Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more)

 

Abstract

Background

Prelabour rupture of membranes at term is managed expectantly or by elective birth, but it is not clear if waiting for birth to occur spontaneously is better than intervening.

Objectives

To assess the effects of planned early birth versus expectant management for women with term prelabour rupture of membranes on fetal, infant and maternal wellbeing.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (November 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2004), MEDLINE (1966 to November 2004) and EMBASE (1974 to November 2004).

Selection criteria

Randomised or quasi-randomised trials of planned early birth compared with expectant management in women with prelabour rupture of membranes at 37 weeks' gestation or more.

Data collection and analysis

Two review authors independently applied eligibility criteria, assessed trial quality and extracted data. A random-effects model was used.

Main results

Twelve trials (total of 6814 women) were included. Planned management was generally induction with oxytocin or prostaglandin, with one trial using homoeopathic caulophyllum. Overall, no differences were detected for mode of birth between planned and expectant groups: relative risk (RR) of caesarean section 0.94, 95% confidence interval (CI) 0.82 to 1.08 (12 trials, 6814 women); RR of operative vaginal birth 0.98, 95% 0.84 to 1.16 (7 trials, 5511 women). Significantly fewer women in the planned compared with expectant management groups had chorioamnionitis (RR 0.74, 95% CI 0.56 to 0.97; 9 trials, 6611 women) or endometritis (RR 0.30, 95% CI 0.12 to 0.74; 4 trials, 445 women). No difference was seen for neonatal infection (RR 0.83, 95% CI 0.61 to 1.12; 9 trials, 6406 infants). However, fewer infants under planned management went to neonatal intensive or special care compared with expectant management (RR 0.72, 95% CI 0.57 to 0.92, number needed to treat 20; 5 trials, 5679 infants). In a single trial, significantly more women with planned management viewed their care more positively than those expectantly managed (RR of "nothing liked" 0.45, 95% CI 0.37 to 0.54; 5031 women).

Authors' conclusions

Planned management (with methods such as oxytocin or prostaglandin) reduces the risk of some maternal infectious morbidity without increasing caesarean sections and operative vaginal births. Fewer infants went to neonatal intensive care under planned management although no differences were seen in neonatal infection rates. Since planned and expectant management may not be very different, women need to have appropriate information to make informed choices.

 

Plain language summary

Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more)

Some evidence in favour of planned management (usually by induction) when women have prelabour rupture of membranes at term.

When women's membranes rupture at or after 37 weeks' gestation without having contractions, they can choose to intervene (usually by immediate induction with oxytocin or prostaglandin) or they can wait for spontaneous labour to occur. The concern that early planned intervention might result in more caesarean and operative births was not supported in this review, which also found that fewer mothers developed infections and that fewer babies were admitted to the neonatal intensive care units than if women waited for spontaneous birth. Similar number of babies developed infections whether intervention was early or whether women waited. In one trial, women clearly preferred early planned intervention.

 

摘要

背景

在足月時(37周或更多)針對母體早期破水時的計畫性提早生產與期待性處理法(等待)之比較

在足月時的母體早期破水(prelabour rupture of membrane)會由期待性的處理或是選擇性生產，但是等待生產行為自行發生，是否會優於醫療干預的方法，目前還不清楚。

目標

評估母體早期破水時計畫性提早生產相對於期待性處理法，對於胎兒、嬰兒以及母體健康之影響。

搜尋策略

我們搜尋了the Cochrane Pregnancy and Childbirth Group Trials Register(2004年11月)、the Cochrane Central Register of Controlled Trials(The Cochrane Library，Issue 4，2004年)、MEDLIN (1966年到2004年11月)，以及EMBASE(1974年到2004年11月)。

選擇標準

在37周的懷孕期或是更多時，在母體早期破水的婦女身上，這些隨機或半隨機的試驗，將計畫性的提早生產與期待性的處理方式進行比較。

資料收集與分析

有2位回顧作者獨立使用了合格的標準，評估了試驗品質並擷取出資料。當中使用了1份隨機效果模式(randomeffects model)。

主要結論

其中共包含了12組試驗(總數為6814名婦女)。計畫性的處理法通常是加入催產素(oxytocin)或是前列腺素(prostaglandin)，其中有1組試驗則是使用了順式療法用的紅毛七屬(homoeopathic caulophyllum)藥物。整體看來，在計畫性與期待性的組別之間，就生產方式而言並沒有偵測到什麼差別：relative risk (RR) of caesarean section 0.94, 95% confidence interval (CI) 0.82 to 1.08(12組試驗，6814名婦女)；RR of operative vaginal birth 0.98, 95% 0.84 to 1.16(7組試驗，5511名婦女)。跟期待性的處理法組別相比，在計畫性的組別中，顯著地有較少的婦女會得到絨毛膜羊膜炎(chorioamnionitis)(RR 0.74, 95% CI 0.56 to 0.97; 9 trials, 6611 women)或是子宮內膜炎(endometritis)(RR 0.30, 95% CI 0.12 to 0.74; 4 trials, 445 women)。對於新生兒感染而言，並沒有發現任何差異(RR 0.83, 95% CI 0.61 to 1.12; 9 trials, 6406 infants)。然而，跟期待性的處理法相比，在計畫性處理法之下的嬰兒，只有比較少的例子會進入新生兒加護病房或是特別照護(RR 0.72, 95% CI 0.57 to 0.92, number needed to treat 20; 5 trials, 5679 infants)。在其中一個試驗中，跟接受期待性處理法的婦女比較起來，顯著地有較多接受計畫性處理法的婦女，對她們所接受到的照護有更為正面的評價(RR of “nothing liked” 0.45, 95% CI 0.37 to 0.54; 5031 women)。

作者結論

計畫性的處理法(使用像是催產素或前列腺素之類的方法)可降低某些母體因為受感染而罹病的風險，但是並不會提高剖腹產以及手術性陰道產的比例。在計畫性的處理法之下，雖然在新生兒感染的比例之中，並沒有發現到任何差異，但是比較少的嬰兒會接受新生兒加護照顧。因為計畫性與期待性的處理法可能不會有很大的差異，婦女們需要有適當的資訊以作出有憑有據的選擇。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

當婦女在足月時發生了母體早期破水的現象時，有些證據會較偏向於計畫性的處理法(通常是引產法)。當婦女在37周的懷孕期或是更晚時，在沒有收縮的情況下發生了羊膜破水，她們就可以選擇醫療干預行為(通常是以催產素或前列腺素進行立即性的引產)，或是她們也可以等待自發性的分娩發生。早期的計畫性醫療干預行為可能會造成更多的剖腹產與手術性的生產，但是在本篇回顧中並不支持這樣的考量，而且本篇回顧也發現，跟假設婦女要等待自發性生產的狀況相比，被感染的母親數目較少，住進新生兒加護病房的嬰兒數目也較少。不論是否較早採取了醫療干預行為，或是不論婦女是否等待，受到感染的嬰兒數目都是類似的。在其中1組試驗中，婦女們很明顯地比較喜歡早期的計畫性醫療干預行為。