Supplemental Reading

Challis JR et al. Prostaglandins and mechanisms of preterm birth. Reproduction 2002;81:633-641.

Cox SM, Sherman M, and Leveno KJ. Randomized investigation of magnesium sulfate for prevention of preterm birth. Am J Obstet Gynecol 1990;163:797-801.

Diddy GA 3rd. Postpartum hemorrhage: New management options. Clin Obstet Gynecol 2002;45:330-344.

Goldberg Ab, Greenberg MB, and Darney PD. Misoprostol and pregnancy. N Engl J Med 2001;344:38-47.

Gyetvai K, Hannah ME, Hodnett ED, and Ohlsson A. Tocolytics for preterm labor: A systematic review. Obstet Gynecol 1999;94:869-77.

Rodts-Palenik S and Morrison JC. Tocolysis: An update for the practitioner. Obstet Gynecol Surv 2002:1:127-131.

Winkler M and Rath W. A risk-benefit assessment of oxytocics in obstetric practice. Drug Safety 1999;20:323-345.

Case Study Is Labor Induction Justified?

A 25-year-old woman is 2 weeks beyond her estimated date of delivery. She reports no pain, no labor contractions, no vaginal bleeding, no leaking fluid from her vagina, and no vaginal discharge. She reports that her fetus is moving. On further history, you find that the patient reports no other complaints, and her medical, surgical, social, and family histories are all negative. The physical examination you perform produces normal findings. Notably, her uterine fundal size measurement is 40 cm. Her pelvic examination reveals that her cervix is 3 cm dilated, 50% effaced, soft in consistency, and midpo-sition in the vagina. The fetal station is presenting at 0. You find no evidence of ruptured membranes. Uterine monitoring shows no contractions. You and the patient decide that labor induction would be safe and appropriate. What would be a good course of action?

Answer: In this case, the decision to induce labor is appropriate. In caring for patients, physicians must decide who are appropriate patients for labor induction. The median length of human pregnancy is 40 weeks (when using the woman's menstrual period to date the pregnancy). Pregnancy is considered to be full-term from the 37 0/7 weeks to 41 6/7 weeks.

Patients who are pregnant 2 or more weeks beyond their due date are classified as having postterm or postdate pregnancy. These prolonged pregnancies carry the increased risk of fetal death (2 to 6 times as high as for women who are at 40 weeks' gestation). Women who are postterm have a higher risk of cesarean section, trauma from delivery, prolonged bleeding after delivery, and prolonged hospitalization. Newborns who are born postterm have an increased risk of being pathologically large (macroso-mia), birth trauma, intolerance to labor, meconium staining, meconium aspiration, and possible subsequent hypoxia or anoxia brain injury. With all these concerns, labor induction may be safer than continuing the pregnancy.

Oxytocin is the drug of choice for inducing labor. In appropriate patients, it nearly always leads to safe vaginal delivery. Patients whose cervix is favorable for labor are good candidates for oxytocin. Obstetricians traditionally use a scoring system to rate the cervix (Bishop EH. Pelvic Scoring for Elective Induction. Obstet Gynecol 1964;24: 266-268). The following table defines the scoring system. Scores of >6 are considered favorable. Our patient has a score of 8.

Cervical Cervical

Score Dilation (cm) Effacement (%) Station Consistency Position

0 Closed 0-30 —3 Firm Posterior

1 1-2 40-50 —2 Medium Midposition

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Pregnancy And Childbirth

Pregnancy And Childbirth

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