A randomised open-label trial to assess outpatient induction of labour (HOMEIND) and compare efficacy of Propess vs Dilapan-S® for induction of labour at 39 weeks' gestation in normal risk nulliparous women: study protocol for a randomised controlled trial.

BACKGROUND: Induction of labour (IOL) at 39 weeks has been shown to decrease maternal and neonatal adverse outcomes. Given the growing demand for 39-week IOL, it is imperative that effective methods be assessed for induction in the outpatient setting. The aim of this study is to answer the clinical question as to whether Dilapan-S® vs Propess® as a method of cervical ripening is non-inferior in the outpatient setting at 39 weeks and to ascertain whether Dilapan-S® 12 h is non-inferior to Dilapan-S® 24 h. METHODS: This study is an open-label parallel group single-centre randomised trial. Participants are normal risk nulliparous women who have no pregnancy-related or medical contraindication to IOL. Women will be randomised to one of three induction groups-Dilapan-S® (12-h insertion or 24-h insertion) or Propess. Induction will be initiated between 39+0 and 39+4 weeks' gestation and participants will return home for either 12 or 24 h. They will be readmitted 12/24 h later in order to continue with induction of labour. Patient recruitment will take place over 30 months within a single centre. The study will recruit a maximum 109 women for each study arm. Total duration of participants' involvement in the trial will be 8 weeks to allow for postpartum follow-up. DISCUSSION: This study will definitively answer whether Dilapan-S is non-inferior to Propess® as a method of induction of labour in the outpatient setting and whether cervical ripening with Dilapan-S over a 12-h timeframe is non-inferior to cervical ripening with Dilapan-S over a 24-h timeframe. TRIAL REGISTRATION: EudraCT Number 2019-004697-25 Registered 14 September 2020.

Spontaneous Human Myometrial Contractility in the Third Trimester of Pregnancy in Relation to Past Mode of Delivery.

OBJECTIVE: It is well established that women with a previous vaginal delivery have higher success rates in relation to vaginal birth after cesarean than those without. The aim of this study was to examine the effect of past mode of delivery on contractile parameters of human myometrium in vitro. STUDY DESIGN: Myometrial strips were excised from 64 women at cesarean delivery (CD) and recordings of spontaneous contractile activity analyzed and compared across three clinical groups: (1) women with no previous delivery (Group 1); (2) women with CD only (Group 2); and (3) women with a history of vaginal delivery and CD (Group 3). RESULTS: Myometrial samples from women in Group 3, women who had a previous vaginal delivery, had a significantly greater maximum amplitude of contractions (p < 0.05), a greater force (mean contractile force) of contractions (p < 0.01), and a faster rate of rise (p < 0.01) and relaxation of contractions (p < 0.05) than those in Groups 1 and 2. CONCLUSION: Many of the functional parameters of human uterine contractions are altered, or enhanced, in the women who have had a previous vaginal delivery, when compared with those without. This may partly explain the clinical differences observed in labor.

Maternal parity and functional contractility of human myometrium in vitro in the third trimester of pregnancy.

OBJECTIVE: It is well established that the duration of the first and second stages of labor are shorter in parous women than in their nulliparous counterparts, a phenomenon not well understood. The aim was to examine the effect of maternal parity on contractile parameters of human myometrium. DESIGN: Myometrial strips were excised from n = 74 women at cesarean delivery and recordings of contractile activity analyzed and compared across three clinical groups: 1. No previous delivery (P0); 2. One previous delivery (P1); 3. Greater than one previous delivery (P>1). RESULTS: There was a trend towards greater mean contractile force in the P>1 group than the P1 and P0 groups (P = 0.412). Frequency of contractions was less in the P1 group than in the P0 and P>1 groups(P = 0.027). No differences were observed in relation to all other parameters. CONCLUSION: Excluding frequency, no intrinsic differences were observed in the functional parameters of human uterine contractions in relation to parity.

Vaginal birth after caesarean section: Current status and where to from here?

Vaginal birth after caesarean (VBAC) delivery remains a controversial topic, and one for which there is a lack of robust data to guide clinicians and parturients regarding their best option for mode of delivery in a subsequent pregnancy. In many developed countries the trend observed in recent years is that of progressively reduced VBAC rates, and hence increased use of elective repeat caesarean section (ERCS). This factor has contributed, more than any other, to the disproportionately high caesarean section (CS) rates in many countries. With current CS rates varying between 30 and 50% in the developed world, a previous CS is the cited primary indication in approximately 30%. To compound matters, there are huge variations in the reported VBAC rates between different countries, regions and even institutions. This review has focused on the recent trends in VBAC attempt, success and overall rates internationally, with inclusion of figures for a period of 25 years from a single Irish institution. An analysis of the reported factors that influence VBAC success, or failure, is presented. The complex task of estimating risk, both perinatal and maternal, for women who pursue VBAC or ERCS, is included in this review. Finally, the current evidence base for clinical practice pertaining to VBAC is outlined, with inclusion of commentary regarding the future for this difficult area of obstetric practice.