Women's experiences and views of outpatient and inpatient induction of labor with oral misoprostol: A secondary qualitative study.

INTRODUCTION: As labor induction rates continue to increase, so has the interest in performing induction in an outpatient setting for pregnancies defined as low-risk. Twenty women participated in the pilot study of a Randomized Controlled Trial (RCT) comparing inpatient and outpatient labor induction with oral misoprostol. This study aimed to explore women's experiences of outpatient induction of labor and their views on this as an alternative method to inpatient labor induction. METHODS: Semi-structured interviews were conducted, from November 2021 to January 2022 with eight women randomized to outpatient induction and four women randomized to inpatient induction. Verbatim transcribed interviews were analyzed using Graneheim and Lundman's content analysis. RESULTS: Three main categories emerged: the required framework around outpatient labor induction, what felt better at home and what felt safer at the hospital. To feel secure at home, women needed sufficient information, close follow-up while at home, and an easy-to-administer induction method. Outpatient labor induction gave women the opportunity of constant support from the partner and increased freedom of movement and self-expression. Some expressed relief over being randomized to inpatient labor induction, because of easy access to health providers, fetal monitoring, and not risking giving birth before arrival to the hospital. Women stressed the importance of being given a choice. CONCLUSIONS: Outpatient labor induction contributed to a positive birth experience and should be considered as an alternative for women with low-risk pregnancies. Shared decision-making, including the opportunity for women to change their mind, is essential as induction and early labor affects women's whole childbirth experience.

Changes in labor outcomes after implementing structured use of oxytocin augmentation with a 4-hour action line.

INTRODUCTION: Oxytocin augmentation is essential in labor management, but how to optimize its use is still debated. Joint international guidelines regarding prolonged labor and the use of oxytocin augmentation are still not available. Due to its potential harmful side effects, a decreased use of oxytocin is encouraged. We aimed to implement a structured protocol on the use of oxytocin augmentation and to observe changes in labor outcomes. MATERIALS AND METHODS: The protocol was implemented at the Obstetric Department of Sørlandet Hospital, Kristiansand, Norway on 1 January 2012; therefore, data from the hospital were collected prospectively and compared for two time-period cohorts: the historic control cohort (2009-2010) and the study period cohort (2012-2013). The structured protocol instructs, and restricts, the birth attendants to diagnose prolonged labor, by protocol definition only, before commencing oxytocin infusion for augmentation. Nulliparous women with singleton, term deliveries (≥37 weeks), cephalic presentation, and spontaneous onset of labor (Ten-Group Classification System (TGCS) group 1) were included in the analysis. The main outcome was use of oxytocin augmentation. RESULTS: The study cohort and control cohort comprised 1103 (26.2%) and 1399 (33.1%) of all laboring women, respectively (p < .01). The protocol was followed satisfactorily in 78% of the study cohort. The use of oxytocin augmentation was reduced in the study cohort versus the control cohort; 41.3 versus 48.9% (p < .01); mean oxytocin infusion duration was shorter (100 versus 123 min; p < .01); and mean total oxytocin dose decreased (1009 versus 1293 mU; p < .01). The cesarean section rate was 5.9% in the study cohort versus 8.0% in the control cohort (p = .04). The estimated mean duration of the active phase of labor increased by 47 min (p < .01) after the implementation. The frequency of estimated postpartum hemorrhage >1000 ml was higher, 4.9 versus 2.0% (p < .01), but the use of blood transfusions remained stable, 2.5 versus 2.7% (p = .78), the study cohort versus control cohort, respectively. CONCLUSIONS: Implementation of a protocol of structured use of oxytocin augmentation reduced the frequency, dosage, and duration of oxytocin without increasing the cesarean section rate in TGCS group 1.

Can oxytocin augmentation modify the risk of epidural analgesia by maternal age in cesarean sections?

INTRODUCTION: Maternal age is an established risk factor for cesarean section; epidural analgesia and oxytocin augmentation may modify this association. We investigated the effects and interactions of oxytocin augmentation, epidural analgesia and maternal age on the risk of cesarean section. MATERIAL AND METHODS: In all, 416 386 nulliparous women with spontaneous onset of labor, ≥37 weeks of gestation and singleton infants with a cephalic presentation during 2000-2011 from Norway and Denmark were included [Ten-group classification system (Robson) group 1]. In this case-control study the main exposure was maternal age; epidural analgesia, oxytocin augmentation, birthweight and time period were explanatory variables. Chi-square test and logistic regression were used to estimate associations and interactions. RESULTS: The cesarean section rate increased consistently with advancing maternal age, both overall and in strata of epidural analgesia and oxytocin augmentation. We observed strong interactions between maternal age, oxytocin augmentation and epidural analgesia for the risk of cesarean section. Women with epidural analgesia generally had a reduced adjusted odds ratio when oxytocin was used compared with when it was not used. In Norway, this applied to all maternal age groups but in Denmark only for women ≥30 years. Among women without epidural, oxytocin augmentation was associated with an increased odds ratio for cesarean section in Denmark, whereas no difference was observed in Norway. CONCLUSIONS: Oxytocin augmentation in nulliparous women with epidural analgesia is associated with a reduced risk of cesarean section in labor with spontaneous onset.

A method to assess obstetric outcomes using the 10-Group Classification System: a quantitative descriptive study.

OBJECTIVES: Internationally, the 10-Group Classification System (TGCS) has been used to report caesarean section rates, but analysis of other outcomes is also recommended. We now aim to present the TGCS as a method to assess outcomes of labour and delivery using routine collection of perinatal information. DESIGN: This research is a methodological study to describe the use of the TGCS. SETTING: Stavanger University Hospital (SUH), Norway, National Maternity Hospital Dublin, Ireland and Slovenian National Perinatal Database (SLO), Slovenia. PARTICIPANTS: 9848 women from SUH, Norway, 9250 women from National Maternity Hospital Dublin, Ireland and 106 167 women, from SLO, Slovenia. MAIN OUTCOME MEASURES: All women were classified according to the TGCS within which caesarean section, oxytocin augmentation, epidural analgesia, operative vaginal deliveries, episiotomy, sphincter rupture, postpartum haemorrhage, blood transfusion, maternal age >35 years, body mass index >30, Apgar score, umbilical cord pH, hypoxic-ischaemic encephalopathy, antepartum and perinatal deaths were incorporated. RESULTS: There were significant differences in the sizes of the groups of women and the incidences of events and outcomes within the TGCS between the three perinatal databases. CONCLUSIONS: The TGCS is a standardised objective classification system where events and outcomes of labour and delivery can be incorporated. Obstetric core events and outcomes should be agreed and defined to set standards of care. This method provides continuous and available observations from delivery wards, possibly used for further interpretation, questions and international comparisons. The definition of quality may vary in different units and can only be ascertained when all the necessary information is available and considered together.

Judicious use of oxytocin augmentation for the management of prolonged labor.

INTRODUCTION: A protocol including judicious use of oxytocin augmentation was investigated to determine whether it would change how oxytocin was used and eventually influence labor and fetal outcomes. MATERIAL AND METHODS: The population of this cohort study comprised 20 227 delivering women with singleton pregnancies ≥37 weeks, cephalic presentation, spontaneous or induced onset of labor, without previous cesarean section. Women delivering from 2009 to 2013 at Stavanger University Hospital, Norway, were included. Data were collected prospectively. Before implementing the protocol in 2010, oxytocin augmentation was used if progression of labor was perceived as slow. After implementation, oxytocin could only be started when the cervical dilation had crossed the 4-h action line in the partograph. RESULTS: The overall use of oxytocin augmentation was significantly reduced from 34.9% to 23.1% (p < 0.01). The overall frequency of emergency cesarean sections decreased from 6.9% to 5.3% (p < 0.05) and the frequency of emergency cesarean sections performed due to fetal distress was reduced from 3.2% to 2.0% (p = 0.01). The rate of women with duration of labor over 12 h increased from 4.4% to 8.5% (p < 0.01) and more women experienced severe estimated postpartum hemorrhage (2.6% vs. 3.7%; p = 0.01). The frequency of children with pH <7.1 in the umbilical artery was reduced from 4.7% to 3.2% (p < 0.01). CONCLUSIONS: The frequency of emergency cesarean section was reduced after implementing judicious use of oxytocin augmentation. Our findings may be of interest in the ongoing discussion of how the balanced use of oxytocin for labor augmentation can best be achieved.

Is there an increase of postpartum hemorrhage, and is severe hemorrhage associated with more frequent use of obstetric interventions?

OBJECTIVE: To analyze changes in postpartum hemorrhage over a 10-year period from 1998 to 2007, and to explore factors associated with severe hemorrhage. DESIGN: Retrospective cohort study, prospectively collected information. SETTING: Stavanger University Hospital, a secondary referral center, Norway. POPULATION: An unselected population of 41,365 women giving birth at the hospital. METHODS: We analyzed changes over time in mean postpartum hemorrhage, severe postpartum hemorrhage and associated factors. Estimated blood loss >1,000 ml was defined as severe hemorrhage. Data were collected from the hospital's database. MAIN OUTCOME MEASURES: Severe postpartum hemorrhage and obstetric interventions. RESULTS: We observed an increase in severe hemorrhage during the study period. After cesarean sections, the risk of severe hemorrhage was twice the risk of severe hemorrhage after vaginal deliveries (5.9%; 95% CI 5.3-6.6 vs. 2.8%; 95% CI 2.6-2.9). The most important factors associated with severe hemorrhage following vaginal deliveries were twin deliveries (OR 6.8), retained placenta (OR 3.9) and inductions of labor (OR 2.2). For cesarean sections, twin deliveries had the strongest association with severe hemorrhage (OR 3.7) followed by general anesthesia (OR 3.0). Obstetric interventions became more frequent; elective cesarean sections increased from 2.4 to 4.9%, acute cesarean sections from 5.5 to 8.9%, operative vaginal deliveries from 9.3 to 12.5%, inductions of labor from 14.3 to 15.8% and augmentations of labor from 5.8 to 29.3%. CONCLUSIONS: The incidence of severe postpartum hemorrhage increased, and this may be related to more frequent use of obstetric interventions.