Question: What is the best way to proceed in a woman with a prior caesarean, and prelabour rupture of membranes at term? Is syntocinon contraindicated?
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Answer: The NICE guideline "Induction of labour"(1) published in 2008 includes sections on prelabour rupture of membranes at term (paragraph 4.3) and previous caesarean birth (para 4.4), making the following recommendations:
"Women with prelabour rupture of membranes at term (at or over 37 weeks) should be offered a choice of induction of labour with vaginal PGE2(*) or expectant management.
Induction of labour is appropriate approximately 24 hours after prelabour rupture of the membranes at term."
*Vaginal PGE2 has been used in UK practice for many years in women with ruptured membranes. However, the SPCs (July 2008) advise that in this situation, the use of vaginal PGE2 is either not recommended or should be used with caution, depending on the preparation (gel, tablet or pessary). Healthcare professionals should refer to the individual SPCs before prescribing vaginal PGE2 for women with ruptured membranes, and informed consent should be obtained and documented.
"If delivery is indicated, women who have had a previous caesarean section may be offered induction of labour with vaginal PGE2(**), caesarean section or expectant management on an individual basis, taking into account the woman’s circumstances and wishes. Women should be informed of the increased risks with induction of labour:
• increased risk of need for emergency caesarean section
• increased risk of uterine rupture."
** Vaginal PGE2 has been used in UK practice for many years in women with a history of previous caesarean section. However, the SPCs (July 2008) advises that the use of vaginal PGE2 is not recommended in women with a history of previous caesarean section. Informed consent on the use of vaginal PGE2 in this situation should therefore be obtained and documented.
(Evidence level IV)
A series of Cochrane reviews have been undertaken to determine the effectiveness and safety of induction agents or procedures for third trimester cervical ripening and induction of labour. A generic protocol (2) has been published which lists 26 different methods of induction, and notes that the reviews will also be analysed by whether the women have had a prior caesarean section or not, or have intact or ruptured membranes. The review for intravenous oxytocin in this series (3) included sixty-one trials (12,819 women) and found:
"When oxytocin inductions were compared with expectant management, fewer women failed to deliver vaginally within 24 hours (8.4% versus 53.8%, risk ratio (RR) 0.16, 95% confidence interval (CI) 0.10 to 0.25). There was a significant increase in the number of women requiring epidural analgesia (RR 1.10, 95% CI 1.04 to 1.17). Fewer women were dissatisfied with oxytocin induction in the one trial reporting this outcome (5.9% versus 13.7%, RR 0.43, 95% CI 0.33 to 0.56).
Compared with vaginal prostaglandins, oxytocin increased unsuccessful vaginal delivery within 24 hours in the two trials reporting this outcome (70% versus 21%, RR 3.33, 95% CI 1.61 to 6.89). There was a small increase in epidurals when oxytocin alone was used (RR 1.09, 95% CI 1.01 to 1.17).
Most of the studies included women with ruptured membranes, and there was some evidence that vaginal prostaglandin increased infection in mothers (chorioamnionitis RR 0.66, 95% CI 0.47 to 0.92) and babies (use of antibiotics RR 0.68, 95% CI 0.53 to 0.87). These data should be interpreted cautiously as infection was not pre-specified in the original review protocol.
When oxytocin was compared with intracervical prostaglandins, there was an increase in unsuccessful vaginal delivery within 24 hours (50.4% versus 34.6%, RR 1.47, 95% CI 1.10 to 1.96) and an increase in caesarean sections (19.1% versus 13.7%, RR 1.37, 95% CI 1.08 to 1.74) in the oxytocin group."
Most of the studies comparing the use of oxytocin with expectant management specifically recruited women with ruptured membranes (i.e. 20 of the 25 studies reported outcomes for women with ruptured membranes). Thus, for all primary outcomes, and for most other outcomes, the results for women with ruptured membranes were the same as, or very similar to, findings for all women.
Only one small study (Morales 1986) provided data on women that had had a previous caesarean section. This study provided information on women having another caesarean section in the index pregnancy. Results were not significant.
(Evidence level 1a)
No more recent trials of syntocinon induction in women with ruptured membranes at term and a prior caesarean section were identified.
References:
- NICE guideline on Induction of labour. London: RCOG Press, 2008
- Hofmeyr GJ, Alfirevic Z, Kelly AJ, Kavanagh J, Thomas J, Neilson JP, Dowswell T. Methods for cervical ripening and labour induction in late pregnancy: generic protocol (Protocol). Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD002074. DOI: 10.1002/14651858.CD002074.pub2 Abstract (and full text in some countries). Full text available to Fellows, Members and Trainees here.
- Alfirevic Z, Kelly AJ, Dowswell T. Intravenous oxytocin alone for cervical ripening and induction of labour. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD003246. DOI: 10.1002/14651858.CD003246.pub2 Abstract (and full text in some countries). Full text available to Fellows, Members and Trainees here
Search date: July 2011
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
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