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Re: IUPC placement was: glove use in L&D From: Jonathan Daniels (jdaniels@sd.cybernex.net) Sat Jan 11 01:17:33 1997 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Dr Eberhard W Lisse: "Re: I have an idea" Previous message: Jonathan Daniels: "Re: IUPC placement was: glove use in L&D" Maybe in reply to: richardc@bcm.tmc.edu: "IUPC placement was: glove use in L&D" Next in thread: DoctorJoe@aol.com: "Re: IUPC placement was: glove use in L&D" At 12:23 PM 1/10/97 -0600, you wrote: >Speaking of which, how often do you examine the cervix? I rarely examine >before 40 weeks, unless there is a reason. Once in labor I remember >what Dr. Day said. "Exam at the time of admission, the time of >analgesia and the time of delivery." I try to follow that, unless there >is a cause to do more. What do y'all do? > >Rick > I agree. I don't routinely examine prior to 40 weeks. I examine pts in labor much less now than in residency, and I rarely see infections. In training patients were examined by nurses, students, residents and attendings sometimes 10 or more times, and chorioamnionitis and endometritis were common. As I recall there were some studies that showed that five or more exams were associated with an increased rate of infection. Also I do not routinely do an amniotomy on admission of my patients as some of my attendings in residency did. I like to have a reason before doing an amniotomy, like: to place internals, to check for meconium, or to speed the progress of labor. Many patients will progress nicely and rupture spontaneously. I even have a few that do not rupture until delivery. I would like to know what some of my colleagues think. I feel that by limiting exams as much as possible, delaying amniotomy for inductions and in spontaneous labor, and inducing for PROM at term, I reduce the rate of infections. Am I all wet? After doing a brief medline search I found a 1995 article in the "grey" journal about early vs. delayed amniotomy for induction of labor that seems to support my thinking. I also found a 1996 article in the NEJM on induction or expectant management for PROM. I'll attach the abstracts. Hannah ME, Ohlsson A, Farine D, Hewson SA, Hodnett ED, Myhr TL, Wang EE, Weston JA, Willan AR Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group [see comments] Department of Obstetrics and Gynaecology, University of Toronto, Canada. N Engl J Med 1996 Apr 18;334(16):1005-10 Article Number: UI96177830 ABSTRACT: BACKGROUND. As the interval between rupture of the fetal membranes at term and delivery increases, so may the risk of fetal and maternal infection. It is not known whether inducing labor will reduce this risk or whether one method of induction is better then another. METHODS. We studied 5041 women with prelabor rupture of the membranes at term. The women were randomly assigned to induction of labor with intravenous oxytocin; induction of labor with vaginal prostaglandin E2 gel; or expectant management for up to four days, with labor induced with either intravenous oxytocin or vaginal prostaglandin E2 gel if complications developed. The primary outcome was neonatal infection. Secondary outcomes were the need for cesarean section and women's evaluations of their treatment. RESULTS. The rates of neonatal infection and cesarean section were not significantly different among the study groups. The rates of neonatal infection were 2.0 percent for the induction-with-oxytocin group, 3.0 percent for the induction-with-prostaglandin group, 2.8 percent for the expectant-management (oxytocin) group, and 2.7 percent for the expectant-management (prostaglandin) group. The rates of cesarean section ranged from 9.6 to 10.9 percent. Clinical chorioamnionitis was less likely to develop in the women in the induction-with-oxytocin group than in those in the expectant-management (oxytocin) group (4.0 percent vs. 8.6 percent, P<0.001), as was postpartum fever (1.9 percent vs. 3.6 percent, P=0.008). Women in the induction groups were less likely to say they liked "nothing" about their treatment than those in the expectant-management groups. CONCLUSIONS. In women with prelabor rupture of the membranes at term, induction of labor with oxytocin or prostaglandin E2 and expectant management result in similar rates of neonatal infection and cesarean section. Induction of labor with intravenous oxytocin results in a lower risk of maternal infection than does expectant management. Women view induction of labor more positively than expectant management. Comment in: N Engl J Med 1996 Apr 18;334(16):1053-4 -- =========================================================================== Mercer BM, McNanley T, O'Brien JM, Randal L, Sibai BM Early versus late amniotomy for labor induction: a randomized trial. Department of Obstetrics and Gynecology, University of Tennessee, Memphis, USA. Am J Obstet Gynecol 1995 Oct;173(4):1321-5 Article Number: UI96041807 ABSTRACT: OBJECTIVE: Our purpose was to determine the impact of early and late amniotomy on labor induction with continuous oxytocin infusion at term. STUDY DESIGN: A total of 209 women admitted for labor induction were randomized to early or late amniotomy. The early amniotomy group (n = 106) had membranes ruptured as soon as it was deemed safe and feasible. The late amniotomy group (n = 103) had membrane rupture performed at > or = 5 cm dilatation. The first 103 women received a continuous oxytocin infusion with incremental adjustments at 60-minute intervals as required. The next 106 women had adjustments every 30 minutes as required. Statistical analysis was confined to concurrent groups. RESULTS: Early amniotomy was associated with shorter labor (13.3 vs 17.8 hours, p = 0.001), chorioamnionitis (22.6% vs 6.8%, p = 0.002), and significant fetal umbilical cord compression (12.3% vs 2.9%, p = 0.017). The benefit regarding shortening of labor was limited to women having oxytocin increments every 30 minutes as required (13.3 vs 17.8 hours, p = 0.001). Alternatively, the increase in chorioamnionitis was confined to the 60-minute group (39% vs 11%, p < 0.001), which also demonstrated a trend toward increased moderate and severe variable decelerations (19.6% vs 6.4%, p = 0.08). CONCLUSIONS: When a protocol of 60-minute increments in oxytocin infusion rate is desired, amniotomy should be performed late in labor to reduce chorioamnionitis and significant umbilical cord compression. Alternatively, if early amniotomy is necessary, oxytocin should be adjusted every 30 minutes as tolerated. =========================================================================== J. Daniels MD Private Practice Ob/Gyn Next message: Dr Eberhard W Lisse: "Re: I have an idea" Previous message: Jonathan Daniels: "Re: IUPC placement was: glove use in L&D" Maybe in reply to: richardc@bcm.tmc.edu: "IUPC placement was: glove use in L&D" Next in thread: DoctorJoe@aol.com: "Re: IUPC placement was: glove use in L&D"

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