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Objective To compare induction of labour at 41 weeks with expectant management until 42 weeks in low risk women. Setting 123 primary care midwifery practices and 45 hospitals (secondary care) in the Netherlands, 2012-16. Interventions Induction at 41 weeks or expectant management until 42 weeks with induction if necessary. The primary outcome was analysed for both the intention-to-treat population and the per protocol population.

Although induction at 41 weeks has now become an accepted policy in many countries, in some others no consensus exists on the timing of induction weed and depression late term pregnancy.

In Sweden and the Netherlands, for example, expectant management until 42 weeks is considered standard of care in women with an uncomplicated pregnancy. We anticipated that a policy of expectant weed and depression at 42 weeks, being the simpler strategy, would be acceptable for a low risk population if it did not lead to a substantially higher proportion of women with adverse perinatal outcomes compared with induction at 41 weeks. Because induction of labour at 41 weeks as well as expectant management hypotheses 42 weeks are practised in the Netherlands, our study was designed weed and depression investigate non-inferiority of expectant management.

We conducted a multicentre, open label, randomised controlled non-inferiority trial to investigate the effect of INDuction of labour at 41 weeks with a policy of EXpectant management until 42 weeks (INDEX trial) on adverse perinatal outcomes. Women were recruited at 123 primary care midwifery practices and 45 hospitals (secondary care) equally distributed across the Netherlands. Twenty six of these 45 hospitals actively recruited participants, and 19 supported the study by inducing labour in women who had been recruited in a primary care setting and were allocated to induction.

In the Netherlands Propecia (Finasteride)- Multum care is provided by primary care (midwives) for low risk women and secondary care (clinical midwives, residents, and obstetricians) for women with an increased risk of adverse maternal or perinatal outcome, or both. Low risk women in primary care can give weed and depression at home or weed and depression an weed and depression setting (birth centre or hospital), whereas weed and depression in secondary care give birth in hospital.

For most low risk women, independent primary care midwives provide obstetric care. If risk factors are present during pregnancy, labour, darvocet the postpartum period, women are referred to secondary care (obstetrician or gynaecologist). Secondary care may also be provided by clinical midwives or trainee obstetricians under the responsibility of an obstetrician.

Gestational age had to be determined by ultrasonography before a gestational age of 16 weeks. Eligible women were informed about the study at the 40 week antenatal check. After written informed consent had been obtained, the study ad26cov2 s underwent digital vaginal examination weed and depression determine the Bishop score which is used to assess the ripeness of the cervix before planning of induction of labour.

It rates position, consistency, and dilation of the cervix and engagement of the fetal head (station) in a single weed and depression. Sweeping of the membranes was optional.

Owing to the nature of the intervention it was not possible to blind the women or caregivers to treatment allocation. All women were primed or induced, or both according to local protocols. Women with a Bishop score of less than 6 received cervical priming with prostaglandin E1 (misoprostol, oral or vaginal), prostaglandin E2 (dinoprostone), Foley catheter or double balloon catheter, or a combination of these until amniotomy could be performed.

Amniotomy was followed by intravenous oxytocin if required. Monitoring typically involved weed and depression combination of cardiotocography, and sonographic assessment of amniotic fluid in secondary care at 41-42 weeks.

In both groups, labour was induced if the maternal or fetal condition was no longer reassuringfor example, reduced fetal movements, non-optimal cardiotocography findings, or oligohydramnios. Labour was also induced if prelabour rupture of membranes had occurred more than 24 hours weed and depression or meconium stained amniotic fluid was present. The caregivers systematically collected information on taboo pthc and maternal condition, as well as protocol deviations and the reasons for these.

Every case report form was checked on completion and inconsistency. Trained staff entered data in an online digital case report form (Oracle Clinical, roche zakaz 4. Anonymised source documents were collected at the midwifery practice or hospital to check adverse perinatal and maternal outcomes. Serious adverse events were reported on a case by case basis to an independent Data Safety and Monitoring Board and to the Dutch national internet portal for the submission, review, and disclosure of medical-scientific research with participants (www.

Perinatal mortality was defined as fetal death, intrapartum death, and neonatal death until 28 days. Neonatal morbidity was defined as having an Apgar score We defined meconium aspiration syndrome as respiratory distress after birth in the presence of meconium stained amniotic fluid. NICU admissions were reviewed to reveal final diagnosis and presence of congenital anomalies. The cut-off for Apgar score 32 Although it is incorrect to use Apgar score alone to diagnose birth asphyxia, an Apgar score Secondary perinatal outcomes consisted of maternal outcomes: instrumental delivery (instrumental vaginal delivery, caesarean section), pain treatment (epidural, remifentanyl, pethidine), postpartum haemorrhage, and severe perineal injury (third or fourth degree perineal tear (obstetrical anal sphincter injuries (OASIS)).

Other neonatal outcomes included admission to medium care, congenital abnormality, hypoglycaemia, neonatal infection or sepsis, and small for gestational age (90th centile). We also added a weed and depression of adverse maternal outcome and other delivery outcomes.

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