Research focused on novel refining of currently used labour induction method or regimen to improve efficiency and acceptability in high, mixed

and also low risk populations.

The candidate put forward the published reports of four randomised clinical trials(Tan, Daud, et al., 2009; Tan, Jacob, et al., 2006; Tan et al., 2013; Tan, Valiapan, et al., 2007) which taken together represent a consistent research program to improve the labour induction process.

2.1.3.1. Tan PC, Jacob R, Omar SZ. Membrane sweeping at initiation of formal labor induction: a randomized controlled trial. Obstet Gynecol. 2006 Mar;107(3):569-77.(Tan, Jacob, et al., 2006)

This trial investigated the utility of a single membrane sweep immediately prior to standard formal labour induction in 264 women of mixed parity and cervical

favourability with various indications for labour induction. Post-intervention, standard labour induction management and labour care was extended to all participants.

Major findings

Women randomised to membrane sweeping compared to controls had higher spontaneous vaginal delivery rate (69% compared with 56%, P = .041), shorter induction to delivery interval (mean 14 compared with 19 hours, P = .003), fewer that required oxytocin use (46% compared with 59%, P = .037), shorter duration of oxytocin infusion (mean 2.6 compared with 4.3 hours, P = .001) and improved visual analog score (VAS) for birth process satisfaction (mean 4.0 compared with 4.7, P = .015). The reduction in dinoprostone dose used (mean 1.2 compared with 1.3, P = .082) was not significant. Post sweeping VAS for pain (mean 4.7 compared with 3.5, P < .001) was significantly increased.

We recommended that adjunctive membrane sweeping at initiation of formal labour induction at term should be performed as there was significant benefit.

2.1.3.2. Tan PC, Valiapan SD, Tay PY, Omar SZ. Concurrent oxytocin with dinoprostone pessary versus dinoprostone pessary in labour induction of nulliparas with an unfavourable cervix: a randomised placebo-controlled trial. BJOG. 2007 Jul;114(7):824-32.(Tan, Valiapan, et al., 2007)

This randomised controlled trial compared titrated oxytocin infusion concurrently with dinoprostone pessary compared with titrated placebo saline infusion

concurrently with dinoprostone pessary for the first 6 hours of labour induction in 208 nulliparas with unfavourable cervixes and intact membranes. After the 6 hours, standard open label induction and labour care was applied.

Major findings

Concurrent oxytocin infusion with dinoprostone pessary did not significantly increase vaginal delivery rate within 24 hours (48.6 versus 35.9%; P = 0.07, RR 1.4 [95% CI 1.0–1.9]). It reduced the requirement for repeat dinoprostone (37.1 versus 61.2%; P = 0.001, RR 0.61 [95% CI 0.45–0.81]) and improved maternal satisfaction with the birth process (median score of 3 versus 5 on a 10-point visual analogue scale, P = 0.007). Caesarean rates were not different (41.9 versus 44.7%, P = 0.52). Uterine hyperstimulation syndrome was uncommon and not different. Induction to delivery interval although shorter (after excluding 2 extreme outliers) 24.2 ± 16.3 versus 26.2 ± 14.2 hours (P = 0.36) was not significantly different.

At the time of publication, this trial was the largest that dealt with concurrent use of dinoprostone and oxytocin for labour induction. Although the trial did not demonstrate an increase in vaginal delivery within 24 hours (P = 0.07), the result was borderline and given the positive data from earlier trials(Bolnick et al., 2004;

Christensen et al., 2002; Hennessey, Rayburn, Stewart, & Liles, 1998; Stewart et al., 1998), our study might still be underpowered as the observed effect was

smaller than the pilot data from earlier trials we used in our sample size

calculation. This intervention should be tested in larger studies. Meaningful meta-analysis is difficult as the earlier trials used very diverse concurrent regimens.

2.1.3.3. Tan PC, Daud SA, Omar SZ. Concurrent dinoprostone and oxytocin for labor induction in term premature rupture of membranes. Obstet Gynecol.

2009 May;113(5):1059-65.(Tan, Daud, et al., 2009)

This original randomised double blind controlled trial compared concurrent dinoprostone pessary and titrated oxytocin infusion to placebo pessary and titrated oxytocin infusion in 114 term nulliparous with unfavourable cervixes who

underwent labour induction indicated by prelabour rupture of membranes.

Major Findings

Vaginal delivery rates within 12 hours were 25/57 (43.9%) versus 27/57 (47.4%), median maternal satisfaction VAS was 8 [interquartile range 2] versus 8 [IQR 2] P

= 0.38, uterine hyperstimulation was 14% vs. 5.3% P = 0.20, overall vaginal delivery rates 59.6% vs. 64.9% P = 0.70 and induction to vaginal delivery interval 9.7 vs. 9.4 hours P = 0.75 for concurrent treatment versus oxytocin. There was no significant difference for any other outcome.

Our original findings were that concurrent vaginal dinoprostone and intravenous oxytocin for labour induction of term PROM did not expedite delivery or improve patient satisfaction. Although not significant, the concurrent use arm generally has

less favourable outcomes. This inverse trend indicates that in women with PROM, the addition of dinoprostone to the “gold standard” titrated oxytocin

infusion(Hannah et al., 1996) is unlikely to be beneficial and there seems little basis for pursuing similar trials.

2.1.3.4. Tan PC, Soe MZ, Sulaiman S, Omar SZ. Immediate compared with delayed oxytocin after amniotomy labor induction in parous women: a randomized controlled trial. Obstet Gynecol. 2013 Feb;121(2 Pt 1):253-9.(Tan et al., 2013)

This original randomised trial compared immediate titrated oxytocin infusion to titrated placebo saline infusion after amniotomy for labour induction in 206 multiparas. After four hours, blinded trial infusions were stopped and open label standard obstetric management was instituted.

Major Findings

Vagina delivery rates at 12 hours were 91/96 (94.8%) vs. 91/94 (96.8%) RR 0.98 95% CI 0.92-1.04) P = 0.72 and satisfaction VNRS (median [interquartile range]) 3 [3-4] vs. 3 [3-5] P = 0.36 for immediate vs. delayed arms respectively and were similar. Caesarean delivery, maternal fever, postpartum haemorrhage, uterine hyperactivity and adverse neonatal outcome rates were similar. The immediate oxytocin arm had a shorter amniotomy to delivery interval of 5.3 ± 3.1 vs. 6.9 ± 2.9 hours P < 0.001 and lower epidural analgesia rate of 2.9% vs. 9.9% RR 0.3 95% CI 0.1-1.0 P = 0.046 but fetal heart rate abnormalities on cardiotocogram

was higher, 28.6% vs.16.8% RR 1.7 95% CI 1.0-2.9 P = 0.048. In the delay arm, oxytocin infusion was avoided by 35.6%.

We concluded that immediate or delayed oxytocin infusions were reasonable options after amniotomy for labour induction in parous women with favorable cervixes. The choice should take into account care provision locally and the woman’s wish.

2.2. Papers are “Thematically linked or tied to a particular research