES: Need for medication and incidence of interventions during delivery (caesarean section, forceps, vacuum extraction, episiotomy), duration of labour, occurrence of severe perineal lesions, maternal blood loss, and perinatal morbidity and death. RESULTS: All women were followed up from their first antenatal visit till three months after delivery. Referrals during pregnancy (n = 37) and labour (70), changes of mind (15 home to hospital, eight hospital to home), and 17 miscarriages resulted in 369 births occurring at home and 486 in hospital. During delivery the home birth group needed significantly less medication and fewer interventions whereas no differences were found in durations of labour, occurrence of severe perineal lesions, and maternal blood loss. Perinatal death was recorded in one planned hospital delivery and one planned home delivery (overall perinatal mortality 2.3/1000). There was no difference between home and hospital delivered babies in birth weight, gestational age, or clinical condition. Apgar scores were slightly higher and umbilical cord pH lower in home births, but these differences may have been due to differences in clamping and the time of transportation. CONCLUSION: Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies.     

Preinduction cervical priming with PGE2 vaginal film in primigravidae--a randomised, double blind, placebo controlled study

Previous reports with an 850 micrograms prostaglandin E2 film for cervical ripening before induction of labour in term pregnancy have been favourable. These studies however had no controls. The present study compares this PGE2 vaginal film with a nonmedicated similar vaginal film (placebo) for preinduction cervical ripening in primigravid women at term. A total of 69 women with modified Bishop's cervical scores 1-5 were assigned randomly to either the PGE2 group (33 women) or placebo group (36 women). Cervical score assessments were made at 12 and 24 hours after which labour was induced by amniotomy and oxytocin infusion. Although the cervical scores between placebo and PGE2 groups at 12 and 24 hours were not significantly different, the scores were marginally better with the prostaglandin film. Pregnancy outcome was satisfactory in both groups with no perinatal or maternal mortality and morbidity. The caesarean rate was 30.6% in the placebo group and 24.2% in the PGE2 group. This study emphasizes the need for a control group when studying the success of agents used for ripening the pregnant cervix at term.     

Associations between cesarean delivery and child mortality: A national record linkage longitudinal study of 17.8 million births in Brazil

BackgroundThere is an increasing use of cesarean delivery (CD) based on preference rather than on medical indication. However, the extent to which nonmedically indicated CD benefits or harms child survival remains unclear. Our hypothesis was that in groups with a low indication for CD, this procedure would be associated with higher child mortality and in groups with a clear medical indication CD would be associated with improved child survival chances.Methods and findingsWe conducted a population-based cohort study in Brazil by linking routine data on live births between January 1, 2012 and December 31, 2018 and assessing mortality up to 5 years of age. Women with a live birth who contributed records during this period were classified into one of 10 Robson groups based on their pregnancy and delivery characteristics. We used propensity scores to match CD with vaginal deliveries (1:1) and prelabor CD with unscheduled CD (1:1) and estimated associations with child mortality using Cox regressions. A total of 17,838,115 live births were analyzed. After propensity score matching (PSM), we found that live births to women in groups with low expected frequencies of CD (Robson groups 1 to 4) had a higher death rate up to age 5 years if they were born via CD compared with vaginal deliveries (HR = 1.25, 95% CI: 1.22 to 1.28; p < 0.001). The relative rate was greatest in the neonatal period (HR = 1.39, 95% CI: 1.34 to 1.45; p < 0.001). There was no difference in mortality rate when comparing offspring born by a prelabor CD to those born by unscheduled CD. For the live births to women with a CD in a prior pregnancy (Robson group 5), the relative rates for child mortality were similar for those born by CD compared with vaginal deliveries (HR = 1.05, 95% CI: 1.00 to 1.10; p = 0.024). In contrast, for live births to women in groups with high expected rates of CD (Robson groups 6 to 10), the child mortality rate was lower for CD than for vaginal deliveries (HR = 0.90, 95% CI: 0.89 to 0.91; p < 0.001), particularly in the neonatal period (HR = 0.84, 95% CI: 0.83 to 0.85; p < 0.001). Our results should be interpreted with caution in clinical practice, since relevant clinical data on CD indication were not available.ConclusionsIn this study, we observed that in Robson groups with low expected frequencies of CD, this procedure was associated with a 25% increase in child mortality. However, in groups with high expected frequencies of CD, the findings suggest that clinically indicated CD is associated with a reduction in child mortality.

In a study of linked population-based data, Enny Paixao and colleagues study the associations between cesarean section and child mortality among 17.8 million live births in Brazil.     

Preinduction cervical priming in high risk pregnancy — experience with a new sustained release PGE2 vaginal film

Experience with a new sustained release PGE2 formulation is presented. 111 high risk primiparae with very poor cervical scores (<3) were studied. In 59 patients, labour was induced by forewater amniotomy and I.V. oxytocin. In the remaining 52 patients, film containing 850 ug of PGE₂ was inserted into the vagina to ripen the cervix 24 hours prior to induction of labour. Indications for elective delivery and maternal characteristics were similar in both groups. There were significant changes in the cervical state within 12 hours of vaginal insertion. By 24 hours, 19 patients receiving vaginal film (36.5%) had established labour of whom 13 proceeded to vaginal delivery. Significantly fewer patients in the priming group required Caesarean delivery. No untoward maternal or fetal side effects were observed.Safety, ease of administration and efficacy make this new PGE₂ formulation a useful agent for priming of the very poor primiparous cervix prior to induction of high risk labour.     

Trends in the Distribution of Gestational Age and Contribution of Planned Births in New South Wales,Australia

Background

There is concern that the rate of planned births (by pre-labour caesarean section or induction of labour) is increasing and that the gestation at which they are being conducted is decreasing. The aim of this study was to describe trends in the distribution of gestational age, and assess the contribution of planned birth to any such changes.

Methods

We utilised the New South Wales (NSW) Perinatal Data Collection to undertake a population-based study of all births in NSW, Australia 1994–2009. Trends in gestational age were determined by year, labour onset and plurality of birth.

Results

From 1994–2009, there was a gradual and steady left-shift in overall distribution of gestational age at birth, with a decline in the modal gestational age from 40 to 39 weeks. For singletons, there was a steady but significant reduction in the proportion of spontaneous births. Labour inductions increased in the proportion performed, with a gradual and changing shift in the distribution from a majority at 40 weeks to an increase at both 37–39 weeks and 41 weeks gestation. The proportion of pre-labour caesareans also increased steadily at each gestational age and doubled since 1994, with most performed at 39 weeks in 2009 compared with 38 weeks up to 2001.

Conclusions

Findings suggest a changing pattern towards births at earlier gestations, fewer births commencing spontaneously and increasing planned births. Factors associated with changing clinical practice and long-term implications on the health and well-being of mothers and babies should be assessed.     

Expression of scaffolding, signalling and contractile-filament proteins in human myometria: effects of pregnancy and labour

Successful parturition requires the co-ordination of numerous myometrial signalling events to allow for timely and efficient uterine contractions. Late pregnancy and labour onset in humans may be associated with changes in the expression of myometrial proteins implicated in such uterine contractile signal integration. Accordingly, in myometria from non-pregnant women and pregnant women, not in labour or in labour, we examined the content of putative plasmalemmal scaffolding proteins (caveolin-1 and -2) and compared these to the proportions of signal transducing rho-associated kinases (ROKalpha and beta) and contractile filament-associated proteins alpha-actin, myosin regulatory light chain (MLC(20)) and h-caldesmon. There was no effect of pregnancy or labour on the proportion of caveolin, ROK betaor alpha-actin. However, pregnancy was associated with a decrease in ROKalpha and MLC(20) such that ROK alpha: alpha-actin and MLC(20): alpha-actin ratios were reduced compared to myometria of non-pregnant women. In contrast, h-caldesmon was up-regulated in pregnancy resulting in an elevated h-caldesmon: alpha-actin ratio. There were, however, no further significant changes in ROK alpha, MLC(20) or h-caldesmon expression with spontaneous or oxytocin-induced labour. These data suggest that the mechanism(s) integrating myometrial signalling events with the onset of human labour does not involve differential alterations of the cellular expressions of caveolins, ROK, alpha-actin, MLC(20) or h-caldesmon.     

Contribution of preterm delivery to perinatal mortality.

A detailed retrospective analysis was made of the records of 486 preterm infants, who accounted for 5-1% of all births during 1973 and 1974. Whereas preterm delivery did not contribute to perinatal mortality in terms of stillbirth, it outweighed all other causes in terms of early neonatal deaths. Preterm birth was responsible for 85% of the early neonatal deaths not due to lethal congenital deformities. Early neonatal mortality rates were closely linked both to gestational age and birth weight and to the reason for preterm birth. Early neonatal mortality was high (97 per 1000) when preterm labour was spontaneous, whether or not associated with material or fetal disease or with multiple pregnancy, but low (27 per 1000) when preterm delivery was elective. Preventing spontaneous preterm labour would considerably reduce neonatal mortality in our community.     

Menstrual induction by the vaginal application of ICI 81008 gel

After ～2 weeks menstrual delay (positive Pregnosticon Tests) “menstrual induction” was attempted in 75 gravidas by repeated vaginal application of a gel, containing 200 or 400 μg/ml ICI 81008. After ～10 minutes, following the 1st vaginal delivery of 400 μg ICI 81008, the uterus responded to this PGF2α analogue with sustained contracture. The highest success rate in induced bleeding (93%) and pregnancy termination (79%), without supportive therapy, was achieved when 400 μg ICI 81008 was administered 2 to 5 times at 4 hour intervals. Those gravidas (21%), who failed in induced menstruation, or stopped bleeding within 24 hours after treatment, had positive Pregnosticon Tests on day 14 and were curetted. The side effects, mostly vomiting and increased blood pressure, were transient and subjectively and medically acceptable. While the vaginal application of the drug is apparently less effective than the intrauterine (1), it has the advantage of simple delivery and the potential of self-administration.     

Spontaneous urogenital infection in macaques

Rates of natural infection of macaques with microorganisms that cause urogenital tract infections (UGT)--chlamydias, mycoplasms, ureaplasms and trichomonades--have been assessed. 198 macaques (rhesus, javan and lapunder) aged from newborn to 25 years (born healthy or from females with complicated pregnancy or labour) were examined. High rate of infection (40%) was observed in healthy macaques by PCR assay. In animals born from females with complicated pregnancy or labour (abortion, complicated labour, stillbirth or inflammatory postdelivery complications) rate of pathogens detection was significantly higher (up to 54,5 - 64,5%). In such animals mixed infection with 2 - 4 microorganisms in association was commonly observed. Births of weak, low weight and vitality monkey's calves was observed in infected macaques aged 17 - 25 years. Pathogens' nucleotide sequences that were analogous to ones detected in mothers were detected in calves that died during 1st month of life. This finding can be the evidence of the intrauterine infection of calves.     

The Effects of Heart Rate Variability Biofeedback in Patients with Preterm Labour

Preterm birth is a highly prevalent phenomenon that was shown to be associated with mental stress during pregnancy (Rich-Edwards and Grizzard in Am J Obstet Gynecol 192(5 Suppl):S30–S35, 2005). We aimed to assess the effects of heart rate variability (HRV)-biofeedback in patients with preterm labour. Therefore, we conducted a controlled randomized parallel group study in 48 female patients aged 19–38 years (median = 29) with preterm labour at gestational week 24th–32nd (median = 29th). In this study, one group (n = 24) attended six sessions of HRV-biofeedback over 2 weeks whereas patients of the other group (n = 24) were assigned to control sessions. In the HRV-biofeedback treated group, perception of chronic stress was decreased 4 weeks after completion of training compared to baseline (p < 0.05) but there was no change in the control group. In the HRV-biofeedback group, preterm birth was seen in 3 patients (13 %) whereas in the control group, preterm delivery occurred in 8 patients (33 %, p = n.s.). There was no difference in birth weight between groups and HRV remained unchanged. In conclusion, our study demonstrates that HRV-biofeedback can reduce chronic stress in patients with preterm labour when administered as an adjunct to routine care. However, it remains unclear whether stress reduction through HRV-biofeedback has a beneficial effect on preterm birth.     

The Associations between Bridal Pregnancy and Obstetric Outcomes among Live Births in Korea: Population-Based Study

Objective

In East Asia the recently increased number of marriages in response to pregnancy is an important social issue. This study evaluated the association of marriage preceded by pregnancy (bridal pregnancy) with obstetric outcomes among live births in Korea.

Methods

In this population-based study, 1,152,593 first singleton births were evaluated from data registered in the national birth registration database from 2004 to 2008 in Korea. In the study population, the pregnancy outcomes among live births from the bridal pregnancy group (N = 62,590) were compared with the outcomes of the post-marital pregnancy group (N = 564,749), composed of women who gave birth after 10 months but before 24 months of marriage. The variables preterm birth (PTB; <37 weeks gestation) and low birth weight (LBW; <2.5 kg) were used to determine the primary outcome. The adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated after controlling for socio-demographic factors.

Results

The socio-demographic factors among the bridal pregnancy group were associated with a social disadvantage and particular risk factors. In the subgroup analyses of maternal age, differences in adverse pregnancy outcomes from bridal pregnancy were identified between women in the following age group: (i) ≤19, (ii) 20–39, and (iii) ≥40 years. After the multivariate analysis, the aORs for each age group were 1.47 (95% CI: 1.15–1.89), 1.76 (1.70–1.83), and 1.13 (0.77–1.66), respectively, for PTB and 0.92 (0.70–1.21), 1.60 (1.53–1.66), and 1.11 (0.71–1.74), respectively, for LBW. In the adjusted logistic regression models, bridal pregnancy was associated with PTB (1.76, 1.69–1.82) and LBW (1.53, 1.48–1.59).

Conclusion

Pregnancy outcomes among live births from bridal pregnancies are associated with higher risks for PTB and LBW in Korea.     

Experience with prostaglandin F2α (free acid) for the induction of labour

Labour was induced or augmented in 115 patients by amniotomy followed by intravenously administered prostaglandin F_2α (PGF_2α). The results were compared to those obtained retrospectively from a similar number of patients, matched for age, parity, induced and augmented labour, epidural anaesthesia and induction score; in whom labour had been induced by amniotomy followed by intravenous oxytocin titration. Both regimes were very effective, but there was a higher incidence of side effects in the patients receiving oxytocin. There was one maternal death associated with Prostaglandin infusion. Labour was also induced in a further group of 50 patients by amniotomy followed by oral PGF_2α (free acid). 42 patients (84%) were successfully induced. Vomiting and diarrhoea occurred in 22 patients (45%).