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PubMed1995

The role of prostaglandins in labor and delivery.

The use of prostaglandins in obstetrics has undergone a rapid evolution since their discovery in the early 1970s. It appears certain now that, at least in some cases, prostaglandins are important mediators of uterine activity. Indeed, a much stronger case can be made for the role of prostaglandins in labor than can be made for oxytocin. The pivotal role of prostaglandins in contraction of the smooth muscle of the uterus and the biophysical changes associated with cervical ripening, however, point to a major problem with their clinical use. Prostaglandins are produced by almost every tissue in the body and serve as important messengers or effectors in a wide variety of functions. Attempts to inhibit the production of prostaglandins to produce a reduction in myometrial contractility are limited by the important role of prostaglandins in maintenance of fetal ductal flow and renal blood flow. Similarly, administration of prostaglandins for the purpose of inducing labor or ripening an unfavorable cervix is tempered by the effects of these agents in other systems, including the gut and brain. Significant advances, however, have been made in the application of prostaglandins to common clinical problems in obstetrics. Of the multitude of products derived from the actions of cyclooxygenase on arachidonic acid, the most important for labor, delivery, and the postpartum period are the F and E series prostaglandins. Unlike oxytocin which requires an induction of receptors that does not usually occur until the later part of pregnancy, prostaglandins receptors always are present in myometrial tissue. This allows for the use of prostaglandins in usual doses throughout pregnancy. Although both F and E series prostaglandins result in uterine contractions, E series prostaglandins are relatively more uteroselective and are clearly superior to F series prostaglandins in producing cervical ripening. Modification of the naturally occurring prostaglandins by blocking the sites that are affected during their usual rapid metabolism, results in products with much longer durations of action, efficacy at much lower concentrations, and a potential for significant savings in cost. We are now able to manage efficiently problems such as intrauterine fetal death and intractable hemorrhage from postpartum uterine atony that often resulted in a surgical procedure prior to the availability of prostaglandin. We can continue to explore the potential of these agents in helping to solve the most difficult problems faced by the obstetrician.

Cervix Uteri↗
PubMed2000

Elective induction of labor as a risk factor for cesarean delivery among low-risk women at term.

OBJECTIVE: To determine the effects of elective induction on the risk of cesarean delivery in a cohort of women with low-risk term pregnancies and to evaluate the costs of elective induction services within our hospital system. METHODS: Records of 1135 eligible women with low-risk, singleton, vertex pregnancies at 38-41 weeks' gestation who were eligible for vaginal delivery were analyzed retrospectively after elective induction (n = 263) or spontaneous labor (n = 872). Outcome measures included cesarean delivery and direct costs. Variables evaluated were parity, maternal age, estimated gestational age, birth weight, prior cesarean delivery, epidural anesthetic use, and provider category. Analysis was by univariable and multivariable regression modeling. RESULTS: Elective induction placed nulliparas at a twofold higher risk for cesarean delivery (odds ratio 2.4, 95% confidence interval 1.2, 4.9) after adjustment for birth weight, maternal age, and gestational age. We found a significantly increased risk of cesarean delivery with increased birth weight for nulliparas (2-66.7%). Increasing maternal age increased the risk of cesarean delivery in all parity groups (P <.05), but particularly among nulliparas (3-26.3%) (P <.001). Electively induced labors that ended in vaginal delivery cost $273 more and required an average of 4 hours more in the hospital before delivery than did noninduced vaginal deliveries (P <.001). CONCLUSION: Elective induction significantly increased the risk of cesarean delivery for nulliparas, and increased in-hospital predelivery time and costs.

Adult↗
PubMed1980

Clinical experiences with a new gel for intracervical application of prostaglandin E2 before therapeutic abortion or induction of term labor.

A new gel for intracervical application of prostaglandin E2 (PGE2) has been elaborated and evaluated. The main component of the gel is a cross-linked starch polymer to which prostaglandins can be added and preserved for long-term storage (> 12 months). In a double blind study, 20 patients requiring legal abortion in late first trimester were given gel containing 0.25 mg PGE2 or gel without PGE2. The gel was applied within the cervical canal. In all patients receiving PGE2-gel, a rapid ripening of the cervix occurred which facilitated the subsequent dilatation and evacuation. In patients receiving gel without PGE2 cervix did not ripen. In a subsequent open study, 30 patients were treated with PGE2-gel before therapeutic abortion. The same degree of cervical ripening was registered as for the patients receiving PGE2-gel in the double blind study. In 50 patients at term, intracervical application of 3 ml gel containing 0.05 mg PGE2 induced labor in 27 cases, i.e. 54 per cent of the patients. In the remaining undelivered women, a prominent cervical ripening occurred within 24 hours. No side effects of the treatment were observed. We conclude the new PGE2-gel to be a promising future alternative in the treatment of patients with an unfavorable cervix, prior to surgical evacuation of the uterus in late first trimester abortion, as well as before induction of labor at term.

Abortion, Therapeutic↗
PubMed2005

Outpatient misoprostol compared with dinoprostone gel for preinduction cervical ripening: a randomized controlled trial.

OBJECTIVE: To determine whether a single outpatient dose of intravaginal misoprostol (versus intracervical dinoprostone gel) reduces the oxytocin use for induction. Despite the numerous trials examining misoprostol for induction, the efficacy of a single outpatient dose of misoprostol followed by oxytocin induction is unknown. METHODS: Patients with a term, vertex, singleton pregnancy and a Bishop score of 6 or less were randomly assigned to receive misoprostol (n = 42, 0.25 microg intravaginally) or dinoprostone gel (n = 42, 0.5 mg intracervically) the evening before oxytocin induction. Patients were monitored for 3 hours after administration and discharged to home if fetal assessment was reassuring, for readmission the next morning for oxytocin. Primary outcomes were oxytocin dose, time, and dose intensity (dose divided by duration). Secondary outcomes were incidence of labor, uterine hyperstimulation, cesarean delivery, Apgar score. Statistics used were chi(2), Student t test, Mann-Whitney rank sum test, and Fisher exact test. P < .05 was accepted as statistically significant. RESULTS: A single dose of misoprostol significantly decreased the cumulative dose of oxytocin, the cumulative time of oxytocin administration, and the dose intensity of oxytocin (dose divided by time). Data are as follows (mean +/- standard error of the mean): oxytocin dose-dinoprostone 10,929 +/- 219 mU, misoprostol 6,081 +/- 170 mU, P = .008; oxytocin time-dinoprostone 798 +/- 11 minutes, misoprostol 531 +/- 11 minutes, P = .009; dose intensity-dinoprostone 11.3 +/- 0.1 mU/min, misoprostol 7.4 +/- 0.2 mU/min, P = .003. Misoprostol induced labor during the ripening period in 19 of 41 of patients, compared with 6 of 42 after dinoprostone (P = .002). There was no difference in cesarean delivery (dinoprostone, 8/42; misoprostol, 9/42; P = 1.00). There was no difference in short-term neonatal outcome. No patient had hyperstimulation or required cesarean delivery for nonreassuring fetal assessment during the ripening period. CONCLUSION: A single dose of misoprostol administered in the outpatient setting significantly decreases oxytocin use, largely due to labor within the ripening period.

Administration, Intravaginal↗
PubMed1987

An active management approach to the postdate fetus with a reactive nonstress test and fetal heart rate decelerations.

Reports have shown that a reactive nonstress test (NST) with decelerations in the postdate patient is associated with an increase in perinatal morbidity. Based on these observations, patients who exhibited this fetal heart rate (FHR) pattern during NST had labor induced. The purpose of this report was to determine what impact, if any, this approach had on subsequent maternal and fetal outcome. The pregnancy outcome of 470 patients who delivered during 1984 within seven days of their last NST was compared with data from this institution in 1980. The last NST was reactive in 420 patients (89.4%) and nonreactive in 50 (10.6%). Fetal heart rate decelerations occurred in 130 patients (27.7%); of these, 96 (73.9%) were reactive and 34 (26.1%) nonreactive. Postdate patients whose last NST was reactive with decelerations had similar outcomes to patients with a nonreactive NST on their last test, but less favorable outcomes than patients with reactive tests alone. Comparison with data from our institution in 1980 shows that prompt induction of labor in the postdate patient with a reactive NST and decelerations resulted in significantly lower perinatal morbidity, with no corresponding increase in maternal morbidity. These results lead us to conclude that a reactive NST without FHR decelerations is a reliable indicator of fetal well-being in the postdate pregnancy. However, in the postdate pregnancy with a reactive NST with FHR decelerations, induction of labor is indicated.

Female↗
PubMed2004

Comparison of oral and vaginal misoprostol for induction of labor at term: a randomized controlled trial.

OBJECTIVE: To compare the efficacy of oral with vaginal misoprostol for induction of labor at term. METHODS: One hundred and fifty-three pregnant women at term with indications for induction of labor and Bishop score < or = 6 were randomly assigned to receive misoprostol either 100 microg orally or 50 microg vaginally every 6 h for 48 h. Repeated doses were given until Bishop score > or = 8 was achieved or spontaneous rupture of membranes occurred. Those who were not in labor after 48 h had labor induced with amniotomy and oxytocin. The main outcome measure was induction to delivery time. RESULTS: The median induction to vaginal delivery time in the oral group (14.3 h) was not significantly different from that of the vaginal group (15.8 h). The median number of doses was also not significantly different in the oral group compared with the vaginal group. There was a significant higher incidence of uterine tachysystole in the vaginal group compared to the oral group (17.1% vs 5.3%, P = 0.032). There was no hyperstimulation in either group. There were no significant differences between the groups with respect to oxytocin augmentation, cesarean section rate, analgesic requirement, and neonatal outcomes. CONCLUSION: Oral administration of 100 microg misoprostol has similar efficacy to intravaginal administration of 50 microg misoprostol for labor induction with less frequent abnormal uterine contractility. 100 microg of misoprostol orally can be used as an alternative to the vaginal route for labor induction.

Administration, Intravaginal↗
PubMed1983

Cervical ripening with intracervical prostaglandin-E2 gel. I. Clinical results and effect on plasma levels of oxytocin and 13,14-dihydro,15-ketoprostaglandin-F2 alpha.

Tylose gel containing 400 micrograms prostaglandin E2 in 3 ml gel was injected into the cervical canal of 20 patients with high-risk pregnancy and indication for induction of labor, but with unfavorable cervix. Ten were studied after the first gel application, five during repeat injection, and five after application of gel without PGE2. Blood samples were drawn serially during the first 8 hours for determination of oxytocin and 13,14-dihydro,15-ketoprostaglandin-F2 alpha (PGFM). The PGE2 gel increased the Bishop score within 8 hours in all patients; in half of them, artificial rupture of the membranes could be performed and labor induced without further gel application; in the others, it was repeated every 8 hours until a Bishop score of greater than or equal to 8 was achieved. Fourteen of the 15 PGE2-induced patients delivered vaginally. Mean PGFM levels did not increase significantly during the 8 hours of observation, but in patients who responded with rapid progression, an increase was seen after cervical dilation was 6 cm or more. The mean oxytocin levels increased within 60 minutes after PGE2 application and were increased for the remaining observation period. Application of inactive gel had no effect on cervical ripening nor on oxytocin or PGFM levels.

Adult↗
PubMed1990

[Personal experience with labor induction using prostaglandins 1985-1987].

The authors evaluate 56 Labors induced with Enzaprost and 141 with Prostin. The main indication for induction was a postdate pregnancy (33%), rupture of the amniotic sac 24 hours previously without contractions (24.5%) and a planned confinement (23%). An initial dose of 1 microgram of Enzaprost per min. was administered or 1 tablet of Prostin in increasing doses after 30 mins. up to three tablets. There were 87.5% successful Enzaprost inductions and 96.5% successful Prostin inductions. The difference is significant at the 5% level.

Administration, Oral↗
PubMed2002

Oral versus vaginal misoprostol for labor induction.

OBJECTIVE: To compare the safety and effectiveness of vaginal with oral misoprostol for induction of labor. METHODS: A total of 107 women with clinical indication for induction were randomly assigned to receive oral or vaginal misoprostol. Doses of 100 microg of oral or 25 microg of vaginal misoprostol were given every 3-4 hours. If cervical ripening or active labor did not occur, repeated doses of oral (100-200 microg) or vaginal (25-50 microg) were given until labor was established. RESULTS: Fifty-nine women received oral misoprostol, and 48 received vaginal administration. Delivery time was similar for the vaginal and oral arms (1074 +/- 488 minutes versus 930 +/- 454 minutes, P =.11). Parity was significantly different (P =.04) for the vaginal and oral groups. The cesarean delivery rate was similar for the vaginal and oral arms (17% versus 15%, P =.72). The number of medication administrations was consistent between groups. Birth weight was not different for patients in the control and treatment groups (vaginal 3281 +/- 507 g versus oral 3359 +/- 541 g, P =.44). Chorioamnionitis and tachysystole were comparable for the oral and vaginal groups. There was no statistical difference in neonatal outcomes. Similar proportions of infants were admitted to the well baby nursery and intermediate care nursery. CONCLUSION: These findings indicate that, in a closely supervised hospital setting with adequate monitoring, oral misoprostol has the potential to induce labor as safely and effectively as its vaginal analogue.

Administration, Intravaginal↗
PubMed1987

Cervical priming and labor induction with vaginal application of 3 mg PGE2 in suppositories in term pregnant women with premature rupture of amniotic membranes and unfavorable cervix.

Sixty-one term pregnant women, 29 nulliparous (Group A) and 32 multiparous (Group B) with unfavorable cervix and premature rupture of the membranes (PROM) were given 3 mg PGE2 in suppository form for cervical ripening and labor induction. Five hours after starting the treatment, 12 women of the 29 in Group A and 21 of the 31 in Group B had a favorable cervix and established labor. The remaining 17 nulliparae and 11 multiparae still had an unfavorable cervix and were then given another PGE2 suppository. Until the next morning, i.e. within 24 h, 19 nulliparous and 22 multiparous women gave birth whereas a further 5 nulliparous women who now had favorable cervix but no uterine contractions were delivered after stimulation with intravenous oxytocin. The remaining undelivered women were given another PGE2 suppository. With or without additional oxytocin stimulation, all but 2 multiparous women could be delivered within a further 12 hours. The total number of instrumental deliveries in Group A was 2 caesarean sections due to disproportion (7%) and 5 ventouses. In Group B, 3 caesarean sections (9%) had to be carried out, one due to fetal distress and 2 due to failed induction. From the results of this study we conclude that vaginal application of 3 mg PGE2 in suppository form can be used to induce labor in patients with PROM and unripe cervix. However, when the results are compared with those obtained in previous studies after application of PGE2 in gel, the latter technique seems preferable.

Cervix Uteri↗
PubMed2006

Bishop score and the outcome of labor induction with misoprostol.

BACKGROUND: The aim of the study was to retrospectively identify possible factors for predicting the outcome of induction with misoprostol. METHODS: Fifty micrograms of misoprostol were administered intravaginally every 6 h during the first 2 days of induction, up to a maximum of 4 doses. The Bishop score, indication for induction, gestational length, maternal age, and parity were analyzed. The study involved 99 patients (47 primiparous and 52 multiparous) at term (>36 weeks of gestation) with unripe cervices. RESULTS: Forty-five per cent of the patients achieved ripening of cervix and went into labor after a single dose of misoprostol; a further 45% required 2 doses. Nine patients received more than 2 tablets. Ninety-seven per cent of all vaginal deliveries occurred within the first 2 days of induction. Ninety-five per cent of the patients delivered vaginally when the Bishop score was >3, compared with 75% of those with a Bishop score of < or =3 (p=0.003). Among factors creating the Bishop scoring system, in logistic regression analysis effacement of the cervix was the only independent, significant predictor of cesarean section (p=0.003, OR = 0.16) even after adjusting for maternal age, which also was a significant predictor in the regression analysis. Eleven patients had previously had a cesarean section; one of them had a uterine rupture with a fatal outcome for the fetus. All women with a previously scarred uterus are now excluded from misoprostol treatment. CONCLUSION: Misoprostol 50 microg administered intravaginally every 6 h according to this protocol is highly effective for inducing labor in carefully selected patients with unripe cervices.

Administration, Intravaginal↗
PubMed2002

A comparison of two dosage regimens of oral misoprostol for labor induction at term.

METHODS: 251 women with indications for labor induction at term were randomised to receive either 50 or 100 microgs of oral misoprostol, repeated every 4 h to a maximum of 5 doses. Parous women in the higher dose group received 50 microgs as their first dose, subsequent doses being 100 microgs. Women who failed to respond to the 5 doses of misoprostol had the option of having vaginal PGE2 gel. The primary outcome measure was the induction to delivery interval in those who delivered vaginally. Patient satisfaction was assessed by postnatal questionnaire. RESULTS: The induction to vaginal delivery interval, although shorter in the 100 microgs group was not statistically significant (26.8 versus 33.7 h, mean difference 6.9 h, 95% CI 0.4-13). There were, however, more failed inductions with misoprostol in the 50 microgs group (12.7% Vs 4.8%, RR 2.6, 95% CI 1.07-6.5). There were no differences in the modes of delivery, number of caesarean sections for fetal distress or in the neonatal outcomes in the two groups. Most patients, 83% and 92% in the 50 and 100 microgs, respectively, were satisfied with their inductions, and 64% of patients would prefer to have the inducing agent given orally if they were to have another induction. CONCLUSION: Oral misoprostol is effective in inducing labor and seems acceptable to patients. Both the 50 and 100 microgs dose regimens have a reasonable safety profile, but in view of the higher incidence of failed inductions with the 50 microgs dosage, the 100 microgs dose regimen may be the preferred dose regimen.

Administration, Oral↗
PubMed2005

A comparison of oral and vaginal misoprostol for induction of labor.

OBJECTIVE: The aim of the study is to compare the efficacy and safety of oral (100 microg) and vaginal (50 microg) misoprostol for labor induction. STUDY DESIGN: Ninety-nine patients with indications for labor induction randomly received 100 microg oral misoprostol every 4 h or 50 microg vaginal misoprostol every 4 h, using maximum six doses. Mean induction to delivery interval, mode of delivery, rates of tachysystole, hypertonus and hyperstimulation syndrome, oxytocin use, number of doses used, failed induction rate and neonatal outcomes were compared for the two groups. RESULTS: Mean dose of misoprostol used for oral and vaginal misoprostol groups were 2.17+/-1.35 and 1.91+/-0.94, respectively (p=0.65). There were two failed inductions in the oral (4%) and one failed induction (2.5%) in the vaginal group after a total of six doses of misoprostol (p=0.58). There was no significant difference for the mean induction to delivery interval, to the beginning of active phase interval, active phase duration, second stage duration and the number of women who received oxytocin for induction or augmentation between the two groups (p>0.05). There were also no significant differences for intrapartum complications and neonatal outcomes between the oral and vaginal misoprostol groups (p>0.05). CONCLUSION: Our findings indicate that, in a closely supervised hospital setting with adequate monitoring, 100 microg oral misoprostol has the potential to induce labor as safely and effectively as its 50 microg vaginal analogue. As oral use of the drug is easier for both the patient and the doctor, oral misoprostol will probably be more preferable than the vaginal route.

Abortifacient Agents, Nonsteroidal↗
PubMed2000

A pilot randomized controlled trial of two regimens of fetal surveillance for small-for-gestational-age fetuses with normal results of umbilical artery doppler velocimetry.

OBJECTIVE: This study was undertaken to determine whether the frequency of fetal surveillance could be safely reduced from twice weekly to fortnightly in the case of small-for-gestational-age fetuses with normal results of umbilical artery Doppler velocimetry studies. STUDY DESIGN: Pregnant women between 24 and 36 weeks' gestation (n = 167) with small-for-gestational-age fetuses and normal results of umbilical artery Doppler velocimetry studies were randomly allocated to undergo twice-weekly or fortnightly fetal surveillance. Statistical analysis was carried out according to intention to treat. RESULTS: Eighty-five women were randomly assigned to undergo twice-weekly fetal surveillance and 82 were randomly assigned to undergo fortnightly fetal surveillance. Those randomly assigned to twice-weekly surveillance were delivered 4 days earlier (264 vs 268 days; P =.04) and were more likely to have labor induced (n = 70, 82%, vs n = 54, 66%; P =.02) than those randomly assigned to fortnightly surveillance. Fifty-four babies (23%) were admitted to the neonatal nursery, but there were no differences in neonatal morbidity between the groups. CONCLUSIONS: Maternal intervention (induction) was more common in the twice-weekly group. No differences in neonatal outcomes were detected. A much larger trial is required to determine the safety and potential benefits of less frequent surveillance of small-for gestational-age fetuses with normal results of umbilical artery Doppler velocimetry studies.

Female↗
PubMed2005

Enema prior to labor: a controversial routine in Taiwan.

While taking an enema to induce labor is a controversial issue worldwide, in Taiwan it remains a routine procedure in many hospitals in preparation for birth. Episiotomy is also a prevalent procedure performed during the birthing process. Some physicians believe that enemas help reduce the risk of feces contamination of the episiotomy incision and, therefore, are justified as a routine procedure. This study compared the neonatal infection rates, times to appearance of fetal head, times to first post-labor bowel movement, and rates of episiotomy dehiscence of women receiving a pre-labor enema against those who did not. A total of 534 women classified with low-risk pregnancies were recruited from a medical center in central Taiwan and assigned randomly into one of two groups for a six-month period. The first group (264 subjects) received routine enema procedures prior to delivery in the first 6 months. The second group (270 subjects) did not receive enemas. Study results revealed no significant difference between enema and non-enema groups in terms of infection rates in mothers or infants or in terms of average time to fetal head appearance. While labor duration was the same for the two groups in the first and third stages of labor, the enema group experienced a relatively shorter second stage. No significant difference was observed in times to first post-labor bowel movement or episiotomy dehiscence rates. The results of this study indicate that the administration of enemas as a routine practice prior to labor is not substantiated by medical necessity. However, limitations of the research design suggest that a randomized clinical trial be adopted in the future to explore further the scientific validity of study results.

Adult↗
PubMed1988

Induction and augmentation of labor: basis and methods for current practice.

Medical control of labor is often necessary in modern obstetrics. The status of the cervix may dictate the method of induction and influence its success. Four milligrams of prostaglandin (PGE2) gel applied intravaginally has been shown to be a safe, efficacious, and extremely well-tolerated agent to promote cervical ripening. The patient should be monitored before and at least 4 hours after PGE2 gel application, since the incidence of uterine activity is high after this treatment and many of these pregnancies are at risk. The rare case of hyperstimulation may be treated with a tocolytic agent. The start of oxytocin may be individually tailored, but we do not recommend its use in less than 4 hours after gel insertion. Oxytocin should be used with great caution if the patient continues to have uterine activity from the PGE2 gel. Because, in part, the use of the PGE2 gel for cervical ripening is not approved by the Food and Drug Administration in the United States, it is prudent to discuss its use with the patient, document carefully, and use this medication only if there is clear indication. Protocols for the use of oxytocin currently used in many hospitals seem to be based on outdated pharmacologic data. Relatively new information on the pharmacology and clinical effects of oxytocin are reviewed to provide a rational approach to its clinical use in accordance with recently published guidelines from the American College of Obstetricians and Gynecologists (ACOG). The current data overwhelmingly indicate that oxytocin should be started at a low dose (0.5-1 mU/min) with a slow, arithmetical increase every 30 to 60 minutes. Previous reports of a high incidence of fetal distress, uterine dysfunction, and hyperstimulation in induced labor may be related to use of oxytocin at doses higher than currently appear appropriate. The risks of induction and augmentation can be reduced by careful patient selection and preparation. Oxytocin is safe and effective with expert medical management which provides careful monitoring, controlled infusion, persistence, and the knowledge of when to stop.

Cervix Uteri↗