Jannet J. H. Bakker

Outcomes after Internal versus External Tocodynamometry for Monitoring Labor

BACKGROUND It has been hypothesized that internal tocodynamometry, as compared with external monitoring, may provide a more accurate assessment of contractions and thus improve the ability to adjust the dose of oxytocin effectively, resulting in fewer operative deliveries and less fetal distress. However, few data are available to test this hypothesis. METHODS We performed a randomized, controlled trial in six hospitals in The Netherlands to compare internal tocodynamometry with external monitoring of uterine activity in women for whom induced or augmented labor was required. The primary outcome was the rate of operative deliveries, including both cesarean sections and instrumented vaginal deliveries. Secondary outcomes included the use of antibiotics during labor, time from randomization to delivery, and adverse neonatal outcomes (defined as any of the following: an Apgar score at 5 minutes of less than 7, umbilical-artery pH of less than 7.05, and neonatal hospital stay of longer than 48 hours). RESULTS We randomly assigned 1456 women to either internal tocodynamometry (734) or external monitoring (722). The operative-delivery rate was 31.3% in the internal-tocodynamometry group and 29.6% in the external-monitoring group (relative risk with internal monitoring, 1.1; 95% confidence interval [CI], 0.91 to 1.2). Secondary outcomes did not differ significantly between the two groups. The rate of adverse neonatal outcomes was 14.3% with internal monitoring and 15.0% with external monitoring (relative risk, 0.95; 95% CI, 0.74 to 1.2). No serious adverse events associated with use of the intrauterine pressure catheter were reported. CONCLUSIONS Internal tocodynamometry during induced or augmented labor, as compared with external monitoring, did not significantly reduce the rate of operative deliveries or of adverse neonatal outcomes. (Current Controlled Trials number, ISRCTN13667534; Netherlands Trial number, NTR285.)

Start of induction of labour with oxytocin in the morning or in the evening. A randomised controlled trial

Objective  The objective of this study was to compare outcomes of induced labour with intravenous oxytocin with a start in the evening versus in the morning.

Does use of an intrauterine catheter during labor increase risk of infection

Objective. To determine whether the use of an intrauterine catheter during labor is related to the occurrence of infection in mother or newborn during labor and up to 3 weeks postpartum. Methods. We performed a follow-up study of 1435 women who participated in a previously published multicentre randomized controlled trial in the Netherlands that assigned women in whom labor was induced or augmented with intravenous oxytocin to internal or external tocodynamometry. In the present post hoc analysis, we assessed the risk for infection, defined as a composite measure of any clinical sign of infection, treatment with antibiotics or sepsis during labor or in the postpartum period up to 3 weeks in mother or newborn. Results. There were 64 cases with indication of infection in the intrauterine catheter group (8.8%) versus 74 cases in the external monitoring group (10.4%). Relative risk: 0.91, 95% confidence interval: 0.77–1.1, and p: 0.33. Conclusion. Use of an intrauterine catheter during labor does not increase the risk of infection.

Does measurement of intrauterine pressure have predictive value during oxytocin-augmented labor?

Abstract Objective: In a previous randomized trial that compared monitoring uterine contractions with an intrauterine pressure catheter (IUPC) versus external monitoring, we demonstrated that use of an IUPC did not improve the outcome of labor. To provide insight in the lack of a positive effect, we evaluated level of IUP in Montevideo units (MU) in correlation with dysfunctional labor and adverse neonatal outcome. Study design: Here, we present two secondary analyses on the 503 women who had IUP measured in the trial. Firstly, we assessed labor outcome in relation to the highest IUP measured at any time during labor. Secondly, we assessed labor outcome to the IUP registered at the last vaginal examination during the first stage of labor in two study groups (above and below 200 MU). Results: Women with lower IUP were statistically significant older, had pregnancies with a longer gestational age, longer labors and neonates with a higher birth weight. The risk of a cesarean section was higher in women who had low IUP during labor (Likelihood Ratio 1.6 for IUP < 100 MU, 0.41 for IUP > 300 MU). IUP was not associated with neonatal outcome. Conclusion: IUP is associated with mode of delivery. However, use of internal tocodynamometry does not improve birth outcomes.

Potential Improvement of Pregnancy Outcome through Prenatal Small for Gestational Age Detection

OBJECTIVE To assess differences in mode of delivery and pregnancy outcome between prenatally detected and nonprenatally detected small for gestational age (SGA) neonates born at term. STUDY DESIGN We performed a retrospective multicenter cohort study. All singleton infants, born SGA in cephalic position between 36(0/7) and 41(0/7) weeks gestation, were classified as either prenatally detected SGA or nonprenatally detected SGA. With propensity score matching we created groups with comparable baseline characteristics. We compared these groups for composite adverse perinatal outcome, labor induction, and cesarean section rates. RESULTS We included 718 SGA infants, of whom 555 (77%) were not prenatally detected. Composite adverse neonatal outcome did not differ statistically significant between the matched prenatally detected and the nonprenatally detected group (5.5 vs. 7.4%, odds ratio [OR] 0.74, 95% confidence interval [CI]: 0.30-1.8). However, perinatal mortality only occurred in the nonprenatally detected group (1.8% [3/163] in the matched cohort, 1.3% [7/555] in the complete cohort). In the propensity matched prenatally detected SGA group both induction of labor (57 vs. 9%, OR 14.0, 95% CI: 7.4-26.2) and cesarean sections (20 vs. 8%, OR 2.9, 95% CI: 1.5-5.8) were more often performed compared with the nonprenatally detected SGA group. CONCLUSION Prenatal SGA detection at term allows timely induction of labor and cesarean sections thus potentially preventing stillbirth.

Start of Induction of Labor With Oxytocin in the Morning or in the Evening. A Randomized Controlled Trial

This randomized controlled trial assessed whether initiating induction of labor with intravenous oxytocin in the evening shortens the duration of labor compared with induction of labor in the early morning. The study was based on observations that the duration of labor and delivery shortens and less intervention is needed when spontaneous contractions start in the evening. The study was conducted between 2003 and 2006 at hospitals in the Netherlands. A total of 371 women at gestational age ≥36 weeks who had an indication for induction of labor with intravenous oxytocin were randomized to either an evening start of induction (9 PM) or a morning start (7 A M ). Randomization was stratified by parity. The primiparous group included 242 women (124 in the morning group and 118 in the evening group) and the multiparous group included 129 (63 in the morning group and 66 in the evening group). The primary study outcome was duration of labor, defined as time between start of labor and time of birth. Secondary outcomes were duration of second stage, rate of vaginal instrumental delivery and caesarean section, adverse neonatal outcomes (including Apgar score below 7 after 5 minutes and neonatal admissions), and the number and indications of pediatric consults as well as the number of intrapartum infections, use of antibiotics, and need for pain relief. Intention-to-treat analysis did not show statistically significant differences among either primiparas or multiparas in the primary outcome, duration of labor (primiparas: morning 12 hours and 8 minutes vs. evening 11 hours and 22 minutes [P = 0.29] and multiparas: morning 7 hours and 34 minutes vs. evening 7 hours and 46 minutes [P = 0.70]). No significant differences between the study groups were found in mode of delivery, use of antibiotics, pediatric consultations, or patient satisfaction. Among primiparas but not multiparas, more children born from mothers in the morning group were admitted to the neonatal ward. The investigators conclude from these findings that there is no clinically relevant difference for duration of labor and most parameters of safety between induction of labor with intravenous oxytocin starting in the evening or the morning.

Use of intra‐uterine pressure catheter (IUPC) versus external tocodynamometry (TOCO) during labour for reducing adverse outcomes

Jannet JH Bakker, Petra F Janssen, Ben Willem J Mol, Dimitri Papatsonis, Jan MM van Lith, Joris AM van der Post