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#Grand Rounds

Secondary Analysis of ARRIVE RCT: The Association Between Amniotomy During Induction and Cesarean Delivery

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BACKGROUND AND PURPOSE:

  • Early amniotomy during induction likely decreases the duration of labor
    • Effect on cesarean delivery is less well understood
  • Battarbee et al. (American Journal of Perinatology, 2020) assessed the association between amniotomy in nulliparous women and risk for cesarean delivery

METHODS:

  • Secondary analysis of the ARRIVE RCT (NICHD/MFMU)
    • Purpose of original study was to assess perinatal outcomes in nulliparous women randomized to elective induction at 39 weeks vs expectant management
  • Participants (inclusion criteria)
    • Low-risk, nulliparous women
    • Induction ≥38 weeks using oxytocin
    • Excluded were women with antepartum stillbirth or fetal anomaly
  • Study design
    • The authors compared outcomes between
      • Women with amniotomy
      • Women with intact membranes and no amniotomy
    • Comparisons were performed at six 2-hour time intervals
      • Before oxytocin initiation
      • 0 to <2 hours after oxytocin
      • 2 to <4 hours after
      • 4 to <6 hours after
      • 6 to <8 hours after
      • 8 to <10 hours after
  • Statistical analysis
    • Multivariable logistic regression
    • Adjustments
      • Maternal age | BMI | Race/ethnicity | Modified Bishop score on admission | Treatment group | Hospital
  • Primary outcome
    • Cesarean delivery
  • Secondary outcomes
    • Maternal and neonatal complications

RESULTS:

  • 2,854 (46.7% of women from the parent trial) met inclusion criteria
    • Amniotomy: 82.0%
      • The majority were performed between 2 and <6 hours after oxytocin
  • After adjusting for confounders, only 6 to <8 hours after oxytocin was associated with lower cesarean rates
    • Amniotomy 6 to <8 hours after oxytocin: 21.9% cesarean rate
    • Without amniotomy: 29.7% cesarean rate
    • Adjusted odds ratio (OR) 0.61 (95% CI, 0.42 to 0.89)
  • Amniotomy at time intervals ≥4 hours after oxytocin was associated with lower odds of labor lasting more than 24 hours
    • 4 to <6 hours after oxytocin: aOR 0.59 (99% CI, 0.41–0.86)
    • 6 to <8 hours after oxytocin: aOR 0.38 (99% CI, 0.24–0.61)
    • 8 to <10 hours after oxytocin: aOR 0.37 (99% CI, 0.21–0.64)
  • Amniotomy at time intervals ≥2 hours and <8 hours after oxytocin was associated with lower odds of maternal hospitalization >3 days
  • There was no association between amniotomy and postpartum or neonatal complications including
    • Chorioamnionitis | PPH | Infection | NICU admission

CONCLUSION:

  • For nulliparous women at term, amniotomy during induction was associated with a risk of cesarean similar or lower compared to that of women with no amniotomy and may be associated with a shorter labor duration

Learn More – Primary Sources:

Maternal and Neonatal Outcomes Associated With Amniotomy Among Nulliparous Women Undergoing Labor Induction at Term

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