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The Effect of Uterine and Nipple Stimulation on Induction With Oxytocin and the Labor Process

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Aims: The present research study was conducted with the objective of determining the effect of uterine and nipple stimulation on induction with oxytocin and the birth process. Methods: A randomized controlled experiment was conducted at the maternity ward of a state hospital located in the province of Sivas in Turkey. Three hundred ninety pregnant women who were giving birth via vaginal delivery were randomly assigned to three groups (nipple stimulation, uterine stimulation, control). After the birth, the groups were assessed in terms of the birth duration and synthetic induction with oxytocin. Statistical analyses were performed through the use of SPSS 14.0 software and included analysis of variance, Tukey's test, Dunnett's test, Tamhane's T2 test, and chi-square test. Results: The study established statistically significant differences (p < .05) among the groups in terms of the average durations of the first, second and third phases of the action of birth, the status concerning delivery by C-section and the application of labor induction. The phases of birth were shorter for the nipple stimulation group (first phase: 3.8 hours, second phase: 16 minutes, third phase: 5 minutes) and the uterine stimulation group (first phase: 4.0 hours, second phase: 21 minutes, third phase: 6 minutes) when compared to the control group (first phase: 6.8 hours, second phase: 27 minutes, third phase: 6 minutes). In the control group, 89.2% of the pregnant women were subject to labor induction and 8.5% to cesarean section. No women in the nipple stimulation group or uterine stimulation group had a cesarean section. Linking evidence to action: Nipple and uterine stimulation reduce the frequency of elective labor induction, the rate of relevant complications, and support normal vaginal birth by providing endogenous labor induction. Therefore, these interventions should be considered for pregnant women in labor.
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Original Article
The Effect of Uterine and Nipple Stimulation
on Induction With Oxytocin and the Labor
Process
Gulbahtiyar Demirel, PhD Handan Guler, PhD
Keywords
care delivery system,
evidence-based
practice,
nurse–midwifery,
obstetrics,
family–child health,
intervention
research/experimental
research
ABSTRACT
Aims: The present research study was conducted with the objective of determining the effect of
uterine and nipple stimulation on induction with oxytocin and the birth process.
Methods: A randomized controlled experiment was conducted at the maternity ward of a state
hospital located in the province of Sivas in Turkey. Three hundred ninety pregnant women
who were giving birth via vaginal delivery were randomly assigned to three groups (nipple
stimulation, uterine stimulation, control). After the birth, the groups were assessed in terms of the
birth duration and synthetic induction with oxytocin. Statistical analyses were performed through
the use of SPSS 14.0 software and included analysis of variance, Tukey’s test, Dunnett’s test,
Tamhane’s T2 test, and chi-square test.
Results: The study established statistically significant differences (p<.05) among the groups
in terms of the average durations of the first, second and third phases of the action of birth,
the status concerning delivery by C-section and the application of labor induction. The phases
of birth were shorter for the nipple stimulation group (first phase: 3.8 hours, second phase: 16
minutes, third phase: 5 minutes) and the uterine stimulation group (first phase: 4.0 hours, second
phase: 21 minutes, third phase: 6 minutes) when compared to the control group (first phase: 6.8
hours, second phase: 27 minutes, third phase: 6 minutes). In the control group, 89.2% of the
pregnant women were subject to labor induction and 8.5% to cesarean section. No women in
the nipple stimulation group or uterine stimulation group had a cesarean section.
Linking Evidence to Action: Nipple and uterine stimulation reduce the frequency of elective
labor induction, the rate of relevant complications, and support normal vaginal birth by providing
endogenous labor induction. Therefore, these interventions should be considered for pregnant
women in labor.
INTRODUCTION
Currently, induction with oxytocin is among the interventions
brought into question (Berghella, Baxter, & Chauhan, 2008).
Induction (e.g., oxytocin, prostaglandin) is utilized to induce
labor in 20%–30% of all pregnancies. This percentage range
indicates how frequently induction is used as a medical in-
tervention (Moleti, 2009). As an example, the percentage of
induction use increased from 9.5% in 1990 to 22.5% in 2006
in the United States (Martin et al., 2009). Although sufficient
data on the use of induction with oxytocin are not available
in Turkey, it is reported to be in widespread use (Demirci,
G¨
urkan, Arslan, & Eksi, 2005).
As stated by American College Obstetrician and Gynecolo-
gist (ACOG, 2008), induction of labor with synthetic oxytocin
should not be performed on the basis of the personal preference
of the doctor or the pregnant woman electively without being
associated with a specific indication (e.g., postterm pregnancy,
ablatio placenta). The studies performed in this context indicate
that elective induction without any basis on a specific indica-
tion increases the rate of complications (e.g., hyperstimulation,
C-section) in pregnant women (Reisner, Wallin, Zingheim, &
Luthy, 2009; Wilson, Effken, & Butler, 2010).
Endogenous (i.e., natural) oxytocin and synthetic oxytocin
are similar in structure (Chapman & Durham, 2010). The re-
lease of endogenous oxytocin increases the Bishop score, as
well as the ratio of spontaneous birth (Franklin & Adewde,
1993). There are nonpharmacological methods available to
stimulate the release of endogenous oxytocin. One of these
methods is nipple stimulation and the other is uterine stim-
ulation. While the literature does not feature any studies on
uterine stimulation, there are only two studies that used nipple
stimulation (Curtis, 1999; Stein, Bardeguez, Verma, & Tegani,
1990). According to Razgaitis and Lyvers (2010), both studies
worked on a limited number of small groups, and failed to
establish the reasons for nipple stimulation success or failure.
Worldviews on Evidence-Based Nursing, 2015; 12:5, 273–280. 273
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2015 Sigma Theta Tau International
Uterine and Nipple Stimulation
They also did not calculate the birth phase suitable for the onset
of nipple stimulation with sufficient accuracy.
PURPOSE
Physicians, nurses, and midwives should seek new alternative
methods to reduce the frequency of elective labor induction
and the rate of relevant complications in order to facilitate a
normal vaginal birth by providing for endogenous labor induc-
tion. Therefore, it is important to determine the effect of nipple
and uterine stimulation as methods to increase the release of
endogenous oxytocin. These methods may prevent the use of
unnecessary drugs and complications of synthetic oxytocin on
the mother and the fetus, thereby contributing to the economy
of individual families and of the country. Therefore, this study
was conducted to determine the effects of uterine and nipple
stimulation on induction with oxytocin and the labor process.
METHODS
Design and Setting
This study was a randomized controlled experiment. The study
period was between February 2011 and June 2012. The research
study was conducted at the Maternity Ward at Sivas State Hos-
pital.
Sample
The number of vaginal births realized at the Maternity Ward
under Sivas State Hospital in 2010 was 3,689. The popula-
tion for this study was comprised of women who had given
birth through normal vaginal delivery on the Maternity Ward
at Sivas State Hospital in 2011. The sample size used in the
present study was calculated through a power analysis. Accord-
ing to the literature, the ratio of induction with oxytocin was
22.5% in 2006 (Moleti, 2009) while induction was required for
the action of birth in 20% to 30% of all pregnancies (Coonrod,
Bay, & Kishi, 2001). With the aim of ensuring the represen-
tation of the population, the sample volume was calculated at
a significance level of α=.05, in the confidence interval of
1α=.95, with a risk of error of β=.20 and at a power of
1β=.80. As a result, the total sample needed for this study
was calculated as 390.
Three hundred ninety pregnant women that satisfied the
criteria (i.e., presence of a single fetus in vertex presentation,
having a Bishop score of 6 or higher) were included in the
sample and randomly assigned to one of three groups. After
the designation of the start column in the table of random
numbers by the author, the pregnant women were randomly
assigned to three groups in such a way as to elect the first
number for the nipple stimulation group (NSG), the second
number for the uterine stimulation group (USG) and the third
number for the control group (CG). The NSG was comprised
of 130 pregnant women, the USG had 130 pregnant women,
and the CG had 130 pregnant women.
MEASUREMENTS
Data Collection and Tools
The preliminary evaluation form prepared by the author was
comprised of 11 questions regarding the criteria for inclusion in
the research study. The action of birth evaluation form prepared
by the author was composed of 12 questions regarding certain
obstetric properties of women and the action of birth itself. The
Bishop scoring system (Bishop, 1964) was utilized to evaluate
the elective induction of the action of birth.
Preliminary Evaluation Form
The preliminary evaluation form was filled out by the author
through interviews with pregnant women, reading of their files,
and provision of information from the relevant doctor. The
form was completed in approximately 5 minutes. Once the
form was complete, eligible pregnant women were designated
from amongst all pregnant women on the basis of the criteria
for inclusion in the research study and then assigned randomly
to NSG, USG, or CG.
Informed consent form 1-2-3. Women who were eligible and
had been assigned randomly to NSG, USG or CG, were given
the informed consent form prepared in accordance with their
respective groups. The literate women read and approved or
rejected the form. Illiterate women were given a read-out of
the consent form by the author and they then approved or re-
jected the form. The application of the form took approximately
4 minutes.
Action of birth evaluation form. Pregnant women who
had approved the informed consent form were accompanied
throughout the action of birth and the action of birth evaluation
form was completed by the author in 8 hours. This form was
used to evaluate such matters as the duration of the first, sec-
ond, and third phases of the action of birth, the performance
of synthetic induction and whether a C-section had been con-
ducted or not.
Bishop scoring. The evaluation of Bishop scoring was per-
formed by the doctor, the midwife and the author. Bishop scor-
ing was taken randomly from the women in nipple and uterine
stimulation and control groups once every 2 hours until the
actual birth. The doctor and the midwife were blind to study
group.
Procedure
Nipple stimulation step. In the first phase of labor, the
women in the NSG were subject to the nipple stimulation
intervention once every half an hour (in the case of contrac-
tions, nipple stimulation was performed after the contractions
stopped). At those times, one nipple of the pregnant women
was rolled and gently pulled forward with the thumb and index
finger for 2 minutes and the same procedure was then repeated
with the other nipple. The procedure was completed in approx-
imately 4–5 minutes. During the implementation phase, cervi-
cal dilation was evaluated once every 2 hours and the procedure
274 Worldviews on Evidence-Based Nursing, 2015; 12:5, 273–280.
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2015 Sigma Theta Tau International
Original Article
was terminated if a progression of 2 cm was not observed in
cervical dilation (Grobman, 2007). If such progression was ob-
served, the procedure was continued. Labor was expected to
start within 8 hours following the onset of the procedure (it is
considered normal 1-cm dilatation at 1 hour along first stage;
Boulvain, Kelly, Lohsec, Stan, & Irion, 2001; Cunningham,
Gant, & Leveno, 2005; Fraser & Cooper, 2009) and the pro-
cedure was terminated if such occurrence was not observed.
The NSG that had been taken onto the obstetric table within 8
hours following the onset of the procedure was made subject
to nipple stimulation once more before labor.
Uterine stimulation step. In the first phase of labor, the
women in the USG were subject to the intervention once ev-
ery half hour in line with the steps of stimulation. Approxi-
mately once every half an hour (in case of contractions, after
they have stopped), all fingers of one hand touched and pulled
away from the uterine tissue concurrently and rhythmically for
2–3 minutes for uterine stimulation starting from the fundus;
this stimulation was applied on the whole uterus. During the
implementation phase, cervical dilation was evaluated once ev-
ery 2 hours and the procedure was terminated if a progression
of 2 cm was not observed in cervical dilation (Simpson, James,
& Knox, 2006). If such progression was observed, the proce-
dure was continued. Labor was expected to start within 8 hours
following the onset of the procedure (it is considered normal
1-cm dilatation at 1 hour along first stage; Boulvain et al., 2001;
Cunningham et al., 2005; Fraser & Cooper, 2009) and the pro-
cedure was terminated if such occurrence was not observed.
The USG that had been taken onto the obstetric table within 8
hours following the onset of the procedure was made subject
to uterine stimulation once more before labor (Figure 1).
Statistical Analysis
Statistical evaluations for the research study were performed
through the use of SPSS 14.0 software package (SPSS Inc.,
Chicago, IL, USA). The statistical evaluations entailed the Lev-
ene test, the Variance analysis (e.g., age, average number of past
pregnancies and births, average Bishop scores, average-phase
durations of the action of birth), Tukey’s test, the Dunnett’s
test, the Tamhane’s T2 test (Bishop score, phase durations of
the action of birth), the chi-square test (application of synthetic
induction or C-section). Assumption of significance as p<.05
in statistical analyses.
Ethical Considerations
The study was carried out in accordance with the principles
of the Helsinki Declaration. Written permission had been ob-
tained from the ethics board (dated 25.01.2011 and No. 11/41)
and from the institution where the study was to be conducted
(dated 02.02.2011 and No.B.104.˙
ISM.4.58.00.09-773/43) be-
fore actual implementation. Only women that had approved
the informed consent form were included in the research
study. The privacy of the pregnant women was duly maintained
during both the completion of the forms and the implementa-
tion of the research study.
Findings
The women in the groups were similar in terms of age, number
of past pregnancies, and number of past births (p>.05). The
mean age of the women was in the range of 26–27 years, the
number of past pregnancies was 1.9 ±1.0 and the number of
past births was 0.9 ±1.0.
No statistically significant difference existed among the
groups in terms of their preapplication average Bishop scores
(p>.05). The difference among the average Bishop scores of
the groups on the second, fourth and sixth hour of application
was found to be statistically significant (p<.05). The pre-
application average Bishop score in the NSG was 9, but this
figure increased to 13 in the sixth hour. The average Bishop
score in the USG was 8.9 before the application, but increased
to 13 in the sixth hour, as well. On the other hand, the average
Bishop score in the CG was 8.9 before the application, but
increased to 11.5 in the sixth hour (Table 1).
The difference among the groups in terms of the average
durations of the first, second, and third phases of the action
of birth was found to be statistically significant (p<.05). The
average duration of the first phase of labor was 3.8 hours in
the NSG and 4.0 hours in the USG, but the average of this
duration increased to 6.8 in the CG. The shortest duration of
second phase was observed in the NSG with 16 minutes. On the
other hand, the average duration of this phase was 21 minutes
in the USG and 27 minutes in the CG. In placental phase (the
third phase), the birth of the placenta occurred in similar times
in the USG (6.3 minutes) and in the CG (6.9 minutes), whereas
the birth of the placenta occurred in a shorter period of time in
the NSG (5.3 minutes; Table 2).
The difference between primipara and multipara women in
terms of the synthetic induction status was found to be statis-
tically significant (p<.05). In addition, as can be seen in the
table, the difference among the groups in terms of the synthetic
induction status of women is also statistically significant (p<
.05). Synthetic induction was applied to 6.9% of the NSG and
12.3% of the USG, while this percentage is 89.2 in the CG.
The group with the lowest percentage of synthetic induction in
both primiparous and multiparous women is the NSG (9.2%
and 4.6%, respectively; Table 3).
The difference among the groups in terms of the C-section
application was found to be statistically significant (p<.05).
Whereas no women in the NSG or the USG underwent
C-section, 8.5% of the CG had a C-section (Table 4).
DISCUSSION
Cervical status is the most important success indicator of labor
induction. A rigid and immature cervix increases the possi-
bility of a failed induction or a lengthy and difficult birth, as
well as the rate of C-section and maternal and fetal morbid-
ity (Cunningham et al., 2005). Therefore, cervical and fetal
Worldviews on Evidence-Based Nursing, 2015; 12:5, 273–280. 275
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2015 Sigma Theta Tau International
Uterine and Nipple Stimulation
Pregnant women
Appropriate criteria
NSG CGUSG
Application
(every 30 min, a
4-5 min)
Application
(every 30 min,
a 2-3 min)
None
applications
Cervical
dilatation (every
2 hours)
Cervical
dilatation
(every 2 hours)
Cervical
dilatation
(every 2 hours)
2 hours 2
cm in
progress
2 hours 2
cm in
progress
Birth was
achieved within 8
hours after the
application start
Evaluated of birth time and frequency applied synthetic oxytocin
2 cm in 2
hours no
progress
2 cm in 2
hours no
progress
Birth was
achieved within
8 hours after the
application start
Cervical
dilatation
yes / no
Application
is continued
Application
is
terminated
Application
is continued
Application
is
terminated
Pregnant
women are
considered
Figure 1. A flow chart of the study. Uterine and nipple stimulation.
status must be assessed before deciding upon any induction
method. The most well-known method for cervical assessment
is Bishop scoring. Boulvain et al. (2001) examined the correla-
tion between cervical scores and the success and failure rates of
induction by utilizing Bishop’s scoring method. They revealed
that pregnant women with a Bishop score of 9 or higher can
be induced to give birth in less than 4 hours (Boulvain et al.,
2001). In our study, 89.2% of women with a preapplication
average Bishop score close to 9 (Table 1) in the control group
were made subject to synthetic induction (Table 3), but approx-
imately 15% of the women in this group (19 women) gave birth
in the first 6 hours (Table 1). On the other hand, it is quite
striking that all women in the NSG and USG that had been
made subject to nipple and uterine stimulation for the release
of endogenous oxytocin and that had preapplication average
Bishop scores of 9 or close to 9 gave birth within 6 hours (p
<.05; Table 1). In line with these findings, it can be consid-
ered that nipple and uterine stimulation improves the release
of endogenous oxytocin and leads to a higher Bishop score.
The first phase of the action of birth is 12–13 hours in nul-
lipara and 6–8 hours in multipara on average (Cunningham
et al., 2005). One of the most important effects of oxytocin on
labor is shortening the duration of labor (Demirci et al., 2005).
Studies in relevant literature indicate that oxytocin shortens the
duration of labor (De Miranda, Van Der Bom, Bonsel, Bleker,
& Rosendaal, 2006; D¨
undar et al., 2006). The duration of the
first phase of labor was found to be 7 hours on average in a
synthetic oxytocin group in a study performed on 56 pregnant
women (De Miranda et al., 2006). The present study estab-
lished the average duration of the first phase as 3.8 hours in
the NSG and as 4 hours in the USG, which were both en-
dogenous oxytocin stimulation groups. On the other hand, this
duration was 6.8 hours on average in the control group and the
difference among the groups in terms of the average durations
of the first phase of the action of birth was found to be statis-
tically significant (p<.05; Table 2). The majority of women
in the CG (89.2%; Table 3) were subject to synthetic oxytocin
application in the latent phase of the first stage of labor and
this application was terminated generally toward the end of the
transition phase. On the basis of these data, it is possible to
state that nipple or uterine stimulation triggers the release of
endogenous oxytocin and is more effective in shortening the
duration of the first phase of the action of birth when compared
to synthetic oxytocin. Curtis (1999) found a statistically signifi-
cant difference between the oxytocin and NSG (on 79 women),
but Stein et al. (1990) could not establish a statistically signifi-
cant difference between stimulation groups (on 84 women) in
terms of the first-phase duration of the action of birth.
276 Worldviews on Evidence-Based Nursing, 2015; 12:5, 273–280.
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Table 1. Average Bishop Scores of Women Before and During the Procedure
Average Bishop scores
NSG USG CG
n n n
Time of Bishop score evaluation ¯x±s ¯x±s ¯x±sF p
1Before the procedure 130 130 130
9.0 ±0.8 8.9 ±0.8 8.9 ±0.8 0.816 .443
2At the second hour of the procedure 130 130 130
11.0 ±1.1a10.8 ±1.1b9.6 ±0.9c64.072 .001
3At the fourth hour of the procedure 121 114 130
12.7 ±0.5a12.7 ±0.5b10.7 ±1.3c202.962 .001
4At the sixth hour of the procedure 27 29 111
13.0 ±0.0a13.0 ±0.0b11.5 ±1.2c41.193 .001
At the 8th hour of the procedure 85
12.0 ±1.2 – –
Difference among the hours 534.623 .001
Note.
2aAgainst Group 2,
p
=.376.
2bAgainst Group 3,
p
=.001.
3cAgainst Group 1,
p
=.001.
4aAgainst Group 2,
p
=1.00.
4bAgainst Group 3,
p
=.001.
1dAgainst the fourth hour of application,
p
=.001.
2dAgainst the fourth hour of application,
p
=.001.
3dAgainst the sixth hour of application,
p
=.99.
2cAgainst Group 1,
p
=.001.
3aAgainst Group 2,
p
=.947.
3bAgainst Group 3,
p
=.001.
4cAgainst Group 1,
p
=.001.
1dAgainst the second hour of application,
p
=.001.
1dAgainst the sixth hour of application,
p
=.001.
2dAgainst the sixth hour of application,
p
=.001.
The second phase takes 30 minutes to 2 hours in prim-
ipara and 5–30 minutes in multiparae after cervical dilation
(Cunningham et al., 2005). A prolonged second phase of la-
bor could lead to multiple interventions and affect the cost
(Hofmeyr, 2005). Studies in the relevant literature point out
that oxytocin also shortens the second-phase duration of the
action of birth (Curtis, 1999; Schiessi et al., 2005). The aver-
age duration of the second phase of labor was established as
70 minutes by Schiessi et al. (2005). In this study, the average
second-phase duration of the action of birth was 16 minutes in
the NSG, 21 minutes in the USG and 27 minutes in the CG
(p<.05; Table 2). The second phase of labor was specifically
shorter in the NSG. This finding leads to the consideration that
nipple stimulation is more effective in stimulating the release
of oxytocin.
The third phase continues for about 5–30 minutes (Cun-
ningham et al., 2005). Oxytocin is influential on the third-phase
duration of labor. The shortest time to placental birth was ob-
served in the NSG (5 minutes) in the present study (Table 2).
This situation gives way to the consideration that nipple stim-
ulation is also more effective in shortening the third-phase
duration of the action of birth. Moreover, this can, in turn,
make us consider that the effects of the nipple stimulations
performed during the first and second phases of the action of
birth for the release of endogenous oxytocin extend also to the
third phase.
The use of intravenous oxytocin is the most commonly em-
ployed method for labor induction (Cunningham et al., 2005).
In our country, it is known to be in frequent use despite the
lack of data on the frequency of labor induction. Demirci et al.
(2005) established that 16% of doctors utilize elective labor in-
duction to accelerate an action of labor that is otherwise moving
on the normal course. In our study, it is striking that the ap-
plication of synthetic induction was at a very low percentage in
Worldviews on Evidence-Based Nursing, 2015; 12:5, 273–280. 277
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2015 Sigma Theta Tau International
Uterine and Nipple Stimulation
Table 2. Average Durations of Birth Phases
Average duration of the action of birth
NSG USG CG
n=121 n=114 n=119
Phases of the action of birth ¯x±s ¯x±s ¯x±sF p
First phase (hour) 3.8 ±39.9 4.0 ±51.3 6.8 ±118.9 195.593 .001
Second phase (minute) 16.3 ±10.8 21.6 ±14.1 27.3 ±16.1 18.932 .001
Third phase (minute) 5.3 ±1.9 6.3 ±2.3 6.9 ±2.6 14.389 .001
Table 3. Breakdown of Synthetic Induction Applica-
tion Status per Parity and Group of Women
Synthetic induction application
Applied Not applied
Parity Groups n%n%χ²/p
Primipara NSG 69.2 59 90.8
USG 812.3 57 87.7 107.150/.001
CG 60 92.3 57.7
Multipara NSG 34.6 62 95.4
USG 812.3 57 87.7 132.407/.001
CG 56 86.2 9 13.8
Table 4. Breakdown of C-Section Application on
Women
C-Section
Applied Not applied
Groups n%n%
NSG 0 0 130 100
USG 0 0 130 100
CG 11 8.5 119 91.5
Note.
χ²=22.639;
p
=.001.
the NSG and USG (6.9%, 12.3%), whereas the majority of the
control group were made subject to induction (89.2%), (p<
.05; Table 3). The group with the lowest rate of synthetic induc-
tion in both primiparae and multiparae was the NSG (9.2%,
4.6%). These findings lead us to consider that nipple and uter-
ine stimulation on women in the NSG and USG is effective in
providing the release of endogenous oxytocin and reduces the
need for the use of synthetic oxytocin.
The literature reported the percentage of clinical failure
in induction with oxytocin in the action of birth as 8%–50%
(De Miranda et al., 2006; Kashanian, Akbarian, Baradaran,
& Samiee, 2006). This failure leads to a higher risk of ma-
ternal and fetal morbidity and mortality and a higher risk of
C-section (Wilson et al., 2010). Relevant studies report that the
rate of spontaneous vaginal birth is 30%–53% (Kashanian et al.,
2006) and the rate of C-section is 24%–56% (Boulvain et al.,
2001; Kashanian et al., 2006) in synthetic oxytocin groups. The
studies reveal that induction with oxytocin increase the rate
of C-section application (Clark et al., 2009; Grobman, 2007;
Hofmeyr, 2005; Sakae, Freitas, & d’Orsi, 2009). Contrary to
this high rate, no C-section procedure was performed in the
NSG and USG after endogenous oxytocin application in our
study. The percentage of C-sections in the CG where induc-
tion was performed on the majority of women (89.2%) was
established to be 8.5 (Table 4). This result shows us that the
release of oxytocin can be improved and delivery by C-section
reduced through the use of nonpharmacological methods such
as nipple stimulation or uterine stimulation.
In line with these results, it is suggested that nipple stim-
ulation and uterine stimulation are effective in improving the
release of endogenous oxytocin, increasing the Bishop score
and accelerating the phases of the action of birth, decreasing
synthetic induction and rate of cesarean section. Therefore, it
is recommended that similar studies should be conducted on
different sample populations.
LINKING EVIDENCE TO ACTION
rNipple and uterine stimulation allow for the re-
duction in frequency of elective labor induction
and the rate of relevant complications.
278 Worldviews on Evidence-Based Nursing, 2015; 12:5, 273–280.
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2015 Sigma Theta Tau International
Original Article
rThese methods allow normal vaginal birth by pro-
viding endogenous labor induction.
rThese methods can increase the Bishop score and
accelerate the phases of labor.
rThese methods can reduce the synthetic induction
of labor and rate of cesarean section.
LIMITATIONS
The study is a single blinded study. The doctor and midwives
were not aware of which pregnant women were assigned to
the various groups. The application was made by researchers
in this study. However, it was our desire to conduct a double-
blind study in which the researchers would not know the group
assignment of the pregnant women.
CONCLUSIONS
According to the results of our study, the Bishop scores of the
nipple and uterine stimulation groups increased substantially
more than in the control group. The phases of the action of
birth had a shorter duration of time in the nipple and uter-
ine stimulation groups than in the control group. The rate
of synthetic induction was very low in the nipple and uter-
ine stimulation groups, but very high in the control group.
The application of synthetic induction was observed to be at
the highest level (especially slightly higher in primiparae) in
the control group. No C-section procedure was performed in
the nipple and uterine stimulation groups and a small num-
ber of C-section procedures was required in the control group.
WVN
Author information
Gulbahtiyar Demirel, Assistant Professor, Department of Mid-
wifery, Faculty of Health Sciences, Cumhuriyet University,
Sivas, Turkey; Handan Guler, Assistant Professor, Department
of Midwifery, Faculty of Health Sciences, Cumhuriyet Univer-
sity, Sivas, Turkey.
This study was supported by the Commission for Scientific
Research Projects of Cumhuriyet University as the doctorate
dissertation project No. SBF-017.
Address correspondence to Dr. Gulbahtiyar Demirel,
Department of Midwifery, Faculty of Health Sci-
ences, Cumhuriyet University, Sivas, Turkey; gulbahti-
yar_doganer@hotmail.com
Accepted 19 August 2015
Copyright C
2015, Sigma Theta Tau International
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... XVIII reportam o recurso à estimulação mamária na gestão do parto pós-datado. Hoje, nomeadamente na India e na cultura japonesa 50% das mulheres recorre a este método e ao exercício físico para ajudar a induzir o trabalho de parto (Demirel & Guler, 2015;Kavanagh, Kelly & Thomas 2005;Takahata et.al, 2018 A definição de EM não é clara, no entanto, esta pode ser definida como a autoestimulação através da massagem manual da mama/mamilo ou através da sucção mecânica por bombas de extração de leite (Demirel & Guler, 2015;Kavanagh, Kelly & Thomas 2005;Takahata et.al, 2018). ...
... XVIII reportam o recurso à estimulação mamária na gestão do parto pós-datado. Hoje, nomeadamente na India e na cultura japonesa 50% das mulheres recorre a este método e ao exercício físico para ajudar a induzir o trabalho de parto (Demirel & Guler, 2015;Kavanagh, Kelly & Thomas 2005;Takahata et.al, 2018 A definição de EM não é clara, no entanto, esta pode ser definida como a autoestimulação através da massagem manual da mama/mamilo ou através da sucção mecânica por bombas de extração de leite (Demirel & Guler, 2015;Kavanagh, Kelly & Thomas 2005;Takahata et.al, 2018). ...
... al, 2014Takahata et. al, 2018Suja, 2015Suresh e Soni, 2019 deve existir pausa e descanso entre cada estimulação(Demirel & Guler, 2015;Kavanagh, Kelly & Thomas, 2005;Razgaitis & Lyvers, 2010;Singh et al., 2014;Suja, 2015;Suresh e Soni, 2019;Takahata et al., 2018). Para os ensaios analisados, identificamos e delineamosindicadores tradutores dos outcomes, eficácia e segurança, baseados nas diretrizes internacionais (ACOG, 2019; NICE, 2019, OMS, 2018). ...
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A OMS define Parto Normal aquele que apresenta início espontâneo, baixo risco desde o início até ao nascimento, excluindo mulheres submetidas a indução de trabalho de parto (TP). A estimulação mamária (EM) tem sido historicamente utilizada como método não farmacológico, natural de indução do TP; Objetivo: Conhecer a eficácia e a segurança da estimulação mamária enquanto método de indução natural do TP Métodos: Revisão Integrativa da Literatura; Resultados: Outcomes eficácia: scores de índice de Bishop significativamente melhores, tendência para início do TP espontâneo em 72h, menores níveis de cesariana e níveis de satisfação excelentes; Outcomes segurança: não existiram diferenças significativas relativamente à presença de mecónio, APGAR < 7 aos 5 minutos e cesariana em comparação com grupos de controlo (sem intervenção) ausência de casos de hiperestimulação uterina; Conclusões: A EM mostra-se segura e eficaz, sendo razoável considerá-la como opção viável para induzir o TP de baixo risco.
... However, the authors went on to recommend not promoting this practice in high-risk women and noted that more information on maternal satisfaction was required. More recently, evidence suggests a role for nipple stimulation at term as a non-pharmacological method of labour induction [5,6]. In 2017, results of the Diabetes and Antenatal Milk Expressing (DAME) trial of 635 pregnant women with low-risk diabetes demonstrated that antenatal expressing did not result in a lower gestational age or increased admissions to the Neonatal Intensive Care Unit [7]. ...
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The use of antenatal colostrum expression in the weeks prior to birth may help improve long-term breastfeeding, but few large-scale studies exist. Typically, antenatal colostrum expression instruction relies on face-to-face education, making large interventions costly. We aimed to determine whether an expert online instructional video can improve knowledge and confidence around antenatal colostrum expressing. Pregnant women were asked to complete a questionnaire pre- and post-watching the instructional video online. Ninety five pregnant women completed both pre- and post-questionnaires. Total antenatal colostrum expression knowledge scores improved after watching the video, from a mean of 3.05 ± 1.70 correct out of a maximum of 7, to 6.32 ± 0.76 (p < 0.001). Self-reported confidence around hand expressing in pregnancy also improved from an average ranking of not confident (2.56 ± 1.17, out of a possible 5) to confident (4.32 ± 0.80, p < 0.001). Almost all women (98%) reported that they would recommend the video to a friend or family member if antenatal colostrum expression was suggested by their healthcare provider. Findings suggest that the use of an online expert video is an acceptable and effective way to educate pregnant women in antenatal colostrum expression.
... It is a natural method that requires no cost and tool, and it can be performed at any time and place depending on a pregnant woman's own initiative. Breast stimulation for inducing labor has been studied by many researchers to date [10][11][12][13][14][15][16]. ...
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Objectives This preliminary study aimed to 1) determine changes in the salivary oxytocin (OT) level during breast stimulation for promoting the spontaneous onset of labor in low-risk term pregnancies, and 2) clarify the feasibility of the breast stimulation intervention protocol in terms of practicality and acceptability. Methods We used a single arm trial design. Sixteen low-risk pregnant women between 38 and 40 weeks of gestation with cephalic presentation participated. They performed breast stimulation for 3 days with an attendant midwife in a single maternity hospital. Each breast was stimulated for 15 minutes for a total of 1 hour per day. Saliva was collected 10 minutes before the intervention and 15, 30, 60, 75, and 90 minutes after the intervention, yielding 18 samples per woman. Results Among a total of 282 saliva samples from the 16 participants, OT level was measured in 142 samples (missing rate: 49.6%). The median OT level showed the highest values on day 3 of the breast stimulation, with a marked increase 30 min after the intervention. In the mixed models after multiple imputation for missing data, the OT level on the first day of intervention was significantly lower than that on the third day of intervention. Fatigue from breast stimulation decreased on subsequent days, and most of the women (75%) felt no discomfort with the protocol. Uterine hyperstimulation was not observed. Conclusion Following a 3-day breast stimulation protocol for spontaneous onset of labor, the mean OT level showed the highest values on day 3. The breast stimulation intervention protocol showed good feasibility in terms of practicality and acceptability among the pregnant women. Additional large-scale studies are warranted to confirm the protocol’s effectiveness.
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Objective Nipple stimulation is purported as a natural and inexpensive method for inducing labor, but its use is understudied. We aimed to assess whether conducting a large randomized controlled trial comparing intrapartum nipple stimulation therapy versus oxytocin infusion is feasible and acceptable to patients and obstetric care providers. Study Design This single-center parallel-group randomized controlled external pilot study (NCT04756089) included women with gestations ≥36 weeks who were planned to receive exogenous oxytocin for their labor induction. Those <18 years old, non-English-speaking, or with fetuses at increased risk for neonatal intensive care were excluded. Stratified by parity, women were randomized 3:1 to intrapartum nipple stimulation therapy or immediate receipt of oxytocin. Women assigned to nipple stimulation therapy were asked to stimulate with an electric breast pump or by hand for periods of at least 30 minutes, with breaks as needed for up to 15 minutes at a time, for at least a cumulative two hours prior to considering initiation of oxytocin, and to complete intrapartum diaries. Labor characteristics and outcomes were examined. Validated questionnaires were used to assess the participants’ pain level during the intervention, their sense of control during childbirth, and their breastfeeding success. Primary outcome measures were recruitment, adherence to study protocol and follow-up, and cross-over rates. Results 620 women underwent labor induction from 3/13/21-6/23/21. Of 557 potentially eligible women, 53 were approached by available research staff. 24 (45%) consented and enrolled: 18 randomized to nipple stimulation and 6 randomized to oxytocin. One woman assigned to nipple stimulation withdrew due to delay of clinical care and received oxytocin (cross-over rate of 1/24 (4%)), and one woman assigned to oxytocin did not receive it due to spontaneous labor progress. All other participants followed their assigned intervention. The 17 women who performed nipple stimulation stimulated for a median duration of 198 (IQR 125-291) minutes and required a median of 69 (IQR 21-80) minutes of stimulation prior to achieving at least three contractions in a 10-minute window, averaged over 30 minutes (a.k.a. “adequate” contractions) Among those assigned to nipple stimulation therapy, 15/17 (88%) later received oxytocin infusion prior to delivery. The median time from intervention start to delivery was 16.4 (IQR 0.6-28.2) and 20.6 (IQR 14.2-23.4) hours for women assigned to nipple stimulation therapy versus oxytocin infusion, respectively. 12 (50%) women completed their postpartum study questionnaires. Conclusion Random assignment to intrapartum nipple stimulation therapy versus oxytocin infusion for labor induction is feasible and acceptable to patients and obstetric care providers.
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Background: Mechanical methods were the first methods developed to ripen the cervix and induce labour. During recent decades they have been substituted by pharmacological methods. Potential advantages of mechanical methods, compared with pharmacological methods may include reduction in side effects that could improve neonatal outcomes. This is an update of a review first published in 2001, last updated in 2012. Objectives: To determine the effectiveness and safety of mechanical methods for third trimester (> 24 weeks' gestation) induction of labour in comparison with prostaglandin E2 (PGE2) (vaginal and intracervical), low-dose misoprostol (oral and vaginal), amniotomy or oxytocin. Search methods: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies (9 January 2018). We updated the search in March 2019 and added the search results to the awaiting classification section of the review. Selection criteria: Clinical trials comparing mechanical methods used for third trimester cervical ripening or labour induction with pharmacological methods.Mechanical methods include: (1) the introduction of a catheter through the cervix into the extra-amniotic space with balloon insufflation; (2) introduction of laminaria tents, or their synthetic equivalent (Dilapan), into the cervical canal; (3) use of a catheter to inject fluid into the extra-amniotic space (EASI).This review includes the following comparisons: (1) specific mechanical methods (balloon catheter, laminaria tents or EASI) compared with prostaglandins (different types, different routes) or with oxytocin; (2) single balloon compared to a double balloon; (3) addition of prostaglandins or oxytocin to mechanical methods compared with prostaglandins or oxytocin alone. Data collection and analysis: Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data and assessed the quality of the evidence using the GRADE approach. Main results: This review update includes a total of 113 trials (22,373 women) contributing data to 21 comparisons. Risk of bias of trials varied. Overall, the evidence was graded from very-low to moderate quality. All evidence was downgraded for lack of blinding and, for many comparisons, the effect estimates were too imprecise to make a valid judgement.Balloon versus vaginal PGE2: there may be little or no difference in vaginal deliveries not achieved within 24 hours (average risk ratio (RR) 1.01, 95% confidence interval (CI) 0.82 to 1.26; 7 studies; 1685 women; I² = 79%; low-quality evidence) and there probably is little or no difference in caesarean sections (RR 1.00, 95% CI 0.92 to 1.09; 28 studies; 6619 women; moderate-quality evidence) between induction of labour with a balloon catheter and vaginal PGE2. A balloon catheter probably reduces the risk of uterine hyperstimulation with fetal heart rate (FHR) changes (RR 0.35, 95% CI 0.18 to 0.67; 6 studies; 1966 women; moderate-quality evidence), serious neonatal morbidity or perinatal death (RR 0.48, 95% CI 0.25 to 0.93; 8 studies; 2757 women; moderate-quality evidence) and may slightly reduce the risk of aneonatal intensive care unit (NICU) admission (RR 0.82, 95% CI 0.65 to 1.04; 3647 women; 12 studies; low-quality evidence). It is uncertain whether there is a difference in serious maternal morbidity or death (RR 0.20, 95% CI 0.01 to 4.12; 4 studies; 1481 women) or five-minute Apgar score < 7 (RR 0.74, 95% CI 0.49 to 1.14; 4271 women; 14 studies) because the quality of the evidence was found to be very low and low, respectively.Balloon versus low-dose vaginal misoprostol: it is uncertain whether there is a difference in vaginal deliveries not achieved within 24 hours between induction of labour with a balloon catheter and vaginal misoprostol (RR 1.09, 95% CI 0.85 to 1.39; 340 women; 2 studies; low-quality evidence). A balloon catheter probably reduces the risk of uterine hyperstimulation with FHR changes (RR 0.39, 95% CI 0.18 to 0.85; 1322 women; 8 studies; moderate-quality evidence) but may increase the risk of a caesarean section (average RR 1.28, 95% CI 1.02 to 1.60; 1756 women; 12 studies; I² = 45%; low-quality evidence). It is uncertain whether there is a difference in serious neonatal morbidity or perinatal death (RR 0.58, 95% CI 0.12 to 2.66; 381 women; 3 studies), serious maternal morbidity or death (no events; 4 studies, 464 women), both very low-quality evidence, and five-minute Apgar score < 7 (RR 1.00, 95% CI 0.50 to 1.97; 941 women; 7 studies) and NICU admissions (RR 1.00, 95% CI 0.61 to 1.63; 1302 women; 9 studies) both low-quality evidence.Balloon versus low-dose oral misoprostol: a balloon catheter probably increases the risk of a vaginal delivery not achieved within 24 hours (RR 1.28, 95% CI 1.13 to 1.46; 782 women, 2 studies, and probably slightly increases the risk of a caesarean section (RR 1.17, 95% CI 1.04 to 1.32; 3178 women; 7 studies; both moderate-quality evidence) when compared to oral misoprostol. It is uncertain whether there is a difference in uterine hyperstimulation with FHR changes (RR 0.81, 95% CI 0.48 to 1.38; 2033 women; 2 studies), serious neonatal morbidity or perinatal death (RR 1.11, 95% CI 0.60 to 2.06; 2627 women; 3 studies), both low-quality evidence, serious maternal morbidity or death (RR 0.50, 95% CI 0.05 to 5.52; 2627 women; 3 studies), very low-quality evidence, five-minute Apgar scores < 7 (RR 0.71, 95% CI 0.38 to 1.32; 2693 women; 4 studies) and NICU admissions (RR 0.82, 95% CI 0.58 to 1.17; 2873 women; 5 studies) both low-quality evidence. Authors' conclusions: Low- to moderate-quality evidence shows mechanical induction with a balloon is probably as effective as induction of labour with vaginal PGE2. However, a balloon seems to have a more favourable safety profile. More research on this comparison does not seem warranted.Moderate-quality evidence shows a balloon catheter may be slightly less effective as oral misoprostol, but it remains unclear if there is a difference in safety outcomes for the neonate. When compared to low-dose vaginal misoprostol, low-quality evidence shows a balloon may be less effective, but probably has a better safety profile.Future research could be focused more on safety aspects for the neonate and maternal satisfaction.
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Objectives—This report presents 2013 data on U.S. births according to a wide variety of characteristics. Data are presented for maternal age, live-birth order, race and Hispanic origin, marital status, attendant at birth, method of delivery, period of gestation, birthweight,and plurality. Birth and fertility rates are presented by age, live-birth order, race and Hispanic origin, and marital status. Selected data by mother's state of residence and birth rates by age and race of father also are shown. Trends in fertility patterns and maternal and infant characteristics are described and interpreted.
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Background: Numerous study results vary when analyzing the relationship between labor induction and the likelihood of cesarean delivery; and few have accounted for the multiple influences of maternal sociodemographic characteristics combined with the provider and hospital in subsequent birth outcomes such as cesarean section. Objective: This study evaluated the likelihood of cesarean birth following labor induction while accounting for maternal, hospital, and provider characteristics. Methods: A cross-sectional retrospective descriptive design using secondary data was employed to determine what variation in cesarean births was due to differences of hospitals, providers, and patients using the Quality Health Outcomes Model (QHOM). Data were partitioned by primiparous and multiparous women. The individual demographic, system, and provider outcomes in all hospitals and single birth center for Maricopa County in 2005 (N=62,816) were analyzed, using both random effects and fixed effects models. Results: For primiparous women, an increased likelihood of cesarean births was associated with medical inductions, maternal age, being Black, and the number of prenatal visits; and less likely in teaching hospitals and women with higher educational attainment. In multiparous women, cesarean births were associated with increased maternal age and medical inductions; and less likely in for-profit hospitals and following elective induction. Discussion: Labor inductions were associated with an increased likelihood of cesarean sections based on parity, age, race, number of prenatal visits, education, and hospital teaching status and ownership. Because the QHOM emphasizes multiple contextual variables that influence the delivery and outcomes of care, it can prove ideal for the study of birth outcomes following interventions such as the induction of labor. Clinical Relevance: Nurses should be well educated about the risks of elective labor induction prior to term gestation and “elective” cesarean birth.
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To assess factors associated to cesarean section. A cross-sectional study was conducted in a university hospital in Florianópolis, Southern Brazil, from 2001 to 2005. Socioeconomic, reproductive, obstetric and institutional information were collected. Data from 7,249 deliveries was obtained from medical records and admission, delivery and post-delivery records. Cox regression was used in the analysis to estimate cesarean prevalence ratios in the categories of variables studied. Cesarean rates increased from 27.5% to 36.5% during the period studied and they were higher than those associated with medical indications. After adjustment for confounders cesarean rates were positively associated with previous cesarean section (PR=2.65, 95% CI: 2.31;3.05), non-cephalic presentation (PR=2.23, 95%CI: 1.69;2.95), oxytocin use (PR=1.77, 95%CI: 1.43;2.19), dilatation at admission (PR=2.74, 95%CI: 2.18;3.44), and obstetrician profile (>35% of cesarean sections) (PR=1.82, 95%CI: 1.36;2.42). The factors associated with cesarean section indicate the need of interventions focusing on women and their reproductive experience and changes in obstetrician practice as well.
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BACKGROUND: Mechanical methods were the first methods developed to ripen the cervix or to induce labour. Devices which were used include various type of catheters and of laminaria tents, introduced into the cervical canal or into the extra-amniotic space. Mechanical methods were never completely abandoned, but were substituted by pharmacological methods during recent decades. Potential advantages of mechanical methods, compared with pharmacological methods, may include simplicity of preservation, lower cost and reduction of the side effects. However, special attention should be paid to contraindications (e.g. low-lying placenta), risk of infection and maternal discomfort when inserting these devices. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. OBJECTIVES: To determine the effects of mechanical methods for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment, prostaglandins (vaginal, intracervical, misoprostol) and oxytocin. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched April 2001. SELECTION CRITERIA: The criteria for inclusion were the following: (1) clinical trials comparing mechanical methods used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate or unclear method for allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions. DATA COLLECTION AND ANALYSIS: A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The data will be extracted from the primary reviews into a series of secondary reviews, arranged by category of woman. MAIN RESULTS: In total, 58 studies were considered; 45 studies have been included and 13 were excluded. Studies generally included women with unfavourable cervix and intact membranes. Comparing mechanical methods with placebo/no treatment, only one study with 48 participants reported on vaginal delivery not achieved in 24 hours (69% with mechanical methods versus 77% with placebo/no treatment; relative risk (RR) 0.90; 95% confidence interval (CI): 0.64-1.26). Hyperstimulation with fetal heart rate changes was not reported. The risk of caesarean section, reported in six studies including 416 women, was similar between groups (34%; RR 1.00; 95% CI: 0.76-1.30). There were no reported cases of severe neonatal and maternal morbidity. Comparing mechanical methods with vaginal PGE2, only one trial (109 women) reported on vaginal delivery not achieved in 24 hours (73% versus 42%; relative risk (RR) 1.74; 95% CI: 1.21-2.49). Compared with intracervical PGE2, only one trial (100 women) reported on vaginal delivery not achieved in 24 hours (68% versus 40%; relative risk (RR) 1.70; 95% CI: 1.15-2.51). Compared with with misoprostol, the effectiveness of mechanical methods was similar (34% versus 30%; relative risk (RR) 1.15; 95% CI: 0.80-1.66). The use of mechanical method reduced the risk of hyperstimulation with fetal heart rate changes when compared with prostaglandins: vaginal PGE2 (0% versus 6%; RR 0.14; 95% CI: 0.04-0.53), intracervical PGE2 (0% versus 1%; RR 0.21; 95% CI: 0.04-1.20) and misoprostol (4% versus 9%; RR 0.41; 95% CI: 0.20-0.87). There was no difference in the risk of caesarean section between mechanical methods and prostaglandins. Serious neonatal (three cases) and maternal morbidity (one case) were infrequently reported. When compared with oxytocin, use of mechanical methods reduced the risk of caesarean section (4 trials; 198 women; 17% versus 32%; RR 0.55; 95% CI: 0.33-0.91). The likelihood of vaginal delivery in 24 hours and of hyperstimulation with fetal heart rate changes was not reported. There were no reported cases of serious maternal morbidity and severe neonatal morbidity was not reported. These results are similar whatever specific mechanical method was used, except with extra-amniotic infusion. When comparing extra-amniotic infusion with any prostaglandins, women were more likely to not achieve vaginal delivery within 24 hours (57% versus 42%; RR 1.33; 95% CI: 1.02-1.75), the risk of caesarean section was increased (31% versus 22%; RR 1.48; 95% CI: 1.14-1.90), without a reduction of the risk of hyperstimulation. REVIEWER'S CONCLUSIONS: There is insufficient evidence to evaluate the effectiveness, in terms of likelihood of vaginal delivery in 24 hours, of mechanical methods compared with placebo/no treatment or with prostaglandins. The risk of hyperstimulation was reduced when compared with prostaglandins (intracervical, intravaginal or misoprostol). Compared to oxytocin in women with unfavourable cervix, mechanical methods reduce the risk of caesarean section. There is no evidence to support the use of extra-amniotic infusion.
Article
The patient is a 36-year-old G3 P0020 at 39 gestational weeks who presented in labor to the hospital where she planned to give birth. She attended prenatal care visits regularly, had a healthy pregnancy, and desired a natural birth without intervention. On admission, her initial cervical examination was 2 to 3 cm, 100% effacement, — 1 station, and membranes intact. She reported regular contractions for 2 hours prior to coming to the hospital. An abdominal examination indicated a longitudinal lie, cephalic presentation, and right occiput posterior position of the fetus. The fetal heart rate pattern was reassuring. Contractions occurred every 3 to 5 minutes via external tocometer. The patient coped well with her husband's support and was encouraged to return home to labor through latent phase. Feeling uncomfortable about the possibility of staying home too long, the patient chose to be admitted and placed on intermittent monitoring. The patient was examined 4 hours later and her cervix was 5 cm, 100% effaced, — 1 station. Her contraction pattern was unchanged. The fetal heart rate pattern was consistently reassuring. Four hours later, 8 hours after her admission, the patient reported increased discomfort and wanted to know how much progress she had made. Her cervix was 7 cm, 100% effaced, — 1 station; her infant remained in occiput posterior position. At this time, the midwife diagnosed a protracted active labor pattern.The midwife encouraged the patient to use positions such as hands and knees and side lunge to encourage rotation of the fetal head, yet her cervical examination remained unchanged over the next 4 hours. At 12 hours after admission, the midwife suggested nipple stimulation in an effort to enhance uterine forces and promote progressive cervical change. The patient's husband stimulated her nipples bilaterally for 15 minutes, followed by a 15-minute rest period. The midwife remained in the room during nipple stimulation to ensure consistent use of the technique. She noted no uterine tachysystole, which she defined as five contractions in 10 minutes, and the fetal heart rate pattern remained reassuring.The cycle was repeated four times over the next 2 hours, at which point the patient's cervix was 8 cm, 100% effaced, 0 station, with contractions every 5 to 10 minutes. Despite cervical change, the contraction strength and frequency pattern were thought to be insufficient for active progress expected at this point in first-stage labor. Fourteen hours after hospital admission, the collaborative decision was made to simultaneously perform amniotomy and initiate oxytocin augmentation at a rate of 1 mU/min. Nipple stimulation was discontinued at this time. Continuous external fetal monitoring was initiated.Oxytocin was progressively increased by 2 mU/min every 30 minutes for the next 6 hours. After more than 20 hours of laboring in the hospital, the patient felt the urge to push and her cervix was completely dilated. She pushed for a full hour and gave birth to a healthy infant girl in direct OP position, with Apgar scores 9 and 9 at 1 and 5 minutes, respectively.
Article
Our goal was to lower unplanned primary cesarean deliveries by reducing elective inductions. To implement and sustain an induction management program, a committee of care providers reviewed induction rates. "Elective" and other categories were defined. An induction consent form was drafted. Consent compliance, induction rates, hours in labor and delivery and mode of delivery were evaluated. Outcomes were compared with historical data from 2 years earlier. A total of 10,166 nulliparas and 9869 multiparas attempted vaginal deliveries. Elective inductions decreased significantly, from 4.3% to 0.8% in nulliparas and from 13% to 9.5% in multiparas. A longer time to delivery was seen for both nulliparas (5.2 hours) and multiparas (4 hours) with elective inductions. Unplanned primary cesarean delivery rates are significantly lower in spontaneously laboring women, compared with those induced. A program aimed at reducing elective inductions was successfully implemented and sustained.
Article
To quantify adverse neonatal and maternal outcomes associated with elective term delivery at less than 39 completed weeks of gestation. Prospective observational study conducted in 27 hospitals over the course of 3 months in 2007. Of 17,794 deliveries, 14,955 (84%) occurred at 37 weeks or greater. Of term deliveries, 6562 (44%) were planned, rather than spontaneous. Among the planned deliveries, 4645 (71%) were purely elective; 17.8% of infants delivered electively without medical indication at 37-38 weeks and 8% of those delivered electively at 38-39 weeks required admission to a newborn special care unit for an average of 4.5 days, compared with 4.6% of infants delivered at 39 weeks or beyond (P < .001). Cesarean delivery rate in women undergoing induction of labor was not influenced by gestational age but was highly influenced by initial cervical dilatation and parity, ranging from 0% for parous women induced at 5 cm or greater to 50% for nulliparous women at 0 cm. Elective delivery before 39 weeks' gestation is associated with significant neonatal morbidity. Initial cervical dilatation is highly correlated with cesarean delivery among women undergoing induction of labor in both nulliparous and parous women. Elective delivery before 39 completed weeks' gestation is inappropriate. Women contemplating elective induction at or beyond 39 weeks' gestation with an unfavorable cervix should be counseled regarding an increased rate of cesarean delivery.