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Sir,

The study ‘Evaluation of postpartum blood loss after misoprostol-induced labour’ by Elsedeek et al.1 identifies an increase in postpartum blood loss in misoprostol induction, in comparison with oxytocin induction.

From the study, I observed a highly significant negative correlation between postpartum blood loss and duration of labour for both groups. I came to note that the major determinant for an increase in postpartum blood loss for the misoprostol induction group is the shorter induction-delivery interval. Would the authors be able to provide information on whether misoprostol is still resulting in an increase in post partum blood loss, after adjusting for induction-delivery interval?

As presented in this study, precipitate labour has been shown to increase maternal morbidity. It has been reported to be associated with increases in grade three perineal tears, cervical tears, postpartum haemorrhage, retained placenta and packed cell transfusions.2 It is also known to be strongly associated with placental abruption.3 Analysis of the study by Sheiner et al.2 showed that prostaglandin E2 induction is an independent risk factor for precipitate labour. These are significant findings for clinicians conducting induction of labour in practice.

During the process of induction of labour, often the aim is to achieve a short induction to delivery interval. It has been reported that women might prefer obstetric interventions that lead to a shorter labour, even if operative outcomes are not altered.4 UK National Institute for Health and Clinical Excellence (NICE) Induction of Labour guideline did not review the induction to delivery interval and its implications, when recommending the methods of induction of labour.3

The finding of this paper and previous studies highlighted the potential risks of a short induction to delivery interval. When choosing the method of induction, consideration should include avoidance of precipitate labour; other risk factors of precipitate labour should also be taken into account. Awareness of the risks will allow adequate preparation, to avoid and manage complications, and ultimately decrease morbidity of precipitate labour.

References

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  2. References
  • 1
    Elsedeek M, Awad E, Elsebaey S. Evaluation of postpartum blood loss after misoprostol-induced labour. BJOG 2009;116:4315.
  • 2
    Sheiner E, Levy A, Mazor M. Precipitate labor: higher rates of maternal complications. Eur J Obstet Gynecol Reprod Biol 2004;116:437.
  • 3
    National Collaborating Centre for Women’s and Children’s Health. Induction of Labour Clinical Guideline July 2008. Commissioned by the National Institute for Health and Clinical Excellence, 2nd edn. London: RCOG Press, 2008.
  • 4
    Kenyon S, Walkinshaw S. Commentary on ‘A randomised controlled trial of early versus delayed oxytocin augmentation to treat primary dysfunctional labour in nulliparous women’. BJOG 2008;115:12956.