362 SPO Abstracts

230 INTRACERVICAl PROSTAGLANDIN E7 FOR INDUCTION OF LABOR IN PATIENTS NITH PREMATURE RUPTURE OF MEMBRANES AND AN UNFAVOURABLE CERVIX. R. Gonen ~ J. Salberg, S. Degan i, M. Sharf. Dept. 08/GYN, Bna i Zion Hospital, Faculty of- Medicine, Technion, Haifa, Israel. OBJECTIVE: To evaluate the efficacy and safety of intracervical prostaglandin (PS) El gel for induction of labor in patients with prelature rupture of the meMbranes (PROM) at terl and an unfavorab le cervi x. STUDY DESIGN: Sixty two patients who did not start labor 6-11 hours after PROM and who had an unfavorab le cervix were randolized to one of two ManageMent protocols: Patients randolized to P6 El received a single intracervical application of 0.5 Mg PG E1. Patients randOMized to the conservative protocol were Managed expectantly for 1( hours. If labor was not established after 6 hours in patients receiving P6 El or after H hours in patients Managed expectantly labor was induced with intravenous oxytocin. The tile interval to de livery, the need for oxyocin, pregnancy outco.e and comp lications were ana 1yzed. RESULTS: Ninety three percent of patients receiving PG El began labor after a single application, and the lean interval to delivery was 6.6 hours. In the conservative group only 571 began labor within H hours, and over ha 1f of the. required auglentation with oxytocin. The lean latency between PROM and de livery was 15 hours in patients managed with PG El and 30 hours in patients lanaged conservatively (p<D.Ol). There were no cOlplications and pregnancy outcole was sililar in the two groups. CONCLUSIONS: Intracervical PG El is safe and effective for inducing labor in patients with PROM and an unripe cervix.

231 CERVICAL RIPENING WITH SUPRACERVICAL BALLOON AND EXTRA-AMNIOTIC SALINE INSTILLATION (SBXAS). DJ. Shennan, S. Arieli, A. Raziel, J. Bukovski, E. Caspi. Dept Ob/Gyn, Assaf-Harofeh Med. Ctr., Sackler School of Medicine-Tel-Aviv University, Zerifin, Israel. OBJECTIVE: Cervical ripening with SBXAS has been used routinely since a preliminary study suggested that it is superior to vaginal prostaglandin E2. We retrospectively evaluated the results and perinatal outcorre of high-risk pregnancies with highly unfavorable cervix, subjected to ripening with this method. Factors related to the mode of delivery were also investigated. STUDY DESIGN: SBXAS was attempted in 190 patients with Bishop scores of <=4, using a Foley catheter with a 30-40ml inflated balloon; normal saline solution was infused extra-amniotically at 1 ml/min. Ten patients were excluded due to inadequate trial (balloon deflated prior to spontaneous expulsion). In the remaining 180, after spontaneous balloon expulsion labor was induced by IV oxytocin and/or amniotomy. Pre- and post-ripening Bishop scores were obtained in all cases. Values are mean ±SEM. RESULTS: Average time for balloon expulsion was 6.1±OJ (hours) and the mean Bishop score changed from 1.5±O.1 to 5.5±O.1. In 63% of the patients, oxytocin was used for labor induction and/or augmentation, but only 24% had dystocias. Other complications included susp. fetal distress (18%) and intrapartum fever (3%). Cesarean section accounted for 16% (2/3 for dystocias) and vaccum extraction for 8% of deliveries. In most patients (98%) delivery occurred within 24h from balloon expulsion or labor induction. Low 5 min. Apgar scores «=7) were noted in 1.7% of newborns. Bishop scores (post- and pre-SBXAS) and the presence of hypertension were significantly correlated with the mode of delivery. CONCLUSIONS: SBXAS is a safe, rapid and effective rrethod for ripening the highly unfavorable cervix. No serious side effects were encountered when used routinely by nurrerous physicians. However, compared with our overall rates, it is associated with increased oxytocin use, dystocia and cesarean section rates.

January 1993 Am J Obstet Gynecol

232 THE EFFECT OF NARCOTlCS AND SPASMOLYTICS ON CERVICAL DILATATlON IN LABOR: A RANDOMIZED PLACEBO-CONTROLLED STUDY. a. laskin', G. Saade', M. BeHort", K. Moise. Depts. OIVGyn, Inonu University, Malatya, Turkey and Baylor College of Medicine, Houston, TX. OBJECTIVE: To evaluate the effects of opiate analgesic and antispasmodic agents on cervical dilatation during the active phase of labor. STUDY DESIGN: Randomized placebo<ontrolled study. Term laboring patients with cervical dilatation ,;; 5 cm. All had an uncomplicated prenatal course. Patients with abnormal presentation, previous cesarean section, ruptured membranes, or evidence of fetal or maternal compromise were excluded. Patients were randomly assigned to receive either meperidine 50 mg (M), hyoscine bromide 20 mg (H), valethamate bromide 8 mg (V), or placebo (P) intravenously at 4-5 cm dilatation. Nulliparous and multiparous patients were studied separately. Patients and physicians were unaware of group assignments. All patients received an oxytocin infusion in order to ensure at least 3 contractions/IO minutes. No patient had regional anesthesia. Cervical examinations were performed at least every hour by a single examiner. The data was analyzed using t>H:JVA, NewmarH<euls, chi-square and randomization tests wherever appropriate. A p < 0.05 was used to denote statistical significance. RESULTS: 20 nulliparous and 10 multiparous patients were randomized into each medication group. The demographic characteristics of the groups were similar and there were no Significant differences in neonatal weight or Apgar scores. Sixteen patients underwent cesarean section prior to full dilatation and were excluded. There was no difference in the rate of cesarean section between .the groups. The administration to complete dilatation time was significanijy shorter in the medicated groups when compared to placebo in the nulliparous (V: 61±14, H: 73±9, and M: 91±16 vs P: 114±11 minutes) and the multiparous patients IN: 20±4, It 25±3, and M: 37±5 vs P: 48±8 minutes~ valethamate and hyoscine were more effective than meperidine or placebo in both nulliparous and multiparous patients. No major maternal or fetal side effects were noted during this study. CONCLUSION: Narcotic analgesics and spasmolytics may be helpful in

shortening the active phase of labor.

233 CONTRIBUI1NG FACfORS TO THE INCREASED CESAREAN BIRTH RATE IN OLDER PARTURIENTS. AdasheklA', PeacemanAM, Lopez-Zeno lA, Minogue Ii>', Socol ML. Department of Obstetrics and Gynecology, NorthWCllcm University Medical School, Chicago 1IIinois. OBJECfIVE: To determine the contribution of physician factors, maternal age, and birth weight to the incrc:ascd utilization of CS in women ;" 35 years of age. STUDY DESIGN: Data were collected prospectively on 599 consecutive nulliparous women in spontaneous labor at term with singleton pregnancies in cephalic presentation. Criteria for the diagnosis of labor were standardized: regular, painful uterine contractions in the presence of either complete cervical effacement or ruptured membranes. Decisions regarding timing of amniotomy and use of oxytocin were made by the managing obstetrician. The labors of women ;,,35 years of age (n=74) were compared to those of women age 20-29 (n=276). RESULTS: The CS rate was significantly greater for women ;,,35 (21.6% vs. 10.1 %, p < .02), primarily due to dystocia. Birth weights were similar in the two groups, but women ;,,35 with infants ;,,3600 gm were three times more likely to be delivered by CS (36.7% vs. 13.2%, p<.OI), whereas for birth weights < 3600 gm, the CS rllle& of the two groups did not differ. There was no difference bctwccn the two age groups in any physician factors examined (dilation at admission, timing of amniotomy , percentage receiving oxytocin augmentation, dilation at augmentation, or use of epidural anesthesia). Of patients delivering vaginally, the older parturients received oxytocin for longer duration (6.4±2.6 vs. 5.0±3.1 hr, p < .05) and at higher maximum doses (12.4±6.1 vs. 9.8±6.2 mU, p< .05). These data reflect that the aggressiveness of management was influenced primarily by labor progress rather than age. After controlling with multiple logistic regression analysis for demographic variables, as well as birth weight, dilation on admission, and usc of epidural anesthesia, maternal age (R=.1252, p< .(05) and birth weight (R=.1963, p< .(05) were still found to contribute significantly to the increased rate of CS. CONCLUSION: Independent of physician factors, maternal age and birth weight contributed significantly to the increased rate of CS. Arrest and protraction disorders were not morc frequent in women > 3S years oJd, but augmentation was less successful. We speculate that age related chang"" occur in the uterus wbich make it less responsive to oxytocin stimulation, especially with larger infants.