Induction of labour: creation of a classification of Grenoble allowing an assessment of the evaluation of practices.

BACKGROUND: Induction of labour, a very common obstetric procedure, affects about one in five pregnant women in most developed countries. Induction of labour is medically indicated, is subject to risks and additional costs, and is often poorly experienced by patients. The practices concerning induction vary widely from centre to centre and therefore need to be evaluated. Our aim was to develop a tool for evaluating induction of labour which would facilitate geographical and temporal comparisons. METHODS: We have created a classification based on the principles of the internationally known Robson classification. It should be simple, robust, reproducible and require readily available data in each file. The groups are fully inclusive and mutually exclusive. This classification has been validated by a Delphi method. RESULTS: Our classification includes 8 clinically relevant groups according to 5 obstetrical criteria. In order to classify each patient into a group, a simple system based on a maximum of 7 successive questions (from 1 to 7 questions) is used. Our classification has been validated by 13 national experts with satisfactory overall approval. CONCLUSIONS: With a view to improving the quality of care, our Grenoble classification would allow a standardization of the evaluation of practices of the induction of labour over time in the same maternity hospital. It would also allow the comparison of practices within different maternity hospitals in a network, a country or even different countries.

Using the Robson 10-Group Classification System to Compare Cesarean Birth Utilization Between US Centers With and Without Midwives.

INTRODUCTION: The Robson 10-group classification system stratifies cesarean birth rates using maternal characteristics. Our aim was to compare cesarean birth utilization in US centers with and without midwifery care using the Robson classification. METHODS: We used National Institute of Child and Human Development Consortium on Safe Labor data from 2002 to 2008. Births to women in centers with interprofessional care that included midwives (n = 48,857) were compared with births in non-interprofessional centers (n = 47,935). To compare cesarean utilization, births were classified into the Robson categories. Cesarean birth rates within each category and the contribution to the overall rate were calculated. Maternal demographics, labor and birth outcomes, and neonatal outcomes were described. Logistic regression was used to adjust for maternal comorbidities. RESULTS: Women were less likely to have a cesarean birth (26.1% vs 33.5%, P < .001) in centers with interprofessional care. Nulliparous women with singleton, cephalic, term fetuses (category 2) were less likely to have labor induced (11.1% vs 23.4%, P < .001), and women with a prior uterine scar (category 5) had lower cesarean birth rates (73.8% vs 85.1%, P < .001) in centers with midwives. In centers without midwives, nulliparous women with singleton, cephalic, term fetuses with induction of labor (category 2a) were less likely to have a cesarean birth compared with those in interprofessional care centers in unadjusted comparison (30.3% vs 35.8%, P < .001), but this was reversed after adjustment for maternal comorbidities (adjusted odds ratio, 1.21; 95% CI, 1.12-1.32; P < .001). Cesarean birth rates among women at risk for complications (eg, breech) were similar between groups. DISCUSSION: Interprofessional care teams were associated with lower rates of labor induction and overall cesarean utilization as well as higher rates of vaginal birth after cesarean. There was consistency in cesarean rates among women with higher risk for complications.

Using the Nippita classification system for women undergoing induction of labour in a large metropolitan maternity service: Bringing simplicity and certainty to an important quality improvement process.

In 2015 Nippita and colleagues developed a novel system to classify women undergoing induction of labour (IOL), which sought to overcome the problems of indication-based classification. We explored the utility and feasibility of this new system at Monash Health in Melbourne. We found overall induction rates of 24.7% compared with the New South Wales rates of 25.4% reported by Nippita et al. The classification system was easy to apply because it uses routinely and accurately collected data. There was no misinterpretation of the classification groups. The system provides a robust means for auditing IOLs and reviewing their appropriateness.

Quality assurance: The 10-Group Classification System (Robson classification), induction of labor, and cesarean delivery.

Quality assurance in labor and delivery is needed. The method must be simple and consistent, and be of universal value. It needs to be clinically relevant, robust, and prospective, and must incorporate epidemiological variables. The 10-Group Classification System (TGCS) is a simple method providing a common starting point for further detailed analysis within which all perinatal events and outcomes can be measured and compared. The system is demonstrated in the present paper using data for 2013 from the National Maternity Hospital in Dublin, Ireland. Interpretation of the classification can be easily taught. The standard table can provide much insight into the philosophy of care in the population of women studied and also provide information on data quality. With standardization of audit of events and outcomes, any differences in either sizes of groups, events or outcomes can be explained only by poor data collection, significant epidemiological variables, or differences in practice. In April 2015, WHO proposed that the TGCS (also known as the Robson classification) is used as a global standard for assessing, monitoring, and comparing cesarean delivery rates within and between healthcare facilities.

Offering induction of labor for 22-week premature rupture of membranes: a survey of obstetricians.

OBJECTIVE: To describe obstetricians' induction counseling practices for 22-week preterm premature rupture of membranes (PPROM) and identify provider characteristics associated with offering induction. METHODS: Surveyed 295 obstetricians on their likelihood (0-10) of offering induction for periviable PPROM across 10 vignettes. Twenty-two-week vignettes were analyzed, stratified by parental resuscitation preference. Bivariate analyses identified physician characteristics associated with reported likelihood ratings. RESULTS: Obstetricians (N=205) were not likely to offer induction. Median ratings by preference were as follows: resuscitation 1.0, uncertain 1.0 and comfort care 3.0. Only 41% of obstetricians were likely to offer induction to patients desiring comfort care. In addition, several provider-level factors, including practice region, parenting status and years in practice, were significantly associated with offering induction. CONCLUSIONS: Obstetricians do not readily offer induction when counseling patients with 22-week ruptured membranes, even when patients prefer palliation. This may place women at risk for infectious complications without accruing a neonatal benefit from prolonged latency.

Parto diferido del segundo gemelo / Delayed-interval delivery in twin pregnancy

La incidencia de embarazos múltiples se ha incrementado en los últimos años. Las pacientes con embarazos múltiples están en riesgo de parto prematuro con una alta asociación a mortalidad y morbididad perinatal. El parto del primer gemelo en una gestación múltiple va normalmente seguido por el parto del siguiente en un corto periodo. Es raro observar un intervalo prolongado entre el parto de los dos fetos de un embarazo múltiple. Nosotros reportamos 7 casos de embarazos múltiples con un parto diferido del segundo gemelo. Basándonos en nuestra experiencia y en la revisión de la literatura, concluimos que el parto diferido del segundo gemelo en edades gestacionales extremas, con un control exhaustivo de las condiciones fetales y maternas, está recomendado para mejorar la supervivencia y disminuir la morbilidad en el segundo gemelo (AU)

The incidence of multiple pregnancies has increased in the last few years. Patients with multiple pregnancies are at risk of preterm delivery associated with high perinatal mortality and morbidity. Delivery of the first twin in a multiple gestation is usually followed by delivery of the second twin shortly thereafter. A prolonged interval between delivery of the fetuses in a multiple pregnancy is infrequent. We report seven cases of multiple pregnancies with delayed- interval delivery of the second twin. On the basis of our experience and a review of the literature, we conclude that delayed delivery of the second twin in very preterm gestational ages, with careful observation of fetal and maternal status, is recommended to improve survival and decrease morbidity in the second twin (AU)

Feasibility study of a Latest Date of Delivery (LDD) system of managing pregnancy.

BACKGROUND: This study aimed to establish the acceptability of a Latest Date of Delivery (LDD) system of managing pregnancy. An LDD is the date at 42 weeks on which labour will be induced if a woman has not delivered by then. This study examined whether women under conventional expected date of delivery (EDD) management would find an LDD system acceptable in principle, and whether they would prefer it to the EDD system. An additional objective was to examine changes in state anxiety in late pregnancy, post-term, and after delivery. METHODS: This was a preliminary survey of women's attitudes towards an LDD system. Sixty-two women under normal pregnancy management completed questionnaires about the acceptability of an LDD system at 36 weeks gestation. In addition, questionnaires measuring state anxiety were completed at 36, 38, 40, and 41 weeks. RESULTS: The majority of women evaluated an LDD system positively, with 64% of women saying they would agree to an LDD and only 11.3% saying they would not. Forty percent of women said they would prefer an LDD to an EDD system and 36% said they were not sure. Women who had not delivered by 41 weeks had significantly more anxiety than those who had delivered. CONCLUSIONS: The LDD system appears to be acceptable to women and, for 40% of women, preferable to the EDD. Anxiety appears to increase as women go post-term, but problems of attrition mean the results regarding anxiety should be treated cautiously. Potential difficulties with implementing an LDD system are discussed.

Estudio comparativo de inducción del parto en gestantes con cérvix inmaduro. Dinoprostona frente a oxitocina / Comparative study of induction of labour in patients with unripe cervix. Dinoprostone vs oxitocyn

Objetivo: comparar la eficacia de la dinoprostona vaginal frente a la oxitocina intravenosa en la inducción del parto con cérvix inmaduro y rotura prematura de membranas. Diseño: estudio prospectivo, comparativo de dos grupos homogéneos. Ámbito: Servicio de Obstetricia del Hospital Universitario Maternal La Fe. Material y métodos: en cada grupo, de forma aleatoria, se incluyen 40 pacientes con indicación de finalizar gestación mediante inducción, con menos de tres partos previos, con gestación única en cefálica, test de Bishop menor de 4 y rotura prematura de membranas o amniorrexis precoz. El grupo estudio se induce con liberación controlada de dinoprostona vaginal y el grupo control mediante perfusión intravenosa de oxitocina. Análisis estadístico: test de Student para muestras independientes, test de chi cuadrado. Resultados: la tasa de éxitos fue del 77,5 por ciento en el grupo dinoprostona frente al 55 por ciento en el grupo oxitocina (p<0,05) (AU)