Failed induction of labor in term nulliparous women with an unfavorable cervix: Comparison of cervical ripening by two forms of vaginal prostaglandins (slow-release pessary and vaginal gel).

OBJECTIVE: To compare the rate of failed induction after cervical ripening by two forms of vaginal prostaglandins. MATERIAL AND METHODS: This two-year retrospective study (January 1, 2016, through December 31, 2017) in two tertiary maternity units included nulliparous women with a singleton fetus in cephalic presentation and an unfavorable cervix requiring labor induction for prolonged pregnancy. The principal endpoint was the rate of failed induction, defined by the performance of a cesarean delivery before 6 cm of dilation. Cervical ripening was initiated by prostaglandins for 24 h, using a slow-release pessary (unit A) or a vaginal gel (unit B). The care protocol of the two groups after the first 24 h were similar. The women's individual characteristics were compared between the two units. The rates of failed induction were then compared between the two units, first by univariate and then by multivariable analysis adjusted for the characteristics that differed significantly between the units. RESULTS: Among the 17,217 women delivered in the two maternity units during the study period, 178 met our inclusion criteria (125 in unit A (slow-release pessary) and 53 in unit B (vaginal gel)). The rate of failed induction was similar: 21.6% in unit A (slow-release pessary) and 17.0% in unit B (vaginal gel) (P = 0.48). The multivariate analysis did not show any difference about failed induction, time from the onset of induction to delivery, and vaginal delivery rate within 24h. CONCLUSION: The rate of failed induction of labor did not differ between slow-release pessary and vaginal gel.

Nulliparous women with an unfavourable cervix at 41 weeks: Which women go into spontaneous labor during the expectant period?

CONTEXT: After 41 weeks, the labor induction term varies according to countries and obstetrical teams. The French recommendations are not to exceed 41 weeks 6 days. However, there are no data on the percentage of nulliparous women with an unfavorable cervix at 41 weeks going into spontaneous labor within five or six days. OBJECTIVE: The objective was to establish the rate of spontaneous labor within five days amongst nulliparous women with an unfavorable cervix at 41 weeks, and to identify the maternal and obstetrical factors associated with this spontaneous labor. MATERIALS AND METHODS: Retrospective study in a University Hospital Maternity between January 1st and December 31st 2017. All nulliparous women with a cephalic fetal presentation and unfavorable cervix at 41 weeks (Bishop ≤ 3) were included. The maximum term for induced labor was set at 41 weeks 5 days. The population was divided into two groups: spontaneous labor and induced labor (induction between 41 weeks and 41 weeks 4 days for medical indications or maternal wish and induction at 41 weeks 5 days for full term). The maternal and obstetrical characteristics of the two groups at 41 weeks were compared as well as the maternal and neonatal outcomes. RESULTS: The rate of spontaneous labor among the 269 women included was 38.3% (n = 103/269). At 41 weeks, the presence of painful uterine contractions and a Bishop score of 3 were associated with spontaneous labor within five days (p < 0.01). The Bishop score criteria most associated with spontaneous labor were cervical dilation and fetal station. The cesarean delivery rate was 20.4% in the group of women with spontaneous labor versus 41.0% in the group of induced labor (p < 0.01). There were no differences between the two groups in terms of neonatal outcome. CONCLUSION: Among nulliparous women with an unfavorable cervix at 41 weeks, almost 40 % will have a spontaneous onset of labor within five days. The only factors found to be associated with this onset of labor are the presence of painful uterine contractions and a higher Bishop score at 41 weeks.

Carbon dioxide monitoring during long-term noninvasive respiratory support in children.

INTRODUCTION: Routine monitoring of noninvasive respiratory support relies on nocturnal pulse oximetry and daytime arterial blood gases, without systematic nocturnal carbon dioxide recording. The aim of the study was to assess if overnight pulse oximetry and daytime blood gases are sufficiently accurate to detect nocturnal hypoventilation in children receiving long-term noninvasive respiratory support. MATERIALS AND METHODS: Pulse oximetry and carbon dioxide pressure measured by capillary arterialized blood gases and a combined transcutaneous carbon dioxide and pulse oximetry (PtcCO(2)/SpO(2)) monitor were compared in 65 patients (asthma, n = 16, recurrent bronchitis, n = 8, lung infection, n = 8, cystic fibrosis, n = 15, interstitial lung disease, n = 6, neuromuscular disease, n = 12). Daytime capillary arterialized blood gases and nocturnal recording of pulse oximetry and carbon dioxide by means of a combined PtcCO(2)/SpO(2) monitor were performed in 50 other patients receiving nocturnal noninvasive respiratory support at home. RESULTS: A correlation was observed between pulse oximetry (r = 0.832, P < 0.0001) and carbon dioxide pressure (r = 0.644, P < 0.0001) measured by capillary arterialized blood gases and the combined PtcCO(2)/SpO(2) monitor. Twenty-one of the 50 patients (42%) on long-term noninvasive respiratory support presented nocturnal hypercapnia, defined by a PtcCO(2) value >50 mmHg, without nocturnal hypoxemia. Daytime capillary arterialized carbon dioxide levels were normal in 18 of these 21 patients. CONCLUSIONS: Nocturnal hypercapnia may occur in children receiving nocturnal noninvasive respiratory support at home. Nocturnal pulse oximetry and daytime arterial blood gases are not sufficiently accurate to diagnose nocturnal hypercapnia, underlying the importance of a systematic carbon dioxide monitoring in children receiving noninvasive respiratory support.