Journal Abstracts: Homebirth safety; Waterbirth safety; Risks of High-tech Intervention

Homebirth Safety

Birth, 1997, 24(1):4-13, discussion 14-16.
Meta-analysis of the safety of home birth.
Olsen, O.
Department of Social Medicine, University of Copenhagen, Denmark.
BACKGROUND: The safety of planned home birth is controversial. This study examined the safety of planned home birth backed up by a modern hospital system compared with planned hospital birth in the Western world
METHODS: A meta-analysis of six controlled observational studies was conducted, and the perinatal outcomes of 24,092 selected and primarily low-risk pregnant women were analyzed to measure mortality and morbidity, including Apgar scores, maternal lacerations, and intervention rates. Confounding was controlled through restriction, matching, or in the statistical analysis.
RESULTS: Perinatal mortality was not significantly different in the two groups (OR = 0.87, 95% Ci 0.54-1.41). The principal difference in the outcome was a lower frequency of low Apgar scores (OR = 0.55; 0.41-0.74) and severe lacerations (OR = 0.67; 0.54-0.83) in the home birth group. Fewer medical interventions occurred in the home birth group: induction (statistically significant ORs in the range 0.06-0.39), augmentation (0.26-0.69), episiotomy (0.02-0.39), operative vaginal birth (0.03-0.42), and cesarean section (0.05-0.31). No maternal deaths occurred in the studies. Some differences may be partly due to bias. The findings regarding morbidity are supported by randomized clinical trials of elements of birth care relevant for home birth, however, and the finding relating to mortality is supported by large register studies comparing hospital settings of different levels of care.
CONCLUSION: Home birth is an acceptable alternative to hospital confinement for selected pregnant women, and leads to reduced medical interventions.

BMJ, 1996, 313(7068):1309-1313.
Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in The Netherlands.
Wiegers, T.A., Keirse, M.J., van der Zee, J., Berghs, G.A.
NIVEL (Netherlands Institute of Primary Health Care), Utrecht, Netherlands.
OBJECTIVE: To investigate the relation between the intended place of birth (home or hospital) and perinatal outcome in women with low risk pregnancies after controlling for parity and social, medical, and obstetric background.
DESIGN: Analysis of prospective data from midwives and their clients.
SETTING: 54 midwifery practices in the province of Gelderland, Netherlands.
SUBJECTS: 97 midwives and 1836 women with low risk pregnancies who had planned to give birth at home or in hospital.
MAIN OUTCOME MEASURE: Perinatal outcome index based on "maximal result with minimal intervention" and incorporating 22 items on childbirth, 9 on the condition of the newborn, and 5 on the mother after the birth.
RESULTS: There was no relation between the planned place of birth and perinatal outcome in primiparous women when controlling for a favourable or less favourable background. In multiparous women, perinatal outcome was significantly better for planned home births than for planned hospital births, with or without control for background variables.
CONCLUSIONS: The outcome of planned home births is at least as good as that of planned hospital births in women at low risk receiving midwifery care in the Netherlands.

BMJ, 1996, 313(7068):1306-1309.
Collaborative survey of perinatal loss in planned and unplanned home births.
Northern Region Perinatal Mortality Survey Coordinating Group.
OBJECTIVE: To document the outcome of planned and unplanned births outside hospital.
DESIGN: Confidential review of every pregnancy ending in stillbirth or neonatal death in which plans had been made for home delivery, irrespective of where delivery eventually occurred. The review was part of a sustained collaborative survey of all perinatal deaths.
SETTING: Northern Regional Health Authority area.
SUBJECTS: All 558,691 registered births to women normally resident in the former Northern Regional Health Authority area during 1981-94.
MAIN OUTCOME MEASURE: Perinatal death.
RESULTS: The estimated perinatal mortality during 1981-94 among women booked for a home birth was 14 deaths in 2888 births. This was less than half that among all women in the region. Only three of the 14 women delivered outside hospital. Independent review suggested that two of the 14 deaths might have been averted by different management. Both births occurred in hospital, and in only one was management before admission of the mother judged inappropriate. Perinatal loss to the 64 women who booked for hospital delivery but delivered outside and to the 67 women who delivered outside hospital without ever making arrangements to receive professional care during labour accounted for the high perinatal mortality (134 deaths in 3466 deliveries) among all births outside hospital.
CONCLUSIONS: The perinatal hazard associated with planned home birth in the few women who exercised this option (< 1%) was low and mostly unavoidable. Health authorities purchasing maternity care need to address the much greater hazard associated with unplanned delivery outside hospital.

BMJ, 1998, 317(7155):384-388.
Perinatal death associated with planned home birth in Australia: population based study.
Bastian, H., Keirse, M.J., Lancaster, P.A.
PO Box 569, Blackwood SA 5051, Australia. hilda.bastian@flinders.edu.au
OBJECTIVE: To assess the risk of perinatal death in planned home births in Australia.
DESIGN: Comparison of data on planned home births during 1985-90, notified to Homebirth Australia, with national data on perinatal deaths and outcomes of home births internationally.
RESULTS: 50 perinatal deaths occurred in 7002 planned home births in Australia during 1985-90: 7.1 per 1000 (95% confidence interval 5.2 to 9.1) according to Australian definitions and 6.4 per 1000 (4.6 to 8.3) according to World Health Organisation definitions. The perinatal death rate in infants weighing more than 2500 g was higher than the national average (5.7 versus 3.6 per 1000: relative risk 1.6; 1.1 to 2.4) as were intrapartum deaths not due to malformations or immaturity (2.7 versus 0.9 per 1000: 3.0; 1. 9 to 4.8). More than half (52%) of the deaths were associated with intrapartum asphyxia.
CONCLUSIONS: Australian home births carried a high death rate compared with both all Australian births and home births elsewhere. The two largest contributors to the excess mortality were underestimation of the risks associated with post-term birth, twin pregnancy and breech presentation, and a lack of response to fetal distress.

Birth, 2004, 31(1):28-33.
Does a pregnant woman's intended place of birth influence her attitudes toward and occurrence of obstetric interventions?
van Der Hulst, L.A., van Teijlingen, E.R., Bonsel, G.J., Eskes, M., Bleker, O.P.
Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, The Netherlands.
BACKGROUND: A home confinement with midwifery care is still an integral part of Dutch maternity care. It has been argued that the existence of home birth itself influences the course of the birth process positively, which is why obstetric interventions are low in comparison with neighboring countries. This study examined the impact of women's intended place of birth (home or hospital) and the course of pregnancy and labor when attended by midwives.
METHODS: This is a prospective study of 625 low-risk pregnant women, gestation 20 to 24 weeks, enrolled in 25 independently working midwifery practices. The course of labor was measured by the frequency of interventions by midwives and obstetricians.
RESULTS: A more non-technological approach to childbirth was observed within the women opting for a home birth compared with the women opting for a hospital birth. Data showed a relationship between interventions and planned birth site: sweeping membranes and amniotomy by midwives were more likely to be conducted in women opting for a home birth. Multiparas opting for hospital birth were more likely to experience consultations and referrals. Within the group of multiparas referred for obstetrician care, women intending to have a home birth experienced fewer interventions (e.g., induction, augmentation, pharmacologic pain relief, assisted delivery, cesarean section) compared with those who had opted for a hospital birth.
CONCLUSIONS: A large proportion of women desire a home birth. The impact of that choice demonstrated a smoother course of the birth process, compared with women who desired to deliver in the hospital, as measured by fewer obstetric interventions. We suggest that psychological factors (expectation and perceptions) influence both a woman's decision of birthplace and the actual birth process.

Waterbirth Safety

Fetal Diagn Ther, 2000, 15(5):291-300.
Waterbirths: a comparative study. A prospective study on more than 2,000 waterbirths.
Geissbuhler, V., Eberhard, J.
Clinic for Obstetrics and Gynecology, Thurgauisches Kantonsspital, Frauenfeld, Switzerland. vgeissbuehler@bluewin.ch
BACKGROUND: Waterbirths were introduced in 1991 as part of a new birth concept which consisted of careful monitoring and birth management, restrictive use of invasive methods and free choice of different birth methods.
METHODS: After the introduction of this new birth concept a prospective observational study was initiated. All parturients of the region give birth in our clinic without preselection, ours being the only birth clinic of the region. 2% of the parturients will be referred to a larger birth clinic (university clinic) mainly because of preterm births before the end of the 33rd week of pregnancy. Every one of the 7,508 births between November 1991, and May 21, 1997, was analyzed. In this article the birth parameters of mother and child in the most often chosen spontaneous birth methods will be compared to assess the safety of alternative birth methods in general and of waterbirths in particular. 2,014 of these 5,953 spontaneous births were waterbirths, 1,108 were Maia-birthing stool births and 2,362 bedbirths (vacuum extractions not included).
RESULTS: The parity and age of the mother as well as the newborn's birth weight are comparable in all 3 groups: waterbirth, Maia-birthing stool, and bedbirths. An episiotomy was performed in only 12.8% of the births in water, in 27. 7% of the births on the Maia-birthing stool and in 35.4% of the bedbirths. These differences are statistically significant. In spite of the highest episiotomy rates, the bedbirths also show the highest 3rd- and 4th-degree laceration rates (4.1%), thus the difference between the rates for bedbirths and alternative births methods for severe lacerations is significant. The mothers' blood loss is the lowest in waterbirths. Fewer painkillers are used in waterbirths and the experience of birth itself is more satisfying after a birth in water. The average arterial blood pH of the umbilical cord as well as the Apgar scoring at 5 and 10 min are significantly higher after waterbirths. Infections of the neonate do not occur more often after waterbirths. No case of water aspiration or any other perinatal complication of the mother or child which might be water-related was reported.
CONCLUSION: Waterbirths and other alternative forms of birthing such as Maia-birthing stool do not demonstrate higher birth risks for the mother or the child than bedbirths if the same medical criteria are used in the monitoring as well as in the management of birth.

Harefuah, 1998, 134(3):161-164, 248.
Experience with under-water birth.
Article in Hebrew
Lachman, E., Finelt, Z.
Dept. of Obstetrics and Gynecology, Yoseftal Hospital, Eilat.
Underwater birth is now deemed an acceptable type of delivery. Safety is a recurring consideration, the main concern being that of drowning. But in reports of 19,000 underwater births no untoward events were noted. Also, need for pain relief and of intervention during labor were both reduced. The short term indicators of neonatal outcome were good. A recent review explains 5 different physiological factors which inhibit initiation of fetal breathing under warm water. Many studies have shown no increase in risk of infection of either mother or baby. We report our experience with 26 women, 23 of whom actually delivered in the pool with excellent results. We believe that birth under water is safe and beneficial if done properly for low-risk patients.

Eur J Obstet Gynecol Reprod Biol, 2000, 91(1):15-20.
A retrospective comparison of water births and conventional vaginal deliveries.
Otigbah, C.M., Dhanjal, M.K., Harmsworth, G., Chard, T.
Department of Obstetrics and Gynaecology, Homerton Hospital, London, UK.
The aim of this study was to document the practice of water births and compare their outcome and safety with normal vaginal deliveries. A retrospective case-control study was conducted over a five year period from 1989 to 1994 at the Maternity Unit, Rochford Hospital, Southend, UK. Three hundred and one women electing for water births were compared with the same number of age and parity matched low risk women having conventional vaginal deliveries. Length of labour; analgesia requirements; apgar scores; maternal complications including perineal trauma, postpartum haemorrhages, infections; fetal and neonatal complications including shoulder dystocias; admissions to the Special Care Baby Unit, and infections were noted. Primigravidae having water births had shorter first and second stages of labour compared with controls (P<0.05 and P<0.005 respectively), reducing the total time spent in labour by 90 min (95% confidence interval 31 to 148). All women having water births had reduced analgesia requirements. No analgesia was required by 38% (95% confidence interval 23.5 to 36.3, P<0.0001) and 1.3% requested opiates compared to 56% of the controls (95% confidence interval 46. 3 to 58.1, P<0.0001). Primigravidae having water births had less perineal trauma (P<0.05). Overall the episiotomy rate was 5 times greater in the control group (95% confidence interval 15 to 26.2, P<0.0001), but more women having water births had perineal tears (95% confidence interval 6.6 to 22.6, P<0.001). There were twice as many third degree tears, post partum haemorrhages and admissions to the Special Care Baby Unit in the controls, although these differences were not significant. Apgar scores were comparable in both groups. There were no neonatal infections or neonatal deaths in the study. This study suffers from many of the methodological problems inherent in investigation of uncommon modes of delivery. However, we conclude that water births in low risk women delivered by experienced professionals are as safe as normal vaginal deliveries. Labouring and delivering in water is associated with a reduction in length of labour and perineal trauma for primigravidae, and a reduction in analgesia requirements for all women.

Minerva Ginecol, 2001, 53(1):29-34.
Birth in water. A comparative study after 555 births in water.
Article in Italian
Thoni, A., Murari, S.
Divisione di Ostetricia e Ginecologia, Ospedale di Vipiteno, Bolzano, Italy. gynaekologie.sterzing@se-nord.provinz.bz.it
BACKGROUND: The object of our study is to research into the quality of the different delivery positions, offered in our hospital with special focus on the advantages for birth in water.
METHODS: From February 1997 to 1 October 2000 we do research retrospectively on data of 555 deliveries in water, 320 on the traditional bed and 125 on the delivery stool give us the possibility to investigate about duration of birth, rate of episiotomies and perineum lacerations, consumption of painkillers, arterial umbilical cord pH and haemoglobin postpartum.
RESULTS: In our comparing analysis of the duration of birth we could show a relevant reduction especially for primiparae which had delivered in water. The reduction is only significant for the first part of labor (360 minutes in the pool, 445 minutes on the traditional bed and 420 minutes on the stool) whereas there is no difference for the second part of labor. The significant reduction on episiotomies (1%) in comparison to the one on the traditional bed (20%) or on the stool (10%) for primiparae in water doesn t mean an increase at perineum lacerations. (each 25%). In water we saw no lacerations/injuries of the perineum for 58% of primiparae, on the traditional bed 36% and on the stool 43%. No woman in labour needed a painkiller in the pool. There was no difference found between the three groups referring to the arterial umbilical cord pH or the haemoglobin postpartum.
CONCLUSIONS: Our study shows relevant medical advantages for a delivery in water: and a significant reduction of the duration of the first part of labour, significant less episiotomies and perineum lacerations and no need for painkillers. The security of the neonate is guaranteed under attention to the known contraindications.

J Nurse Midwifery, 1989, 34(4):165-170.
Water birth: one birthing center's observations.
Church, L.K.
This paper discusses the water birth experiences of women who delivered at The Family Birthing Center of Upland, California, from February, 1985 to June 1, 1989. Of the 831 who used warm water immersion during their labor, 483 gave birth in the water with good Apgar scores; and there was only one minor maternal infection. These results clearly suggest that water birth--with certain precautions--is not only a desirable alternative for many women, but also a safe and positive intrapartum intervention.

Risks of High-tech Intervention

J Obstet Gynecol Neonatal Nurs., 2003, 32(6):767-779.
Trends and issues in labor induction in the United States: implications for clinical practice.
Simpson, K.R, Atterbury, J.
St. John's Mercy Medical Center, St. Louis, MO, USA. krsimpson@prodigy.net
The labor induction rate is at an all-time high in the United States. Although induction of labor is recommended as a therapeutic option only when the benefits of expeditious birth outweigh the risks of continuing the pregnancy, a "psychosocial indication" has become a common rationale for elective induction in the United States. It is unlikely that all women are provided with a complete discussion of the cascade of interventions that frequently accompany labor induction and the risks of cesarean birth. Although at first glance elective labor induction may seem more convenient, an appreciation of the inconvenience of the greater rates of interventions, the longer labor and overall hospital stay, the higher costs, the additional attention required by the primary health care provider when complications occur, and the risk of an adverse outcome for a mother or baby after an elective procedure with subsequent litigation should cause everyone to exercise caution and reevaluate current practice. Professional organizations should take proactive steps to advocate for pregnant women so they are fully aware of the risks and benefits. A public campaign to discourage elective labor induction for nulliparous women is worth serious consideration.

Pediatrics, 2003, 112(3, Pt 1):607-619.
Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss.
Dewey, K.G., Nommsen-Rivers, L.A., Heinig, M.J., Cohen, R.J.
Department of Nutrition, University of California, Davis 95616-8669, USA. kgdewey@ucdavis.edu
OBJECTIVE: Some mothers have difficulty initiating lactation even when highly motivated to breastfeed. The purpose of this study was to determine the incidence of and risk factors for suboptimal infant breastfeeding behavior (SIBB), delayed onset of lactation, and excess neonatal weight loss among mother-infant pairs in a population with high educational levels and motivation to breastfeed.
METHODS: All mothers residing in Davis, California, who gave birth to a healthy, single, term infant at 1 of 5 area hospitals during the 10-month recruitment period in 1999 were invited to participate if they were willing to attempt to breastfeed exclusively for at least 1 month. Lactation guidance was provided and data were collected in the hospital (day 0) and on days 3, 5, 7, and 14. Infant breastfeeding behavior was evaluated by trained lactation consultants using the Infant Breastfeeding Assessment Tool. Onset of lactation was defined based on maternal report of changes in breast fullness. Infant weight loss was considered excessive if it was >or=10% of birth weight by day 3.
RESULTS: Of the 328 eligible mothers, 280 (85%) participated in the study. The prevalence of SIBB was 49% on day 0, 22% on day 3, and 14% on day 7. SIBB was significantly associated with primiparity (days 0 and 3), cesarean section (in multiparas, day 0), flat or inverted nipples, infant status at birth (days 0 and 3), use of nonbreast milk fluids in the first 48 hours (days 3 and 7), pacifier use (day 3), stage II labor >1 hour (day 7), maternal body mass index >27 kg/m(2) (day 7) and birth weight <3600 g (day 7). Delayed onset of lactation (>72 hours) occurred in 22% of women and was associated with primiparity, cesarean section, stage II labor >1 hour, maternal body mass index >27 kg/m(2), flat or inverted nipples, and birth weight >3600 g (in primiparas). Excess weight loss occurred in 12% of infants and was associated with primiparity, long duration of labor, use of labor medications (in multiparas), and infant status at birth. The risk of excess infant weight loss was 7.1 times greater if the mother had delayed onset of lactation, and 2.6 times greater if the infant had SIBB on day 0.
CONCLUSIONS: Early lactation success is strongly influenced by parity, but may also be affected by potentially modifiable factors such as delivery mode, duration of labor, labor medications, use of nonbreast milk fluids and/or pacifiers, and maternal overweight. All breastfeeding mother-infant pairs should be evaluated at 72 to 96 hours' postpartum.

J Allergy Clin Immunol., 2003, 112(2):420-426.
Is delivery by cesarean section a risk factor for food allergy?
Eggesbo, M., Botten, G., Stigum, H., Nafstad, P., Magnus, P.
Norwegian Institute of Public Health, Division of Epidemiology, Oslo, Norway.
BACKGROUND: Cesarean delivery might delay the colonization of the newborn intestine. A delayed or aberrant colonization process has been offered as an explanation for the increase in allergic diseases.
OBJECTIVE: The aim of this study was to examine whether cesarean delivery and the use of antibiotics were associated with subsequent food allergy.
METHODS: In a population-based birth cohort of 2803 children, information regarding mode of delivery, maternal or infant use of antibiotics, and information on potential confounders was obtained prospectively from parental reports and the Norwegian Birth Registry. Parentally perceived reactions to egg, fish, or nuts, as well as objectively confirmed reactions to egg at the age of 2 1/2 years, were chosen as outcomes.
RESULTS: Among children whose mothers were allergic, cesarean section was associated with a 7-fold increased risk of parentally perceived reactions to egg, fish, or nuts (odds ratio, 7.0; CI, 1.8-28; P =.005) and a 4-fold increased risk of confirmed egg allergy (odds ratio, 4.1; CI, 0.9-19; P =.08) in a logistic regression analysis, adjusting for pregnancy complications, birth weight, gestational length, and socioeconomic factors. Among children whose mothers were not allergic, the association was much weaker and not significant. Maternal or infant use of antibiotics was not associated with an increased risk of food allergy.
CONCLUSION: The results indicate that in predisposed children cesarean section might increase the risk of development of food allergy, which supports the theory that factors interfering with the colonization process might play a role in the development of food allergy.

Birth, 2004, 31(1):17-27.
A negative birth experience: prevalence and risk factors in a national sample.
Waldenstrom, U., Hildingsson, I., Rubertsson, C., Radestad, I.
Department of Nursing, Karolinska Institutet, Stockholm, Sweden.
BACKGROUND: A woman's dissatisfaction with the experience of labor and birth may affect her emotional well-being and willingness to have another baby. The aim of this study was to investigate the prevalence and risk factors of a negative birth experience in a national sample.
METHODS: A longitudinal cohort study of 2541 women recruited from all antenatal clinics in Sweden during 3 weeks spread over 1 year was conducted. Data were collected by three questionnaires, which measured women's global experience of labor and birth 1 year after the birth, and obtained information on possible risk factors during pregnancy and 2 months after the birth.
RESULTS: Seven percent of the women had a negative birth experience. The following risk factors were found: (1) factors related to unexpected medical problems, such as emergency operative delivery, induction, augmentation of labor, and infant transfer to neonatal care; (2) factors related to the woman's social life, such as unwanted pregnancy and lack of support from partner; (3) factors related to the woman's feelings during labor, such as pain and lack of control; and (4) factors that may be easier to influence by the caregivers, such as insufficient time allocated to the woman's own questions at antenatal checkups, lack of support during labor, and administration of obstetric analgesia.
CONCLUSIONS: Many risk factors were related to unexpected medical problems and participants' social background. Of the established methods to improve women's birth experience, childbirth education and obstetric analgesia seemed to be less effective, whereas support in labor and listening to the woman's own issues may be underestimated.

Birth, 2002, 29(2):83-94.
Prevalence and persistence of health problems after childbirth: associations with parity and method of birth.
Thompson, J.F., Roberts, C.L., Currie, M., Ellwood, D.A.
Women & Children's Health, The Canberra Hospital, Australia.
BACKGROUND: Awareness about the extent of maternal physical and emotional health problems after childbirth is increasing, but few longitudinal studies examining their duration have been published. The aim of this study was to describe changes in the prevalence of maternal health problems in the 6 months after birth and their association with parity and method of birth.
METHODS: A population-based, cohort study was conducted in the Australian Capital Territory (ACT), Australia. The study population, comprising women who gave birth to a live baby from March to October 1997, completed 4 questionnaires on the fourth postpartum day, and at 8, 16, and 24 weeks postpartum. Outcome measures were self-reported health problems during each of the three 8-week postpartum periods up to 24 weeks. RESULTS: A total of 1295 women participated, and 1193 (92) completed the study. Health problems showing resolution between 8 and 24 weeks postpartum were exhaustion/extreme tiredness (60-49), backache (53-45), bowel problems (37-17), lack of sleep/baby crying (30-15), hemorrhoids (30-13), perineal pain (22-4), excessive/prolonged bleeding (20-2), urinary incontinence (19-11), mastitis (15-3), and other urinary problems (5-3). No significant changes occurred in the prevalence of frequent headaches or migraines, sexual problems, or depression over the 6 months. Adjusting for method of birth, primiparas were more likely than multiparas to report perineal pain and sexual problems. Compared with unassisted vaginal births, women who had cesarean sections reported more exhaustion, lack of sleep, and bowel problems; reported less perineal pain and urinary incontinence in the first 8 weeks; and were more likely to be readmitted to hospital within 8 weeks of the birth. Women with forceps or vacuum extraction reported more perineal pain and sexual problems than those with unassisted vaginal births after adjusting for parity, perineal trauma, and length of labor.
CONCLUSIONS: Health problems commonly occurred after childbirth with some resolution over the 6 months postpartum. Some important differences in prevalence of health problems were evident when parity and method of birth were considered.

Int J Gynaecol Obstet., 2001, 75(Suppl. 1):S25-37.
Fish can't see water: the need to humanize birth.
Wagner, M.
Formerly Women's and Children's Health, WHO, Copenhagen, Denmark. marsden.patricia@starpower.net
Humanized birth puts the woman in the center and in control, focuses on community based primary maternity care with midwives, nurses and doctors working together in harmony as equals, and has evidence based services. Western, medicalized, high tech maternity care under obstetric control usually dehumanizes, often leads to unnecessary, costly, dangerous, invasive obstetric interventions and should never be exported to developing countries. Midwives and planned out-of-hospital births are perfectly safe for low-risk births.

J Perinat Med., 2004, 32(1):31-36.
Indicated labor induction with vaginal prostaglandin E2 increases the risk of cesarean section even in multiparous women with no previous cesarean section.
Ben-Haroush, A., Yogev, Y., Bar, J., Glickman, H., Kaplan, B., Hod, M.
Perinatal Division, WHO Collaborating Center for Perinatal Care, Department of Obstetrics and Gynecology, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel. yudavi@inter.net.il
AIMS: To evaluate the impact of induction of labor with vaginal tablets of prostaglandin E2 on the rate of cesarean section (CS), and to identify possible predictors of successful vaginal delivery.
METHODS: 1541 consecutive women admitted for induction of labor with vaginal tablets of PGE2 were retrospectively compared with 574 consecutive women with spontaneous onset of labor.
RESULTS: Maternal age, nulliparity, previous CS, gestational age, and birth weight were similar in the study and control groups. The CS rate was twofold higher in the study group (20.7% vs 10.6%). CS rates in the study and control groups were 26.9% and 12.8% for the nulliparous women, and 11.2% and 5.1% for the multiparous women with no previous CS. Neither group had major maternal or fetal complications. A logistic regression model and stepwise analysis showed that nulliparity, previous CS, maternal age, number of PGE2 applications, birth weight, and the induction of labor by itself were independent significant risk factors for increased CS rate.
CONCLUSIONS: Induction of labor with vaginal PGE2 tablets results in a vaginal delivery rate of 79.3%, with apparently no serious maternal or fetal complications. Nulliparity, and previous CS are the most significant risk factors for increased CS rate. However, even after these risk factors are excluded and controlling for possible predictors for CS, PGE2 induction is independently associated with a twofold increase in CS rate, most often because of labor dystocia.

J Obstet Gynaecol Can., 2003, 25(12):1007-1009.
Birth can be a hazardous journey: electronic fetal monitoring does not help.
Natale, R., Dodman, N.
Department of Obstetrics and Gynaecology, St Joseph's Health Care/London Health Sciences Centre, London, Ontario, Canada.
Intrapartum fetal health surveillance, in particular electronic fetal heart-rate monitoring (EFM), is a perinatal issue that has sparked much debate both nationally and internationally. Prevention of cerebral palsy is a major objective of all health-care providers when assessing fetal health in labour. The Fetal Health Surveillance Working Group of the Society of Obstetricians and Gynaecologists of Canada (SOGC) should be commended for its efforts in presenting and discussing the literature and for raising important issues in EFM in the SOGC's Clinical Practice Guideline on Standard Fetal Surveillance in Labour, published in JOGC in March 2002, the first half of the SOGC document Fetal Health Surveillance in Labour. These, as all, SOGC Clinical Practice Guidelines are widely used by hospitals and health-care providers when evaluating practices in their own environments, and we believe, as practitioners of and investigators in fetal health surveillance, that there is not good supporting evidence for recommending continuous intrapartum EFM for pregnancies in which there is an increased risk of perinatal death, cerebral palsy, or neonatal encephalopathy, or when oxytocin is being used for induction of labour, and that if we recommend that the fetal heart be electronically monitored while the nurse is elsewhere, we are on a slippery slope. We encourage reopening discussion regarding these recommendations in the document.

Gynecol Obstet Invest., 2003, 56(3):133-138.
Intervention rates after elective induction of labor compared to labor with a spontaneous onset. A matched cohort study.
van Gemund N, Hardeman A, Scherjon SA, Kanhai HH.
Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands. n.van_gemund@lumc.nl
INTRODUCTION: Elective induction of labor has become a widely used procedure in obstetrics. A number of studies have shown an increased incidence of operative deliveries. The objective of this study was to evaluate the rate of interventions in our hospital, including operative delivery.
METHODS: A matched cohort study in which labor of 122 electively induced women and 122 women with labor with a spontaneous onset were analyzed retrospectively. These women were matched for parity and gestational age.
RESULTS: Pain relief, fetal scalp blood sampling and operative deliveries were recorded more frequently in the electively induced labor group. Cesarean delivery was found in 15% of women with induced labor, and in 1% of labors with a spontaneous onset (relative risk 18 (95% CI 2.4-132.7)). No differences were found in neonatal outcomes.
CONCLUSIONS: Elective induction of labor leads to increased intervention rates during labor. The rate of cesarean delivery is high, particular in nulliparous women and multiparous women without a previous vaginal birth.

Chin Med J (Engl)., 2004, 117(3):449-452.
Misoprostol in labour induction of term pregnancy: a meta-analysis.
Li, X.M., Wan, J., Xu, C.F., Zhang, Y., Fang, L., Shi, Z.J., Li, K.
Department of Obstetrics and Gynaecology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China. tigerlee777@163.net
OBJECTIVE: To evaluate the efficacy and safety of misoprostol in term labour induction.
DATA SOURCES: Data from published English and Chinese literatures about misoprostol in term labour induction were identified from Medline and CBMdisk (using the search terms "misoprostol" and "labour induction") before 2001; hand searches of reference lists of original studies and reviews (including meta-analyses) and contact with investigators in this field before 2001.
STUDY SELECTION: Studies were included if they had data on misoprostol and labour induction. Altogether 623 articles were found and 124 were admitted, including 19,287 cases.
DATA EXTRACTION: Data were collected on efficacy and incidence of side-effects of misoprostol and oxytocin. Data were checked for consistency within the published articles and converted into a standard format for incorporation into a central database.
DATA SYNTHESIS: The average successful induction rate, rates of caesarean section; incidence of tachysystole, hypertonus of uterus and precipitous labour, and rates of meconium stained amniotic fluid between the misoprostol and oxytocin groups were significantly different (P < 0.05). There were no significant differences between the two groups concerning the average interval from the administration of misoprostol and oxytocin to the onset of labour, duration of the total stage of labour, incidence rate of foetal distress, neonatal asphyxia (1-minute Apgar score < and= 7), postpartum haemorrhage or amount of blood loss in postpartum.
CONCLUSIONS: Misoprostol is a superior agent over oxytocin on the induction of term labour, but its application might increase the risk of precipitous labour, abnormal uterine contractions or meconium stained amniotic fluid. Therefore, the dosages and regimens of the agent need further investigation.

Drug Saf., 2002, 25(9):665-676.
A benefit-risk assessment of misoprostol for cervical ripening and labour induction.
Wing, D.A.
Division of Maternal-Fetal Medicine, Department of Obstetrics-Gynecology, University of Southern California School of Medicine, Los Angeles, California
Misoprostol, a prostaglandin E(1) analogue, is widely used in the US and other countries for cervical ripening and labour induction. Its use for these indications is not approved by the US Food and Drug Administration (FDA). The manufacturer of misoprostol issued a letter to American healthcare providers in August 2000, cautioning against the use of misoprostol in pregnant women and citing a lack of safety data for its use in obstetrical practice. The only FDA-approved indication in the product labelling is the treatment and prevention of intestinal ulcer disease resulting from nonsteroidal anti-inflammatory drug use. Multiple trials have proven that when applied vaginally, misoprostol is an effective agent for cervical ripening and labour induction in term pregnancy. The use of oxytocin augmentation is reduced when intravaginal misoprostol is used compared with other agents. Misoprostol use in obstetrics carries the added benefits of temperature stability at room temperature, which is unlike other prostaglandin preparations which require refrigeration or freezing, and reduced cost. However, debate continues regarding the optimal dose, dosage regimen, and route of administration. Uterine contraction abnormalities are often found in association with higher misoprostol doses (50 microg or more) given vaginally or orally. Some trials also indicate increased frequencies of meconium passage, neonatal acidaemia and caesarean delivery for fetal distress in women receiving higher doses of vaginally applied misoprostol. However, most trials fail to demonstrate a significant change in the caesarean delivery rate with the use of misoprostol, although a recent meta-analysis indicated that the use of intravaginal misoprostol is associated with a lowering of the caesarean rate when compared with pooled controls. Low-dose misoprostol (25 microg) is an effective agent for cervical ripening and labour induction when used in a judicious and cautious fashion. There are insufficient data to support the widespread use of oral misoprostol for cervical ripening and labor induction. Some trials suggest that this approach may be effective; however, the ideal dose and administration regimen have yet to be defined.

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