Methods of classification for women undergoing induction of labour: a systematic review and novel classification system

OBJECTIVE To develop and demonstrate the applicability of a classification system for induction of labour (IOL) that fulfils recognised classification system attributes for clinical, surveillance and research purposes. DESIGN Proof of concept. SETTING, POPULATION Applicability demonstrated in a population cohort of 909,702 maternities in New South Wales, Australia, 2002-2011. METHODS A multidisciplinary collaboration developed a classification system through a systematic literature review, development of a clinically logical model, and presentation to stakeholders for feedback and refinement. Classification factors included parity (nulliparous, parous), previous caesarean section (CS), gestational age (≤36, 37-38, 39-40, ≥41 weeks gestation), number (singleton, multiple) and presentation of the fetus (cephalic, non-cephalic). We determined: the size of each classification group, the contribution each group made to overall IOL rates, and within-group IOL rates (calculated as proportions of all maternities, all maternities excluding prelabour CS and of all continuing maternities). MAIN OUTCOME MEASURES Applicability of IOL classification using routinely collected obstetric data. RESULTS A 10 group classification system was developed. Of all maternities, 25.4% were induced. Nulliparous and parous women without a prior CS at 39-40 weeks gestation with a singleton cephalic-presenting fetus were the largest groups (21.2% and 24.5% respectively) and accounted for the highest proportion of all IOL (20.7% and 21.5% respectively). The highest within group IOL rates were for nullipara (53.8%) and multipara (45.5%) ≥41 weeks gestation. CONCLUSION We propose a classification system for IOL that has the attributes of simplicity and clarity, utilises information that is readily and reliably collected and reported, and enables standard characterisation of populations of women having an IOL.NHMRC 1021025, ARC FT12010006

The Breathing for Life Trial: A randomised controlled trial of fractional exhaled nitric oxide (FENO)-based management of asthma during pregnancy and its impact on perinatal outcomes and infant and childhood respiratory health

Asthma exacerbations are common during pregnancy and associated with an increased risk of adverse perinatal outcomes. Adjusting asthma treatment based on airway inflammation rather than symptoms reduces the exacerbation rate by 50 %. The Breathing for Life Trial (BLT) will test whether this approach also improves perinatal outcomes. Methods/design: BLT is a multicentre, parallel group, randomised controlled trial of asthma management guided by fractional exhaled nitric oxide (FENO, a marker of eosinophilic airway inflammation) compared to usual care, with prospective infant follow-up. Women with physician-diagnosed asthma, asthma symptoms and/or medication use in the previous 12 months, who are 12-22 weeks gestation, will be eligible for inclusion. Women randomised to the control group will have one clinical assessment of their asthma, including self-management education. Any treatment changes will be made by their general practitioner. Women randomised to the intervention group will have clinical assessments every 3-6 weeks during pregnancy, and asthma treatments will be adjusted every second visit based on an algorithm which uses FENO to adjust inhaled corticosteroid (ICS) dose (increase in dose when FENO > 29 parts per billion (ppb), decrease in dose when FENO < 19 ppb, and no change when FENO is between 19 and 29 ppb). A long acting beta agonist (LABA) will be added when symptoms remain uncontrolled. Both the control and intervention groups will report on exacerbations at a postpartum phone interview. The primary outcome is adverse perinatal outcome (a composite measure including preterm birth, intrauterine growth restriction, neonatal hospitalisation at birth or perinatal mortality), assessed from hospital records. Secondary outcomes will be each component of the primary outcome, maternal exacerbations requiring medical intervention during pregnancy (both smokers and non-smokers), and hospitalisation and emergency department presentation for wheeze, bronchiolitis or croup in the first 12 months of infancy. Outcome assessment and statistical analysis of the primary outcome will be blinded. To detect a reduction in adverse perinatal outcomes from 35 % to 26 %, 600 pregnant women with asthma per group are required. Discussion: This trial will provide evidence for the effectiveness of a FENO-based management strategy in improving perinatal outcomes in pregnant women with asthma. If successful, this would improve the management of pregnant women with asthma worldwide. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12613000202763. © 2016 Murphy et al. Background:Associated Grant:Australian National Health and Medical Research CouncilAssociated Grant Code:Project Grant 106098