A comparison of vaginal versus buccal misoprostol for cervical ripening in women for labor induction at term (the IMPROVE trial): a triple-masked randomized controlled trial.

BACKGROUND: Cervical ripening is commonly needed for labor induction. Finding an optimal route of misoprostol dosing for efficacy, safety, and patient satisfaction is important and not well studied for the buccal route. OBJECTIVE: To compare the efficacy and safety of vaginal and buccal misoprostol for women undergoing labor induction at term. STUDY DESIGN: The IMPROVE trial was an institutional review board-approved, triple-masked, placebo-controlled randomized noninferiority trial for women undergoing labor induction at term with a Bishop score ≤6. Enrolled women received 25 mcg (first dose), then 50 mcg (subsequent doses) of misoprostol by assigned route (vaginal or buccal) and a matching placebo tablet by the opposite route. The primary outcomes were time to delivery and the rate of cesarean delivery performed urgently for fetal nonreassurance. A sample size of 300 was planned to test the noninferiority hypothesis. RESULTS: The trial enrolled 319 women, with 300 available for analysis, 152 in the vaginal misoprostol group and 148 in the buccal. Groups had similar baseline characteristics. We were unable to demonstrate noninferiority. The time to vaginal delivery was lower for the vaginal misoprostol group (median [95% confidence interval] in hours: vaginal: 20.1 [18.2, 22.8] vs buccal: 28.1 [24.1, 31.4], log-rank test P = .006, Pnoninferiority = .663). The rate of cesarean deliveries for nonreassuring fetal status was 3.3% for the vaginal misoprostol group and 9.5% for the buccal misoprostol group (P = .033). The rate of vaginal delivery in <24 hours was higher in the vaginal group (58.6% vs 39.2%, P = .001). CONCLUSION: We were unable to demonstrate noninferiority. In leading to a higher rate of vaginal deliveries, more rapid vaginal delivery, and fewer cesareans for fetal issues, vaginal misoprostol may be superior to buccal misoprostol for cervical ripening at term.

Women's experiences with water birth: A matched groups prospective study.

BACKGROUND: Water birth has become an increasingly popular childbirth option, but has also come under scrutiny because of its possible risks and benefits. The primary objective of this study was to explore potential benefits of water birth by comparing the experiences of women who gave birth in water versus conventionally. We also compared maternal and newborn outcomes. METHODS: We performed a prospective study of 66 women who had water births and 132 who had conventional births. Data collected included demographics, labor and birth characteristics, perinatal outcomes, and maternal scores on the Childbirth Experience Questionnaire (CEQ). Groups were matched for variables known to influence CEQ scores. RESULTS: Women in the water birth group had more positive childbirth experiences compared with the conventional birth group (P < .001), and also compared with the subgroup of women who had epidural anesthesia (P = .002). After controlling for potential confounders, water birth was associated with a decreased likelihood of perineal lacerations requiring repair (P = .001) and a higher rate of breastfeeding initiation in the delivery room (P < .001). Adverse outcomes such as neonatal intensive care unit admission, blood loss >500 mL, 3rd/4th degree lacerations, and perinatal infections were rare. The study was not sufficiently powered to detect differences in rare outcomes. CONCLUSION: Water birth was associated with more positive maternal childbirth experiences as represented by CEQ scores. Adverse outcomes were rare in both the water birth and conventional birth groups.

Induction of labor: update and review.

Rates of labor induction in the United States have more than doubled in the past 2 decades. Trends of indications and risk factors related to induction of labor are also increasing. Professional organizations such as the American College of Obstetricians and Gynecologists and The Joint Commission have taken steps to discourage elective induction of labor prior to 39 weeks' gestation and have created new definitions of early-term, full-term, late-term, and postterm gestation to guide clinicians in the timing of birth for specified indications. Induction of labor is associated with potential risks to both the woman and her fetus. The cost associated with induction of labor and the impact on the health care system is of growing concern. Education of women and the process of shared decision making when obtaining informed consent are key factors in reducing early elective births. Use of tools such as scheduling forms, hard stop methods, induction of labor indication tools, and informed consents may aid the provider in reducing overdiagnosis, overtreatment, and disease creep. This article provides a review of the trends of induction of labor, medical indications and criteria, associated risks, cost and health system impact, and initiatives to lower the incidence of induction of labor.

Peace and quiet.

Consider implementing a Quiet Time for patient relaxation to enhance the healing process and increase patient satisfaction.

High-tech high-touch: mission possible? Creating an environment of healing.

As the result of assuming the role of a family member of a patient, the authors discovered that the stress made them really see how many nurses respond to patients' needs on a busy shift. They were dismayed at their reaction and immediately reverted to "Nursing 101." This article will describe the journey to establish the mission of restoring "Nursing 101" to the practice environment of an intensive care unit (ICU) and an intermediate care unit.