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The journey from induction to birth and beyond
BJOG: An International Journal of Obstetrics & Gynaecology ( IF 4.7 ) Pub Date : 2024-07-03 , DOI: 10.1111/1471-0528.17883
Makrina Savvidou

“I would rather stand three times with a shield in battle than give birth once.” (Euripides, Medea 251)

Misoprostol, a synthetic analogue of prostaglandin E1, was approved in 1988, for the prevention and treatment of peptic ulcers associated with the use of nonsteroidal anti-inflammatory drugs. It is hard to believe that a drug initially used by gastroenterologists could become a crucial medication in obstetric practice. Misoprostol's versatility in administration, affordability, efficacy, relative safety and easy storage have contributed to its popularity. In 1987, the first studies on the off-label use of misoprostol for pregnancy termination, medical evacuation of missed abortions and as a cervical-priming agent prior to vacuum aspiration of the uterus started being published. These were followed by studies on its use for mid-trimester termination of pregnancy, management of intra-uterine fetal death, third stage of labour, induction of labour and post-partum haemorrhage.1 It wasn't until nearly 15 years later that the FDA finally approved a new label addressing the use of misoprostol during pregnancy. This was followed by a number of trials demonstrating that misoprostol is at least as safe and effective as dinoprostone, the previous most popular agent for labour induction.2 In this issue of BJOG (pages 1167-1180) Patabendige et al. conducted an individual participants' data meta-analysis of randomised controlled trials comparing the use of vaginal misoprostol and dinoprostone for the induction of labour. They concluded that both methods of labour induction were comparable in terms of effectiveness and perinatal safety as well as mode of delivery including vaginal, instrumental or Caesarean birth performed for failure to progress or fetal distress, supporting the non-inferiority of vaginal misoprostol.

Approximately, 30% of women in the UK and US deliver by Caesarean section3, 4 and at least 5% of these deliveries are performed in the second stage of labour. Full dilatation caesarean sections can be associated with significant maternal and neonatal complications, mainly due to extension of the uterine incision, resulting in haemorrhage, and birth injuries related to ‘impacted fetal head’; both of which are classified as obstetric emergencies. There is no consensus on the definition of ‘impacted head’ and consequently data on its incidence and guidance on the most effective and safest method of management, are lacking. Several management strategies including tocolysis, vaginal disimpaction (‘push’ method), breech extraction, Patwardhan method and use of the Fetal Pillow® have been employed. In 2022, a UKOSS prospective survey showed that the ‘push’ technique was the most commonly used technique to facilitate the delivery of the deeply engaged head, followed by the Fetal Pillow®.5 The Fetal Pillow® was first introduced in 2014 and initial small studies suggested a reduction in maternal and fetal complications. However, subsequent studies failed to demonstrate any significant improvement in perinatal complications and as a result, the National Institute for Health and Care Excellence (NICE) withdrew its support for the device, recommending further research before its introduction into clinical practice. Despite this, the Fetal Pillow® is now widely used worldwide. In the current issue (pages 1240-1248), Sadler et al. retrospectively investigated, the effect of the Fetal Pillow® on maternal and neonatal morbidity in two maternity units in New Zealand. They compared the rates of adverse outcomes before and after the introduction of the Fetal Pillow®, and between cases where the Fetal Pillow® was used, or not used despite being available. Despite the large number of births analysed, the study failed to demonstrate a significant difference in the risk of major uterine extensions or composite neonatal adverse outcomes in cases where the Fetal Pillow® was used (N = 375). Despite being retrospective, the study provides valuable insights into the use of this device in clinical practice. Only a randomised trial that compares various techniques for managing an impacted fetal head can provide definite answers to this complex problem. Until such a trial is undertaken, the use of high-fidelity simulation training, and the implementation of standardised management pathways, are likely to be the safest and most effective approach.

The management of fetal head impaction and caesarean section at full dilatation presents significant challenges, with potential negative impacts on maternal and neonatal health, including the increased risk of preterm labour in subsequent pregnancies. Unfortunately, there is no current consensus on the best way to deliver a pregnant person with prolonged second stage of labour. Beyond the immediate consequences, we need to consider the extent to which a prolonged second stage and the mode of delivery affect the pelvic floor function in the long term. Some (but not all) studies have associated a prolonged second stage with urinary and anal incontinence as well as pelvic organ prolapse. In the current issue (pages 1279-1289), Bergendahl et al. employed a population-based questionnaire to explore the impact of vacuum extraction and Caesarean section, in comparison to expectant management, on the pelvic floor function of primiparous women, 1–2 years following childbirth. This research focused specifically on birth complicated by prolonged (≥3 h) second stage. The response rate was only 45.8%, so conclusions must be guarded. However, in the responding population one in three women experienced subsequent moderate-to-severe pelvic floor dysfunction and this risk was increased following the use of vacuum extraction. Interestingly, Caesarean section did not significantly decrease the risk when compared to expectant management. As the unpredictable nature of childbirth poses challenges, we may need to wait for advancements in artificial intelligence, machine learning and complex algorithms to tell us when and how to deliver pregnant individuals.



中文翻译:


从引产到出生及之后的旅程



“我宁愿拿着盾牌在战场上站三次,也不愿生一次。” (欧里庇得斯、美狄亚251)


米索前列醇是前列腺素 E1 的合成类似物,于 1988 年被批准用于预防和治疗与使用非甾体抗炎药相关的消化性溃疡。很难相信最初由胃肠病学家使用的药物可能成为产科实践中的关键药物。米索前列醇在给药方面的多功能性、经济性、有效性、相对安全性和易于储存使其广受欢迎。 1987 年,第一份关于超说明书使用米索前列醇终止妊娠、稽留流产医疗后送以及在子宫真空吸引术前作为宫颈启动剂的研究开始发表。随后进行了关于其用于妊娠中期终止妊娠、宫内胎儿死亡处理、第三产程、引产和产后出血的研究。 1直到近 15 年后,FDA 才最终批准了针对妊娠期间使用米索前列醇的新标签。随后进行的多项试验表明,米索前列醇至少与以前最受欢迎的引产药物地诺前列酮一样安全有效。 2本期 BJOG(第 1167-1180 页)Patabendige 等人。对比较使用阴道米索前列醇和地诺前列酮引产的随机对照试验进行了个体参与者的数据荟萃分析。 他们的结论是,两种引产方法在有效性和围产期安全性以及分娩方式(包括因进展失败或胎儿窘迫而进行的阴道分娩、器械分娩或剖腹产)方面具有可比性,支持阴道米索前列醇的非劣效性。


在英国和美国,大约 30% 的女性通过剖腹产3、4分娩,其中至少 5% 在第二产程中进行。完全扩张剖腹产可能会导致严重的孕产妇和新生儿并发症,主要是由于子宫切口扩大,导致出血,以及与“胎头受影响”相关的产伤;两者都被归类为产科紧急情况。对于“头部受影响”的定义尚未达成共识,因此缺乏有关其发生率的数据以及最有效和最安全的治疗方法的指导。已采用多种管理策略,包括安胎、阴道松解(“推”法)、臀位拔出、Patwardhan 法和使用 Fetal Pillow®。 2022 年,UKOSS 的一项前瞻性调查显示,“推”技术是最常用的促进深度接合头部分娩的技术,其次是胎儿枕®。 5 Fetal Pillow® 于 2014 年首次推出,最初的小型研究表明可以减少母婴并发症。然而,随后的研究未能证明围产期并发症有任何显着改善,因此,国家健康与护理卓越研究所 (NICE) 撤回了对该设备的支持,建议在将其引入临床实践之前进行进一步研究。尽管如此,胎儿枕®现已在全球范围内广泛使用。在本期(第 1240-1248 页)中,Sadler 等人。回顾性调查了胎儿枕头®对新西兰两个产科中心孕产妇和新生儿发病率的影响。 他们比较了引入 Fetal Pillow® 前后的不良后果发生率,以及使用 Fetal Pillow® 或尽管可用但未使用 Fetal Pillow® 的病例之间的不良后果发生率。尽管分析了大量新生儿,但该研究未能证明使用 Fetal Pillow® 的情况下,主要子宫扩张或复合新生儿不良结局的风险存在显着差异 ( N = 375)。尽管是回顾性的,但该研究为该设备在临床实践中的使用提供了宝贵的见解。只有比较各种处理受影响胎头的技术的随机试验才能为这个复杂的问题提供明确的答案。在进行这样的试验之前,使用高保真模拟培训并实施标准化管理路径可能是最安全、最有效的方法。


胎头嵌塞和全扩张剖腹产的处理面临着巨大的挑战,对孕产妇和新生儿健康有潜在的负面影响,包括增加随后怀孕中早产的风险。不幸的是,目前对于第二产程延长孕妇的最佳分娩方式尚未达成共识。除了直接后果之外,我们还需要考虑第二产程延长和分娩方式对盆底功能的长期影响程度。一些(但不是全部)研究将第二阶段延长与尿失禁、肛门失禁以及盆腔器官脱垂相关。在本期(第 1279-1289 页)中,Bergendahl 等人。采用基于人群的问卷调查来探讨负压吸引术和剖腹产与期待治疗相比,对初产妇产后 1-2 年盆底功能的影响。这项研究特别关注第二产程延长(≥3 小时)并发的分娩。答复率仅为45.8%,因此结论必须谨慎。然而,在受访人群中,三分之一的女性随后经历了中度至重度盆底功能障碍,并且在使用负压吸引后这种风险增加。有趣的是,与期待治疗相比,剖腹产并没有显着降低风险。由于分娩的不可预测性带来了挑战,我们可能需要等待人工智能、机器学习和复杂算法的进步来告诉我们何时以及如何分娩怀孕的个体。

更新日期:2024-07-03
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