Induction of labor and nulliparity: A nationwide clinical practice pilot evaluation.

INTRODUCTION: Induction of labor has become an increasingly common obstetric procedure, but in nulliparous women or women with a previous cesarean section, it can pose a clinical challenge. Despite an overall expansion of medical indications for labor induction, there is little international consensus regarding the criteria for induction, or for the recommended methods among nulliparous women. In this light, we assessed variations in the practice of induction of labor among 21 birth units in a nationwide cohort of women with no prior vaginal birth. MATERIAL AND METHODS: We carried out a prospective observational pilot study of women with induced labor and no prior vaginal birth, across 21 Norwegian birth units. We registered induction indications, methods and outcomes from 1 September to 31 December 2018 using a web-based case record form. Women were grouped into "Nulliparous term cephalic", "Previous cesarean section" and "Other Robson" (Robson groups 6, 7, 8 or 10). RESULTS: More than 98% of eligible women (n=1818) were included and a wide variety of methods was used for induction of labor. In nulliparous term cephalic pregnancies, cesarean section rates ranged from 11.1% to 40.6% between birth units, whereas in the previous cesarean section group, rates ranged from 22.7% to 67.5%. The indications "large fetus" and "other fetal" indications were associated with the highest cesarean rates. Failed inductions and failure to progress in labor contributed most to the cesarean rates. Uterine rupture occurred in two women (0.11%), both in the previous cesarean section group. In neonates, 1.6% had Apgar <7 at 5 minutes, and 0.4% had an umbilical artery pH <7.00. CONCLUSIONS: Cesarean rates and applied methods for induction of labor varied widely in this nationwide cohort of women without a prior vaginal birth. Neonatal outcomes were similar to those of normal birth populations. Results could indicate the need to move towards more standardized induction protocols associated with optimal outcomes for mother and baby.

The use of oral misoprostol for pre-abortion cervical priming: a randomised controlled trial of 400 versus 200 microg in first trimester pregnancies.

OBJECTIVE: To compare the impact of 200 and 400 microg oral misoprostol on pre-operative cervical priming in both primi- and multigravidae prior to first trimester termination of pregnancy. Pre-operative cervical dilatation and bleeding were assessed. DESIGN: Randomised controlled trial. SETTING: Norwegian university teaching hospital. SAMPLE: Five hundred and fifty-one women undergoing surgical termination of pregnancy between 7 and 12 weeks of gestation. METHODS: Patients were randomised to either 200 or 400 microg of oral misoprostol 10-16 hours before vacuum aspiration. The degree of cervical dilatation prior to abortion by vacuum aspiration was measured. Pre-operative bleeding and pain were recorded and vaginal bleeding was measured. MAIN OUTCOME MEASURES: Degree of pre-operative cervical dilatation and pre-operative bleeding. RESULTS: The mean cervical dilatation was 5.8 mm (SD 1.7) for the women who received 400 microg misoprostol and 5.4 mm (SD 1.4) for those who received 200 microg (P= 0.004). The pre-operative dilatation was larger in multigravidae than in primigravidae in both dosage groups. The odds ratio (OR) of pre-operative bleeding was 3.3 (95% confidence interval [CI] 2.1-5.0) in the 400 microg dosage group, as compared with the group receiving 200 microg misoprostol. The occurrence of bleeding was dose-dependent. Frequency of bleeding was similar in multigravidae compared with primigravidae in the 400 microg dosage group, whereas the occurrence of bleeding was less in primigravidae than multigravidae in the 200 microg dosage group. Only 89 out of 551 patients bled one or more grams. The volumes measured were not statistically significantly different. Complications were minor, and were distributed equally between the two dosage groups. CONCLUSIONS: The 200 microg oral misoprostol compared with the 400 microg oral misoprostol given 10-16 hours before first trimester surgical abortions results in less pre-operative vaginal bleeding and in a statistically, although not clinically significant reduction in cervical dilatation.