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Macrosomic fetuses are at increased risk of shoulder dystocia. We aimed to compare induction of labour with expectant management for large-for-date fetuses for prevention of shoulder dystocia and other neonatal and maternal morbidity associated with macrosomia. We did this pragmatic, randomised controlled trial between Oct 1, 2002, and Jan 1, 2009, in 19 tertiary-care centres in France, Switzerland, and Belgium. Women with singleton fetuses whose estimated weight exceeded the 95th percentile, were randomly assigned (1:1), via computer-generated permuted-block randomisation (block size of four to eight) to receive induction of labour within 3 days between 37+0 weeks and 38+6 weeks of gestation, or expectant management. Randomisation was stratified by centre. Participants and caregivers were not masked to group assignment. Our primary outcome was a composite of clinically significant shoulder dystocia, fracture of the clavicle, brachial plexus injury, intracranial haemorrhage, or death. We did analyses by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00190320. We randomly assigned 409 women to the induction group and 413 women to the expectant management group, of whom 407 women and 411 women, respectively, were included in the final analysis. Mean birthweight was 3831 g (SD 324) in the induction group and 4118 g (392) in the expectant group. Induction of labour significantly reduced the risk of shoulder dystocia or associated morbidity (n=8) compared with expectant management (n=25; relative risk [RR] 0·32, 95% CI 0·15–0·71; p=0·004). We recorded no brachial plexus injuries, intracranial haemorrhages, or perinatal deaths. The likelihood of spontaneous vaginal delivery was higher in women in the induction group than in those in the expectant management group (RR 1·14, 95% CI 1·01–1·29). Caesarean delivery and neonatal morbidity did not differ significantly between the groups. Induction of labour for suspected large-for-date fetuses is associated with a reduced risk of shoulder dystocia and associated morbidity compared with expectant management. Induction of labour does not increase the risk of caesarean delivery and improves the likelihood of spontaneous vaginal delivery. These benefits should be balanced with the effects of early-term induction of labour. Assistance Publique–Hôpitaux de Paris and the University of Geneva.

AbstractObjectiveTo evaluate if induction of labour at 41 weeks improves perinatal and maternal outcomes in women with a low risk pregnancy compared with expectant management and induction of labour at 42 weeks.DesignMulticentre, open label, randomised controlled superiority trial.Setting14 hospitals in Sweden, 2016-18.Participants2760 women with a low risk uncomplicated singleton pregnancy randomised (1:1) by the Swedish Pregnancy Register. 1381 women were assigned to the induction group and 1379 were assigned to the expectant management group.InterventionsInduction of labour at 41 weeks and expectant management and induction of labour at 42 weeks.Main outcome measuresThe primary outcome was a composite perinatal outcome including one or more of stillbirth, neonatal mortality, Apgar score less than 7 at five minutes, pH less than 7.00 or metabolic acidosis (pH <7.05 and base deficit >12 mmol/L) in the umbilical artery, hypoxic ischaemic encephalopathy, intracranial haemorrhage, convulsions, meconium aspiration syndrome, mechanical ventilation within 72 hours, or obstetric brachial plexus injury. Primary analysis was by intention to treat.ResultsThe study was stopped early owing to a significantly higher rate of perinatal mortality in the expectant management group. The composite primary perinatal outcome did not differ between the groups: 2.4% (33/1381) in the induction group and 2.2% (31/1379) in the expectant management group (relative risk 1.06, 95% confidence interval 0.65 to 1.73; P=0.90). No perinatal deaths occurred in the induction group but six (five stillbirths and one early neonatal death) occurred in the expectant management group (P=0.03). The proportion of caesarean delivery, instrumental vaginal delivery, or any major maternal morbidity did not differ between the groups.ConclusionsThis study comparing induction of labour at 41 weeks with expectant management and induction at 42 weeks does not show any significant difference in the primary composite adverse perinatal outcome. However, a reduction of the secondary outcome perinatal mortality is observed without increasing adverse maternal outcomes. Although these results should be interpreted cautiously, induction of labour ought to be offered to women no later than at 41 weeks and could be one (of few) interventions that reduces the rate of stillbirths.Trial registrationCurrent Controlled Trials ISRCTN26113652.

Purpose Incorporating regular physical activity into the lifestyle of a pregnant woman offers numerous health benefits and prepares her effectively for labor. This study was conducted to determine the impact of antenatal exercise on labor, delivery and perinatal outcome. Methods An interventional study was conducted including 200 women attending the antenatal clinic of Obstetrics and Gynaecology department of PGIMS Rohtak, India. The study subjects were randomly divided into two groups—exercise group and control group. Results The demographic profile of both the groups was similar. A higher proportion of patients in control group required labor induction compared to exercise group (33% vs 16%, P  = 0.002). The rate of vaginal delivery was significantly higher in exercise group than in control group (71% vs 56%, P  = 0.027). Additionally, women in exercise group had fewer assisted vaginal deliveries than control group (7% vs 20%, P  = 0.007). Rates of cesarean section were comparable between both groups ( P  = 0.736). The mean duration of labor was significantly shorter in exercise group compared to control group (428.69 ± 131.242 min vs 516.91 ± 143.105 min, P  < 0.0001). Mean Visual Analog Scale (VAS) score for pain was 6.38 ± 1.94 in exercise group compared to 7.89 ± 1.49 in control group ( P  < 0.0001). No significant difference was observed between the groups in birth weight and APGAR score of neonates. Conclusion A structured exercise program, practiced regularly during the antenatal period reduced the need for labor induction, shortened labor duration, increased the incidence of vaginal deliveries, and decreased pain perception during labor and delivery.

Background In the Twin Birth Study, women at 32 0/7 –38 6/7 weeks of gestation, in whom the first twin was in cephalic presentation, were randomized to planned vaginal delivery or cesarean section. The study found no significant differences in neonatal or maternal outcomes in the two planned mode of delivery groups. We aimed to compare neonatal and maternal outcomes of twin gestations without spontaneous onset of labor, who underwent induction of labor or pre-labor cesarean section as the intervention of induction may affect outcomes. Methods In this secondary analysis of the Twin Birth Study we compared those who had an induction of labor with those who had a pre-labor cesarean section. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity. Secondary outcome was a composite of maternal morbidity and mortality. Trial Registration: NCT00187369. Results Of the 2804 women included in the Twin Birth Study, a total of 1347 (48%) women required a delivery before a spontaneous onset of labor occurred: 568 (42%) in the planned vaginal delivery arm and 779 (58%) in the planned cesarean arm. Induction of labor was attempted in 409 (30%), and 938 (70%) had a pre-labor cesarean section. The rate of intrapartum cesarean section in the induction of labor group was 41.3%. The rate of the primary outcome was comparable between the pre-labor cesarean section group and induction of labor group (1.65% vs. 1.97%; p  = 0.61; OR 0.83; 95% CI 0.43–1.62). The maternal composite outcome was found to be lower with pre-labor cesarean section compared to induction of labor (7.25% vs. 11.25%; p  = 0.01; OR 0.61; 95% CI 0.41–0.91). Conclusion In women with twin gestation between 32 0/7 –38 6/7 weeks of gestation, induction of labor and pre-labor cesarean section have similar neonatal outcomes. Pre-labor cesarean section is associated with favorable maternal outcomes which differs from the overall Twin Birth Study results. These data may be used to better counsel women with twin gestation who are faced with the decision of interventional delivery.

Consensus is lacking as to whether routine screening and treatment for gestational diabetes mellitus is warranted. This large randomized trial of the treatment of gestational diabetes demonstrated that serious perinatal complications were significantly less common among the offspring of women who received dietary advice, blood glucose monitoring, and insulin therapy as needed to maintain glycemic control than among the offspring of women who received routine care. This trial demonstrated that serious perinatal complications were significantly less common among the offspring of women who received screening and treatment for gestational diabetes mellitus than among the offspring of women who received routine care. Gestational diabetes mellitus occurs in 2 to 9 percent of all pregnancies 1 , 2 and is associated with substantial rates of maternal and perinatal complications. The risk of perinatal mortality is not increased, 3 but the risk of macrosomia is. Other perinatal risks include shoulder dystocia, birth injuries such as bone fractures and nerve palsies, and hypoglycemia. Long-term adverse health outcomes reported among infants born to mothers with gestational diabetes include sustained impairment of glucose tolerance, 4 subsequent obesity 5 (although not when adjusted for size 6 ), and impaired intellectual achievement. 7 For women, gestational diabetes is a strong risk factor for diabetes. 8 Although the . . .

Background Fragile and conflict-affected states contribute with more than 60% of the global burden of maternal mortality. There is an alarming need for research exploring maternal health service access and quality and adaptive responses during armed conflict. Taiz Houbane Maternal and Child Health Hospital in Yemen was established during the war as such adaptive response. However, as number of births vastly exceeded the facility’s pre-dimensioned capacity, a policy was implemented to restrict admissions. We here assess the restriction’s effects on the quality of intrapartum care and birth outcomes. Methods A retrospective before and after study was conducted of all women giving birth in a high-volume month pre-restriction (August 2017; n  = 1034) and a low-volume month post-restriction (November 2017; n  = 436). Birth outcomes were assessed for all births (mode of birth, stillbirths, intra-facility neonatal deaths, and Apgar score < 7). Quality of intrapartum care was assessed by a criterion-based audit of all caesarean sections ( n  = 108 and n  = 82) and of 250 randomly selected vaginal births in each month. Results Background characteristics of women were comparable between the months. Rates of labour inductions and caesarean sections increased significantly in the low-volume month (14% vs. 22% (relative risk (RR) 0.62, 95% confidence interval (CI) 0.45-0.87) and 11% vs. 19% (RR 0.55, 95% CI 0.42-0.71)). No other care or birth outcome indicators were significantly different. Structural and human resources remained constant throughout, despite differences in patient volume. Conclusions Assumptions regarding quality of care in periods of high demand may be misguiding - resilience to maintain quality of care was strong. We recommend health actors to closely monitor changes in quality of care when implementing resource changes; to enable safe care during birth for as many women as possible.

Background The prevalence of obesity amongst women bearing children in Australia is rising and has important implications for obstetric care. The aim of this study was to assess the prevalence and impact of mothers being overweight and obese in early to mid-pregnancy on maternal, peripartum and neonatal outcomes. Methods A secondary analysis was performed on data collected from nulliparous women with a singleton pregnancy enrolled in the Australian Collaborative Trial of Supplements with antioxidants Vitamin C and Vitamin E to pregnant women for the prevention of pre-eclampsia (ACTS). Women were categorized into three groups according to their body mass index (BMI): normal (BMI 18.5-24.9 kg/m 2 ); overweight (BMI 25-29.9 kg/m 2 ) and; obese (BMI 30-34.9 kg/m 2 ). Obstetric and perinatal outcomes were compared by univariate and multivariate analyses. Results Of the 1661 women included, 43% were overweight or obese. Obese women were at increased risk of pre-eclampsia (relative risk (RR) 2.99 [95% confidence intervals (CI) 1.88, 4.73], p < 0.0001) and gestational diabetes (RR 2.10 [95%CI 1.17, 3.79], p = 0.01) compared with women with a normal BMI. Obese and overweight women were more likely to be induced and require a caesarean section compared with women of normal BMI (induction - RR 1.33 [95%CI 1.13, 1.57], p = 0.001 and 1.78 [95%CI 1.51, 2.09], p < 0.0001, caesarean section - RR 1.42 [95%CI 1.18, 1.70], p = 0.0002 and 1.63 [95%CI 1.34, 1.99], p < 0.0001). Babies of women who were obese were more likely to be large for gestational age (LFGA) (RR 2.08 [95%CI 1.47, 2.93], p < 0.0001) and macrosomic (RR 4.54 [95%CI 2.01, 10.24], p = 0.0003) compared with those of women with a normal BMI. Conclusion The rate of overweight and obesity is increasing amongst the Australian obstetric population. Women who are overweight and obese have an increased risk of adverse pregnancy outcomes. In particular, obese women are at increased risk of gestational diabetes, pregnancy induced hypertension and pre-eclampsia. Effective preventative strategies are urgently needed. Trial Registration Current Controlled Trials ISRCTN00416244

IntroductionAround the world, rates of induction of labour (IOL) among nulliparous mothers have increased in the last 10 years. In Australia, rates have increased over the last decade by 43%, from 32% to 46%. There is growing concern about the rapid rise in IOL before 41 weeks for nulliparous women without medical complications because of the associated increased rates of caesarean section, reduced satisfaction with birth, and birth trauma. Melatonin potentiates the action of oxytocin and may promote the spontaneous onset of labour; therefore, we will test the hypothesis that exogenous melatonin supplementation in late pregnancy will reduce the rate of labour induction by 30% or more.Methods and analysesThis is a double-blind, randomised, placebo-controlled trial in nulliparous pregnant women to reduce IOL rates. We will randomise 530 women to receive either 3 mg oral melatonin or placebo daily from 39+0 weeks’ gestation until they give birth. The primary endpoint will be IOL rate after 39 weeks post enrolment. Secondary endpoints will include the following: interval between administration of trial medication and birth; a range of maternal and neonatal outcomes, including birth outcomes; breastfeeding on discharge, at 10 days and at 2 months; maternal satisfaction; child developmental outcomes at 2 months of age; and cost-effectiveness of melatonin compared with standard care. All data will be analysed by intention to treat.Ethics and disseminationThe study is approved by the Western Australia Health Central Human Research Ethics Committee (RGS0000006283). Trial findings will be disseminated through conference presentations and peer-reviewed publications.Trial registration numberThe trial has been prospectively registered on the Australian New Zealand Clinical Trials Registry as ACTRN12623000502639 on 17/05/2023.

41 weeks looks like the safer option for women and their babies

Background The socioecological resilience (SER) model explains that individual, relational, and structural factors influence child development and mental health. Children in low-to middle-income countries (LMICs) are affected by multiple risk factors on different SER levels. This cross-sectional study aimed assess the influence of experience of child labour and poor caregiving practices on child development in LMICs using the SER model. Method Data regarding child development, caregiving practices, and child labour collected through Multiple Indicator Cluster Surveys (MICS) by UNICEF were analysed. Differences in prevalence of developmental delays, mental illness, child labour, and poor caregiving practices were compared across countries and across different sociodemographic index (SDI) levels. Multi-level modelling was used to determine factors associated with developmental difficulties, and anxiety, and depression symptoms in children. Results 251,681 children were included in the analysis. Significant variations in child labour engagement existed across low to upper-middle SDI countries. Prevalence of anxiety (30.8%), depression (40.8%) and socio-emotional difficulties (mean score = 0.115) were highest in low SDI countries. Poor physical caregiving, engagement in child labour, and low maternal education was significantly associated with higher socio-emotional difficulties, anxiety, and depression. Conclusion To address the complex interplay between extreme poverty and adverse child health outcomes across low SDI countries, a multifaceted approach aimed at alleviating poverty, improving access to education, strengthening social protection systems, and promoting effective caregiving practices are required.