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PubMed1993

Two different regimens of preinduction ripening of the uterine cervix with prostaglandin E2: a randomized clinical study.

A randomized clinical study was designed to test the relative efficacy of preinduction cervical ripening with 0.25 mg prostaglandin E2 (PGE2), repeated if necessary (group 1) compared to a single maturation with 0.50 mg PGE2 (group 2). In group 1 (n = 42), the ripening process was repeated every day until spontaneous onset of labor occurred or induction with oxytocin was decided (for improved Bishop score above 5, or maternal or fetal distress). In group 2 (n = 42) the patients who had not labored 12 h after the maturation procedure had labor induced with oxytocin, irrespective of their cervical status. In group 1, 28 patients experienced repeated maturations (from 2 to 9). Thirty patients had an induction of labor with oxytocin in group 2 and only 12 in group 1 (P < 0.0001). There were four failures of induction of labor in group 2 and none in group 1 (P < 0.05). Three episodes of myometrial hyperstimulation requiring an emergency cesarean section for acute fetal distress occurred in group 2 and none in group 1. There were 13 cesarean sections in group 2 and eight in group 1. The outcome of pregnancy was otherwise similar in both groups. In order to avoid failure of induction of labor, pre-induction cervical ripening with 0.25 mg PGE2, repeated daily if necessary, is therefore recommended in high risk pregnancy unless a severe maternal or a fetal distress call for a prompt delivery irrespective of the cervical status.

Adult↗

PubMed1999

A comparison of breast stimulation and intravenous oxytocin for the augmentation of labor.

BACKGROUND: Breast stimulation to augment labor has been used for centuries in tribal societies and by midwives. In recent years it has been shown to be effective in ripening the cervix, inducing labor, and as an alternative to oxytocin for the contraction stress test. This study compared the effectiveness of breast stimulation with oxytocin infusion in augmenting labor. METHODS: Women admitted to the labor ward were eligible for the study if they had inadequate labor with premature rupture of the membranes and met inclusion criteria. They were assigned to oxytocin augmentation or breast stimulation (manual or pump), and were switched to oxytocin in the event of method failure. Outcomes included time to delivery, intervention to delivery, proportion of spontaneous deliveries, and Apgar scores. One hundred participants were needed in each arm of the study to demonstrate a 2- to 3-hour difference in delivery time, with a power of 80 percent. RESULTS: Analysis was performed on 79 women, of whom 49 were in the breast stimulation group and 30 in the oxytocin group. Sixty-five percent of the participants failed breast stimulation and were switched to oxytocin infusion. Although augmentation start to delivery was shorter for the oxytocin group (p < 0.001), no differences in total labor time occurred between the groups. Nulliparas receiving breast stimulation had more spontaneous (relative risk 1.7, p = 0.04), and fewer instrumental deliveries than those receiving oxytocin (relative risk 0.2, p = 0.02). No significant differences in adverse fetal outcomes occurred between the study groups. CONCLUSIONS: The small number of participants and a variety of problems with the conduct of the study prevented the formulation of reliable conclusions from the results. However, the study provided important insights into the feasibility and problems of developing a high-quality randomized trial of augmentation by breast stimulation.

Adolescent↗

PubMed2002

Sublingual misoprostol for the induction of labor at term.

OBJECTIVE: To evaluate the efficacy, safety, and patient acceptability of sublingual misoprostol compared with an equivalent dose administered orally for labor induction at term. STUDY DESIGN: One hundred women with medical or obstetric indications for induction of labor after 37 weeks of gestation and unfavorable cervices were randomized to receive 50 microg of misoprostol either orally or sublingually. The dose was repeated every 4 hours to a maximum of 5 doses if indicated. Previous cesarean delivery was a criteria for exclusion. Our primary outcome measure was the number of patients who went on to have a vaginal delivery within 24 hours of the induction. The need for oxytocin, mode of delivery, number of cesarean deliveries for fetal distress, uterine hyperstimulation rates, and neonatal outcomes were secondary outcome measures. Patient acceptability was assessed by questionnaires completed after delivery. RESULTS: Significantly more patients were delivered of infants within 24 hours (73.8% versus 45.7%; relative risk, 1.6; 95% confidence interval, 1.1 to 2.4) and the induction to delivery intervals were significantly shorter (20 hours versus 28.3 hours; mean difference, 8.3 hours; 95% confidence interval, 1.2 to 15.4) in the sublingual group compared with the oral group. There was 1 case of uterine hyperstimulation in the sublingual group. There were no significant differences in the mode of delivery, interventions for fetal distress, or neonatal outcomes in the 2 groups. The satisfaction rates were 82.5% and 85.7% in the oral and sublingual groups respectively, and 9.5% of patients thought that the sublingual tablets did not dissolve completely. CONCLUSION: There has been no previous report in the literature of misoprostol given sublingually for labor induction. Sublingual misoprostol seems to have better efficacy than oral misoprostol, seems to be acceptable to patients, and is an option to be considered to induce labor at term.

Administration, Oral↗

PubMedDate not supplied

[Premature rupture of the fetal membranes--an active or expectant approach in management of this obstetrical problem].

INTRODUCTION: A prospective investigation and comparative analysis of clinical and microbiological results have been performed as to point to some facts of possible significance in solving the dilemmas concerning the problem of pregnant women with premature rupture of the membranes. MATERIAL AND METHODS: Intensive clinical monitoring of the course, methods and complications of the labor was undertaken in 75 pregnant women with premature rupture of the membranes and term delivery. Smears from the vagina, cervix, amnion and amniotic fluid were obtained from each pregnant woman, as well as nasal and throat smears from newborn infants in order to microbiological analysis. According to the method of labor treatment, the investigated patients (n = 75) were distributed into 2 groups. Early induction of labor was applied in 39 pregnant women (labor induction 6 h following rupture of the membranes) and expectatively treated 37 pregnant women (the control of pregnant women until initiation of the spontaneous contractions associated with antibiotic prophylaxis). RESULTS AND DISCUSSION: Duration of labor (period from rupture of the membranes to the delivery and from the initiation of regular contractions to the delivery) was significantly shorter (p < 0.01) in the induced labor group. Cesarean section was performed in 18.4% od labors in the first and in 13.5% of labors in the second group. Chorioamnionitis occurred in 7.9% in the first and in 21.6% in the second group during the labor (p < 0.05). The incidence of puerperal and neonatal infection was lower in the first investigated group (7.9% and 5.2%) than in the second group (18.9% and 16.2%). Positive microbiological finding was recorded in 13.2% of pregnant women from the first group and in 27.0% from the second group (p < 0.05). CONCLUSION: From the medical point of view it is reasonable to apply early induction of labor in pregnant women at more than 34 weeks' gestation. In pregnant women of less than 34 weeks' gestation, the expectant management of labor is recommended only in the next 48-72 hours.

Adult↗

PubMed2003

A comparison of two methods of labor induction with vaginal misoprostol.

OBJECTIVES: To evaluate if labor induction with 50 microg of vaginal misoprostol twice per day is as effective as and safer than 100 microg used once per day. METHODS: Misoprostol was used to induce labor in 204 consecutive pregnant women assessed as needing labor induction, 104 at the University Hospital of the West Indies in Kingston, Jamaica, and 100 at the Victoria Jubilee Hospital, also in Kingston. At the former institution the women were administered 100 microg of misoprostol once per 24 h and at the latter 50 microg every 12 h. The doses were repeated if there was no cervical change or if the woman was not in labor. Bishop scores were determined before initiation of induction and again 12 h later. Women's records were reviewed after 24 h to determine delivery outcome. RESULTS: The indications for labor induction were similar in each group. There was no significant difference in the group demographics. In the group given 50 microg of misoprostol twice per day the mean time+/-S.D. from insertion of misoprostol to delivery was significantly shorter than in the other group (560.14+/-269.20 min vs. 729.90+/-471.65 min; P<0.01), and the percentage of women who were delivered within 12 h was higher (75% vs. 56.8%; P<0.002). There was no significant difference between the two groups in the rate of cesarean births, the need for oxytocin, or blood loss. Only two patients experienced uterine hyperstimulation, both in the group that had received 100 microg of misoprostol per day. There was no significant difference between the two groups in the birthweight of the neonates and in the number of neonates with Apgar scores less than 7 at 1 min and 5 min. There were, however, significantly fewer neonates who needed resuscitation (6% vs. 14.7%; P=0.04) and admission to the special care nursery (7% vs. 17%; P=0.03) in the group that had received 50 microg of misoprostol twice per day. CONCLUSIONS: A dose of 50 microg of misoprostol twice per day appears to be more efficient and safer than a dose of 100 microg once per day, but this may partially be due to weaknesses in the study design.

Administration, Intravaginal↗

PubMed2005

When has an induction failed?

OBJECTIVE: To evaluate the length of the latent phase that, during labor inductions in nulliparous women, is associated with significantly decreased chance of vaginal delivery and increased risk of maternal and neonatal morbidity. METHODS: All inductions of labor during a 6-month period were identified. Only those women who were nulliparous with a pregnancy of 36 weeks or more of gestation underwent further data analysis. Demographic data, intrapartum course, and maternal and neonatal outcomes were abstracted from the medical record. The latent phase was defined as beginning after oxytocin had been initiated and amniotomy performed and continuing until either 4 cm cervical dilation and 80% effacement or 5 cm cervical dilation regardless of effacement. RESULTS: A total of 397 nulliparous women, 32% of whom underwent cervical ripening, presented during the study period. Only 8 women (2%) never achieved active phase labor before cesarean, and the overall cesarean rate was 26.0%. A longer latent phase was associated with a greater rate of cesarean delivery, although only after 18 hours did a majority of induced labors result in cesarean. Chorioamnionitis and postpartum hemorrhage were more frequent with latent phases of labor greater than 18 hours (16% and 26%, respectively), although these diagnoses did not translate into greater risk of transfusion, hysterectomy, or prolonged hospitalization. Neonatal outcomes, including meconium passage, fetal acidemia, neonatal intensive care unit admission, or other morbidity did not increase in conjunction with longer latent phases. CONCLUSION: A latent phase of as long as 18 hours during induction of labor in nulliparous women allows the majority of these women to achieve a vaginal delivery without being subject to a significantly increased risk of significant maternal or neonatal morbidity. LEVEL OF EVIDENCE: II-2.

Adult↗

PubMed1990

A prospective comparison of hourly and quarter-hourly oxytocin dose increase intervals for the induction of labor at term.

Fifty-two women undergoing labor induction and vaginal delivery at term were randomized between two oxytocin infusion protocols, involving hourly versus quarter-hourly increases in dose. Potential differences were sought of duration of labor, amount of uterine activity generated, and amount of oxytocin required. Starting at 0.5 mU/minute, oxytocin infusion was increased regularly in small increments every hour or every 15 minutes, according to group assignment. No differences were observed in potentially confounding clinical and demographic factors between the groups, including time to ruptured membranes. There were no clinically or statistically significant differences found for the duration of any phase or stage of labor, quantitative assessment of uterine activity, incidence of hyperstimulation, or neonatal outcome. The average dose of oxytocin used was lower in the hourly than in the quarter-hourly, protocol (4.4 versus 6.7 mU/minute; P less than .005). Significantly fewer patients on the hourly protocol required a maximum infusion rate exceeding 8 mU/minute (P less than .05). More patients on the hourly protocol either had oxytocin discontinued completely or were maintained at 4 mU/minute or less during the active phase of labor (P less than .05 and P less than .001, respectively). We conclude that a slower rate of increase in oxytocin administration via continuous infusion results in no prolongation of any phase of induced labor, while permitting lower infusion rates of the drug.

Drug Administration Schedule↗

PubMed2005

Labor-associated regulation of prostaglandin E and F synthesis and action in the ovine amnion and cervix.

OBJECTIVE: Prostaglandins (PGs) are key regulators of cervical dilatation and membrane breakdown at the onset of labor. PG synthase and receptor expression has been previously documented in uterine tissues; however, mechanisms governing the changes occurring in the cervix and amnion are less well established. The aim of the current study was to determine the level of expression of PG synthetic enzymes and receptors in these tissues in association with induced labor in sheep. METHODS: Labor was induced in sheep at 135 days of gestation by continuous fetal dexamethasone infusion. Amnion and cervical tissue was obtained before and after labor for measurement of mRNA encoding enzymes (cytosolic phospholipase A2 [cPLA2], PGH synthase-2 [PGHS-2], PGF synthase [PGFS], and PGE synthase [PGES]) and receptors (FP and EP1-4) by real-time polymerase chain reaction (PCR). RESULTS: cPLA2 expression increased significantly in cervical tissue at labor onset, whereas expression of the other enzymes measured did not change. There was a marked rise in EP3 expression in the cervix, but abundance of this receptor was lower than EP2 and FP expression, which did not change. The amnion exhibited a labor-associated decrease in PGHS-2, PGFS, and FP mRNA expression. CONCLUSION: The regulation of PG synthesis and action occurring in the amnion and cervix in association with labor appear to differ markedly between the two tissues, indicating tissue-specific roles for PGs. The data support a role for increased PG synthesis and action in the cervix and suggest a decrease in PG production and action in the amnion, in sharp contrast to the pattern reported in human amnion.

Amnion↗

PubMedDate not supplied

Misoprostol as a labor induction agent.

The objective of this investigation was to compare the efficacy, safety, and cost of intravaginal misoprostol as a labor induction agent to a standard protocol using prostaglandin E2 (Prepidil) and intravenous oxytocin. Thirty-eight patients requiring induction of labor with an unfavorable cervix (Bishop score < or = 5) were prospectively randomized to receive either 50 mcg misoprostol every 4 hours until delivery, or a single dose of PGE2 gel (0.5 mg) followed by intravenous oxytocin infusion. Changes in Bishop scores were recorded in a blinded fashion. Clinical outcomes were compared in the two groups, including induction-to-delivery times and cesarean section rates. Seventeen women were treated with misoprostol, 19 patients received PGE2/oxytocin, and two patients dropped out of the study. The groups did not differ significantly with respect to age, parity, gestational age, weight, height, reason for induction, or initial Bishop score. There was a significant difference in the median change of the Bishop score among those treated with misoprostol (4) and those of the control group (1) (P < 0.001). Fifteen (88%) receiving misoprostol delivered within 36 hours compared with 9 (47%) of controls (P = 0.01). Significantly more women in the misoprostol arm (8) experienced tachysystole when compared with the control group (0) (P < 0.01). There were no perinatal morbidities in either group. These data support misoprostol as an effective and economical cervical-ripening and labor-inducing agent.

Administration, Intravaginal↗

PubMed1993

Late vaginal induced abortion after a previous cesarean birth: potential for uterine rupture.

This descriptive study was conducted to evaluate the risk of uterine rupture in cases of late vaginal induced abortions among women with previous cesarean sections. 23 women were referred at a mean gestational age of 23.9 (SD 6.9) weeks of gestation after one or two cesarean sections. Indications for terminating the pregnancy were maternal diseases in 4 cases and fetal anomalies in 19 cases. RU 486 and/or prostaglandins were used for cervical ripening and to induce labor. Vaginal birth was obtained in 20 cases (86.9%) with an average duration of 72 (SD 52) h. Cesarean section was performed in the remaining 3 women because no cervical dilation could be obtained. One uterine rupture occurred and was treated with conservation of the uterus. Late termination of pregnancy in such cases can be achieved without cesarean section with a high success rate.

Abortifacient Agents, Nonsteroidal↗

PubMed1980

Induction of labor with low-dose prostaglandin F2 alpha and oxytocin.

A double-blind study was performed in 50 patients with the use of low-dose intravenous oxytocin or PGF2 alpha for the induction of labor for elective or high-risk indications. Both agents were equally effective for the induction of labor. No major complications were encountered with either drug in mother or infant. The ability to induce labor with relatively small, infrequently increased doses of either inducing agent was an unexpected finding.

Double-Blind Method↗

PubMed1983

Intravaginal versus intracervical application of prostaglandin E2 in viscous gel for cervical priming and induction of labor at term in patients with an unfavorable cervical state.

Sixty term pregnant women with unripe cervix were randomly given either 0.5 mg of prostaglandin E2 (PGE2) in 2 ml of gel intracervically or 4 mg of PGE2 in 3 ml of gel intravaginally to prime the cervix and/or to induce labor. In patients with a highly unfavorable cervix (cervical score less than or equal to 3), the intracervical application was significantly more effective than the intravaginal. In patients with a more favorable cervical state (cervical score 4 or 5), the two routes of application were equipotent. Gastrointestinal side effects were registered after intravaginal but not after intracervical application. Myometrial activity was significantly more increased after intravaginal than after intracervical gel application. All children were born in good condition with an Apgar score greater than 7 within 5 minutes.

Adult↗

PubMed2000

Clinical trial of induction of labor versus expectant management in twin pregnancy.

OBJECTIVE: The appropriate date of delivery in twin pregnancies is supposed to be earlier than that in singleton pregnancy. The aim of this study was to compare two strategies for managing twin pregnancies (i.e., immediate induction and expectant management). METHODS: Seventeen patients underwent immediately induced labor by administration of oral prostaglandin E(2) at 37 weeks, while 19 patients underwent expectant management. RESULTS: The average gestational age at delivery in the induction group was 37.5 +/- 0.4 weeks, significantly earlier than that in the expectant management group (39.0 +/- 1.1 weeks). However, there were no significant differences in the average birth weight between the two groups (2, 700 +/- 330 g in the induction group vs. 2,672 +/- 392 g in the expectant management group). The cesarean delivery rate in the induction group was 18%, not significantly different from that in the expectant management group (32%). The most common indication for cesarean section in the expectant management group was maternal infection, while there was no maternal infection in the induction group (p = 0.08). CONCLUSION: It may be acceptable do intervene in twin pregnancies earlier than in singleton pregnancies during term.

Adult↗

PubMed1988

Amniotomy or oxytocin for induction of labor. Re-analysis of a randomized controlled trial.

A recently reported "prospective, randomized study into amniotomy and oxytocin as induction methods in a total unselected population" was examined for selection bias and bias after entry into the study. The null hypothesis that clinical attitudes to amniotomy as a means for inducing labor had no influence on the decision to enter women into the trial and allocate them to either amniotomy or oxytocin was rejected at p less than 0.00025. Clinical attitudes were further found to statistically significantly influence the prescribed assessments 4 h after entry into the trial and the selection of the second intervention that was required in the absence of acceptable progress (p less than 0.0005). Bias at the time of this prescribed assessment was large enough to result in an inverse relationship between "acceptable progress within 4 hours" and "delivery within 24 hours" after induction. A subanalysis of the nulliparae entered into the trial further substantiated both bias at entry and bias in following the prescribed protocol. As hypothesized, these biases reached a greater statistical significance in nulliparous than in parous women. The likelihood that all of these observations would be encountered in a truly randomized study of this size can be estimated to be less than one in a billion (or p less than 0.000,000,000,000,1). The study, therefore, provides a classical example of the dangers of non-blind allocation to different treatment groups in clinical trials. It is further concluded that no randomized controlled studies between amniotomy and oxytocin in a "total unselected population" are available.

Amnion↗

PubMed2006

PLAC1 mRNA levels in maternal blood at induction of labor correlate negatively with induction-delivery interval.

OBJECTIVE: This study was conducted to determine whether, in low risk women having labor induced using prostaglandin gel (dinoprostone gel), there is a relationship between the concentration of mRNA for the PLAC1 gene (a trophoblast-specific gene) in maternal blood and the time elapsed between the first gel administration and spontaneous delivery. STUDY DESIGN: Blood was collected from 49 selected women at 40.2-41.4 weeks' gestation. Total RNA was extracted by means of an ABI Prism 6100 nucleic acid Prep Station and quantitative real-time PCR analysis was performed by use of a PE Applied Biosystems 5700 Sequence Detection System. Sequence data were obtained from the Genebank Sequence Database. To determine the amount of cDNA, the PLAC1 locus was used. RESULTS: Thirty women (61.2%) had a spontaneous delivery. A caesarean section, either for fetal dystocia or fetal distress, was performed in 19 (38.8%). The crude delivery rates of the women who ended up with a spontaneous delivery were 30% at 24 h and 43% at 48 h. Women (n=19) with a blood concentration of logPLAC1 mRNA>or=2.00 displayed a median time to delivery of 23.50h, (95% CI: 13.13-33.87) while those with a logPLAC1 mRNA<2.00 (n=30) had a median time of 54 h. (95% CI: 37.86-70.14; p=0.0043, log-rank test). By means of multivariate analysis, quantitative Bishop score (from 2 to 7) at the time of the first gel administration and logPLAC1 mRNA>or=2.00 were associated with a higher rate of delivery per unit of time with an odds ratio of 1.35 (95% CI: 1.07-1.71) and 3.48 (95% CI: 1.55-7.80), respectively. CONCLUSIONS: In induced term pregnancies, PLAC1 mRNA in maternal blood at the beginning of the treatment correlates with the time elapsed before delivery. This evidence demonstrates that the fetomaternal trafficking of nucleic acids is more consistent when the labor is about to begin.

Adult↗

PubMedDate not supplied

The nurse's role in misoprostol induction: a proposed protocol.

The use of misoprostol (PGE 1) for induction of labor has been studied in the United States since 1993. The current medical literature contains studies of this non-FDA-approved indication for misoprostol. The data reveal that misoprostol is as effective or more effective in inducing labor as are oxytocin and prostaglandin E2 (PGE 2), with less cost. Nurses need to understand the physiology of prostaglandins and management of misoprostol in labor. Nurses often must assess the safety of mother and fetus during a misoprostol induction without a protocol based on research findings. This article presents a sample protocol.

Administration, Intravaginal↗

PubMed1999

Uterine rupture after hysteroscopic metroplasty and labor induction. A case report.

BACKGROUND: Hysteroscopic metroplasty has become the method of choice for the treatment of uterine septa. Uterine perforation has been reported in about 1% of surgical hysteroscopic procedures. Ultrasound allows the detection of uterine lesions. CASE: A woman who conceived after complicated hysteroscopic metroplasty underwent emergency cesarean section because of uterine rupture during labor induced with prostaglandins (PGE2). An ultrasound scan performed two years later revealed a uterine lesion that corresponded to the myometrial tear reported at cesarean section. CONCLUSION: Complicated hysteroscopic metroplasty may promote acute uterine rupture during pregnancy and labor. Ultrasound is a useful tool for the detection of uterine lesions. If adequately considered, it might have allowed more rational management of labor in this case. PGE2 should never be used for induction of labor after complicated metroplasty.

Adult↗

PubMed2006

[Misoprostol--a safe preparation for induction of labor?].

INTRODUCTION: Vaginal application of prostaglandins is well known and accepted for induction of labor. In this study we compared 50 microg misoprostol to 25 microg misoprostol and 3 mg Minprostin, applied as a single dose every 24 hours. MATERIALS AND METHODS: Three periods in which three different prostaglandin preparations were given to induce labor were retrospectively evaluated. RESULTS: The median time from induction to delivery showed 50 microg misoprostol (25 hours) to be more potent than 25 microg (38 hours) and Minprostin (35 hours). As a consequence, hyperstimulation was more frequent (10% vs. 4% & 1%), as well as caesarean section on the indication of foetus mortuus imminens. The advantages were fewer caesarean sections on the indication of dystocia and therefore no difference in the overall section rate. The oxytocin augmentation rate was also less frequent, as were the instrumental delivery rate, anal sphincter disruptions and postpartum hemorrhage. CONCLUSION: This study indicates that one must choose between a potent treatment, which implies a 10% risk of uterine hyperstimulation, and a less potent treatment with an enhanced risk of instrumental delivery and disruption of the anal sphincter.

Dinoprost↗