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Excerpt
The increasing number of women undergoing trial of vaginal delivery after one or more cesarean deliveries raises the question of the safety and efficacy of ripening agents in these cases. There are limited data addressing this subject in the literature. The purpose of the present study was to evaluate the safety and efficacy of cervical ripening in women with previous low transverse cesarean deliveries undergoing labor, with unfavorable cervices.
This retrospective study was performed at the University Medical Center of Jacksonville, the hospital for the University of Florida Health Science Center in Jacksonville. Approximately 4000 women are delivered annually at this institution. The study group was composed of all the women delivered there between January 1, 1988 and December 31, 1992, who underwent cervical ripening followed by induction of labor, and who had had at least one prior low transverse cesarean delivery each. The comparison group consisted of multiparas who underwent cervical ripening with the same agents, followed by induction of labor during the same time frame, but had not had previous cesarean deliveries.
Ripening of the cervix before induction of labor was performed with an extemporaneous preparation of intracervical prostaglandin E2 gel (PGE2) or an osmotic dilator.
One hundred fifty women met the criteria for inclusion in the study. Of 89 women in the study group, 36 (40.4 percent) received PGE2 gel, 41 (46.1 percent) received an osmotic dilator, and 12 (13.5 percent) received both. In the comparison group, 28 of 61 women (47.9 percent) received PGE2 gel, 25 (41.0 percent) received an osmotic dilator, and 8 (13.1 percent) received both.
The mean gestational age at delivery was 39.6 plus/minus 2.6 and 38.2 plus/minus 2.9 weeks for the study and comparison groups, respectively. There were no differences between the groups in preinduction Bishop score, duration of the first stage of labor, maximum rate of oxytocin, birth weight, Apgar score, cord blood pH values, or maternal hematocrit. Sixty-four percent (57/89) of the study women delivered vaginally, as compared with 82 percent (50/61) of those in the companion group. Of the total cesarean deliveries, 12 (28.6 percent) were for fetal distress, 8 (19.0 percent) for failure to progress, 17 (40.5 percent) for failed induction, and 1 (2.4 percent) for fetal malpresentation. There were no differences between the study and comparison groups in terms of indications for cesarean delivery.
The incidence of postpartum endometritis was analyzed separately. Nineteen of 89 women in the study group (21.3 percent), compared with 8 of 61 (13.1 percent) in the comparison group, developed this complication. Twenty-five neonates were admitted to the neonatal intensive care unit (NICU) for a 16.7 percent total NICU admission rate. Seventeen of 89 neonates in study group (19.1 percent) were admitted to the NICU, as compared with 8 of 61 (13.1 percent) in the comparison group.
The data were analyzed separately for those women in both groups undergoing cervical ripening with PGE2 gel only. There were 36 and 28 women identified in the study and comparison groups, respectively. No differences were found between the groups in any of the outcome variables analyzed Table 1. Twenty-five women in this study subgroup (69.4 percent) delivered vaginally, as compared with 23 (82.1 percent) in the comparison subgroup.
