EDITORIAL COMMENT: This study is important and unusual, the latter because the control series of nulliparas with an unfavourable cervix having labour induced by amniotomy and oxytocin infusion were managed by the same authors and reported in this journal in 1985 (1). One could argue that the 2 groups should not be compared because the indicatons for induction of labour were different, and other clinical regimens had changed. Nonetheless this paper is important because it reaffirms that induction of labour, by amniotomy and oxytocin infusion, in nulliparas with an unfavourable cervix is likely to result in Caesarean section; in 43.5% in the previous study and 48.6% in the present subgroup. Patients may well elect to be managed by elective Caesarean section if counselled regarding the prospects of vaginal delivery with such a regimen when the cervical score is poor. The takeaway message is that prostaglandin vaginal pessaries (2 doses of 3 mg of PGE^, 4 hours apart) in such women reduces the Caesarean rate significantly, especially in those who come into established labour within 24 hours of insertion of the pessaries, or when the cervical score improved within 24 hours of their insertion. Summary: In a previous study nulliparas with poor cervical score (≤ 5 out of 10) had a 43.5% Caesarean section (CS) rate of which 55% were for failed induction when labour was induced by artificial rupture of membranes and oxytocin infusion. In this study induction of labour by 2 doses of 3 mg prostaglandin E2 (PGE2) vaginal pessaries, 4 hours apart, and if necessary by artificial rupture of membranes and oxytocin infusion 24 hours later, resulted in a CS rate of 23.7% of which 38.9% were for failed induction. The latter regimen resulted in a significantly lower CS rate compared with labour induced by oxytocin infusion and rupture of membranes without the use of prostaglandins (p < 0.001). In the prostaglandin group 53.3% were established in labour within 24 hours of inserting the pessary and in these patients the CS rate was 18.5%. In those who did not start labour and needed rupture of membranes and oxytocin infusion 24 hours after the first pessary, 34 (47.9%) had a good cervical score (≥ 6 out of 10) and 37 (52.1%) had a poor cervical score (≤ 5 out of 10) at the time of amniotomy. The CS rates in these groups were 8.8% and 48.6% respectively (p < 0.001). In nulliparas with poor cervical score induction is better performed with vaginal prostaglandin pessaries in order to reduce the high CS rate associated with artificial rupture of membranes and oxytocin infusion.
|Number of pages||4|
|Journal||Australian and New Zealand Journal of Obstetrics and Gynaecology|
|Publication status||Published - 1991|