Synnytyksen käynnistäminen, kun raskaus on täysiaikainen

•Synnytyksistä 20–30 % alkaa käynnistyksellä, ja käynnistysten osuus on jatkuvasti kasvanut. •Synnytys käynnistetään lääketieteellisestä syystä, kun raskauden jatkamisen riskit ovat suuremmat kuin käynnistykseen liittyvät riskit. •Käynnistykseen liittyy lisääntynyt pitkittyneen synnytyksen ja päivystyskeisarileikkauksen riski. •Kohdunkaula kypsytetään lääkkeellisesti misoprostolilla tai mekaanisesti laajentamalla balonkimenetelmällä vaiheeseen, jossa lapsivesikalvojen puhkaisu on mahdollinen. Tarvittaessa käytetään oksitosiinia supistusten aloittamiseksi tai voimistamiseksi. •Lääkkeellisen ja mekaanisen käynnistysmenetelmän välillä ei ole todettu eroja tehossa, keisarileikkausten määrissä, infektioissa tai vastasyntyneen voinnissa.Peer reviewe

Synnytyksen mekaaninen balonkikäynnistys

The rates of induction of labor (IOL) are rising worldwide; currently every fourth labor is induced. Prostaglandins and balloon catheters, including Foley catheter (FC), are available for IOL. The vaginal delivery rates are comparable, but FC is associated with lower risk of uterine hyperstimulation and adverse events. The mechanism of FC use consists of direct mechanical dilation of the cervix, and local secretion of endogenous prostaglandins. The aim of this study was to evaluate FC for labor induction in prolonged and post-term pregnancies, in women with premature rupture of membranes (PROM) at term, and in outpatient use. The secondary aim was to investigate cervical biomarkers insulin-like growth factor binding protein-1 (IGFBP-1), matrix metalloproteinases (MMP) -2, -8, and -9, and their tissue inhibitors (TIMP)-1 and -2 in IOL by FC. The study was conducted in the Department of Obstetrics and Gynecology of Helsinki University Hospital between 2011 and 2015. The main outcome measures were the rates of cesarean section (CS) and maternal and neonatal infections. The total study population consisted of 1693 women. The lowest rate of CS (24 %) occurred in women undergoing IOL after term PROM, and the highest rate (44 %) was observed in nulliparous post-term women. In post-term pregnancy, a sixfold risk (OR 6.2, 95 % CI 3.2−12.1) of CS occurred in nulliparous women undergoing IOL compared to spontaneous onset of labor. The CS rates were significantly different neither between FC and misoprostol groups (24% vs. 18 %; p=0.36), nor between outpatients and inpatients (32 % vs. 32 %; p=0.82).The median (range) rate of maternal intrapartum infections following IOL by FC was 5 (2−6) %, and the rate of postpartum infections was 3 (1−4) %. The rate of neonatal clinical sepsis following FC induction was 2 (1−3) %, and the rate of and suspected neonatal infections was 4 (1−5) %. The maternal and neonatal infection rates were similar between the use of FC and misoprostol, and between outpatients and inpatients. There were no significant differences in the concentrations of cervical IGFBP-1 or MMPs -2,-8,or -9 in successful and failed IOL. In conclusion, FC appears safe and feasible for IOL in prolonged and post-term pregnancies, in women with PROM, and in outpatient use. The cervical biomarkers IGFBP-1 and MMPs appear unsuitable for predicting the success of IOL.Synnytyksen käynnistysten määrä on kasvanut, nykyisin joka neljäs synnytys käynnistetään. Synnytyksen käynnistys aloitetaan kohdunkaulan kypsyttämisellä lääkkeellisesti misoprostolilla tai mekaanisesti pallokatetrilla, ns. balonkimenetelmällä. Menetelmien tehossa ei ole todettu eroja, mutta balonkimenetelmässä esiintyy vähemmän haittatapahtumia, kuten sikiön sykemuutoksia. Balonkimenetelmässä kohdunkaulan sisäsuun ja lapsivesikalvojen väliin viedään katetri, jonka päässä oleva balonki täytetään fysiologisella suolaliuoksella nestepalloksi. Balonki laajentaa kohdunkaulaa mekaanisesti ja aiheuttaa biokemiallisten välittäjäaineiden vapautumista kudoksista. Helsingin yliopistollisessa keskussairaalassa vuosina 2011−2015 toteutettu tutkimus selvittää balonkimenetelmän tehokkuutta ja turvallisuutta, sekä kohdunkaulakanavassa tapahtuvia biokemiallisia muutoksia synnytyksen balonkikäynnistyksen aikana. Tulostemme mukaan balonkikäynnistys on yliaikaisessa raskaudessa (≥41+5 raskausviikolla) yhtä turvallinen kuin synnytyksen spontaani käynnistyminen, mutta käynnistys kuitenkin lisää keisarileikkausten määrää ensisynnyttäjillä. Äidin synnytyksenaikaisten infektioiden esiintyvyys oli 5 % ja vastasyntyneiden kliinisten infektioiden esiintyvyys oli 2 %. Helsingin, Tampereen ja Oulun yliopistosairaaloiden yhteisessä satunnaistetussa balonki- ja misoprostolikäynnistystä lapsivedenmenon jälkeen vertailevassa tutkimuksessa totesimme molempien menetelmien olevan turvallisia vaihtoehtoja ilman eroja keisarileikkausten tai infektioiden määrissä. Tulostemme mukaan myös polikliininen balonkikäynnistys, jossa kohdunkaulan kypsytys tapahtuu kotona, on täysiaikaisissa normaaleissa raskauksissa turvallinen vaihtoehto, johon 85 % synnyttäjistä oli tyytyväisiä. Analysoimiemme kohdunkaulan biokemiallisten välittäjäaineiden, kuten insuliininkaltaista kasvutekijää sitovan proteiinin-1 (IGFBP-1) ja matriksin metalloproteinaasien (MMP) -2, -8 tai -9 pitoisuuksien muutosten avulla ei voitu ennustaa synnytyksen käynnistyksen kulkua. Yhteenvetona voidaan todeta, että balonki on tehokas ja turvallinen synnytyksen käynnistysmenetelmä, joka soveltuu myös polikliiniseen käyttöön ja synnytyksen käynnistykseen lapsivedenmenon jälkeen. Tutkimuksemme mukaan synnytyksen käynnistys ensisynnyttäjän yliaikaisessa raskaudessa kuitenkin lisää keisarileikkauksen todennäköisyyttä

Planned vaginal and planned cesarean delivery outcomes in pregnancies complicated with pregestational type 1 diabetes - A three-year academic tertiary hospital cohort study

Background Finland has the world's highest incidence of 62.5/100000 of diabetes mellitus type 1 (DM1) with approximately 400 (1%) DM1 pregnancies annually. Pregnancies complicated by DM1 are accompanied with increased risk for perinatal morbidity and mortality. Timing and mode of delivery are based on the risk of complications, yet the data on labor induction is limited. The aim of this study was to compare delivery outcomes in planned vaginal (VD) and planned cesarean deliveries (CD) in late preterm and term DM1 pregnancies, and to evaluate the feasibility of labor induction. Materials and Methods Pregnant women with DM1, live singleton fetus in cephalic presentation >= 34 gestational weeks delivering in Helsinki University Hospital between January 1st 2017 and December 31st 2019 were included. The primary outcome were the rates of adverse maternal and perinatal outcome. The study population was classified according to the 1980-revised White's classification. Statistical analyses were performed by IBM SPSS Statistics for Windows. Results Two hundred four women were included, 59.8% (n = 122) had planned VD. The rate of adverse maternal outcome was 27.5% (n = 56), similar between the planned modes of delivery and White classes. The rate of perinatal adverse outcome was 38.7% (n = 79), higher in planned CD (52.4% vs. 29.5%;p = 0.001). The most common adverse perinatal event was respiratory distress (48.8% vs. 23.0%;p < 0.001). The rate of adverse perinatal outcome was higher in White class D + Vascular compared to B + C (45.0% vs. 25.0%, OR after adjustment by gestational age 2.34 [95% CI 1.20-4.50];p = 0.01). The total rate of CD was 63.7% (n = 130), and 39.3% (n = 48) in planned VD. Women with White class D + Vascular more often had emergency CD compared to White Class B + C (48.6% vs. 25.0%;p = 0.009). The rate of labor induction was 51%, being 85.2% in planned VD. The rate of VD in induced labor was 58.7% (n = 61) and the rate of failed induction was 14.1% (n = 15). Conclusion Planned VD was associated with lower rate of adverse perinatal outcome compared to planned CS, with no difference in the rates of adverse maternal outcome. Induction of labor may be feasible option but should be carefully considered in this high-risk population.Peer reviewe

Maternal childbirth experience in induced and spontaneous labour measured in a visual analog scale and the factors influencing it; a two-year cohort study

Background Poor maternal childbirth experience plays a role in family planning and subsequent pregnancies. The aim of this study was to compare childbirth experiences in induced and spontaneous labor and to investigate the factors influencing the childbirth experience. Methods This two-year cohort study included all women with term singleton pregnancies in cephalic presentation aiming for vaginal delivery at Helsinki University Hospital between January 2017 and December 2018. Maternal satisfaction in the childbirth experience was measured after delivery using a Visual Analog Scale (VAS) score. A low childbirth experience score was defined as VAS <5. The characteristics and delivery outcomes of the study population were collected in the hospital database and analyzed by SPSS. Results A total of 18,396 deliveries were included in the study, of which 28.9% (n = 5322) were induced and 71.1% (n = 13 074) were of spontaneous onset. The total caesarean delivery rate was 9.3% (n = 1727). Overall, 4.5% (n = 819) of the women had a low childbirth experience VAS score. The women who underwent labor induction were less satisfied with their birth experience compared to women with spontaneous onset of labor [7.5% (n = 399) vs. 3.2% (n = 420);p <0.001]. Poor childbirth experience was associated with primiparity [OR 2.0 (95% CI 1.6-2.4)], labor induction [OR 1.6 (95% CI 1.4-1.9)], caesarean delivery [OR 4.5 (95% CI 3.7-5.5)], operative vaginal delivery [OR 3.3 (95% CI 2.7-4.0)], post-partum hemorrhage [OR 1.3 (95% CI 1.1-1.6)], and maternal infections [OR 1.7 (95% CI 1.3-2.4)]. Conclusions Poor childbirth experience was associated with labor induction, primiparity, operative delivery, and labor complications, such as post-partum hemorrhage and maternal infections. These results highlight the aspects of care for which patient experience may be improved by additional support and counselling.Peer reviewe

Comparison of primiparous women & apos;s childbirth experience in labor induction with cervical ripening by balloon catheter or oral misoprostol - a prospective study using a validated childbirth experience questionnaire (CEQ) and visual analogue scale (VAS)

Introduction Primiparity and labor induction, especially when cervical ripening is required, are risk factors for a negative childbirth experience. Our aim was to compare childbirth experience in primiparous women with cervical ripening by balloon catheter or oral misoprostol using the validated Childbirth Experience Questionnaire (CEQ). We also wanted to compare assessment of a negative childbirth experience by visual analogue scale (VAS) and CEQ. Material and methods This is a prospective study of 362 primiparous women undergoing cervical ripening and labor induction by balloon catheter (67.4%) or oral misoprostol (32.6%) at Helsinki University Hospital, Finland, between January 1, 2019 and January 31, 2020. After delivery, the women assessed their childbirth experience using the CEQ, and patient records provided the patient characteristics, delivery outcomes and VAS ratings. We analyzed the results using IBM SPSS Statistics. Results Overall, the women experienced their labor and delivery rather positively, with a mean CEQ score of 2.9 (SD 0.6) (scale 1-4), and no differences were detectable when comparing women with cervical ripening by balloon catheter or misoprostol. However, women with balloon catheter were more often satisfied with the method chosen for them and would choose the same method in a future pregnancy. Compared with CEQ, VAS seems mainly to reflect the women's perception of their own capacity to give birth and the safety of the hospital setting, not the level of professional support or participation in decision-making. According to our results, CEQ and VAS are comparable, but the usability of the CEQ is limited by its inability to distinguish the most negative and the most positive experiences, and the VAS is limited by its simplicity. Conclusions Women with cervical ripening by balloon catheter or oral misoprostol experienced their childbirth rather positively, results being similar in both groups. However, women with cervical ripening by balloon catheter were more content with their labor induction. The CEQ and VAS can both be used to assess the childbirth experience of primiparous women undergoing labor induction, but both methods have limitations.Peer reviewe

Comparison of delivery outcomes in low-dose and high-dose oxytocin regimens for induction of labor following cervical ripening with a balloon catheter : A retrospective observational cohort study

A variety of oxytocin regimens are used for labor induction and augmentation. Considering the increasing rates of labor induction, it is important to assess the most optimal oxytocin regimen without compromising maternal and fetal safety. The aim of this study was to compare delivery outcomes of low-dose and high-dose oxytocin induction protocols. This retrospective cohort study of 487 women comparing low-dose oxytocin protocol (n = 280) and high-dose oxytocin protocol (n = 207) in labor induction following cervical ripening by balloon catheter was performed in Helsinki University Hospital after implementation of a new oxytocin induction protocol. The study included two six-month cohorts from 2016 and 2019. Women with vital singleton pregnancies >= 37 gestational weeks, cephalic presentation, and intact amniotic membranes were included. The primary outcome was the rate of vaginal delivery. The secondary outcomes were the rates of maternal and neonatal infections, postpartum hemorrhage, umbilical artery blood pH-value, admission to neonatal intensive care, and induction-to-delivery interval. Statistical analyses were performed by using IBM SPSS Statistics for Windows (Armonk, NY, USA). The rate of vaginal delivery was higher [69.9% (n = 144) vs. 47.9% (n = 134); pPeer reviewe

Vaginal streptococcus B colonization is not associated with increased infectious morbidity in labor induction

Introduction Labor induction rates are increasing and, in Finland today, one of three labors is induced. Group B streptococcus (GBS) is a bacterium found in 10%-30% of pregnant women and it can be transmitted to the neonate during vaginal delivery. Although GBS is rarely harmful in the general population, it is the leading cause of severe neonatal infections such as sepsis, pneumonia, and meningitis. In addition, GBS can cause maternal morbidity. Labor induction in GBS-positive women has not yet been investigated but concerns of infectious morbidity associated with balloon catheters have been raised. Material and methods A historical cohort study of 1959 women undergoing labor induction by balloon catheter in Helsinki University Hospital, Finland, between January 1, 2014 and December 31, 2017. Women with viable singleton term pregnancy in cephalic presentation, unfavorable cervix (Bishop score Results Of the women, 469 (23.9%) were GBS-positive. The rate of maternal intrapartum infection was 7.4%, being lower in the GBS-positive group compared with the GBS-negative group (4.7% vs 8.3%; p = 0.01). The rate of maternal postpartum infection was 3.9%, and the rate of neonatal infection was 3.3%, both being similar between the groups. Also, no difference in the rates of other adverse neonatal outcomes was seen. No GBS sepses occurred in the study. In multivariable logistic regression, rupture of membranes to delivery interval >= 12 hours was associated with maternal intrapartum and postpartum infection, as well as neonatal infection. Other risk factors for maternal intrapartum infection were GBS-negativity, nulliparity, prolonged pregnancy (>= 41 weeks), and Bishop score Conclusions Regarding maternal and neonatal infectious morbidity, labor induction with balloon catheter appears safe in women colonized with GBS when prophylactic antibiotics are administered at the onset of labor or at membrane rupture.Peer reviewe

Breaking the myth : the association between the increasing incidence of labour induction and the rate of caesarean delivery in Finland - a nationwide Medical Birth Register study

Objectives To determine the association between the rate of labour induction and caesarean delivery. Design Medical Birth Register-based study. We used data from the nationwide Medical Birth Register collecting data on delivery outcomes on all births from 22+0 weeks and/or birth weight of at least 500 g. Setting Finland. Participants 663 024 live births in Finland from 2008 to 2019. Main outcome measures The rates of labour induction and caesarean delivery. Results The rate of labour induction increased from 17.8% to 30.3%; p Conclusions The 70% increase in the rate of labour induction in Finland has not led to a significant increase in the rate of caesarean delivery, which has remained one of the lowest in the world. Pregnant women in Finland are more frequently obese, older and diagnosed with gestational diabetes, which may partly explain the increase in the rate of labour induction.Peer reviewe

Success of trial of labor in women with a history of previous cesarean section for failed labor induction or labor dystocia : a retrospective cohort study

BackgroundThe rates of cesarean section (CS) are increasing worldwide leading to an increased risk for maternal and neonatal complications in the subsequent pregnancy and labor. Previous studies have demonstrated that successful trial of labor after cesarean (TOLAC) is associated with the least maternal morbidity, but the risks of unsuccessful TOLAC exceed the risks of scheduled repeat CS. However, prediction of successful TOLAC is difficult, and only limited data on TOLAC in women with previous failed labor induction or labor dystocia exists. Our aim was to evaluate the success of TOLAC in women with a history of failed labor induction or labor dystocia, to compare the delivery outcomes according to stage of labor at time of previous CS, and to assess the risk factors for recurrent failed labor induction or labor dystocia.MethodsThis retrospective cohort study of 660 women with a prior CS for failed labor induction or labor dystocia undergoing TOLAC was carried out in Helsinki University Hospital, Finland, between 2013 and 2015. Data on the study population was obtained from the hospital database and analyzed using SPSS.ResultsThe rate of vaginal delivery was 72.9% and the rate of repeat CS for failed induction or labor dystocia was 17.7%. The rate of successful TOLAC was 75.6% in women with a history of labor arrest in the first stage of labor, 73.1% in women with a history of labor arrest in the second stage of labor, and 59.0% in women with previous failed induction. The adjusted risk factors for recurrent failed induction or labor dystocia were maternal heightPeer reviewe

Success of trial of labor in women with a history of previous cesarean section for failed labor induction or labor dystocia : a retrospective cohort study

BackgroundThe rates of cesarean section (CS) are increasing worldwide leading to an increased risk for maternal and neonatal complications in the subsequent pregnancy and labor. Previous studies have demonstrated that successful trial of labor after cesarean (TOLAC) is associated with the least maternal morbidity, but the risks of unsuccessful TOLAC exceed the risks of scheduled repeat CS. However, prediction of successful TOLAC is difficult, and only limited data on TOLAC in women with previous failed labor induction or labor dystocia exists. Our aim was to evaluate the success of TOLAC in women with a history of failed labor induction or labor dystocia, to compare the delivery outcomes according to stage of labor at time of previous CS, and to assess the risk factors for recurrent failed labor induction or labor dystocia.MethodsThis retrospective cohort study of 660 women with a prior CS for failed labor induction or labor dystocia undergoing TOLAC was carried out in Helsinki University Hospital, Finland, between 2013 and 2015. Data on the study population was obtained from the hospital database and analyzed using SPSS.ResultsThe rate of vaginal delivery was 72.9% and the rate of repeat CS for failed induction or labor dystocia was 17.7%. The rate of successful TOLAC was 75.6% in women with a history of labor arrest in the first stage of labor, 73.1% in women with a history of labor arrest in the second stage of labor, and 59.0% in women with previous failed induction. The adjusted risk factors for recurrent failed induction or labor dystocia were maternal heightPeer reviewe