OBJECTIVES: To assess the optimal mode of delivery in women with, or carriers of, bleeding disorders.
SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the Cochrane Pregnancy and Childbirth Group's Trials Register as well as trials registries and the reference lists of relevant articles and reviews.Date of last search of the Group's Trials Registers: 16 February 2017.
SELECTION CRITERIA: Randomised controlled trials and all types of controlled clinical trials investigating the optimal mode of delivery in women with, or carriers of, any type of bleeding disorder during pregnancy were eligible for the review.
DATA COLLECTION AND ANALYSIS: No trials matching the selection criteria were eligible for inclusion MAIN RESULTS: No results from randomised controlled trials were found.
AUTHORS' CONCLUSIONS: The review did not identify any randomised controlled trials investigating the safest mode of delivery and associated maternal and foetal complications during delivery in women with, or carriers of, a bleeding disorder. In the absence of high quality evidence, clinicians need to use their clinical judgement and lower level evidence (e.g. from observational trials, case studies) to decide upon the optimal mode of delivery to ensure the safety of both mother and foetus.Given the ethical considerations, the rarity of the disorders and the low incidence of both maternal and foetal complications, future randomised controlled trials to find the optimal mode of delivery in this population are unlikely to be carried out. Other high quality controlled studies (such as risk allocation designs, sequential design, and parallel cohort design) are needed to investigate the risks and benefits of natural vaginal and caesarean section in this population or extrapolation from other clinical conditions that incur a haemorrhagic risk to the baby, such as platelet alloimmunisation.
METHODS: Low-risk women at 40 weeks' gestation undergoing membrane sweeping to expedite labor were recruited. Participants were scheduled for labor induction at 41 weeks' gestation. Transvaginal ultrasonography was performed immediately before and after membrane sweeping to measure the cervical length. Three presweep and postsweep cervical lengths were measured. The shortest lengths before and after the sweep were taken as the representative lengths. The effect of membrane sweeping on cervical length was analyzed. Multivariable logistic regression analysis was performed to evaluate the effect of cervical shortening on labor induction and the mode of delivery.
RESULTS: For the 160 participants, the mean presweep cervical length ± SD was 21.0 ± 10.0 mm; the postsweep length was 23.8 ± 10.9 mm, an average increase of 2.8 ± 0.6 mm (P < .001). Cervical shortening after membrane sweeping was noted in 53 of 160 cases (33%). Cervical shortening was associated with a reduction in all-cause cesarean delivery but not labor induction on bivariate analysis. After adjustment for maternal age, parity, presweep Bishop score, postsweep cervical length, oxytocin augmentation, epidural analgesia, and meconium-stained fluid, cervical shortening after membrane sweeping was independently predictive of a reduction in cesarean deliveries (adjusted odds ratio, 0.24; 95% confidence interval, 0.06-0.90; P = .034).
CONCLUSIONS: Membrane sweeping was associated with lengthening of the cervix. A shortened cervix after sweeping was independently predictive of vaginal delivery.